The title of this column refers to one of the most common problems singers experience. Sore throats are, for the most part, just that: a feeling of scratchy discomfort, accompanied by a transient difficulty in swallowing. They almost inevitably progress to a cough, perhaps chest congestion, and, in a few days, resolution. Almost always.
On occasion, however, a sore throat can persist, turning into chronic pharyngitis. It may begin with the usual signs of infection, or mysteriously appear on its own—but it doesn’t resolve. Instead, it persists, often for weeks, even months. Waiting, antibiotics, and gargling don’t work.
What can it mean, and what to do?
When a patient presents with prolonged throat discomfort, I always inquire about how it developed. Is it constant or recurring, unchanging or worse at certain times of the day or night? Is the pain localized or generalized? Is it associated with certain activities? These questions, and others, are in some ways more revealing than examining the throat, since it often appears surprisingly benign.
Several rather common conditions may cause persistent throat discomfort, and should be considered. One is a low-grade yeast infection of the pharynx. This is commonly seen in patients who have been taking several courses of antibiotics. Another cause is the ongoing use of steroid inhalers for asthma. Some patients are just generally more prone to yeast infections, a problem that can be discovered in their medical histories.
I said low-grade yeast infection, because the classic florid yeast infection (thrush) is an easy diagnosis: white patches on the back of the throat, palate, and base of the tongue. Low-grade yeast infections, however, can cause no more than a nondescript, diffuse redness, with sticky mucus and a need to clear the throat and swallow frequently.
Discomfort or even pain on swallowing are marks of a slightly more advanced yeast infection. Importantly, with chronic yeast infections cortisone or additional antibiotics don’t help, and may even worsen the condition.
What about the tonsils? Interestingly, chronic tonsillitis does not usually cause unremitting throat pain. Rather, the pattern is one of frequently recurring sore throats, separated by periods of relative comfort. Chronically infected tonsils flare up repeatedly, usually when the immune system is weakened by stress, either physical or psychological. Once the immune system regains the upper hand, the throat stops hurting—until next time.
In cases of chronic tonsillitis, gargling with warm salt water or a water-peroxide mix can help a bit, but avoid commercial mouthwashes. They reduce the bacterial population in the throat transiently, but they can also damage the mucous membranes, leaving the throat surfaces more vulnerable when the microbe count climbs again, usually within a couple of hours. (Yes, those little rascals reproduce very quickly!)
Acid reflux irritating the pharynx may also present as chronic pharyngitis. Patients with laryngopharyngeal reflux (LPR) may not have the usual esophageal symptoms of burning pain behind the breastbone. Apparently, the stomach and the esophagus are more protected against acid irritation than the pharynx and the larynx.
Once again, findings on physical examination may be surprisingly nondescript. Not every patient with throat pain and hoarseness has acid reflux, but some do, and a rapid response to appropriate medications usually clinches the diagnosis.
Vocal strain is another potential culprit. Most singers with vocal strain usually link the pain to singing, and the condition disappears with rest, then recurs with singing. This is obviously a technical problem that needs to be remedied by the singer and his or her teacher or voice therapist.
Some singers are in a chronic state of strain, however. The larynx is abnormally elevated, the hypopharynx above the vocal folds tight and constricted, the neck tender to the touch. Day jobs such as serving in a noisy restaurant certainly don’t help! Working in noise, even without talking, causes increased throat tension—the larynx unconsciously positions itself, as if preparing to speak over the noise (prephonatory posturing). Add to this the stress of such a job, the need for constant loud talking, and perhaps an already tense personality, and the throat discomfort can become chronic, and not just associated with episodes of singing.
So, what to do? If you have a chronic sore throat, one that has not responded to patient waiting, or even a course of antibiotics, don’t accept it as “normal.” This article lists only some of the many conditions that may be responsible. Most cases of chronic sore throat can be resolved, or at least remedied, with correct diagnosis and proper treatment.
