Diagnosis & Treatment

Throat

Treatments of sore throats
Swallowing problems
Hoarseness
Gastroesophageal Reflux Disease and Laryngopharyngeal Reflux


Sore Throats
Insight into causes and treatments of sore throats

What Causes a Sore Throat?
Sore throat is a symptom of many medical disorders. Infections cause the majority of sore throats and are contagious. Infections are caused either by viruses such as the flu, the common cold, mononucleosis, or by bacteria such as strep, mycoplasma, or hemophilus. While bacteria respond to antibiotic treatment, viruses do not.

Viruses: Most viral sore throats accompany flu or colds along with a stuffy, runny nose, sneezing, and generalized aches and pains.

These viruses are highly contagious and spread quickly, especially in winter. The body builds antibodies that destroy the virus, a process that takes about a week.

Sore throats accompany other viral infections such as measles, chicken pox, whooping cough, and croup. Canker sores and fever blisters in the throat also can be very painful.

One viral infection takes much longer than a week to be cured: infectious mononucleosis, or “mono.” This virus lodges in the lymph system, causing massive enlargement of the tonsils, with white patches on their surface and swollen glands in the neck, armpits, and groin. It creates a severely sore throat and, sometimes, serious breathing difficulties. It can affect the liver, leading to jaundice—yellow skin and eyes. It also causes extreme fatigue that can last six weeks or more. “Mono,” a severe illness in teenagers but less severe in children, can he transmitted by saliva. So it has been nicknamed the “kissing disease,” but it can also be transmitted from mouth-to­hand to hand-to-mouth or by sharing of towels and eating utensils.

Bacteria: Strep throat is an infection caused by a particular strain of streptococcus bacteria. This infection can also damage the heart valves (rheumatic fever) and kidneys (nephritis), cause scarlet fever, tonsillitis, pneumonia, sinusitis, and ear infections.

Because of these possible complications, a strep throat should be treated with an antibiotic. Strep is not always easy to detect by examination, and a throat culture may be needed. These tests, when positive, persuade the physician to prescribe antibiotics. However, strep tests might not detect other bacteria that also can cause severe sore throats that deserve antibiotic treatment. For example, severe and chronic cases of tonsillitis or tonsillar abscess may be culture negative. Similarly, negative cultures are seen with diphtheria, and infections from oral sexual contacts will escape detection by strep culture tests.

Tonsillitis is an infection of the lumpy tissues on each side of the back of the throat. In the first two to three years of childhood, these tissues “catch” infections, sampling the child’s environment to help develop his immunities (antibodies). Healthy tonsils do not remain infected. Frequent sore throats from tonsillitis suggest the infection is not fully eliminated between episodes. A medical study has shown that children who suffer from frequent episodes of tonsillitis (such as three- to four- times each year for several years) were healthier after their tonsils were surgically removed.

Infections in the nose and sinuses also can cause sore throats because mucus from the nose drains down into the throat and carries the infection with it.

The most dangerous throat infection is epiglottitis, caused by bacteria that infect a portion of the larynx (voice box) and cause swelling that closes the airway. This infection is an emergency condition that requires prompt medical attention. Suspect it when swallowing is extremely painful (causing drooling), when speech is muffled, and when breathing becomes difficult. A strep test may miss this infection.

Allergy: The same pollens and molds that irritate the nose when they are inhaled also may irritate the throat. Cat and dog danders and house dust are common causes of sore throats for people with allergies to them.

Irritation: During the cold winter months, dry heat may create a recurring, mild sore throat with a parched feeling, especially in the mornings. This often responds to humidification of bedroom air and increased liquid intake. Patients with a chronic stuffy nose, causing mouth breathing, also suffer with a dry throat. They need examination and treatment of the nose.

Pollutants and chemicals in the air can irritate the nose and throat, but the most common air pollutant is tobacco smoke. Other irritants include smokeless tobacco, alcoholic beverages, and spicy foods.

A person who strains his voice (yelling at a sports event, for example) gets a sore throat not only from muscle strain but also from the rough treatment of his throat membranes.

Reflux: An occasional cause of morning sore throat is regurgitation of stomach acids up into the back of the throat. To avoid reflux, tilt your bed frame so that the head is elevated four- to six- inches higher than the foot of the bed. You might find antacids helpful. You should also avoid eating within three hours of bedtime, and eliminate caffeine and alcohol. If these tips fail, see your doctor.

Tumors: Tumors of the throat, tongue, and larynx (voice box) are usually (but not always) associated with long-time use of tobacco and alcohol. Sore throat and difficulty swallowing—sometimes with pain radiating to the ear—may be symptoms of such a tumor. More often the sore throat is so mild or so chronic that it is hardly noticed. Other important symptoms include hoarseness, a lump in the neck, unexplained weight loss, and/or spitting up blood in the saliva or phlegm.

When should I take antibiotics?
Antibiotics are drugs that kill or impair bacteria. Penicillin or erythromycin (well-known antibiotics) are prescribed when the physician suspects streptococcal or another bacterial infection that responds to them.

However, a number of bacterial throat infections require other antibiotics instead. Antibiotics do not cure viral infections, but viruses do lower the patient’s resistance to bacterial infections. When such a combined infection occurs, antibiotics may be recommended.

When an antibiotic is prescribed, it should be taken as the physician directs for the full course (usually 10 days). Otherwise the infection will probably be suppressed rather than eliminated, and it can return.

Some children will experience recurrent infection despite antibiotic treatment. When some of these are strep infections or are severe, your child may require a tonsillectomy.

Should other family members be treated or cultured?
When a strep test is positive, many experts recommend treatment or culturing of other family members. Practice good sanitary habits; avoid close physical contact; and sharing of napkins, towels, and utensils with the infected person. Handwashing makes good sense.

What if my throat culture is negative?
A strep culture tests only for the presence of streptococcal infections. Many other infections, both bacterial and viral, will yield negative cultures and sometimes so does a streptococcal infection. Therefore, when your culture is negative, your physician will base his/her decision for treatment on the severity of your symptoms and the appearance of your throat on examination.

How Can I Treat My Sore Throat?
A mild sore throat associated with cold or flu symptoms can be made more comfortable with the following remedies:

— Increase your liquid intake. Warm tea with honey is a favorite home remedy.
— Use a steamer or humidifier in your bedroom.
— Gargle with warm salt water several times daily: 1/4 tsp. salt to 1/2 cup water.
— Take mild pain relievers such as acetaminophen (Tylenol Sore Throat®, Tempra®) or ibuprofen (Advil®).

When Should I See a Doctor?
Whenever a sore throat is severe, persists longer than the usual five- to seven- day duration of a cold or flu, and is not associated with an avoidable allergy or irritation, you should seek medical attention. The following signs and symptoms should alert you to see your physician:

— Severe and prolonged sore throat
— Difficulty breathing
— Difficulty swallowing
— Difficulty opening the mouth
— Joint pain
— Earache
— Rash
— Fever (over 101˚)
— Blood in saliva or phlegm
— Frequently recurring sore throat
— Lump in neck
— Hoarseness lasting over two weeks


Trouble Swallowing
Insight into dysphagia — swallowing problems

 
Swallowing Disorders
Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are not threatening and temporary. Difficulties in swallowing rarely represent a more serious disease, such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself, in a short period of time, you should see an otolaryngologist–head and neck surgeon.

How you swallow
People normally swallow hundreds of times a day to eat solids, drink liquids, and swallow the normal saliva and mucus that the body produces. The process of swallowing has four stages:

— The first is oral preparation, where food or liquid is manipulated and chewed in preparation for swallowing.

— During the oral stage, the tongue propels the food or liquid to the back of the mouth, starting the swallowing response.

—The pharyngeal stage begins as food or liquid is quickly passed through the pharynx (the canal that connects the mouth with the esophagus) into the esophagus or swallowing tube.

— In the final, esophageal stage, the food or liquid passes through the esophagus into the stomach.

Although the first and second stages have some voluntary control, stages three and four occur by themselves, without conscious input.

What causes swallowing disorders?

Any interruption in the swallowing process can cause difficulties. It may be due to simple causes such as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastroesophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes may include: stroke; progressive neurologic disorder; the presence of a tracheostomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.

Symptoms of swallowing disorders may include:
— drooling,
— a feeling that food or liquid is sticking in the throat,
— discomfort in the throat or chest (when gastroesophageal reflux is present),
— a sensation of a foreign body or “lump” in the throat,
— weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing, and
— coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs.

Who evaluates and treats swallowing disorders?
When dysphagia is persistent and the cause is not apparent, the otolaryngologist–head and neck surgeon will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors or a small tube (flexible laryngoscope), which provides vision of the back of the tongue, throat, and larynx (voice box). If necessary, an examination of the esophagus, stomach, and upper small intestine (duodenum) may be carried out by the otolaryngologist or a gastroenterologist. These specialists may recommend X-rays of the swallowing mechanism, called a barium swallow or upper G-I, which is done by a radiologist.

If special problems exist, a speech pathologist may consult with the radiologist regarding a modified barium swallow or videofluroscopy. These help to identify all four stages of the swallowing process. Using different consistencies of food and liquid, and having the patient swallow in various positions, a speech pathologist will test the ability to swallow. An exam by a neurologist may be necessary if the swallowing disorder stems from the nervous system, perhaps due to stroke or other neurologic disorders.

Possible Treatments
Many of these disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.

Gastroesophageal reflux can often be treated by changing eating and living habits — for example:

— Eat a bland diet with smaller, more frequent meals,

— Eliminate alcohol and caffeine,

— Reduce weight and stress,

— Avoid food within three hours of bedtime, and

— Elevate the head of the bed at night.

If these don’t help, antacids between meals and at bedtime may provide relief.

Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or restimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully.

Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.

Surgery is used to treat certain problems. If a narrowing or stricture exists, the area may need to be stretched or dilated. If a muscle is too tight, it may need to be dilated or even released surgically. This procedure is called a myotomy and is performed by an otolaryngologist–head and neck surgeon.

Many causes contribute to swallowing disorders. If you have a persistent problem swallowing, see an otolaryngologist–head and neck surgeon.

Once the cause is determined, swallowing disorders may be treated with:

— Medication
— Swallowing therapy
— Surgery


Hoarseness
Insight into causes, prevention, and when to see an ENT

 How Are Vocal Disorders Treated?
The treatment of hoarseness depends on the cause. Most hoarseness can be treated by simply resting the voice or modifying how it is used. The otolaryngologist may make some recommendations about voice use behavior, refer the patient to other voice team members, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Avoidance of smoking or exposure to secondhand smoke (passive smoking) is recommended to all patients. Drinking fluids and possibly using medications to thin the mucus are also helpful.

Specialists in speech/language pathology (voice therapists) are trained to assist patients in behavior modification that may help eliminate some voice disorders. Patients who have developed bad habits, such as smoking or overuse of their voice by yelling and screaming, benefit most from this conservative approach. The speech/language pathologist may teach patients to alter their method of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules. When a patients’ problem is specifically related to singing, a singing teacher may help improve the patients’ singing techniques.

What can I do to prevent and treat mild hoarseness?
If you smoke, quit.
— Avoid agents which dehydrate the body, such as alcohol and caffeine.
— Avoid secondhand smoke.
—Drink plenty of water.
— Humidify your home.
— Watch your diet: Avoid spicy foods.
— Try not to use your voice too long or too loudly.
— Use a microphone in situations where you need to protect your voice.
— Seek professional voice training.
— Avoid speaking or singing when your voice is injured or hoarse. Don’t sing when you are sick.

Who Can Treat My Hoarseness?
Hoarseness due to a cold or flu may be evaluated by family physicians, pediatricians, and internists (who have learned how to examine the larynx). When hoarseness lasts longer than two weeks or has no obvious cause it should be evaluated by an otolaryngologist–head and neck surgeon (ear, nose and throat doctor). Problems with the voice are best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologist–head and neck surgeons, speech/language pathologists, and teachers of singing, acting, or public speaking. Voice disorders have many different characteristics that may give professionals a clue to the cause.

How Is Hoarseness Evaluated?
An otolaryngologist will obtain a thorough history of the hoarseness and your general health. Your doctor will usually look at the vocal cords with either a mirror placed in the back of your throat, or a very small, lighted flexible tube (fiberoptic scope) may be passed through your nose in order to view your vocal cords. Videotaping the examination or using stroboscopy (slow motion assessment) may also help with the analysis.

These procedures are not uncomfortable and are well tolerated by most patients. In some cases, special tests (known as acoustic analysis) designed to evaluate the voice, may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in establishing a diagnosis and guiding treatment.

When Should I See an Otolaryngologist (ENT doctor)?
— hoarseness lasting longer than two weeks, especially if you smoke
— pain not from a cold or flu
— coughing up blood
— difficulty swallowing
— lump in the neck
— loss or severe change in voice lasting longer than a few days


Gastroesophageal Reflux Disease and Laryngopharyngeal Reflux

What is GERD?
Gastroesophageal reflux, often referred to as GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from “refluxing” or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid to move up the esophagus. When stomach acid touches the sensitive tissue lining the esophagus and throat, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn.

In some cases, reflux can be SILENT, with no symptoms until a problem arises. Almost all individuals have experienced reflux (GER), but the disease (GERD) occurs when reflux happens on a frequent basis often over a long period of time.

What is LPR?
During gastroesophageal reflux, the acidic stomach contents may reflux all the way up the esophagus, beyond the upper esophageal sphincter (a ring of muscle at the top of the esophagus), and into the back of the throat and possibly the back of the nasal airway. This is known as laryngopharyngeal reflux (LPR), which can affect anyone. Adults with LPR often complain that the back of their throat has a bitter taste, a sensation of burning, or

something “stuck.” Some may have difficulty breathing if the voice box is affected. In infants and children, LPR may cause breathing problems such as: cough, hoarseness, stridor (noisy breathing), croup, asthma, sleep disordered breathing, feeding difficulty (spitting up), turning blue (cyanosis), aspiration, pauses in breathing (apnea), apparent life threatening event (ALTE), and even a severe deficiency in growth. Proper treatment of LPR, especially in children, is critical.

What are the symptoms of GERD and LPR?
The symptoms of GERD may include persistent heartburn, acid regurgitation, nausea, hoarseness in the morning, or trouble swallowing. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be severe enough to mimic the pain of a heart attack. GERD can also cause a dry cough and bad breath. Some people with LPR may feel as if they havefood stuck in their throat, a bitter taste in the mouth on waking, or difficulty breathing, although uncommon.

If you experience any of the following symptoms on a regular basis (twice a week or more) then you may have GERD or LPR. For proper diagnosis and treatment, you should be evaluated by your primary care doctor for GERD or an otolaryngologist— head and neck surgeon (ENT doctor).

Who gets GERD or LPR?
Women, men, infants, and children can all have GERD. This disorder may result from physical causes or lifestyle factors. Physical causes can include a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors include diet (chocolate, citrus, fatty foods, spices), destructive habits (overeating, alcohol and tobacco abuse) and even pregnancy. Young children experience GERD and LPR due to the developmental immaturity of both the upper and lower esophageal sphincters.

Unfortunately, GERD and LPR are often overlooked in infants and children leading to repeated vomiting, coughing in GER and airway and respiratory problems in LPR such as sore throat and ear infections. Most infants grow out of GERD or LPR by the end of their first year; however, the problems that resulted from the GERD or LPR may persist.

What role does an ear, nose, and throat specialist have in treating GERD and LPR?
A gastroenterologist, a specialist in treating gastrointestinal orders, will often provide initial treatment for GERD. But there are ear, nose, and throat problems that are either caused by or associated with GERD, such as hoarseness, laryngeal (singers) nodules, croup, airway stenosis (narrowing), swallowing difficulties, throat pain, and sinus infections. These problems require an otolaryngologist—head and neck surgeon, or a specialist who has extensive experience with the tools that diagnose GERD and LPR. They treat many of the complications of GERD, including: sinus and ear infections, throat and laryngeal inflammation and lesions, as well as a change in the esophageal lining called Barrett’s esophagus, which is a serious complication that can lead to cancer.

Your primary care physician or pediatrician will often refer a case of LPR to an otolaryngologist—head and neck surgeon for evaluation, diagnosis, and treatment.

Diagnosing and Treating GERD and LPR
In adults, GERD can be diagnosed or evaluated by a physical examination and the patient’s response to a trial of treatment with medication. Other tests that may be needed include an endoscopic examination (a long tube with a camera inserted into the nose, throat, windpipe, or esophagus), biopsy, x-ray, examination of the throat and larynx, 24 hour pH probe, acid reflux testing, esophageal motility testing (manometry), emptying studies of the stomach, and esophageal acid perfusion (Bernstein test). Endoscopic examination, biopsy, and x-ray may be performed as an outpatient or in a hospital setting. Endoscopic examinations can often be performed in your ENT’s office, or may require some form of sedation and occasionally anesthesia.

Symptoms of GERD or LPR in children should be discussed with your pediatrician for a possible referral to a specialist.

Most people with GERD respond favorably to a combination of lifestyle changes and medication. On occasion, surgery is recommended. Medications that could be prescribed include antacids, histamine antagonists, proton pump inhibitors, pro-motility drugs, and foam barrier medications. Some of these products are now available over-the-counter and do not require a prescription.

Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention. Such treatment includes fundoplication, a procedure where a part of the stomach is wrapped around the lower esophagus to tighten the LES, and endoscopy, where hand stitches or a laser is used to make the LES tighter.

Adult lifestyle changes to prevent GERD and LPR

—Avoid eating and drinking within two to three hours prior to bedtime

— Do not drink alcohol

— Eat small meals and slowly

— Limit problem foods
       *Caffeine
       *Carbonated drinks
       *Chocolate Peppermit
       *Tomato and citrus foods
       *Fatty and fried foods
       *Lose weight
       *Quit smoking
       *Wear loose clothing