Other Causes of a Sore Throat

First, you can try to rule out things like strep and other viral illnesses (be aware that a sore throat often comes on a day or two before a cold or other viral illnesses hit, like a cold, flu, or COVID).

Take a good look at your throat. Besides colds, viruses, and strep, there are lots of other causes of a sore throat. The following contains helpful descriptions and photos of some of these.

Besides strep, there can be many other causes of a

sore throat

SORES AS THE CAUSE OF A SORE THROAT

These are canker sores (aphthous ulcers). They can appear anywhere in your mouth and can become extremely painful. Sometimes, when they are near the tonsil so people think it is a tonsil problem or strep.

Oral ulcers (Sores)-Ouch!

It is not unusual for a patient to come to the clinic with a severe sore throat (usually more on one side), thinking they have a strep exudate (white patches) on or near their tonsils. On closer examination, it is not a white film-type patch that can characterize a strep, but the spot is a raw sore or ulcer in the back of the throat. These sores are whitish in the middle with a red discrete edge and are typically circular or oval.

HERPES SIMPLEX 1, a virus, can sometimes cause sores in your mouth. HSV1 is extremely common - most people carry the virus, and some never get oral ulcers. They are USUALLY not the same strain as genital herpes (HSV 2), so don't jump the gun and tell your partner you got herpes from that person! These can also be caused by a compromised immune system, trauma or stress. Viruses love to break out when a person's immune system is weakened. These can be contagious and spread to the genital area during oral sex. A person can be treated with an antiviral medicine, which will never cure herpes but can help treat and/or prevent the ulcers.

​CANKER SORES (aphthous ulcers) also form in the mouth. They are not a virus and are not contagious. There are MANY potential causes:

•  Excess stress, fatigue, or underlying illness (I see this often in patients who come in with these ulcers).

•  Both nutritional/vitamin deficiencies (especially deficiencies in vitamin B12, folic acid, C, and D) and/or mineral deficiencies—especially iron, zinc, and lysine—can cause oral ulcers.

• Food allergies or hypersensitivities can also cause these ulcers. Fruits – especially acidic foods like citrus fruits, pineapple, and tomatoes are common perpetrators. Some of our favorites, like coffee and chocolate, can also cause them. Some people even have hypersensitivities to toothpaste components (sodium lauryl sulfate, "SLS") or other chemical substances that come into contact with their mouths.

• ​Dental problems and poor oral hygiene can cause them.

• Bacterial overgrowth inside the mouth or throat can cause oral ulcers.

• Sometimes, hormonal changes cause these sores, especially during the premenstrual phase.

• Medications are another culprit, especially antibiotics.

• We even see these run in families. Susceptibility can sometimes be genetic. 

I always consider these sores a kind of "barometer": Some people get them as a warning that they are getting sick or that something is amiss with their underlying health and wellness. Commonly, stress which causes a weakened immune system, causes an outbreak.

These sores tend to be very uncomfortable, and the pain may extend to other parts of the respiratory tract, such as the mouth, throat and, sometimes, even the ear. The sore(s) and pain can take up to 10 days to go away. Canker sores are not contagious.

If you get these often, consider the possible reasons behind them (above) and see if changing your diet, lifestyle, or supplementing with vitamins (etc.) helps. If you think the sores may be due to the herpes virus, you can easily get a blood test to check. Schedule one online with a local lab: Quest or LabCorp if you have one around.

Note: If the sore in your throat does not heal within about three weeks, you may want to get it checked by a healthcare provider

Short-term over-the-counter treatment and supportive care of oral ulcers

• Cepacol (benzocaine) lozenges may help numb sores. This is sold over the counter.

• Zinc Lozenges - soothing and may speed healing

• While dairy could remotely be the culprit, yogurt (with lactobacillus-acidophilus) may speed up healing and improve discomfort

• Gargles:

1. Baking soda and water gargles hasten healing (spit). Mix one teaspoon baking soda in1/2 cup of warm water—swish and spit. Do this 2-3 times daily. This usually shortens the duration of sores by couple of days.

2. Hydrogen peroxide (antiseptic) and water, Milk of Magnesia (pain reducer and promotes healing) and Benadryl Solution (numbing).

Mix 1/2 hydrogen and 1/2 water (50:50) and apply it to sore(s). Then, mix 1/2 Milk of Magnesia solution with 1/2 Benadryl Allergy Solution (50:50) and then dab

    this solution of hydrogen peroxide and water on the sore(s). You can also swish and spit. Repeat 3-4 times a day- (This solution is similar to what healthcare providers prescribe you go to a clinic but without prescription medications like liquid steroids or viscous lidocaine).

•  Oral L-lysine: There is a lot of information claiming that this works (for many people) to keep these sores away and also to enhance more rapid healing.

•  ​Cold/Ice Chips - to help decrease inflammation and pain (very short-term relief)

• Salt - Put salt on a Q-tip and apply it to the ulcer directly - hold it there as long as you

can stand it: It will burn and sting a lot. Rinse and the pain is gone! Do this as needed. It often helps the ulcer heal faster.

•  Ibuprofen, as an anti-inflammatory, may help decrease inflammation and pain,

marginally. But beware - sometimes this is what causes the sores!

If you get canker sores often, you might want to find the underlying cause or problem so that you can control the sores. Initially, you will probably want to take the shortest path to discovery first.

First, you can add vitamins and supplements to your diet (as those below) to determine if these sores are due to a deficiency in one of these. Quite a few patients feel that over-the-counter L-lysine, an amino acid, helps to keep these sores from developing. Besides L-lysine supplements, you can only get this from your diet in things like high-protein foods such as eggs, meat (red meat, lamb, pork, and poultry), soy, beans and peas, some cheeses, and certain fish (such as cod and sardines).  

Second, evaluate your overall health in terms of rest, diet, stress, and illness (often, these are not easy to fix because they are significant lifestyle changes). Third: Try the elimination "diet." Start by making a food "diary" and eliminating foods/changing toothpaste (see below), and mouthwash one at a time. 

Last, sometimes, these ulcers can be due to medications you are taking—particularly if you take a lot of anti-inflammatory medications. Rarely beta-blockers ("lol" medications) can play a part, as can chemotherapy, but do not change these medications without discussing them with your healthcare provider.

Preventive: Consider adding a good vitamin B-complex to your diet. You can also add an L-lysine supplement on a daily preventive basis or as needed when you first notice a cold sore developing. 

If all else fails and you are unable to get rid of these, speak to your healthcare provider. They may need to examine your health history/immune status, vitamin and mineral deficiencies, or other causes more closely. Pain is your body's warning that something is wrong.

If you have an oral sore that does not go away after two to three weeks (especially if you drink a lot of alcohol or smoke) see a dentist or other healthcare provider.

TONSILLAR STONES AS A CAUSE OF A SORE THROAT

Large tonsillar stone

These are pesky, irritating little things which I see more and more of these days. Every once in a while, a patient will present with white "stuff" on their tonsils that they think must be strep. On further examination, the white matter is, in fact, not spread out on the tonsil or streaked in the crevice but little solid white "chunks" stuck in the crevice(s) in and around their tonsil(s). These often fall out  of the crevices, and they smell bad. They are called "tonsillar stones" or "tonsilloliths" – some people get them rarely, some people get one, and some people get a collection of them. They can cause a sore throat-often more on one side than another). Sometimes, they cause pain in swallowing, pain in the ear, and nasty breath. Unless you have an infection along with the tonsil stones (which is pretty rare), the white spots on your tonsils won't cause a fever.

These originate from tiny particles of food that get caught in the tonsillar crevices(crypts). Bacteria, dead cells, and mucous collect around the food particle(s) and start to calcify and form these stones. Sometimes there is one or several white little "chunks" that stick out of the tonsil. Usually they are smaller than the one pictured. Antibiotics do NOT help eliminate these. 

Conventional Approaches to Tonsillar Stones

1) Many of these stones will not harm you and do not require treatment. You can be seen by a healthcare provider if you are not sure if they are a tonsillar stone and suspect something else but, otherwise, if they are not too uncomfortable, let them fall out on their own with time. Try not to obsess over them—sometimes they are more annoying than anything else.

2) If you can see the stone(s) when you open your mouth, you may try to remove it with a cotton swab. Look in the mirror, press next to the stone, and apply gentle pressure to coax it out. Afterward, gargle with non-alcoholic mouthwash or saline solution (1/2 tsp salt in 1 cup warm water). Sometimes you can cause a sore throat to get worse if you keep poking and don't be surprised if you gag yourself.

3) In fact, a cough or a gag will sometimes help push these stone(s) out of the tonsils.

4) Try gargling with 1/2 tsp salt in 4 ounces of warm water twice daily. Gargle for at least 30 seconds.

5) Gargle with non-alcoholic mouthwash twice daily - this will help kill bacteria and keep your breath fresh.

6) Gently flush tonsils with a Water Pik regularly - (There are mixed reviews on this, so if you        do not have a Water Pik, I am not sure I would invest in one). 

Alternative Approaches to Tonsillar Stones

This alternative gargle is reputed to have antimicrobial/antibacterial properties, so it may help keep the bacteria away if done regularly:

1) Myrrh gargle (antibacterial properties and breath freshener):

    Recipe: 5 Drops of Myrrh Essential Oil in 4 oz of water: gargle and spit 1-2 times daily.

​​Unless the stone is terribly uncomfortable or large, you have many, or they recur - if you can swallow and have no fever - a wait-and-watch approach is best. If you are unable to wait for the stone(s) to fall or are unable to remove it/them you can see a healthcare provider. Warning: Removal of these stones may entail gagging and can sometimes be a difficult process if lodged far into a tonsillar crypt. Once the stone is gone you typically feel much relief. 

Prevention of Tonsillar Stones

​If you find that you get these stones fairly often, prevention is often the best place to start to keep them away in the first place. Patients tell me these are hard to keep away, but you may try one or two ideas below:

Long-Term Treatment of Tonsillar Stones

If you only occasionally get tonsillar stones, there is typically nothing to worry about. If you get them frequently and are unable to keep them away, especially if they are multiple or very large stones, you may want to discuss them with an ENT. Sometimes, the ENT may recommend a tonsillectomy. For adults, this is typically a very unpleasant experience.

MONONUCLEOSIS ("Mono" or "Kissing Disease" Can Cause a Very Sore Throat)

The mono presentation is initially very similar to strep, except it usually lasts much longer and can be more severe. It is often characterized by a severe sore throat, tonsils with white patches or exudates, enlarged, tender lymph nodes, excessive fatigue, fever, headache, body aches, diminished appetite, weakness, and, sometimes, a rash.

Mono is caused by the Epstein-Barr Virus, which is typically spread through oral secretions (henceforth "the kissing disease"). The incubation period is about six weeks (that is, symptoms usually show up within six weeks after exposure). Everyone is different when they get mono symptoms: They can range from relatively mild to severe.

A person with severe symptoms or an ongoing sore throat should consider following up with a healthcare provider. It is important to know if you have mono because there are potential and sometimes life-threatening complications of an enlarged spleen, which can rupture.

You can be diagnosed with mono through a blood test (1). Often, a person is tested for mono when they show one or more of the following: 

     1) Have had known exposure AND have developed symptoms

     2) Test negative for strep but have a nasty sore throat, white patches, and enlarged lymph               node (or continued symptoms such as these days after testing negative for strep)

     3) A rash develops when taking a penicillin product while sick with these symptoms.

Treatment for Mononucleosis "Mono"

Unfortunately, very little will make mono go away except for time.

Treatment is primarily symptomatic. Because the acute symptoms can last for a period of 2-4 weeks (sometimes months), this illness can make it difficult if you are in school or work due to excessive fatigue. Because a virus causes it, antibiotics do not help. All a person can do is to use supportive and symptomatic treatment, that is, rest, hydration and a healthy diet are imperative. EXTREME EXERTION AND CONTACT SPORTS ARE TO BE AVOIDED BECAUSE OF POTENTIAL SPLEEN INVOLVEMENT.​​

A person with mono mustn't share anything (like water bottles) or have oral contact with others while they have mono. It spreads easily.

A question I often hear: Can mono come back? Yes. It can reactivate, but this is quite rare. The virus lays dormant in your system, and if it comes back, it is usually because your immune system is very weak (stress, lack of rest, underlying illness). Several blood tests can be done to determine reactivation.

After having had an active case of mono, about 70% of people continue to test positive for it (even with NO symptoms) so it is difficult to tell if it is recurring. 

Chronic mono (chronic active Epstein-Barr viral disease) is a very rare, severe ongoing case of mono with a poor prognosis. It is beyond the scope of this site. 

A PERITONSILLAR ABSCESS CAN CAUSE A SEVERE SORE THROAT

Unilateral throat swelling: Peritonsillar abscess

We do not see these too often in the clinic, but they appear occasionally. In general, a collection of pus builds up behind the tonsil. It is usually easily recognized by significant swelling in and around one of the tonsils (rarely two) - occasionally extending into the roof of the mouth on the same side. Symptoms include a severe sore throat with pain that may radiate to the ear and jaw, fever, difficulty swallowing, and a "hot potato voice" (voice changed by swelling).

The abscess is noted by swelling in the back of the throat on one side-near the roof of the mouth

Treatment for a Peritonsillar Abscess 

There is no good over-the-counter treatment for a peritonsillar abscess. These are potentially dangerous and may cause sepsis, airway obstruction, meningitis, or endocarditis, among other things. If you believe you have a peritonsillar abscess, you need to seek treatment at an urgent care or ER. Occasionally, oral and injectable antibiotics do work, but if the infection is severe, the pus pocket needs to be drained. 

UVULITIS

This is one of those odd things you wake up with one day: Maybe your uvula (the thing that hangs down in the back of your throat-see photo above) became enlarged because you had a long night of snoring and irritated your throat or because you had some overnight sinus drainage, reflux, chemicals in foods, allergies. 

I have seen only a handful of patients with this problem, but it is disconcerting enough that they come to the clinic. Their uvula becomes enlarged, swollen, and red, accompanied by a sore throat in that area (the skin hanging down in the back of your throat - in the midline); sometimes, it is so large it causes gagging and excessive salivation. 

Viruses, bacteria, postnasal drainage, smoking, alcohol, and snoring can all cause this problem. It is usually short-lived due to "trauma" - likely will not need an antibiotic or throat culture but may need corticosteroids for the inflammation.

Over-the-Counter Treatment and Remedies for Uvulitis

Anti-inflammatories:

• Ibuprofen (common: Motrin, Advil)—400-600 mg every 6 hours as needed—should reduce inflammation. Follow package directions.

• Naproxen (Aleve) 550 mg initially, then 275 every 12 hours after that as needed. Follow package directions.

  
  

Alternative Approaches and Remedies You Can Try for Uvulitis

Salt Water Gargles - This should help decrease some of the swelling. Gargle with a mixture of 1 tsp of salt in warm water every 1-4 hours as needed

Tumeric-Curcumin - 500 mg twice a day (anti-inflammatory)

If All Else Fails...See a Healthcare Provider

• The pain gets worse.

• You have new or worse trouble swallowing.

• You are getting sicker or developing a fever

• Swelling gets worse

• A feeling of obstructed breathing

Prescriptive Treatment of Uvulitis

Oral Corticosteroids (common: prednisone) to reduce the inflammation.

OTHER THROAT PROBLEMS

Any kind of trauma to your throat can cause inflammation of the throat and/or vocal cords. Vocal damage can cause hoarseness, "breathiness" (lack of sound), a rough or scratchy voice, decreased pitch range, voice exhaustion, sometimes persistent clearing and possibly accompanied by pain.

​CHRONIC THROAT CLEARING

This can result from a number of factors: From asthma to postnasal drainage caused by allergies or chronic sinus drainage, to snoring, to acid reflux, to those with vocal nerve damage, or the development of vocal nodes from strenuous use like singing or yelling. There are also those who just clear their throat out of habit: A situation called vocal "tics". This chronic irritation can cause voice changes.

​Let's look at some of these:

ALLERGIES

Postnasal Drainage, from allergies: Many times, postnasal drainage is "silent."—People may not be aware of mucus in the throat. Like a cold, allergies can irritate the nasal passages and sinuses resulting in a postnasal drip. This mucous constantly drips down the throat, which causes clearing and irritation which may lead to a chronic, frequent or recurrent sore throat.

People with chronic allergies tend to clear their throats more than those without allergies. Both mucus and clearing irritate the throat, in turn, causing inflammation and a chronic or recurrent sore throat. Usually, a sore throat related to allergies is relatively minor but annoying.

For more information about allergies, treatment, and support check this link to allergies.

SNORING

Snoring can be caused by several things: weak throat muscles, too much soft tissue (often caused by excessive weight), a long soft palate, enlarged tonsils or adenoids (tissue in the back of the nasal passages), tonsils, or an enlarged uvula. 

Mouth breathing at night and the resulting dry mouth can also cause the throat to become sore. 

Some people are aware of their own snoring but, more often, their bed partner lets them know. Once in a while, snoring is accompanied by obstructive sleep apnea, which occurs when the tissues in the back of the throat obstruct the windpipe, and a person stops breathing for several seconds (this "apnea" starves your heart and brain of oxygen and can cause all kinds of physical and mental problems). A person usually informs their bed partner of their apnea, too, when they notice that their partner stops breathing for prolonged periods followed by aloud "gasp").

If you snore, there are all kinds of over-the-counter gadgets available at stores, including nasal strips (they widen your nasal passages only), various oral and nasal devices, chin straps, and so on. Whether they work depends on the cause of the snoring to begin with. If you plan to purchase something, read the reviews. You can also consider sleeping on your side or using extra pillows. But, if nothing seems to work or if you do not want to jump through a lot of hoops, discuss it with an ENT. There are various surgical procedures that may help.

If you suspect you may have sleep apnea, let your healthcare provider know or contact a sleep specialist.

ACID REFLUX

Reflux (GERD): When acid reflux occurs, acid contents from the stomach back up from the esophagus into the throat. This can be obvious or it can be "silent" (when a person does not realize that this backup occurs). Silent reflux can occur during the day or night. The acid causes inflammation of the mucus membranes of the throat, and the result can be episodes of hoarseness, persistent throat clearing, a sore throat, sometimes a postnasal drip, and, if severe, vocal nodules "nodes". ​Cleveland Clinic has some excellent information about this.

VOCAL OVERUSE

Singing and Voice Overuse: Without care, voice overuse and abuse can cause irritation and inflammation of the vocal cords, resulting in a sore throat or hoarse voice. When the voice is repeatedly strained, it can damage the vocal cords and create polyps as well. It is important to take care of your voice.

For more information about performers and throat irritation, please see the section on Singer and the Sore Throat.

​

GONORRHEA AND CHLAMYDIA

These sexually transmitted diseases can also cause a sore throat with white or off white patches. If you test negative for strep and feel that you may have been exposed through oral sex, you should be tested by a healthcare provider.

If you have extreme pain, DROOLING, and a great deal of difficulty swallowing, you should see a healthcare provider as soon as you can.

For more chronic problems, if you cannot get to the root of the problem and you frequently clear; if you have frequent recurrent sore throats, persistent hoarseness or change in your voice; ongoing difficulty with swallowing, or an oral sore that does not heal, a lump or swelling in your neck, you should follow up with an ear, nose, and throat (ENT) specialist.