Journal of Otology & RhinologyISSN: 2324-8785

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Research Article, J Otol Rhinol Vol: 5 Issue: 6

Changes in Sore Throat Symptoms throughout the Day and Night: A Questionnaire-Based Survey of Five Countries

Shephard A*
Reckitt Benckiser Healthcare International Ltd, Slough, UK
Corresponding author : Shephard A
BSc (Hons), CBIOL, FSB, Reckitt Benckiser Healthcare International Ltd, Slough, UK
Tel: +44 (0)1753 446748
Fax: 01753 217899
E-mail: [email protected]
Received: October 12, 2016 Accepted: November 01, 2016 Published: December 08, 2016
Citation: Shephard A (2016) Changes in Sore Throat Symptoms throughout the Day and Night: A Questionnaire-Based Survey of Five Countries. J Otol Rhinol 5:5. doi: 10.4172/2324-8785.1000298

Abstract

Objective: Night-time symptoms of upper respiratory tract infection often feel more severe, but it is not known how sore throat symptoms might vary over 24 hours. The aim of the current analysis was to determine any effect of time of day on sore throat symptoms and treatment practices across five countries.

Methods: Adults who had used a sore throat remedy at least once in the preceding 12 months answered a 30-minute questionnaire and then undertook a 7-week diary to document sore throat pain and treatment episodes. Analyses were conducted to investigate effect of time of day on sore throat symptoms, severity, and the use of throat products, as well as differences in functional and emotional needs.

Results: A total of 5000 participants (1000 in each of the UK, Italy, Russia, USA, and Thailand) took part. Sore throat was reported more frequently in the morning and the evening/night-time, while fewer participants reported sore throat in the afternoon; similarly, sore throat products were reported to be taken more frequently in the morning and the evening/night-time.

Conclusion: This survey shows an increased frequency of people reporting sore throat symptoms in the morning and the evening compared with other times of the day. Research is warranted to investigate the potential of a long-acting product such as flurbiprofen for alleviating night-time sore throat (and hence minimising sleep disruption and the impact on next-day functioning).

Keywords: Pharyngitis; Circadian rhythm; Nocturnal; Sore throat; Inflammation; Flurbiprofen; Morning; evening

Keywords

Pharyngitis; Circadian rhythm; Nocturnal; Sore throat; Inflammation; Flurbiprofen; Morning; evening

Introduction

Sore throat (pharyngitis) is usually caused by a self-limiting viral upper respiratory tract infection (URTI) [1], being at its worst in the first few days and generally resolving within a week [2,3]. A range of non-infectious environmental insults (including pollution, temperature, and humidity) can also trigger pharyngeal inflammation, resulting in sore throat [4]. URTIs tend to be seasonal [5,6] whilst environmental sore throat may be persistent/chronic [4]. Symptoms have been reported to reflect the perceived aetiology [7], and are highly individual to each patient [8] varying from mild (described by patients as dry, scratchy, tickly, and itchy throat) to severe (stabbing, sharp pain, and cut throat) [9]. They include sensory (burning, raw, dry, irritated/scratchy, tight, like a lump in the throat, swollen) and functional (husky/hoarse voice, difficulty swallowing) symptoms, and affective descriptors (agonising) [10].
Sore throat can have a considerable impact on quality of life, with patients reporting difficulty swallowing, talking and eating [11] but also emotional effects including frustration and a lack of control [7]. Furthermore, sore throat also results in low energy and an inability to concentrate [7] as well as impaired ability to sleep and work [11]. A lack of energy may in fact be a physiological mechanism to aid recovery from the URTI [12]. Although the terms are often used interchangeably, this malaise (fatigue) is different from tiredness (sleepiness) which eventually results in an uncontrollable urge to sleep [13]. Disrupted sleep is one of the unfortunate consequences of a URTI, especially with a severe night-time cough, blocked nose, or sore throat. Feeling tired and difficulty sleeping are considered highly interfering [14] in terms of their impact on people’s lives, with poor sleep adversely affecting daytime functioning [15] and cognition [16]. The fatigue and tiredness resulting from sore throat therefore has the potential to affect performance and wellbeing the following day.
Anecdotally, night-time symptoms of URTIs often feel more severe, making them a priority for treatment. Although it has not yet been established that sore throat symptoms vary throughout the day, online search activity for sore throat by the general public peaks in the early morning in the UK [17]. The aim of the current analysis was to determine any effect of time of day on sore throat symptoms and treatment practices across five countries.

Methods

A survey was conducted in November and December 2008 across five countries (UK, Italy, Russia, USA, and Thailand). The study aimed to investigate the occurrence and treatment approach of those suffering with sore throat over a 7-week period across multiple countries. Eligible for inclusion were adults (aged 18-70 years, or 18- 65 years in Thailand) who had used a sore throat remedy (medicated or non-medicated) at least once in the preceding 12 months.
The participants each completed a 30-minute questionnaire and were then asked to complete a diary for a maximum of seven sore throat episodes over a 7-week period. For each episode, once all diary entries for a whole day had been completed, one diary occasion was selected at random and more detailed questions asked (a ‘deep dive’). Whilst the 30-minute questionnaire largely required recall of experiences over the previous 12 months, the diary was designed to capture data from current experiences. The content of the questionnaires is described briefly below, and key questions are summarised in Table 1.
Table 1: Summary of key questions from 30-minute questionnaire and diary questionnaire.
Participants were recruited by email and door-to-door. The survey was conducted online in the UK, Italy, Russia, and the USA, following emails sent to panellists (Research Now). In Thailand, the survey was conducted face-to-face (by a TNS-affiliated agency), using a door-todoor method for the main questionnaire, whereupon the diary was left with the respondent for subsequent completion.
The research was conducted in accordance with the Market Research Society Code of Conduct and Data Protection Act of 1998. A small financial incentive was provided to each respondent.
Questionnaire
The 30-minute questionnaire gathered demographic data (including sex, age, employment status, and living situation) and general information on sore throat, treatments, and attitudes.
Diary
During the 7-week diary phase, each participant completed the diary for up to 7 days when they experienced sore throat and/or took a product (selected from a specified country-specific list). The diary took 5 minutes to complete at the end of the day.
The diary prompted respondents to log symptoms and products taken at various times of the day; each answer was logged independently (that is, it was possible to experience symptoms without treatment, and to take products in the absence of symptoms). The times of day categories included: upon first waking up; early morning; late morning; lunchtime; early afternoon; late afternoon; evening; before bed; night-time. The symptom categories were: dry throat; early signs of throat discomfort; scratchy/tickly/itchy throat; husky voice; post nasal drip or catarrh; multiple symptoms; swollen/tight or inflamed throat; prickly throat; lump in throat; throat infection; stabbing/sharp pain in throat; burning and very painful throat; cut throat; other; none of these.
Deep dive
At the end of each day on which the diary was completed, one diary occasion was selected at random for in-depth questions about what treatment had been used, and where, when, and why. The ‘deep-dive’ questions included the severity of symptoms and why the respondent took the product.
Data analysis
The sample for each country was weighted by age and sex to be representative of the entire population.
The data were analysed descriptively to assess effect of time of day on sore throat symptoms, severity, and the use of throat products, as well as differences in functional and emotional needs.

Results

Disposition and demographics
A total of 5070 respondents took part (unweighted, Table 2). The data from 5000 participants who completed the 30-minute questionnaire were analysed, including 1000 in each of the five countries (weighted, see Table 2). Of these, 3364 completed diary entries for a total of 99,191 occasions, and 17,000 of these occasions (3400 in each country) were further interrogated in the ‘deep-dive’ phase.
Table 2: Baseline participant characteristics and demographics.
The study population (mean age 40.1 years) included slightly more females (53%) than males (47%), and the majority were employed and living with other people (Table 2).
Participants in Thailand completed fewer diary occasions than the other four countries (Table 2), suggesting a lower frequency of sore throat symptoms and/or product use during the evaluation period.
Sore throat symptoms
The type of sore throat symptoms varied (n=4867, question G5). When those people that had experienced sore throat in the last 12 months were asked about their symptoms, the participants reported they had experienced dry throat (81%), early signs of throat discomfort (87%), scratchy/itchy/tickly throat (81%), husky voice (68%), post nasal drip/catarrh (62%), swollen/tight/inflamed throat (55%), prickly throat (42%), lump in throat (49%), stabbing/ sharp pain in throat (45%), burning/very painful throat (46%), cut throat (40%), and throat infection (51%), with 3% reporting ‘other’ symptoms. This split of symptoms varied across the five countries, for example dry throat (range 72% in UK to 90% in Thailand and Russia), scratchy/itchy/tickly throat (67% in Russia to 94% in Thailand), swollen/tight/inflamed throat (22% in Thailand to 71% in Russia), stabbing/sharp pain (35% in Thailand to 58% in Russia), burning/very painful throat (30% in Thailand to 70% in Italy), and throat infection (24% in Thailand to 67% in Russia and Italy).
When asked how painful their current sore throat was, it was rated to be most severe (very sore and painful) for 6% of deep-dive occasions overall, with 20% of occasions rated quite sore and painful, 26% not sore but quite irritating, 23% just mildly irritating, 16% uncomfortable, 7% as could be felt but did not irritate, and 2% as couldn’t really be felt (n=15,014, question 4a). Severity was broadly similar across the five countries, with around 50% of all occasions described as irritating in some way (n=15,014, question 4a).
The majority of the most severe current sore throat occasions (very sore and painful/quite sore and painful/not sore but quite irritating [question 4a]) were associated with medicated (61%) rather than non-medicated product use (38%); in contrast, non-medicated product use was more associated with less severe sore throat (just mildly irritating/uncomfortable [28% medicated versus 35% nonmedicated] or can feel it but it doesn’t irritate/can’t really feel it [4% medicated versus 8% non-medicated]) (n=17,000).
Effect of time of day on symptoms
Sore throat symptoms varied throughout the day. When asked what time of day they had suffered sore throat over the previous 12 months, it was more frequent in the early morning and evening across all five countries (Figure 1) (n=4867, question G4). Overall, 39% of participants reported sore throat upon waking and 30% in the early morning, while 29% reported sore throat in the evening, 23% before bed and 21% at night-time (Table 3). This split was broadly similar across the countries (Figure 1).
Figure 1: Time of day when participants reported experiencing sore throat, based on previous 12 months (n=4867, 30-minute questionnaire, question G4). Multiple answers were allowed.
Table 3: Time of day when participants reported experiencing sore throat and taking products, based on previous 12 months for the whole population.
Of the current symptoms participants experienced, dry throat was more frequent upon first waking (data not shown).
Irrespective of the symptom descriptors they used, when asked how painful their current sore throat was, it was rated to be most severe (very sore and painful/quite sore and painful/not sore but quite irritating) for 53% of deep-dive occasions upon first waking, 53% for early mornings, 58% at lunchtime, 54% in the evening, 59% before bed, 57% at night, and for 48-50% of occasions at other times of the day (Figure 2) (n=15,014, question 4a). Less severe sore throat (just mildly irritating/uncomfortable or can feel it but it doesn’t irritate/ can’t really feel it) was most prominent in the late morning and during the afternoon (Figure 2). This split of severity ratings throughout the day was broadly similar across the five countries (data not shown).
Figure 2: Time of day effects on how participants described the severity of current sore throat (n=15,014, deep-dive, question 4a). Only one answer was allowed. Groups created by summing responses for the different symptoms.
Effect of time of day on product use
As might be expected, sore throat product use over the previous 12 months was reported to be more frequent in the morning and evening (Figure 3) (n=4834, question B3). Overall, 25% of participants reported taking products upon waking and 27% in the early morning, while 29% took them in the evening, 28% before bed and 17% at nighttime (Table 3). Medicated product use was more prominent than nonmedicated product use upon waking and in the early morning, as well as before bed, with a greater proportion of participants reporting they had used only medicated products over the last 12 months (n=1012) compared with only non-medicated products (n=360), saying they used products at these times of day (Figure 4).
Figure 3: Time of day when products were reported to be taken, based on the previous 12 months (n=4834, 30-minute questionnaire, question B3). Multiple answers were allowed.
Figure 4: Time of day when products were reported to be taken, based on a subset of participants who reported only medicated (n=1012) or non-medicated (n=360) product use over the previous 12 months (30-minute questionnaire, question B3). Multiple answers were allowed.
The top five functional reasons given for currently taking a sore throat product included lubricates throat and keeps it moist (47% of deep-dive occasions), has a pleasant taste/flavour (45%), stops the irritation/tickle (45%), soothes sore throat (40%), and is easy to take on the move/at work (34%) (n=14,858, question 8a). These were the top five functional reasons whatever the severity of sore throat, but the rank order differed for those participants reporting the most severe sore throat (very sore and painful/quite sore and painful/not sore but quite irritating) with soothes sore throat (47%) and stops the irritation/tickle (47%) clearly more important in this group (compared with lubricates throat and keeps it moist (40%), has a pleasant taste/ flavour (35%), and is easy to take on the move/at work (29%) the rank order was largely consistent with the overall group for less severe sore throat. Medicated product use (43%) rather than non-medicated product use (37%) was more prominently associated with soothes sore throat, whereas non-medicated product use was more frequent for the other functional reasons. The functional reasons did not vary much throughout the day (Figure 5), although the convenience aspect was less frequent in the evening (when people might be expected to be at home).
Figure 5: Variation across the day in the top 5 functional reasons for currently taking sore throat products (n=14,858, deep-dive, question 8a, for which multiple responses were requested: Which of the following describes what was important for you when you chose to take [the product you took]).
The top 5 emotional reasons given for currently taking a sore throat product included a sense of relief (54% of deep-dive occasions), comforted (41%), in control of my sore throat (40%), takes my mind off irritation/pain (38%), and I am doing something to prevent it from getting worse (32%) (n=14,858, question 8c). This rank order was largely unaffected by severity of sore throat, although for those with the most severe sore throat (very sore and painful/quite sore and painful/not sore but quite irritating), the emotional reason ‘comforted’ (35%) was ranked lower – after a sense of relief (55%), in control of my sore throat (48%), takes my mind off irritation/pain (44%), and I am doing something to prevent it from getting worse (36%). The emotional reasons did not vary much throughout the day (data not shown), although the prevention of worsening aspect was less frequent in the middle of the day (when people might be expected to be occupied with work). Medicated product use rather than nonmedicated product use was more prominently associated with doing something to prevent it getting worse (38% versus 27%) and in control of my sore throat (45% versus 35%). In contrast, there was little difference between medicated and non-medicated products for most of the other emotional reasons with the exception of comforted (34% medicated versus 49% non-medicated).

Discussion

This survey shows an increased frequency of people reporting sore throat symptoms – which can be described in a variety of ways, such as sore, irritating, uncomfortable, or just ‘felt’ – in the morning and the evening compared with at other times of the day, and appears to be the first study to investigate this.
These data suggest that people may experience sore throat more often and/or may find their symptoms most bothersome at these times of day; there may also be increased severity at night, although this is hard to establish definitively from this type of data. It is feasible that sore throat symptoms could feel worse at night/upon first waking due to snoring [4] or throat dryness. Lying flat can exacerbate any nasal congestion, causing mouth breathing and consequently dehydration of already inflamed pharyngeal membranes [4]. Nasal or sinus drainage down the back of the throat during the night can also irritate it. Furthermore, swallowing is reduced during sleep [18] reducing salivary flow over the pharynx and mucociliary clearance is decreased [19], which could compromise barrier function. The inflammation underlying both infectious and environmental sore throat [4] may be heightened at night, resulting in more severe symptoms, because it is known that the circadian clock regulates the immune system [20] and affects inflammation [21], and a nocturnal exacerbation of symptoms has been observed in other immune and inflammatory conditions [22,23]. Hence, with heightened inflammation at night, sore throat symptoms may actually be worse in the morning, although taking into account the potential confounding factors (snoring, dehydration) it is difficult to establish causality. There may be other factors in nighttime worsening too, including fewer distractions from the pain and reduced frequency of treatment administration. Whatever the underlying causes for night-time worsening of sore throat or the increased awareness of it, pain during the night has considerable potential to disrupt sleep and hence impact on performance, activities, and well-being the following day.
Although the findings for the five countries were broadly in agreement in terms of symptom prevalence at different times of day, there are differences evident in the data. Compared with the other countries, morning and evening symptoms were particularly frequent in Thailand compared with the afternoon, whilst in the USA; daytime symptoms were relatively more prominent (Figure 1). These differences probably originate from the different climates and environments, and sore throat of different aetiologies. For example, sore throat due to pollution may be worse at times of the day when traffic is heaviest, whereas sore throat due to allergy may reflect peaks in pollen. It is feasible that with a relatively constantly warm annual climate, participants in Thailand were afflicted more with environmental sore throat compared with the URTIs that are common in more seasonal climates (such as the UK). The most severe sore throat symptoms are attributable to infection [7]. In the current study, participants in Thailand reported the lowest frequency of ‘throat infection’ but a high frequency of dry throat. The underlying aetiology of sore throat was not established in this study, but it is likely that since it was conducted in November/December the majority of sore throat in the seasonal climates was due to URTI, whilst very cold/dry weather [4] could be a factor in Russia, and in Thailand there may have been a relatively higher frequency of environmental sore throat.
As might be expected, sore throat product use reflected the occurrence of symptoms and was reported to be more frequent in the morning and evening across the five countries. There were a range of functional and emotional reasons that participants gave for taking products, and these did not vary much across the day. The variety of symptoms experienced is likely to be a factor in the range of functional and emotional reasons given for taking products. With many people experiencing throat irritation, for example, their need for a lubricating product becomes clear. In fact, medicated products were frequently taken for soothing sore throat symptoms, doing something to prevent it getting worse and for gaining control of sore throat – and were particularly prominent when sore throat was most severe.
Sore throat symptoms are individual to each patient [8] and this survey also found a range of attitudes to products. Treatment choices will be driven not only by symptoms – especially severity [9] – but also by individual attitudes and lifestyles. The needs of patients with sore throat are likely to change throughout the day. For example, whilst convenience may be a primary consideration during working hours, it is intuitive that a long-lasting solution may be particularly relevant for night-time symptoms when re-dosing is less practical or not wanted. It comes as no surprise that the current data suggest that medicated product use is frequent before bed, a likely reason being an attempt to control symptoms to enable sleep. There is a range of sore throat treatments and formulations available over the counter, including lozenges, gargles and sprays, each with different attributes, to cater to these various needs. Some, such as sprays, may be more suitable for night-time use especially if they are sugar-free. The products differ not only in format but also in active ingredients, including local anaesthetics, anti-inflammatories, analgesics, and antimicrobial agents [24], and these too have different attributes. Those with a longlasting duration of effect may be more appropriate when dosing is less frequent (for example, overnight). An anti-inflammatory may be particularly useful for infectious and non-infectious sore throat [4] even if symptoms are severe, whilst a short-acting soothing action may be sufficient for milder symptoms or throughout the day. A sugar-free sore throat spray containing the nonsteroidal anti-inflammatory drug flurbiprofen is a long-lasting treatment option. Flurbiprofen (8.75 mg) delivered to the throat has proven efficacy for sore throat including that associated with streptococcal infection [25-27], and reduces not only throat soreness but also the sensory (burning, raw, dry, irritated/ scratchy, tight, like a lump in the throat, swollen), functional (difficulty swallowing, husky/hoarse voice) and affective (agonising) qualities of throat pain [28]. In a spray format, flurbiprofen can relieve soreness, difficulty swallowing, and swollen throat for up to 6 hours [29]. The potential for alleviating sleep disruption with proper control of URTI symptoms has not been systematically studied, but the potential is clear. In fact, unpublished data support the use of flurbiprofen spray in the morning and evening, with over one-half of 100 German users reporting its use at these times of day (58% in the morning and 53% in the evening, compared with 7–38% at other times of day) (unpublished data on file).
The large sample size of the current study lends confidence to the findings. Weighting the sample to reflect the demographics of each country provided an equally sized sample for each, which reflected the wide age range in the general population. The five countries studied vary widely in terms of climate, culture, ethnic groups, and sore throat treatment practices which further generalises the findings. The study has some limitations, however. The respondents were rewarded for participating, which may have biased the results, and the survey did not take into account any co-morbidity. Although these data are from fieldwork conducted in 2008, it is expected that the trends would not be dramatically different from today in the countries studied.
In conclusion this study has shown that sore throat is more frequently reported in the morning and evening. Further studies will be required to determine if symptom control overnight can improve sleep and daytime functioning.

Acknowledgments

The survey and data collation was completed by Clear-ideas (London, UK) and funded by Reckitt Benckiser Healthcare International Ltd (Slough, UK). Medical writing assistance was provided by Kim Russell at Elements Communications Ltd (Westerham, Kent) and was funded by Reckitt Benckiser Healthcare International, Ltd (Slough, UK).

Study Funding

The study was funded by Reckitt Benckiser Healthcare International Ltd (Slough, UK)

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