Sore Throats & Tonsillitis

Almost everyone will suffer with a sore throat at some stage in their lives. In fact a sore throat can mean different things to different people, ranging from a mild irritation to dryness to severe acute pain. In more severe cases, this may cause difficulties in swallowing or even airway problems depending on the cause.

The majority of sore throats are caused by a viral infection, usually associated with a cold or ‘flu. Remember that although tonsillitis is quite common, not every sore throat is tonsillitis. The symptoms and possible causes do vary somewhat in children and adults, although many of the conditions can occur in most age groups so they will be considered together.

Viral Sore Throat

This usually occurs at the same time as, or shortly follows, an ‘flu-like illness or cold affecting the nose and sinuses (also known as the upper respiratory tract). As part of the illness, the throat usually becomes inflamed and sometimes infected as well. Symptoms may include a runny nose, sneezing, hoarseness, dry cough, decreased hearing and redness of the pharynx and tonsils.

Treatment is generally supportive, aimed at dealing with the symptoms as they appear, as the viral cause of the sore throat will improve by itself with time. It is recommended to use salt water gargles, take common painkillers such as paracetamol and/ or ibuprofen, drink plenty of fluids and do steam inhalations.

If symptoms persist or recur several times over a short time period, it is advisable to make an appointment with your GP as further tests or treatment may be required. A throat swab may need to be taken to identify the exact cause of the infection. If the results show a bacterial infection, a course of antibiotics is usually prescribed.

Tonsillitis

The tonsils are part of the immune system and are made up of lymphoid tissue, whose job it is to fight infections or viruses when they occur. In most people the tonsils therefore play an important role but if they become unhealthy in their own right, they can occasionally give rise to infections of their own. An acute attack of tonsillitis can be quite severe and debilitating for the patient. It usually causes a particularly severe sore throat which is the main symptom, occasionally but not always associated with flu-like symptoms, during which the tonsils become enlarged, red and inflamed and cause pain on eating, fever, referred pain to the ears and enlarged neck glands.

Initial treatment is as for a viral sore throat as it is sometimes difficult to distinguish the two, although antibiotics may need to be given if the tonsillitis is prolonged, severe or where the evidence points towards a bacterial cause. In people with recurrent tonsillitis occurring several times a year and associated with time off school or work, it may be necessary to remove the tonsils (tonsillectomy).

Current guidelines produced by the Scottish Intercollegiate Guidelines Network (SIGN) suggest that there need to be at least 5 episodes of tonsillitis a year, occurring over a timeframe of at least a year, before tonsillectomy should be considered. It must be noted that these are only guidelines for your specialist to bear in mind whilst assessing your case, as in some instances tonsillectomy may well be recommended if there are fewer than five attacks a year if other relevant factors are present, such as a quinsy (see below) or hospital admissions for tonsillitis in severe cases.

Children most commonly suffer with sore throats and tonsillitis as they are frequently exposed to viruses transmitted by contact with other children at nursery or school. Treatment is as for adults, with the exception that in children, the adenoids (lymphoid tissue behind the nose) are also often inflamed and enlarged, which can give rise to problems of their own such as blocked nose, snoring or even hearing problems due to glue ear. In such circumstances, consideration may need to be given to additional treatments.

If you think that you or your child is suffering with severe sore throats and/or tonsillitis, it would be sensible to discuss the options with your GP or ENT specialist who will be happy to answer any questions you may have.

Quinsy (Peritonsillar Abscess)

This is a condition in which an abscess forms next to the tonsil. It usually occurs following a severe episode of acute tonsillitis, which results in spread of the infection to the tissues outside the tonsil and the subsequent build up of pus. This causes the tonsil to bulge in wards, pushing part of the soft palate over to the other side.

Symptoms of quinsy tend to be more severe than those of tonsillitis, although as they often begin in a similar way, the symptoms can overlap. Symptoms include acute sore throat, inability to swallow, neck swelling, fever, and difficulty in opening the mouth fully. Treatment of a quinsy is usually with antibiotics in the first instance. If there is a fully developed abscess, then intravenous antibiotics will need to be given. In addition it is usually necessary to drain the pus by making a small incision under local anaesthetic in the mouth where the abscess is bulging most prominently.

Glandular Fever (Infections Mononucleosis)

This condition most often occurs in teenagers and young adults. It is caused by the ‘Epstein- Barr’ virus, which is easily transmitted from person to person through saliva or droplets. Symptoms include a severe sore throat, feeling of tiredness and lethargy which can outlast the duration of the infection, fever, enlarged tonsils often with a surface white membrane, enlarged neck lymph nodes (cervical lymphadenopathy) and occasionally the presence of a red rash. A blood test is performed to diagnose Glandular Fever. It is also important to check the liver function as glandular fever can be associated with an enlarged liver (hepatomegaly) and also an enlarged spleen (splenomegaly).

Treatment for Glandular Fever is initially supportive and targeted at symptomatic relief as the virus cannot be cured by medications. Take painkillers such as paracetamol or ibuprofen as and when required, drink plenty of fluids and have plenty of rest. On occasions, the infection may be sore severe that a secondary bacterial infection occurs, in which case a course of antibiotics may be given. In such situations, your doctor will probably avoid the use of amoxicillin as it can cause a raised red rash in glandular fever patients. Penicillin therefore tends to be the antibiotic of choice.

Because of the possibility of an enlarged liver and/or spleen, it is important to advise patients not to engage in contact sports for a period of 4 -6 weeks after the infection. This is important as the target population are teenagers and young adults who may be involved in sports such as rugby, football or hockey. You should also visit your GP for an examination before resuming such activities to ensure that any enlargement of the liver or spleen has reduced back to normal. On occasions an ultrasound of the abdomen may be required to confirm that this is the case.

Other causes of a sore throat

Below are some other, not so common causes of a sore throat which may need to be considered if none of the above applies.

  • Blocked nose: If you cannot breathe well through your nose, you will tend to breathe through your mouth, which, particularly at night, causes dryness of the mouth and throat and an increased chance of suffering with a sore throat. There are many different causes of a blocked nose which your ENT surgeon can evaluate.
  • Acid reflux: Patients with indigestion may notice a bitter taste in the mouth or throat particularly in the mornings, or a burning sensation behind the breastbone or in the throat. This may signify that acid is refluxing out of the stomach up into the throat and mouth, which in turn can cause a sore feeling.
  • Tumours of the throat: In some cases, a growth or cancer can cause a sore throat. This is more likely in males over the age of 40 who are heavy smokers and drinkers. This causes a sore throat which, unlike the acute infections described above, is not usually associated with a fever or flu-like symptoms, is often on one side of the throat only and persists on a daily basis, usually increasing in severity gradually with time. If you are worried about this, you should see your GP urgently for an initial examination. You may then be referred to an ENT specialist if symptoms do not improve.