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Probability diagnosis

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Viral pharyngitis

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Epstein–Barr mononucleosis (glandular fever)

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Streptococcal (GABHS) tonsillitis

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Chronic sinusitis with postnasal drip

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Oropharyngeal candidiasis

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Serious disorders not to be missed

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Cardiovascular:

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  • angina

  • myocardial infarction

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Neoplasia/cancer:

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  • cancer of oropharynx, tongue

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Blood dyscrasias (e.g. agranulocytosis, acute leukaemia)

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Infection:

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  • acute epiglottitis (children and adults)

  • peritonsillar abscess (quinsy)

  • pharyngeal abscess

  • diphtheria (very rare)

  • HIV/AIDS

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Pitfalls (often missed)

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Foreign body (e.g. fish bone)

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Epstein—Barr mononucleosis (glandular fever)

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Candida:

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  • common in infants

  • steroid inhalers

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STIs:

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  • gonococcal pharyngitis

  • herpes simplex (type II)

  • syphilis

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Irritants (e.g. cigarette smoke, chemicals)

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Reflux oesophagitis → pharyngolaryngitis

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Tonsilloliths

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Cricopharyngeal spasm

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Kawasaki disease

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Chronic mouth breathing

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Aphthous ulceration

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Thyroiditis

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Glossopharyngeal neuralgia

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Rarities:

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  • scleroderma

  • Behçet disease

  • sarcoidosis

  • malignant granuloma

  • tuberculosis

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Masquerades checklist

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Depression

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Diabetes (Candida)

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Drugs (e.g. NSAIDS, cytotoxics)

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Anaemia (possible)

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Thyroid disorder (thyroiditis)

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Spinal dysfunction (cervical referred pain)

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Is the patient trying to tell me something?

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Unlikely, but the association with depression is significant.

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Key history

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First determine whether the patient has a sore throat, a deep pain in the throat or neck pain. Enquire about relevant associated symptoms such as a metallic taste in the mouth, fever, upper respiratory infection, postnasal drip, sinusitis, cough and other pain such as ear pain. Note whether the patient is an asthmatic and uses a steroid inhaler or is a smoker or exposed to environmental irritants.

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Key examination

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  • On inspection note the general appearance, look for toxicity, the anaemic pallor of leukaemia, the nasal stuffiness of infectious mononucleosis or the halitosis of a streptococcal throat

  • Palpate the neck for soreness and lymphadenopathy and check the sinus area

  • Then inspect the oral cavity and pharynx

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Key investigations

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Consider:

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  • throat swab

  • FBE

  • mononucleosis test

  • blood sugar

  • biopsy of suspicious lesions.

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Diagnostic tips

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  • Tonsillitis with a covering membrane may be caused by Epstein–Barr mononucleosis.

  • Admit if any suspicion of epiglottitis—and do not examine the throat.

  • The triad-hoarseness, pain on swallowing and referred ear pain → pharyngeal cancer.

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