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What is Sore in a Sore Throat?

By Dr. Arthur Lavin

Have you ever met someone who has never had a sore throat?  I haven’t and I suspect no one has, because having a sore throat is one of those universal human experiences, painful, unfortunate, but very universal.

I recently had a very, very sore throat, and so had a chance once again to ponder, what is this about, what is a sore throat, what causes this misery, and what physically is going on?

Many human painful experiences are far from mysterious.  If we cut our skin or break our bones, or drop a rock on our foot, there is on question why we hurt.  The cut cuts nerves in our skin, the fracture tears the membrane of our bone which is loaded with pain-sensing nerves, and a bruise bothers nerves in the skin and muscle.

But what about the throat?   How is it that for really most of our life we swallow with no pain, no real awareness our throat is even there, and then one day, out of the blue, suddenly, our throat is killing us, each swallow is a horrible, painful agony, then a few days later, back to normal, we swallow with barely a care in the world?

What Hurts When our Throat Hurts

It turns out there are only a couple of ways your throat can turn into a raging place of pain.

The first is direct harm to the tissue of the throat.  That could come from a burn, some other sort of direct damage, or infection.   Burns to the throat come in a variety of ways- hot liquids or foods can cause thermal burns, swallowing a caustic or acidic substance can cause a chemical burn.   Viral infections tend not to cause this sort of mechanism of pain, but bacterial infections can and do.  Strep throat is a situation where you can see the physical damage, the surface of the throat can be red and coated with pus.

In each of these instances, there is no mystery about why your throat hurts, the lining has been damaged by heat, chemicals, or bacteria.  Direct damage, like a cut on the skin, a broken bone, a rock dropped on a foot, causes pain.

But that’s not what causes at least 70% of sore throats.  If you get a sore throat from being sick, the sort of sore throat we are talking about, you have about a 70% chance that the sore throat is from a viral, not bacterial infection, and often viruses do not cause direct visible damage to the throat.

I noticed this many years ago when I had a cold and a really, really painful sore throat.  I looked in the mirror and had the same experience I suppose many of you have when your child sees me with their sore throat, disappointment.  Here I was in terrible pain and when I looked at my throat it looked completely normal.  What a disappointment!  With all that pain, the least that my body could do is look dramatically awful, give me some explanation for the pain, maybe even generate a little sympathy.

Further, when I really examined my throat, I found that even though it hurt like blazed to swallow, when I touched various parts of the throat, almost all of them felt fine, not painful at all.

How could such a normal looking structure, which when touched evinced no experience of any pain or discomfort cause such blazing pain on swallowing?

The answer came in two words: lymph nodes.   I found the areas that generated all the pain, were small, hard to see, little areas of swelling, like little bumps, on the back of the throat.  I have since seen them commonly in children with viral sore throats.

What are the Sore Lumps on a Viral Sore Throat?

What is going on, why are there small lumps, what are they, why do they hurt?

The answer lies in an especially fascinating system in the body, the immune system.  As we all know, the immune system is tasked with a simple but daunting challenge:  finding dangerous germs and cells and destroying them before they destroy us.  To that end, every tissue of the body is scanned by our immune system cells, and if danger is found, the system revs up production of all sorts of molecules, including antibodies, and all sorts of cells, to destroy the threat.

To monitor the body, the body has an independent circulation of fluid called lymph that flows into over 600 stations called lymph nodes. The fluid lymph is created as the blood flows from artery through the capillary network and drains back into veins.  As the fluid of the blood seeps through the capillaries in every tissue, but our cornea and cartilage, some of that fluid is left behind when it drains back into the veins.  That bit of fluid drains separately into fluid vessels called the lymphatics.  All the lymphatic fluid eventually drains into the great veins draining blood back to the heart.  But along the way, the lymph fluid flows through complex way stations of the immune system which sample the fluid and see if any germs or bad cells are present, in any part of the body.

If a lymph node detects a problem, it activates and makes those immune system chemicals such as antibodies, and cells, such as T& B cells, that destroy the germ or bad cell.  But if a lymph node activates and makes antibodies and white cells, it expands, it grows, it enlarges.  It has too, just like a factory that makes 100 cases of tennis balls must get bigger if it starts making 1 million cases.

The lumps in the back of  virally infected throat are little patches of lymph node like material that pepper the lining of the throat and gut.  When a virus infects the nose and throat, these patches of lymph tissue enlarge to meet the threat, to literally cure us of this cold.  And when they enlarge, they are sore, sometimes very painfully sore.

If you leave these little lumps alone, you may be fine, but swallowing squeezes them, and that hurts, or to put it another way, that’s a sore throat.

(by the way, enlarging lymph nodes can happen wherever the immune system gets wind of a viral infection, most commonly in the neck, the famous “swollen glands” which hurt for the same reason).

Viral v. Strep Sore Throat

​An interesting fact about sore throats, is that one cannot tell the difference between a viral and strep throat by looking, one must do the swab and see if strep is there to know.  This test has been done with the world’s top infectious disease experts, even they fail to get it right just by looking.  How is this possible?

It goes to the nature of a sore throat.  If the strep germ only causes the lymph tissue to enlarge, then the throat will look like a viral infection, pretty normal looking.  And, if a virus, which can happen, causes direct physical harm to the throat lining making it red and dripping with pus, it will look like a bacterial (strep) infection, pretty raw looking.

The point is that both strep and virus can do both of what each do.

But remember, if you examine 100 people with sore throats, about 70 will have a viral infection, and about 30 strep throat.  And, these are by far the very most common causes of sore throat by infection.  Which is to say, strep is by far and away the most common bacteria that causes throat infections, so if you don’t have strep, you have a virus.  And, of all sore throats, nearly 3/4 of them are caused by viruses.

What to Do?

Here we come to a problem we all face.  Everyone experiences a sore throat.  What to do when your children do?

First and foremost, comfort them.  Find foods and drinks that they find comforting, that does more than anything to help.

Sometimes ibuprofen can be helpful when food and drink don’t help enough.

Some patterns do suggest strep- such as significant fever and lack of cough and mainly a sore throat, but if your child’s sore throat really hurts and lasts more than a day or two, it’s a good idea to get swabbed and see if it’s strep or not.  If it’s strep, we can treat with antibiotic and get rid of it.

If not strep, and again, a pretty big majority of sore throats are not strep, there is no cure, only comfort, but time is on our side, the misery of a sore throat always ends.

BOTTOM LINES

  1.  All of humanity suffers from a sore throat from time to time.
  2.  Throats can hurt from direct injury, from burns, cuts, many bacterial and even some viral infections.
  3.  But a sizable majority of sore throats come from viral activation of little patches of lymph tissue in the throat, that when enlarged are very sore when squeezed, causing pain on swallowing, what we call a sore throat.
  4.  For viral sore throats there is no cure, but ice cream, popsicles, tea, soup, or other liquids or foods can give much comfort.
  5.  Most colds start in the nose, travel to the throat, end in the lung, causing the familiar sequence of first runny nose, then sore throat, then cough.  This sequence makes strep less likely and virus more likely, but only a throat swab can tell the difference reliably.

We hope during this cold and flu season, everyone stays well, but if you or your child get sick, we hope you recover rapidly with a minimum of discomfort.

To your health,
Dr. Arthur Lavin​

 

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