Encountering Chronic Sore Throat: How Challenging is it for the Otolaryngologists?

Abstract

Objective To explore and diagnose the underlying causes of chronic, recalcitrant sore throat. Methodology In this descriptive, cross-sectional study spanning 3 years (January 2014–December 2016), 1580 patients with chronic sore throat (>12 weeks duration, despite conventional medication) were evaluated for the possible cause(s) in a tertiary care teaching institute of eastern India, through proper history, appropriate investigations, and a self-designed algorithm. Results The common causes for chronic sore throat were chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, and laryngopharyngeal reflux disorder, respectively. Allergy, psychiatric illnesses, oral submucous fibrosis, systemic comorbidities (diabetes mellitus, hypothyroidism, uremia, arthritides), stylalgia, Koch’s pneumonitis, recurrent aphthous ulcers, and dietary deficiencies formed the other major causes. There was a minimal female preponderance, the female: male ratio being 1.25. About 39% patients were chronic smokers, and 31% addicted to alcohol. Forty-three (2.72%) patients were reactive to HIV 1/2. Conclusion The study provided with a detailed account of the heterogeneous etiology of chronic sore throat, and an overall structured idea on how to approach to its work-up and diagnosis. Proper history taking and appropriate structured investigations are the keys. Chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, and laryngopharyngeal reflux disorder were the chief causes of chronic sore throat.

Introduction

Chronic sore throat is to an otolaryngologist, as headache is to neurologist—an often seemingly trivial symptom but heavily demanding for bringing relief. Often used irreversibly with odynophagia, the symptom of chronic sore throat not only includes painful swallowing, but also encompasses a wide variety of complaints like scratchy or hot, burning sensation, lancinating pain, a sort of “raw” feeling, and the typical deep boring pain that worsens with mastication, swallowing and talking. The pain often radiates to the ears and temporomandibular joints, aggravating its intensity. Considering the extent to which the quality of life of the patients is impaired, it is often challenging for the practicing otolaryngologists to deal with this recalcitrant, nagging problem without dismissing the symptoms as “fictitious” and “psychogenic”. Acknowledging the psychosomatic nature of most of the modes of presentation, it is a fact that there is a serious dearth of an accepted, practical guideline, or a standardized and generalized algorithm on how to approach a patient presenting with chronic sore throat. The multiplicity and heterogeneity of the spectrum of etiologies of chronic sore throat make the task of enumerating them far from exhaustive. Nevertheless, the present article attempts to explore this unique clinical problem through the authors’ experience in a tertiary care teaching institute, by investigating its etiology, presentations and differential diagnoses, through a representative and reproducible disease-based algorithm for practical use.

Materials and Methods

Study Setting

Inflammation of the pharyngeal mucosa and/or a burning or pricking sensation in the throat persisting for >12 weeks despite medication has been considered as the conventional and working definition of “chronic sore throat” in this study. Patients with chronic sore throat attending the otolaryngology out-patients’ department, Medical College and Hospital, Kolkata, satisfying the above definition, were evaluated and followed up at intervals for a period of 3 years (January 2014–December 2016). The primary objective of the study was to know the relative incidence and distribution of the various causes of chronic sore throat through a working algorithm that would help us arrive at a diagnosis, and treat the condition accordingly.

Study Technique

It is a descriptive, cross-sectional study.

Study Tool

Informed consent in written was obtained from every subject included in the study. Approval from the Institutional Ethical Committee was also obtained. Proper history was elicited from the patients regarding the nature of sore throat, its duration and progression, presence of diurnal variation, exacerbating and relieving factors, localization and radiation, relation with mastication, deglutition, phonation, and respiration. Information was also gathered about food habits, addiction (including smoking, alcohol, betel nut chewing), voice abuse, heartburn, nausea/vomiting, and headache. Any systemic history including chronic low-grade fever, cough, hemoptysis, lymphadenopathy, recurrent exacerbation of chronic sore throat, local inflammatory disorders or ulcers (like recurrent aphthous), and associated significant ophthalmic, cutaneous, musculoskeletal and genitourinary symptoms were also emphasized. Personal and family history of metabolic and other systemic disorders like diabetes, hypothyroidism, anemia of chronic disease, collagen vascular disorder etc. were inquired for. Chronic drug use, like psychiatric medications, anti-tubercular medications etc., were also considered. Allergy, professional and working environment were noted. Travel, long-term outstation stay, and visit to prohibitive sites were specifically inquired.

The patients were next subjected through a general survey, and their oral cavity including lips, gum, alveoli, teeth, tongue, floor of mouth including submandibular and sublingual glands, hard palate, buccal mucosa, gingivolabial and gingivobuccal sulci, openings of Stensen and Wharton ducts, and retromolar trigone were thoroughly examined. Any abnormality on inspection and palpation of these structures or the overlying mucosa were noted. Clinical examination of the pharynx was carried out with a flexible nasopharyngolaryngoscope with special attention to the tonsils and their pillars, posterior pharyngeal wall, soft palate, base of tongue, vallecula, pyriform sinuses, and laryngeal inlet with glottic and supraglottic structures. Attention was also given to the structures of neck including lymph nodes, thyroid, and the laryngeal framework to look for laryngeal crepitus and flaring. Neck pain and any focal point of tenderness were carefully documented.

Locoregional examination of nasal cavity and ears were carried out next. Relevant systems, like the nervous, respiratory, cardiovascular, gastrointestinal, and musculoskeletal, were also examined.

The thorough clinical evaluation was followed by routine hematology tests, like complete hemogram, blood sugar, urea and creatinine, serology, along with chest skiagram. Other relevant investigations like throat swab, total immunoglobulin E, skin-prick test, thyroid profile, liver function test, ASO titer and other rheumatologic markers, proper imaging [intraoral occlusal view, reverse Towne’s view, skiagram of soft tissue neck and cervical spine, barium swallow, computed tomography (CT)-scan and/or magnetic resonance imaging (MRI)], gastroduodenoscopy etc. were undertaken as required.

Throughout the entire process, interdepartmental liaison was maintained with psychiatry, medical gastroenterology, pulmonology, rheumatology, microbiology and dermatology departments.

The information thus collected was entered in a comprehensive manner in Microsoft Excel sheets in tabular form, and statistical calculations were done in percentages, culling data from the Excel sheets as required.

Results

A total of 1580 patients with chronic, refractory sore throat attending the out-patients’ department were included in the study. The number of female patients constituted 879, the female:male ratio being 1.25. The incidence of the various causes of chronic sore throat as obtained from the information gathered by history, general examination, routine and special tests (including appropriate imaging) are summarized in Tables 1 and 2. The most common cause was found to be chronic tonsillopharyngitis (~43%), followed by gastroesophageal reflux (~27%), submandibular sialadenitis (22%), and laryngopharyngeal reflux (~20%). Clinically evident allergy, psychiatric illnesses, oral submucous fibrosis, systemic illnesses (like diabetes mellitus, hypothyroidism, uremia, arthritides, etc.), stylalgia, Koch’s pneumonitis, recurrent aphthous ulcers, and dietary deficiencies (including anemia) constituted the other major causes. Overall, about 39% patients were chronic smokers, and 31% were addicted to alcohol. Forty-three (2.72%) patients were found to be reactive to HIV 1/2. Figure 1 shows the working algorithm which depicts the way to approach to a patient with chronic sore throat to arrive at a definitive diagnosis.

Table 1.

Etiology of chronic sore throat in the study population

Etiology, overall	Number of patients (n = 1580)	Percentage of patients (%)
Chronic tonsillopharyngitis	685	43.35
Gastroesophageal reflux disorder	432	27.34
Submandibular sialadenitis	348	22.02
Laryngopharyngeal reflux disorder	312	19.75
Allergy/postnasal drip/chronic rhinitis	167	10.57
Neuralgia/stylalgia	79	5
Psychogenic	48	3.04
Miscellaneous	252	15.95

Patients with addiction to alcohol and smoking constituted 495 (31.33%) and 620 (39.24%), respectively. Forty-three (2.72%) patients were reactive to HIV 1/2

Table 2.

Etiology (the “miscellaneous” group) of chronic sore throat in the study population

Etiology, miscellaneous	Number of patients (n = 252)	Percentage of Miscellaneous patients (%)
Submucosal fibrosis	98	38.89
Systemic causes, like diabetes mellitus, hypothyroidism, thyroiditis, uremia, arthritides, etc.	83	32.94
Koch’s pneumonitis/persistent cough	58	23.02
Recurrent aphthous	54	21.43
Dietary deficiency disorders/anemia	48	19.05
Temporomandibular joint disorders	20	7.94
Oral/oropharyngeal candidiasis	19	7.54
Concealed neoplasm/malignancy	18	7.14
Toxic fibromyositis (hyoid)	13	5.16
Atrophic rhinopharyngitis	10	3.97
Cervical spondylosis	8	3.17
Trauma	8	3.17
Retropharyngeal abscess	2	0.8

Patients with addiction to alcohol and smoking constituted 182 (72.22%) and 205 (81.35%), respectively. Thirty-two (1.27%) patients were reactive to HIV 1/2

Fig. 1.

The working algorithm based on disease entity describing the approach to diagnose a patient with chronic sore throat. DMARD Disease-modifying antirheumatic drugs

Discussion

Chronic sore throat, alternatively referred to as “chronic pharyngitis” by otolaryngologists, connotes a recalcitrant medical condition that often defies all possible forms of management. Approximately 30% of patients with chronic pharyngitis have no identifiable cause [1]. Considering the burden of this condition in the daily out-patients’ visit, and the impaired quality of life it associates with, we have attempted in this study to analyze the different causes of chronic sore throat, and to design an algorithm to reach at a possible diagnosis of this intriguing problem. A thorough search in the PubMed/MEDLINE, Cochrane Library and Google Scholar with the given keywords did not reveal any study that primarily dealt with the etiologies of chronic sore throat at a large scale in the general population. In this context, we believe our study would be a unique addition to the understanding of the etiopathogenesis of chronic sore throat.

Owing to lack of proper consensus regarding the optimum duration when a persisting sore throat can be termed “chronic”, we have considered “inflammation of the pharyngeal mucosa and/or the sensation of burning or pricking sensation in the throat that has persisted for more than 3 months despite medication” as the conventional, working definition in our study.

Where the source of inflammation in chronic sore throat is too obvious in the form of focal or diffuse clinically evident inflammation in the primary areas of inspection, like the tonsils, adenoids, lingual tonsillar hypertrophy, or the paranasal sinuses, treatment of the source in the form of adenotonsillectomy or functional endoscopic sinus surgery following adequate pre-medications, and with a compliant follow-up schedule after the specific treatment, can lead to prompt relief. The problem becomes difficult to manage when despite these treatments or in the absence of visible mucosal inflammation, “sore throat” ruminates.

When chronic pharyngitis persists despite optimum management, especially in chronic granular pharyngitis, an allergic etiology (atopy) may be found associated with rhinosinusitis [2]; a course of steroids in conjunction with antibiotics and topical gargle may lead to temporary remission. Further related investigations like absolute eosinophil count, immunoglobulin E assay, skin prick test for allergens, radio-allergosorbent test (RAST) can be carried out, and subsequent prolonged antiallergic/immunomodulatory treatment with rehabilitation might lead to long-term resolution. But where no such cause can be established, it might be judicious to take a throat swab for aerobic culture and sensitivity. An antibiogram with causative organism(s) promises a good prognosis. However, when there is an absence of growth at 48 h, a trial of second or third generation cephalosporins or macrolides with azoles or antifungals might produce surprising results.

The disseminated form of pulmonary tuberculosis in a patient with severe odynophagia can generally be distinguished by the typical laryngeal features. However, even if the patient is on anti-tuberculosis regimen, the pain may continue, making the treatment schedule more intense, directed towards pain management with topical anesthetic gargle and xylocaine lozenge [3]. Here it should be remembered that pulmonary tuberculosis disseminating to the head-neck region might involve extra-laryngeal areas as well, and might present with characteristic oral manifestations in the form of irregular ulcers, granulations, or indurated lesions in tongue, palate, and buccal mucosa, which require biopsy for confirmation, and pain management. On the other hand, persistent cough in patients suffering from asthma and/or allergy might lead to recalcitrant sore throat [1]. This can be controlled with proper medication including steroids and inhaled long-acting bronchodilators. In our study population, we encountered few patients with subclinical retropharyngeal/parapharyngeal abscesses persisting for several weeks without detectable external or internal features. Such hidden foci of infection might often be missed due to lack of proper imaging (skiagram of soft tissue neck, or CT). Also, we have in our records patients with foreign body lodged in the parapharyngeal space that remained undetected for months, causing sore throat and trismus.

Another challenge is with persistence of sore throat sans clinical pharyngitis, or following remission of clinically evident pharyngitis. In such situations, exploring the adjacent anatomic areas/structures for other causes becomes necessary. These include the submandibular glands (chronic sialadenitis) [4], elongated styloids (stylalgia/Eagle syndrome) [5, 6], and neuralgias. Appropriate investigations directed towards evaluating the other reasons for chronic sialadenitis and neuralgia, and treating them accordingly [antibiotics (like fluoroquinolones) with/without surgical excision for chronic sialadenitis, and carbamazepine/tricyclic antidepressants and surgery (if required) for neuralgia], produce gratifying results. Neoplasms at the base of tongue, vallecula and tonsils require special mention as they often remain hidden and need to be visualized through indirect laryngoscopy and flexible nasopharyngolaryngoscopy. Also chronic laryngitis and laryngopharyngeal reflux might, not too infrequently, give rise to this peculiar “sore throat” sensation [7, 8]. These conditions are identifiable clinically by flexible nasopharyngolaryngoscopy from the characteristic mucosal changes, and treated subsequently after exclusion of other surgical pathologies like hiatus hernia.

Dietary deficiencies, often associated with clinical pallor, cheilosis, glossitis, dysphagia, aphthous ulcers, dermatitis, and diarrhea, might also result in chronic sore throat [9, 10]. Supplementation accordingly with hematinics, multivitamins with microelements like zinc, apart from treating the primary cause when elicited, are the options for treatment.

Certain common systemic disorders and comorbidities causing immunosuppression can also affect the throat, like type 2 diabetes mellitus [11], hypothyroidism with history of subacute thyroiditis [12], and uremia [13]. These need to be identified promptly as the possible cause(s) or contributing factor(s) for persistence of sore throat, and respective directed treatments should be initiated at the earliest.

Patients on disease modifying antirheumatic drugs (DMARD) as in arthritides, skin ailments like pemphigoid or lichen, and connective tissue disorders, and long term oral steroids for asthma are also prone to repeated attacks of sore throat and its persistence, along with recurrent aphthous ulcers, oral candidiasis and xerostomia [14–16]. In these patients, systemic examination of musculoskeletal, urogenital, integumentary and uveoretinal systems becomes mandatory. Infectious viruses, especially hepatitis C and human immunodeficiency virus (HIV) bring with them their own oral and oropharyngeal manifestations which might result in chronic sore throat [17]. Use of betel quid, tobacco as pan masala and smoking, complicated by chronic alcohol intake, might lead to oral submucous fibrosis. The condition is characterized by intense burning sensation in mouth and mucosal changes where the oral and oropharyngeal mucosa becomes smooth, atrophic, characterized by hyaline degeneration resulting in decreased elasticity, often associated with vesicles, erosion, and hypermelanosis. Abstinence from the primary cause with topical/systemic/intralesional steroids along with long-term antioxidant therapy can potentially lead to clinical remission in most patients. Besides, toxic fibromyositis may be encountered following influenza that might result in prolonged tenderness over anterior aspect of neck, especially over the greater cornu of hyoid, producing pain during swallowing [18].

Not too infrequently, pain in the nape of the neck mimicking chronic sore throat are encountered in spondyloarthritis [19] where the standard regimen of non-steroidal anti-inflammatory drugs (NSAIDS), muscle relaxant, calcium and methylcobalamin improves the condition. Erratic instances of chronic sore throat have also been documented where patients provide past history of blunt trauma to neck, like throttling during assault [20]. Since subsequent examination of the neck and laryngopharynx mostly turn out to be unremarkable, a probable psychosomatic etiology should be explored, apart from eliciting clinico-radiologic features of soft-tissue and bone injury. The rare cases of laryngitis sicca, atrophic rhinopharyngitis, and prolonged radiation mucositis as primary causes of chronic sore throat are not common but treatable. Other relatively less common entities associated with chronic sore throat but often ignored include burning mouth syndrome and chronic fatigue syndrome [21, 22]. Trial by antidepressants, oral artificial saliva application, lifestyle modification, and treatment of the respective causes of dry mouth have provided rewarding results in many occasions.

Our study over a period of 3 years reveals the relative incidence of various causes of chronic sore throat in a representative population set-up. Chronic tonsillopharyngitis, gastroesophageal reflux disoder, submandibular sialadenitis, and laryngopharyngeal reflux formed, in that order, the most frequent causes. It is only after excluding all possible pathologies that chronic sore throat was considered to be of psychogenic origin. In this cross-sectional study, we have attempted to delineate the different causes of chronic sore throat in a large number of subjects, and devised an algorithm to provide an overall idea on how to deduce those causes, and to approach the problem in the day-to-day clinical practice of otolaryngology and general medicine. There are limitations of our study as well. For example, the study population, although large enough to predict reproducibility of the results, could have been further increased considering the population density a tertiary-care referral hospital caters in India. Further, it could be made more representative of the prevailing economic strata of the society, had it been designed as multicentric, involving the other teaching referral hospitals of the area as well as the corporate institutions. Again, since the mode of diagnosis was mostly based in the out-patients’ set-up, many of them might appear rather crude. However, since the study was chiefly population-based and considered a multiplicity of causes for chronic sore throat, the “investigation of choice” for certain ailments were out of scope for the study design. For example, 24-h double probe pH monitoring, the gold standard for the diagnosis of laryngopharyngeal reflux disorder, could not be followed in a study that primarily aimed at delineating the differential diagnoses of one of its symptoms; we rather had to rely on the patients’ history and the findings from nasopharyngolaryngoscopy for its diagnosis. Notwithstanding these limitations, we believe that the study would provide a useful overview of the wide spectrum of differential diagnoses of chronic sore throat, and would be helpful in a practical set-up that deals with a huge number of patients with such complaints.

Conclusion

Managing a patient with chronic, recalcitrant sore throat is often one of the most challenging encounters to the physician-surgeon. However, logical structuring of the clinical problem, with the help of proper history, examination, directed investigations, and appropriate drug and/or surgical therapy, might prove to have a rewarding outcome at the end. In this study with a large patient cohort in a tertiary care provision, we have analyzed the problem by considering a wide spectrum of possible differential diagnoses through a structured algorithm as the basis of our management protocol. Chronic tonsillopharyngitis, gastroesophageal reflux disorder, submandibular sialadenitis, laryngopharyngeal reflux and allergy constituted the most frequent reasons for chronic sore throat and its persistence. We consider that this particular analytical, problem-based attempt would be reproducible and beneficial in dealing patients with chronic sore throat in a larger, more heterogeneous population set-up.

Compliance with Ethical Standards

Conflict of interest

All authors declare that they have no conflict of interest.