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Programme 4 - Sore Throats
RADIO 4
THURSDAY 16/12/05 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
CHRIS MILFORD
PRODUCER:
ANNA BUCKLEY
NOT CHECKED AS BROADCAST
MYERS
Hello. Today sore throats. If you woke up with one this morning and you were out last night smoking and drinking and talking too loud then you'll know what to do next time. Indigestion - acid reflux - could be another reason for a sore throat or if you also have a runny nose or are coughing and spluttering then of course it's part and parcel of your cold. Anything else and you might want to take some medical advice. Why do some people keep getting really bad sore throats and why do antibiotics work sometimes and not others? Is it just a sore throat or is it tonsillitis and what's the difference anyway? And if you do get tonsillitis should you have your tonsils removed?
Well call us now with your questions for Chris Milford, he's an ear, nose and throat surgeon and he's secretary of ENT UK. 08700 100 444 is the phone number, you can of course e-mail checkup@bbc.co.uk.
Marian is on the phone, she's in Harlow, she's had her tonsils taken out a good time ago so what's the problem Marian, hasn't that sorted things for you?
MARIAN
No, I've got a swelling on the side of my throat that's taking up half the airway. Do they grow back?
MYERS
Well Chris that would be a shame if they did because it's not a very nice operation, I don't know if you remember it Marian, if you were a youngster at the time.
MARIAN
Yes I was 27.
MYERS
Oh okay you will remember it in that case. Do they grow back Chris?
MILFORD
Hello Marian. I think the first thing I'd say is you're very unlucky because they can regrow but it's very unusual.
MARIAN
I've only got one.
MILFORD
Yes. In the past tonsils were taken out using what's called a guillotine and there was probably a greater risk of leaving small bits of the tonsil behind and sometimes if you continue to get sore throats then that little bit of tonsil continues to get tonsillitis and can regrow.
MYERS
What do you have to do in that case, do you have to have that removed?
MILFORD
Well it depends how much of a problem it is. If it's enough of a problem for you to consider having something further done, then yes occasionally we do take out tonsillar remnants, regrowth of small bits of the tonsil. But it is very unusual.
MYERS
Would that be Marian's call or would she take advice on what to do?
MILFORD
I think it would be reasonable to at least chat it through with your doctor and he may feel it's appropriate to send you to your local ENT department and then there will be a discussion and there will be a large element of personal choice, I mean there'll be - so long as people are happy that this is nothing serious then they would end up saying look if this is a major problem for you, you could undergo removal of that little bit of tonsil that's been left behind.
MYERS
Okay Marian thanks for that, I hope that's helpful advice, bad luck that it's grown again but there we are. We'll go to Chris now, he's sent an e-mail and he's speaking about his son who's had recurrent tonsillitis from an early age. And apparently the family's been asking all this time for the tonsils to be removed and they've been fobbed off and the son is now 20, he's at university, been ill with tonsillitis for the last three months. Chris, should he have gone with the idea of a removal at an earlier age, I mean it hasn't gone away has it in this case?
MILFORD
No, I think he's been unlucky again because there are a reasonable number of children who do develop tonsillitis over a year or perhaps slightly longer and then it will resolve, so things do settle down spontaneously. But for the group of children or adults where it doesn't settle on its own then tonsillectomy is to a degree something that should be discussed with your own doctor and possibly the ENT surgeon and there's an element of how much of a problem is it. Now clearly in Chris's case it's continued to be a major problem and it would sound as though he has a very reasonable case for having his tonsils out. When he was younger if it was very young then the doctors may have taken a view that he was too small to have his tonsils out because when we're small we have a much smaller blood volume and there are risks associated with tonsillectomy and the - one of those risks is bleeding in the two weeks following the surgery. If you have a very small blood volume then the risk involved with that bleeding, if it were to occur, which doesn't occur very often, but if it were to occur the results are potentially more serious.
MYERS
Does it take longer to recover from a tonsillectomy as an adult than perhaps as a child of a suitable age and stage of course?
MILFORD
I'm not sure if we know. What I would say is that children tend to bounce, so they - you'll often see children in the children's ward after they've had their tonsils out and they're racing around and playing and they seem to really shrug things off pretty well, that would be very unusual in an adult and I'd normally say to them look this is the worst sore throat you're ever going to have. So there's an element of yes adults do find that post-operative two weeks tough. Children - some children dip and are unwell but a lot of them seem to just coast through and get through more easily.
MYERS
We've got another Chris on the line from Oxford, worried about having his tonsils out, I don't know whether that's because of the kind of experience during the recovery period that our expert here, Chris, has just been mentioning. Chris, what's your particular concern?
CHRIS
Well I had a problem with a quinsy about six months ago and my GP's recommended to me maybe I should have my tonsils out. What really concerns me is the use of reusable instruments or otherwise when taking the tonsils out. I believe there has been some question over CJD in the tonsils and one of the things I'm just worried about is how safe is it having a tonsillectomy with reusable instruments?
MILFORD
Chris, I mean it's a very good question and it's one that's taxed an awful lot of people. As far as we're aware there's no incidence of transmission of the CJD prion during tonsillectomy. So we have no evidence but there is a theoretical risk and in fact in 2001 the Department of Health took advice from a committee and they'd introduced single use instruments. The problem was that following the use of those single use instruments, which probably weren't of the same quality as reusable instruments, we started to see a suggestion that there was an increased incidence of post-operative complications and in particular bleeding. And we reached a point where actually as a group ENT surgeons went back to the Department of Health and suggested or at least raised this problem and we went back to reusable instruments. There have been good audits to look at that recently and you can say that 95% of patients having tonsils out will have a completely uneventful recovery. But the issue of CJD is still unanswered at the moment but as far as we're aware that risk is minimal. The Department of Health introduced more stringent decontamination measures to try and make sure that the reusable instruments were better sterilised. But this is a - if you said actually the worry is too great for me you do not have to have your tonsils out, it is not an absolute indication.
MYERS
It's your call Chris. Thank you very much for that, it's an interesting question. Have you yourself, Chris, as a surgeon, used these disposable instruments and do they not seem to have quite the cutting edge?
MILFORD
Yeah they were introduced and we - there was no choice in the matter, we had to use reusable instruments but I think they will - they've already started to improve those but the bottom line was they were not as good and they were not as user friendly.
MYERS
Okay, thank you very much. We've got a lot of calls, let's go to Patrick who's on the line, has had his tonsils out but not happy - Patrick, what's the problem?
PATRICK
Hi. I basically had my tonsils out about four years ago and since then I've had a recurring sore throat, probably once or twice every month, in fact it's not as regular as that, sometimes I have a break but most times I wake up in the morning and I have a pain in a specific spot. And I've been to see a specialist since then - an ENT specialist - and he said that it's basically to do with a very highly allergic nose, he thought, he said I'm producing a lot - far too much mucus now and it's dripping down and sticking to the side of my throat and it's causing infection. So I don't even know when I had my tonsils taken out it was every necessary.
MYERS
Okay let's see if Chris has got a comment on that, that's an interesting conundrum there, so still the sore throats but maybe now an allergy comes into question.
MILFORD
Patrick, that's a difficult question to answer, the first thing you would say to someone about tonsillectomy is have we got the right indication, does someone have their tonsils out usually because of recurrent acute tonsillitis, so if that was the cause then if you had your tonsils removed then you certainly shouldn't get tonsillitis again. The question of why you're having your ongoing problem, all I would say to people is look even if we remove your tonsils you will still get a sore throat from time to time, you may not get tonsillitis but you can get inflammation of that area of your throat, that's called your pharynx, so you can get pharyngitis. Your particular problem, I have to say, I think might be a very difficult one to make a specific diagnosis and clearly it's difficult to say but sometimes you end up saying I don't have an answer, I don't know if conventional medicine will provide a solution to that particular problem.
MYERS
And we've had another e-mail from David who's interested in sore throats, can it be caused by a throat or a nasal allergy, he regularly gets sore throats. He seems to link it in with when he's been travelling on congested roads. His actual question is can he control it in some way or relieve the discomfort?
MILFORD
Under those circumstances it's very much trying to provide a symptomatic relief because it would be very difficult to know if it's allergy, if it's chemical irritants - pollution, all of these things. But using either an anti-inflammatory tablet, gargle, topical anti-inflammatories, chemists, pharmacists, would certainly provide some information about what they felt would be helpful. But apart from that it can be very difficult.
MYERS
Okay, well thanks for the call Patrick and for the e-mail David. We'll move to another caller, Martin in West Wycombe I think has got a remedy that suits him, Martin what's your remedy?
MARTIN
Well for many years the family has had or used to use glycerin and thymol, it was a perfectly standard BP item, it was about 50p a half litre, you dilute it at I think three or four to one with warm water and gargled. And certainly in my experience if you've got a scapey throat or signs of a cold or anything like that a good gargle with glycerin and thymol would prevent it heading south. And about 8 or 10 years ago it seemed to disappear from the chemists and instead you got highly expensive proprietary ready diluted gargles. I just wonder what on earth was the matter with glycerin and thymol. Looking it up on the web I now find you can only apparently get it in India, seems a hell of a long way to go for a gargle.
MYERS
Chris, what do you think?
MILFORD
Yeah that's a very tough question. I have no idea why it disappeared and whether it's to do with the - there are some medicines that we use, certainly in ENT in the past that are no longer available simply because manufacturers don't find it a commercial proposition to make or sometimes some of the things have such a short shelf life that pharmacies say look this is no longer viable, everything has to be sterile, have a use by date. But I have no idea why those have disappeared, sounds like an excellent idea.
MYERS
What about other things, I've certainly myself used salt water gargle and that's fairly - you can get that out of the kitchen cupboard - does that actually help?
MILFORD
I don't know. I say to all of my patients if you can find something that helps I'd put my hands up and say often conventional medicine doesn't have a perfect solution, so great if you find something fantastic.
MYERS
Because sometimes just actually trying to relieve the symptoms is the only thing you can do and is the right thing to do, so would you recommend taking simple painkillers?
MILFORD
Yeah, I mean I think it's very much self-treatment or talking to the pharmacist and trying to find something that will tied you over, hopefully what will be a short-lived viral problem or whatever the cause of the sore throat is.
MYERS
And what might you have to put up with - three or four days, maybe up to a week after that, should you be going to the doctor?
MILFORD
I think probably a week to 10 days. The problem with post-viral things is that it's a bit like when people get viral illness like glandular fever, sometimes the recovery period for most of us would be a week or two. You come across the exceptions where people are still suffering effects several months later.
MYERS
We'll go to another call now, we've got Mrs Hollowell who's in Devon and it's not her problem but it's her daughter's problem, who's having sore throats at night, is that right?
HOLLOWELL
Well she wakes up in the morning with a sore throat quite often, twice a week sometimes and it just lasts for about half an hour and disappears again. But she's been - she's prone to ear infections and she's had a lump on the outside of her neck for about three years and it comes up when she doesn't feel well, which again she often says I don't feel very well and that'll last for an hour or so.
MYERS
Did you say how old she was?
HOLLOWELL
She's 13 now.
MYERS
Chris any comments on that?
MILFORD
Mrs Hollowell - what you would say is that for it to be short-lived, half an hour, an hour, it's very difficult to sit here and say look this is why your daughter's getting the problem. What would you say is that it's highly unlikely that's anything like conventional tonsillitis and anyone's going to start suggesting that they take her tonsils out. But in terms of the lump in the neck the commonest reason for that in children is that we have lymph glands in our neck which help to fight inflammatory problems and infection and it's quite likely that there is some inflammatory process going on if she gets the lump in her neck and that's something that if it persisted or got bigger and bigger then certainly you'd want to go and see your GP about. But I doubt if there's going to be a perfect solution to that particular problem, I hate to say.
HOLLOWELL
It's all linked I expect - ear infections and the feeling unwell and the sore throat.
MYERS
And just being 13 maybe.
HOLLOWELL
And with the glands, she's had it for about three years now.
MYERS
Isn't there something in a way a bit reassuring if you have had something for that length of time it hasn't got worse, maybe hasn't gone away, but hasn't developed into anything.
MILFORD
Absolutely correct. I mean it's maybe not what you sometimes want to hear but actually if it has been going on for that length of time and it's been recurring and relapsing then I think it's very unlikely there'll be a serious underlying cause. Clearly if that lump stayed and got bigger then that's something that your doctor would be concerned about and would probably arrange a referral to the local specialist.
MYERS
Thank you for that. We'll go to Wiltshire, Terhi's waiting to talk to us, Terhi your question?
TERHI
Yes I've had this sensation, I'm told, of a lump in my throat for about three months now and basically there's no pain but it just feels that there's something stuck in my throat, that I have to clear my throat every time I swallow. And I've seen my GP a couple of times, I've seen a specialist and I have had an operation where they looked in and found absolutely nothing but the lump hasn't gone away. And I'd like to know what it is and get rid of it.
MYERS
Did you say it's the feeling of a lump or there is a lump?
TERHI
Well I've had various people looking into my throat and they can't find a physical lump in there.
MYERS
Alright, let's ask the ENT surgeon. Is this something you've come across in your practice?
MILFORD
Hello Terhi. This sounds like a very, very common problem so the doctors who've seen you may have mentioned a strange condition called globus. All that really means is that you have a feeling of a lump in your throat and no one can find a specific reason, there's no obvious cause for that problem. So to some degree it's a diagnosis of exclusion, it's common and in the vast majority of people it is something that will improve. I appreciate you've had it for three months already but the vast majority of people that will resolve spontaneously. And the fact that they've looked and made sure that there's nothing else underlying that is reassuring. It's - as I said - extremely common and it is something that would be very difficult to say look take these pills and we can make it better. And I'm afraid for the moment there's probably very little that anyone else can do, they've excluded a serious cause.
MYERS
Okay Terhi, I hope that is reassuring to you. If I may I'll move to another call, in Somerset now Margaret Rees is on the line. Not her problem, her son's problem, in which case it is your problem isn't it Margaret.
REES
It is, it is.
MYERS
Tell us about it.
REES
My son has suffered from very, very sore throats since the age of about two years old. It's really been the bane of our lives. It's so bad the whole house as you walk in the door you can just smell the infection, it's dreadful. Back in the summer he was staying with friends and he was so poorly he was in hospital for five days on a drip because of his sore throat because when he gets a very, very bad sore throat he can't swallow his saliva, so in consequence he can't eat, he can't drink and he can't sleep. He was bounced out of hospital with really no answers for any of us and a fortnight later I was phoning up NHS Direct and taking him for emergency treatment. We find he's always really got a sore throat and then it flares up and it's really bad and then it eases off. He takes salt water ...
MYERS
Margaret, I think we've certainly got quite a picture there, it does sound very distressing. I'm wondering why and how and it can have gone on for so long without something fairly major being done. Anyway let's ask the expert. Chris, what would you do if Margaret's son came into your surgery, you would smell him coming quite frankly is the way she's putting it?
MILFORD
Certainly that smell is a feature of true acute tonsillitis so I don't know what the hospital said when your son was admitted but I mean certainly a bad bout of tonsillitis could lead to an admission to hospital. And certainly if it's been going on for a length of time then one of the issues would be well would he benefit from having his tonsils out.
MYERS
Has that been suggested so far?
REES
No I've suggested it, he's suggested it but the GPs sort of say no, no, we would resist doing that.
MYERS
Chris, would you resist if he came to you?
MILFORD
I think having your tonsils removed is a very - is something to discuss, it's something that you would have an input into and your GP and your ENT surgeon, if you ended up seeing an ENT surgeon. But usually there are very good guidelines that would say that if someone's been having five or more bouts of true tonsillitis for more than a year and it's causing significant disability, as it obviously is in your son's case, then he has a reasonable case for having his tonsils out.
MYERS
Margaret thank you for that, it sounds as though it's well worth pursuing, going to see an ENT person. We'll go to Laura who's in a sense got a little bit of the same problem to do with both a foul smell and a foul taste in her mouth but she knows where it's coming from, she had glandular fever. At the time this emerged as huge white golf balls in the back of her throat, is the way she describes it and ever since then little white lumps have been coming off her tonsils. Chris, what would you suggest, how can she get rid of them, that's her question?
MILFORD
It's a difficult problem but it sounds as though Laura's getting problems with what's called tonsillar debris. Our skin sheds itself and we have exactly the same or a very similar lining in our throat and sometimes if we have particularly deep pockets within the tonsils that the debris builds up and people will describe these horrible little white things that smell awful, taste awful. And to be honest the only solution is if you don't have your tonsils, so if you have a tonsillectomy that isn't again an absolute indication but it's a solution to the problem.
MYERS
So very quickly for people who as a result of hearing what you've said may be thinking yes tonsillectomy could be the answer, I mean a very quick - pros and cons really.
MILFORD
The pro is that if that were related to true tonsillar debris then a tonsillectomy would solve the problem. The cons are that having your tonsils out is a tough trip and certainly as an adult I would say to someone look you've got two weeks when life's going to be pretty miserable and pretty tough. After that the payoff is you don't get a problem with your tonsils again. The downside is the risk of bleeding in the two weeks following the surgery, which is of the order of about 2-3%.
MYERS
Okay, we've got another quick question. Mrs Fuller in London who's got some concerns about her throat. What's the worry?
FULLER
It's not a personal worry, it was a comment, I think it's important to be aware that a persistent sore throat, particularly men over 50, can be indicative of something more serious. And it should be investigated by your GP.
MYERS
Well that's a very good cautionary note to sound. Chris would you like to pick up and comment on that?
MILFORD
You're absolutely correct. Although throat cancer is rare and there are only about seven to seven and a half thousand new cases per year in the UK, if someone has a persistent sore throat, especially if they happen to be a smoker, then it is certainly significant and someone should be looking at that if it persists or becomes worse over a period of several weeks.
MYERS
And is there a simple test that you can carry out as a surgeon to exclude it if you can?
MILFORD
We could certainly have a very good idea of excluding it by using a small telescope on an outpatient visit under local anaesthetic. So it's a very straightforward way of us visualising the throat.
MYERS
Okay, well thank you very much indeed. We will have to leave that there. There are more links as ever to more information and you can follow the trails through bbc.co.uk/radio4 to Check Up where you can listen to this programme again and you can indeed listen to all the programmes in past series. The 大象传媒 action line is another point of contact and the number there is 0800 044 044. But for today thank you very much indeed to my expert ENT surgeon Chris Milford and thank you all too those who called and got through and of course to the many more who called and e-mailed both today and in the series who didn't get through, we appreciate your contact. We're now taking a break, we'll be back though in February and until then may I wish you the very best of health.
ends
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