Chronic Pharyngitis
Definition
Chronic Pharyngitis is a chronic inflammatory condition of the pharynx. Pathologically, it is characterized by hypertrophy of mucosa, seromucous glands, sub epithelial lymphoid follicles also even the muscular coat of the pharynx. [1]
Chronic pharyngitis doesn’t have perfect synonyms, but here are some related terms you can consider depending on the context:
Formal Medical Terms:
- Chronic sore throat: This is a straightforward way to describe the condition for a general audience while maintaining some medical accuracy.
- Persistent pharyngitis: Emphasizes the long-lasting nature of the sore throat.
Informal Terms (use with caution):
- Long-term sore throat: Similar to "chronic sore throat" but less formal.
- Reoccurring sore throat: This might not be entirely accurate as chronic pharyngitis often involves persistent irritation rather than distinct recurring episodes.
Other Related Terms:
- Laryngopharyngitis: This term refers to inflammation of both the larynx (voice box) and pharynx (throat), which can sometimes occur in chronic pharyngitis.
- Postnasal drip pharyngitis: This highlights chronic irritation caused by drainage from the nose down the back of the throat, a possible cause of chronic pharyngitis.
Choosing the Right Term:
- Medical Setting: Use "chronic pharyngitis" for clarity and precision in medical discussions.
- Patient Education: "Chronic sore throat" is a good option for clear communication with patients.
- Informal Context: "Long-term sore throat" can be understood in casual conversation, but avoid oversimplification.
Overview
Epidemiology
Causes
Types
Risk Factors
Pathogenesis
Pathophysiology
Clinical Features
Sign & Symptoms
Clinical Examination
Diagnosis
Differential Diagnosis
Complications
Investigations
Treatment
Prevention
Homeopathic Treatment
Diet & Regimen
Do’s and Don'ts
Terminology
References
Also Search As
Overview
Overview of Chronic Pharyngitis
A triad of sore throat, fever, and pharyngeal inflammation marked by erythema and edema are usually described as acute pharyngitis, although exudates, vesicles, or ulcerations may also be present.
The inflammation of the pharynx, which presents as a sore throat, is pharyngitis. It is a painful inflammation of the pharynx and is colloquially referred to as a sore throat.
Pharyngitis is a common medical problem in the outpatient medical setting, resulting in more than seven million pediatric visits each year.
Most types of pharyngitis are caused by infectious etiologies. The most common cause of pharyngitis is a viral infection.
However, some of the more serious types of pharyngitis are attributed to bacterial etiologies, such as group A-hemolytic Streptococcus pyogenes (GAS).
Complications from GAS pharyngitis include rheumatic fever, deep space abscesses, and toxic shock. Although most episodes of pharyngitis are acute in nature, a small percentage becomes recurrent or chronic. With regards to chronic pharyngitis, non-infectious etiologies, such as Laryngopharyngeal reflux disease and periodic fever, aphthous ulcers, pharyngitis, and adenitis syndrome also need to be considered.
Both medical and surgical therapies are effective in managing pharyngitis. Antibiotic treatment requires first-line medical therapy. Surgical management via adenotonsillectomy is recommended for certain indications. Adenotonsillectomy has been shown to be effective in reducing the burden of disease and improving the global quality of life and disease-specific.
Several procedures, including traditional and intracapsular tonsillectomies, exist for adenotonsillectomy. [3]
Epidemiology
Epidemiology
There is a lack of specific epidemiological studies on chronic pharyngitis in India. However, several studies have reported on the prevalence of pharyngitis (acute and chronic) in specific populations or regions.
Reference:
- Joshi, A. R., & Joshi, K. (2010). Prevalence of upper respiratory tract infections in children attending a tertiary care hospital in Western Nepal. Kathmandu University Medical Journal, 8(3), 326-330.
Year of publication: 2010
While this study does not solely focus on chronic pharyngitis and is based in Nepal, it provides insights into the prevalence of upper respiratory tract infections, which can include pharyngitis, in a neighboring region with potentially similar environmental and socioeconomic factors.
Additional research focusing specifically on the Indian population is needed to determine the accurate epidemiology of chronic pharyngitis within the country.[6]
Causes
Causes of Chronic Pharyngitis
A large number of factors are responsible:
- Persistent infection in the neighborhood. In detail, In chronic rhinitis and sinusitis, purulent discharge constantly trickles down the pharynx and provides a constant source of infection. Furthermore, This causes hypertrophy of the lateral pharyngeal bands. Similarly, chronic tonsillitis and dental sepsis are also responsible for chronic pharyngitis and recurrent sore throats. [1]
- Mouth breathing. Besides this, Breathing through the mouth exposes the pharynx to air which has not been filtered, humidified and adjusted to body temperature thus making it more susceptible to infections. Mouth breathing is due to:
(a) Firstly, Obstruction in the nose, e.g. nasal polypi, allergic or vasomotor rhinitis, turbinal hypertrophy, deviated septum or tumors.
(b) Secondly, Obstruction in the nasopharynx, e.g. adenoids and tumors.
(c) Thirdly, Protruding teeth which prevent apposition of lips.
(d) Lastly, Habitual, without any organic cause.
- Chronic irritants. For example, Excessive smoking, chewing of tobacco and pan, heavy drinking or highly spiced food can all lead to chronic pharyngitis.
- Environmental pollution. In detail, Smoky or dusty environment or irritant industrial fumes may also be responsible for chronic pharyngitis.
- Faulty voice production. Less often realized but an important cause of chronic pharyngitis is the faulty voice production. Excessive use of voice or faulty voice production seen in certain professionals or in “pharyngeal neurosis” where person resorts to constant throat clearing, hawking or snorting, also that may cause chronic pharyngitis, especially of hypertrophic variety
Types
Types of Chronic Pharyngitis
- Chronic catarrhal Pharyngitis
- Chronic hypertrophic Pharyngitis
Other types
KERATOSIS PHARYNGITIS
In general, It benign condition characterized by horny excrescences on the surface of tonsils, pharyngeal wall or lingual tonsils. Moreover, They appear as white or yellowish dots. These excrescences the result of hypertrophy also keratinization of epithelium. They are firmly adherent and cannot wipe off. There is no accompanying inflammation nor any constitutional symptoms and thus can easily differentiate from acute follicular tonsillitis. Besides this, The disease may show spontaneous regression and may not require any specific treatment except for reassurance to the patient.
ATROPHIC PHARYNGITIS
It a form of chronic pharyngitis often seen in patients of atrophic rhinitis. Pharyngeal mucosa along with its mucous glands shows atrophy. Additionally, Scanty mucus production by glands leads to formation of crusts, which later get infected giving rise to foul smell.
Dryness also discomfort in throat are the main complaints. Hawking and dry cough may present due to crust formation. Finally, Examination shows dry and glazed pharyngeal mucosa often covered with crusts.
Risk Factors
Risk factors of Chronic Pharyngitis
- History of ill contact
- Over crowding
- Frequent sinus infections
- Smoking
- Attending day care
- Immunocompromised
- Cold season
- Allergic rhinitis
- Gastroesophageal reflux disease
- Use of corticosteroids
- Oral sex
- Multiple sexual partners
- Unprotected sex [3]
Pathogenesis
Pathogenesis
"Chronic pharyngitis is more often a symptom complex than a specific disease. Most cases result from persistent irritation of the pharyngeal mucosa. This can occur from chronic mouth breathing, untreated allergic rhinitis with postnasal drip, chronic sinusitis, or gastroesophageal reflux disease. Other causes include chronic infection (e.g., fungal), tobacco use, and exposure to environmental irritants."[7]
Pathophysiology
Pathophysiology of Chronic Pharyngitis
- Most viruses, such as adenovirus or coxsackie virus, can cause inflammation of the pharyngeal mucosa by direct invasion of the mucosa or by secondary to supra pharyngeal secretions. Other viruses, such as rhinoviral infections produce bradykinin and lysyl bradykinin, which are known inflammatory mediators that can excite nerve endings in the pharynx to cause pain.
- Pathogenesis of bacterial pharyngitis varies with etiology. In streptococcal pharyngitis (which is the most common bacterial pharyngitis), the bacteria release exotoxins and proteases. Erythrogenic exotoxins are responsible for the development of the scarlatiniform exanthem. Secondary antibody cross react against M2-protein of the myocardial tissue that may result in rheumatic fever and valvular heart diseasea(type II hypersensitivity reaction)nd the antigen-antibody complexes can lead to acute poststreptococcal glomerulonephritis (type 3 hypersensitivity reaction).[3]
Clinical Features
Clinical Features
"The clinical features of chronic pharyngitis are variable and often depend on the underlying cause. Patients often present with a sensation of throat irritation or fullness, dryness, or a nonproductive cough. Other symptoms can include hoarseness, halitosis, and persistent mucus in the throat. On examination, the pharyngeal mucosa may appear erythematous or granular, and lymphoid hyperplasia may be present. It is important to identify any underlying causes of chronic pharyngitis, such as allergic rhinitis, sinusitis, or gastroesophageal reflux disease, as treatment of these conditions is often necessary for resolution of the pharyngitis."[8]
Sign & Symptoms
Sign & Symptoms of Chronic Pharyngitis
SIGNS
- Chronic catarrhal pharyngitis. In this, there is a congestion of posterior pharyngeal wall with engorgement of vessels; facial pillars may thicken. Additionally, There increased mucus secretion which may cover pharyngeal mucosa.
- Chronic hypertrophic (in other words, granular) pharyngitis
(a) Firstly, Pharyngeal wall appears thick and edematous with congested mucosa and dilated vessels.
(b) Secondly, Posterior pharyngeal wall may studded with reddish nodules (hence the term granular pharyngitis). These nodules due to hypertrophy of subepithelial lymphoid follicles normally seen in pharynx. [1]
(c) Thirdly, Lateral pharyngeal bands become hypertrophied.
(d) Lastly, Uvula may be elongated also appear edematous.
SYMPTOMS
Severity of symptoms in chronic pharyngitis varies from person to person.
- Discomfort or pain in the throat. Moreover, This is noticed in the mornings.
- Foreign body sensation in throat. Generally, Patient has a constant desire to swallow or clear his throat to get rid of this “foreign body.”
- Tiredness of voice. Patient cannot speak for long and has to make undue effort to speak as throat starts aching. Besides this, The voice may also lose its quality and may even crack.
- Cough. Throat is irritable and there is tendency to cough. Mere opening of the mouth may induce either retching or gagging.
Clinical Examination
Clinical examination of Chronic Pharyngitis
Vital Signs
- High/ low-grade fever
Skin
- Scarlatiniform rash associated with GAS, Arcanobacterium haemolyticum.
- Pharynx shows erythema, hypertrophy, tonsilar exudates, masses, Soft-palate petechiae (“doughnut” lesions), and beefy red, swollen uvula associate with Streptococcal pharyngitis.
- Grayish brown diphtheritic pseudomembrane which may involve one or both tonsils or may extend widely to involve the nares, uvula, soft palate, pharynx, larynx, and tracheobronchial tree associate with Corynebacterium diphtheria.
- Conjunctivitis and periauricular lymphadenopathy associate with adenoviral infection.
- Blisters or ulcers in the anterior mouth or lips are seen in herpes simplex infection.
Heart
- Heart murmur associate with rheumatic fever due to streptococcal pharyngitis.
Abdomen
- Hepato spleenomegaly: associate with pharyngitis caused by group A streptococcus, infectious mononucleosis
Neck
- Cervical adenopathy [3]
Diagnosis
Diagnosis of Chronic Pharyngitis
According to the diagnosis of chronic pharyngitis involves a combination of:
History and physical examination:
- The clinician should inquire about the duration and character of the patient’s symptoms, including the presence of throat pain, hoarseness, cough, and dysphagia (difficulty swallowing).
- Physical examination focuses on the pharynx and larynx, assessing for erythema (redness), edema (swelling), lymphoid hyperplasia (enlarged lymphoid tissue), and any exudate (pus or discharge).
Laboratory evaluation:
- Throat cultures are typically obtained to rule out bacterial infection, especially if the patient presents with fever, tonsillar exudate, or cervical lymphadenopathy (swollen lymph nodes in the neck).
- Additional tests, such as rapid antigen detection tests for streptococcal infection, CBC, may be considered based on the clinical presentation.
Imaging studies:
- In some cases, imaging studies like lateral neck radiographs or computed tomography (CT) scans may be ordered to evaluate the extent of pharyngeal inflammation or to rule out other conditions.
Book [11] The authors also emphasize the importance of considering other potential causes of chronic pharyngitis, such as allergies, gastroesophageal reflux disease (GERD), and environmental irritants. They note that a comprehensive evaluation is necessary to determine the underlying etiology and guide appropriate management. [11]
Differential Diagnosis
Differential diagnosis of Chronic Pharyngitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpes simplex virus (HSV),
- Parainfluenza virus
- Influenza virus
- Epstein—Barr Virus (EBV)
- Human immunodeficiency virus (HIV). [4]
Complications
Complications
The Complications of chronic pharyngitis are rare but can include:
The book Kliegman’s Nelson Textbook of Pediatrics does not specifically mention chronic pharyngitis complications, but it does discuss complications related to acute pharyngitis, particularly those caused by bacterial infections. These complications, although rare, can also potentially arise from chronic pharyngitis if left untreated or if the underlying cause is not addressed.[9]
Investigations
Investigation of Chronic Pharyngitis
Rapid antigen detection test
Throat culture
Anti–streptococcal antibody titers
Rapid influenza diagnostic tests
Immunoassays that can identify the presence of influenza A and B viral nucleoprotein antigens in respiratory specimens
Complete blood count with differential
An increased percentage of neutrophils may be due to acute bacterial infection
An increase in lymphocytes may be related to viral infection Increased total number of lymphocytes, with greater than 10% atypical lymphocytes (large with irregular nuclei) is present in Epston- Bar virus (EBV) infection
May be useful when presenting amononucleosis-type syndrome
Monospot test
A monospot test (heterophile antibody test) is a rapid test for infectiousmononucleosis due to EBV.
Epstein-Barr virus serologic profile
Serologic profile will include testing for immunoglobulin G (IgG) and M (IgM) antibodies
Acute HIV infection tests
ELISA test: Uses an enzyme immunoassay to detect specific antibodies (3)
Treatment
Treatment of Chronic Pharyngitis
Firstly, In every case of chronic pharyngitis, etiological factor should be sought also eradicated.
- Secondly, Voice rest and speech therapy is essential for those with faulty voice production. Hawking, clearing the throat frequently or any other such habit should be stopped.
- Thirdly, Warm saline gargles, especially in the morning, are soothing and relieve discomfort.
- Besides this, Mandl’s paint may be applied to pharyngeal mucosa.
- Lastly, Cautery of lymphoid granules is suggested. Additionally, throat is sprayed with local anesthetic and granules are touched with 10–25% silver nitrate. Either electrocautery or diathermy of nodules may require general anesthesia. [1]
Prevention
Prevention of Chronic Pharyngitis
- Gargle with warm saline solutions
- Stay well-hydrated
- Avoid smoking
- Manage pain with over-the-counter medication such as acetaminophen/paracetamol [5]
Homeopathic Treatment
Homeopathic Treatment of Chronic Pharyngitis
Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.
Which includes
- The medical history of the patient,
- Physical and mental constitution,
- Family history,
- Presenting symptoms,
- Underlying pathology,
- Possible causative factors etc.
A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.
What Homoeopathic doctors do?
A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?
The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. Now a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.
The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improve with homeopathic medicines.
Homeopathic Medicines for Chronic Pharyngitis
The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy, potency and repetition of dose by Homeopathic doctor.
So, here we describe homeopathic medicine only for reference and education purpose. Do not take medicines without consulting registered homeopathic doctor (BHMS or M.D. Homeopath).
Medicines
Aesculus HippocampusDry, uncomfortable feeling in fauces and pharynx, a sense of constriction, with raw, either excoriated feeling or a sense of pricking and yet no swelling; frequent desire to swallow, uneasiness in deglutition; troublesome tickling cough, with constant hawking up of mucus which is not tenacious or stringy; fauces, vulva and back of pharynx dusky red, relaxed or swollen; tongue coated, feeling of general malaise also depression; catarrhal
| ||||||
DroseraRough, dry, scraping sensation specifically, on soft palate and in fauces, inducing cough; pharyngeal anaemia; pharynx pale, discolored also blanched, often a premonitory symptom of tuberculosis pulmonum. [2] | ||||||
Hepar SulphChronic venous congestion of pharyngo-laryngeal mucous membrane; feeling of dullness also constriction in throat, with desire to swallow, but no pain during deglutition; throat
|
Kali Mur
Pharyngitis, GREAT DEAL OF FOETOR IN BREATH, hawks up cheesy lumps of the size of a split pea; throat swollen, either spots or pustules appear with gray or whitish exudation; adherent crusts especially, in vault of pharynx; tongue coated grayish-white, slimy or dry; biliousness, dyspepsia, fatty or rich food causes indigestion. [2]
Diet & Regimen
Diet & Regiment of Chronic Pharyngitis
- Warm Water Gargle
- Rest
- Adequate Water
- Nutritious Diet
Do’s and Don'ts
Do’s & Don’ts
There is no specific book that explicitly lists "Do’s and Don’ts" for chronic pharyngitis. However, based on the information provided in various medical texts, here are some recommendations derived from expert opinions and clinical practice:
Do’s:
- Stay hydrated: Drink plenty of fluids to keep your throat moist and prevent irritation.
- Rest your voice: Avoid excessive talking or shouting to reduce strain on your throat.
- Use a humidifier: Adding moisture to the air can help soothe a dry and irritated throat.
- Gargle with warm salt water: This can help reduce inflammation and discomfort.
- Follow a healthy diet: Eat a balanced diet rich in fruits and vegetables to boost your immune system.
- Treat underlying conditions: If your chronic pharyngitis is caused by allergies, acid reflux, or other medical issues, addressing these conditions is crucial for managing your symptoms.
Don’ts:
- Smoke or use tobacco products: These can irritate your throat and worsen your symptoms.
- Consume alcohol excessively: Alcohol can dehydrate you and irritate your throat.
- Shout or strain your voice: This can further irritate your throat and prolong your recovery.
- Ignore your symptoms: If your symptoms persist or worsen, consult a doctor to rule out other potential causes and receive appropriate treatment.
Disclaimer: This information is not a substitute for professional medical advice. Always consult with your doctor for diagnosis and treatment.[10]
Terminology
Terminology
Pharynx: The part of the throat behind the mouth and nasal cavity.
Chronic Pharyngitis: Long-term inflammation or irritation of the pharynx.
Hypertrophy: Enlargement of an organ or tissue due to an increase in the size of its cells.
Seromucous Glands: Glands in the mucous membranes that secrete a fluid containing both mucus and serum.
Sub-Epithelial Lymphoid Follicles: Small masses of lymphoid tissue located beneath the epithelial lining.
Lateral Pharyngeal Bands: Vertical folds of mucous membrane on the lateral walls of the pharynx.
Keratosis Pharyngitis: A benign condition characterized by horny growths on the tonsils, pharyngeal wall, or lingual tonsils.
Atrophic Pharyngitis: A form of chronic pharyngitis where the pharyngeal mucosa and glands shrink, leading to crust formation and foul smell.
Laryngopharyngeal Reflux Disease (LPRD): A condition where stomach acid travels back up the esophagus and irritates the larynx and pharynx.
Adenotonsillectomy: Surgical removal of the adenoids and tonsils.
Exudates: Fluids, cells, or other substances that have oozed out of blood vessels or an organ, especially in inflammation.
Vesicles: Small fluid-filled blisters.
Ulcerations: Open sores on an external or internal surface of the body.
Miasmatic Tendency: In homeopathy, a predisposition to certain types of diseases based on inherited or acquired weaknesses.
Potency: The strength or dilution of a homeopathic remedy.
Repetition: The frequency with which a homeopathic remedy is administered.
References
Reference
- Diseases_of_Ear_Nose_and_Throat_6Edition
- Homoeopathic Therapeutics by Lilienthal
- https://www.wikidoc.org/index.php/Pharyngitis_overview
- https://www.google.com/search?q=differntial+diagnosis+of+chronic+pharyngitis
- ttps://www.google.com/search?q=prevention++of+chronic+pharyngitis
- Joshi, A. R., & Joshi, K. (2010). Prevalence of upper respiratory tract infections in children attending a tertiary care hospital in Western Nepal. Kathmandu University Medical Journal, 8(3), 326-330.(2010).
Cummings Otolaryngology: Head and Neck Surgery, 7th Edition, Authors: Paul W. Flint, Bruce H. Haughey, Valerie J. Lund, John M. Graham, K. Thomas Robbins, Jatin P. Shah, Harrison W. Lin, Clough Shelton,(2021) Publisher: Elsevier.
CURRENT Diagnosis & Treatment in Otolaryngology—Head and Neck Surgery, 4th Edition, Authors: Anil K. Lalwani,(2021), Publisher: McGraw Hill.
Kliegman’s Nelson Textbook of Pediatrics, 21st Edition, Authors: Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina Felice. Schor, Richard E. Behrman(2020), Publisher: Elsevier.
- Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases, 9th Edition
Authors: John E. Bennett, Raphael Dolin, Martin J. Blaser
Year of Publication: 2020
Publisher: Elsevier. - Cummings Otolaryngology: Head and Neck Surgery, 7th Edition by Paul W. Flint, Bruce H. Haughey, Valerie J. Lund, John M. Niparko, Mark A. Richardson, K. Thomas Robbins, and Jatin P. Shah (published in 2021 by Elsevier),
Also Search As
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General Search Terms:
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- Persistent sore throat
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Additional Tips:
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Frequently Asked Questions (FAQ)
What is chronic pharyngitis?
Definition:
Chronic pharyngitis is a persistent inflammation or irritation of the pharynx, the back of the throat. Unlike acute pharyngitis, which is often caused by a viral or bacterial infection, chronic pharyngitis tends to be ongoing and can be caused by a variety of factors.
What causes chronic pharyngitis?
Chronic pharyngitis can be caused by several factors which is given below:
- Environmental irritants like pollution or smoke, allergies, postnasal drip, acid reflux, chronic sinusitis, or even certain medications.
How is chronic pharyngitis diagnosed?
Diagnosis typically involves a physical examination of the throat, and a medical history review. Sometimes additional tests like throat swabs, allergy tests, or endoscopy might be needed.
What are the symptoms of chronic pharyngitis?
Common symptoms include:
- A persistent sore throat
- Scratchy or dry throat
- Difficulty swallowing
- A feeling of a lump in the throat
- A cough.
Which homeopathic remedies are commonly used for chronic pharyngitis?
Several Homeopathic remedies are commonly used, including:
- Belladonna, Lachesis, Mercurius solubilis, Phytolacca, and Hepar sulph. The most suitable remedy depends on the individual’s specific symptoms and constitution.
Can homeopathy treat chronic pharyngitis effectively?
Yes,
Homeopathy offers various remedies that can effectively address the root cause of chronic pharyngitis and provide relief from its symptoms. Homeopathic treatment aims to stimulate the body’s natural healing processes.
How can homeopathy help in managing chronic pharyngitis?
- Explanation of the homeopathic approach to chronic diseases
- Focus on individualization and treating the root cause
- Selection of remedies based on specific symptoms and constitution
How long does it take to see improvement with homeopathic treatment?
- Explanation that the response time varies depending on individual factors
- Importance of regular follow-ups with the homeopath
Are there any lifestyle changes that can help with chronic pharyngitis?
Yes there is several changes which helps like,
- Avoiding irritants and allergens
- Staying hydrated
- Gargling with warm salt water
- Using a humidifier
- Managing stress
