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Probability diagnosis

Viral pharyngitis

Epstein–Barr mononucleosis (glandular fever)

Streptococcal (GABHS) tonsillitis

Chronic sinusitis with postnasal drip

Oropharyngeal candidiasis

Serious disorders not to be missed


  • angina

  • myocardial infarction


  • cancer of oropharynx, tongue

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


  • acute epiglottitis (children and adults)

  • peritonsillar abscess (quinsy)

  • pharyngeal abscess

  • diphtheria (very rare)


Pitfalls (often missed)

Foreign body (e.g. fish bone)

Epstein—Barr mononucleosis (glandular fever)


  • common in infants

  • steroid inhalers


  • gonococcal pharyngitis

  • herpes simplex (type II)

  • syphilis

Irritants (e.g. cigarette smoke, chemicals)

Reflux oesophagitis → pharyngolaryngitis


Cricopharyngeal spasm

Kawasaki disease

Chronic mouth breathing

Aphthous ulceration


Glossopharyngeal neuralgia


  • scleroderma

  • Behçet disease

  • sarcoidosis

  • malignant granuloma

  • tuberculosis

Masquerades checklist


Diabetes (Candida)

Drugs (e.g. NSAIDS, cytotoxics)

Anaemia (possible)

Thyroid disorder (thyroiditis)

Spinal dysfunction (cervical referred pain)

Is the patient trying to tell me something?

Unlikely, but the association with depression is significant.

Key history

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.

Key examination

  • 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

Key investigations


  • throat swab

  • FBE

  • mononucleosis test

  • blood sugar

  • biopsy of suspicious lesions.

Diagnostic tips

  • 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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