I have a recurrent, intense "pinching" pain in the back of my throat, which starts most often at night and gets worse the next day. My throat doesn't look inflamed, but it hurts intensely to swallow or even move my tongue. I do not have a runny or stuffy nose, fever or body aches. I am, however, tired and lethargic. What can it be? I am in my 30s and have had three ulcers, although am asymptomatic most of the time and take Zantac (ranitidine) only periodically. I have no acid reflux. Any information would be appreciated.

A.N.

There's a devilish test for acid reflux known as a double pH probe study. In this test, a long tube is placed into your nose; it extends down the back of your throat, into your esophagus, almost all the way to your stomach. There are two sensors for pH (acidity); one is positioned close to the bottom of the probe (near the junction between the esophagus and stomach) and one closer to the top of the esophagus. These sensors record sudden drops in pH, which correspond to acid traversing up the esophagus -- acid reflux, in other words. Here's the truly devilish part: The probe stays in place for 24 hours!
When this test was initially evaluated, many "normal" individuals (people who denied they had symptoms of acid reflux) volunteered for the study. A large number of these "normal" folks actually had severe reflux! We now realize that many patients with significant gastroesophageal reflux disease, or GERD, have symptoms other than the classic heartburn -- including hoarseness, chronic throat-clearing, globus sensation, chronic dry cough and, yes, throat pain.

I'm not saying you have GERD; I'm only saying that a person in her 30s who has had three ulcers could easily have GERD.

What if it's not GERD -- what else could it be? Here are a few possibilities:

• Chronic pharyngitis. Specifically, chronic tonsillitis and/or adenoiditis could present in the fashion that you describe. Treatment would involve appropriate medications AND avoidance of other irritants. Occasionally, adults with chronic tonsillitis/adenoiditis may require a tonsillectomy/adenoidectomy to relieve their problems.
  
• Chronic sinusitis. The crud that drains from chronically infected sinuses is very irritating to the throat. Since it drains from the nasal cavities, it hits all parts of the pharynx, including the nasopharynx ("roof of the throat"). This drainage is often more problematic at night (but bear in mind that GERD is also more problematic at night).
  

• Exposure to irritants. Have you noticed any association with alcohol or tobacco use? Do you get this problem only after you have been exposed to particular fumes (cleaning fluids, paints and so forth)? Do you live in a smoggy area?
  
• Allergic rhinitis. Like chronic sinusitis, allergic rhinitis can lead to postnasal drainage, and the mucus that drains down your throat may be causing your symptoms.
  
• Dehydration. Sounds obvious, but dehydration is a commonly missed contributing factor to chronic irritation of the throat or nose. Unless you have a medical condition that limits your ability to drink lots of fluids (such as congestive heart failure or kidney failure), you should try to drink eight to 10 eight-ounce glasses per day of noncaffeinated, nonalcoholic beverages -- more if your work involves physical labor. If you have any questions as to whether it is safe for you to do this, ask your doctor.
  

• Food allergy. This is not common, but is also rarely thought of and rarely diagnosed. Careful attention to the relationship between your diet and your symptoms is necessary to figure this one out. Keeping a "symptom diary" is helpful.
  
• Multiple factors. Many of the above conditions are quite common. Thus, it is not uncommon for an individual to have several of these conditions. If one condition (such as GERD) is detected, the doctor must still consider whether other conditions may also be present. A poor response to treatment could indicate that the diagnosis was incorrect, but it could also indicate that coexisting problems were not effectively treated.
  
• A good general practitioner could help you sort through this, as could a good ear, nose and throat doctor.