Miss N Su
To cover the broad topic of “sore throat”,
focusing on conditions of the oropharynx
Accidental biting, other trauma and burns all
cause mouth ulcers.
These should heal within 7-14 days
Any patient with a single mouth ulcer
persisting for greater than 2-3 weeks should
have it further investigated.
Common, reoccurring episodes of ulcers,
usually from childhood or adolescence
Aggravating factors: stress, trauma, cessation
of tobacco smoking
10-20% have an underlying haematological
pathology
Recurrent aphthous stomatitis plus genital
ulceration and eye disease
Genetic background
Males 30-40yrs most commonly affected
Treated with colchine, steroids and
immunosuppressants
Herpes simplex virus
Herpes zoster (look for immunocompromise
in young patients
EBV
Coxsaccie virus (herpangia or hand foot and
mouth)
During what stage of syphilis would you find
oral ulceration?
Primary syphilis – primary hard or huntarian
chancre
Secondary – mucous patches and snail track
ulcers
Tertiary – localised granulation - gumma
Rare but can present with oral lesions-
ulceration of dorsum of tongue described as
an irregular ulcer with a granulating base.
Looks similar to and SCC
Overlaps with the common cold, mild form
with low grade fever is assoc with rhinovirus,
coronavirus and RSV.
More severe form is assoc with fever, sore
throat, malaise, pharyngitis and cervical
lymphadenopathy – caused by adenovirus,
influenza virus, enterovirus, EBV, herpes
simplex and HIV
6 yr old boy
48hr history of sore throat, pyrexia and
malaise
O/E T 38.5 , bilateral tender cervical
lymphadenopathy and enlarged erythematous
tonsils.
Bacterial
◦ Group A beta-haemolytic streptococcus
◦ Groups C and G beta-haemolytic streptococcus
Viral
◦ Rhinovirus
◦ Corona virus
◦ Respiratory syncytal virus
◦ Parainfluenza
◦ EBV
Fungal
◦ Candida albicans
Supportive treatment with fluids
Calpol
?antibiotics
Need to avoid aspirin due to risk of Reye's
syndrome
Avoid ampicillin
Rheumatic fever
0.3% of untreated
Pxs
Post strep
glomerulonephritis
Abscess formation
Septacaemia
Acute OM /
mastoiditis
Lemierre syndrome
Rheumatic fever occurs in 0.5-3% of ineffectively
treated patients with GABHS.
Occurs approx 20 days after the sore throat.
Diagnosed on the presence of 2 major criteria,
or 1 major criteria and 2 minor criteria
Major criteria Minor criteria
Polyarthritis Fever
Carditis High ESR
Subcutaneous skin Joint pain
nodules
Sydenham chorea
Erythema marginatum
Antibiotics should not be used to routinely
prevent from developing RF or
glomerulonephritis
Antibiotics do improve symptom control, but
only marginally compare to simple analgesia-
increased benefit in symptoms occurred 16
hours earlier in patients given antibiotics
Age range 14-25yrs
Tonsillitis with thick exudate and palatal
petechiae .
Up to 50% develop splenomegally
5% have a rash, this will increase to 90% if
given ampicillin or amoxicillin.
Treatment is largely supportive, can lead to
airway compromise requiring tonsillectomy or
even tracheostomy
Name 3 different
causes of exudate
on the tonsils
How can you tell
these conditions
apart?
Glandular fever
Vincent’s angina
Diphtheria
If you scrape the exudate off in diphtheria the
underlying mucosa bleeds, the underlying
mucosa in Vincent’s is erythematous but
doesn’t bleed.
Present in the unimmunised population
Causes a greyish exudate extending
from the tonsils to soft palate
Spreads via respiratory droplets and
infected objects or food
Mortality rate remains 5-10%
Toxins can cause cardiac and neural toxicity
Treatment involves antitoxin and penicillin or
erythromycin
Primary HIV infection can cause an acute
retroviral syndrome:
Fever
Non-exudative pharyngitis
Arthralgia
Malaise and lethargy
Macculopapular rash in 40-80%
Idiosyncratic drug reaction, may present with
fever and sore throat.
Diagnosed on FBC
Drugs implicated:
◦ Antiepileptics
◦ Antithyroid drugs
◦ Antibioitcs – penicillin, chloramohenicol, co-
trimoxale
◦ Cytotoxic drugs
◦ Gold
◦ NSAIDs
◦ Some anti-depressants and anti-psychotics
All forms may present with nonspecific
sloughing ulcers on the gums, oral cavity and
pharynx and possible cervical
lymphadenopathy
Diagnosis is based on blood film and bone
marrow examination
What is the differential diagnosis?
Malignancy - asymmetry in normal tonsil – in
the absence of cervical lymphadenopathy has
a 7% risk of malignancy
Chance or malignancy if mucosa abnormality
or lymphadenopathy is very high
Rare tumours
◦ Extramedullary plasmacytomas
◦ Hodgkin’s disease
◦ Leukaemia and metastatic deposits
Infection- candida and actinomycosis
Quinsy /parapharyngeal space mass
What is the differential diagnosis?
Neoplastic – SCC, salivary gland tumours,
lymphoma, melanoma, myeloma
Infection – acute strep inf, quinsy, diphtheria,
EBV and CMV mononucleosis and Vincent's
angina
Chronic- syphilis, TB and AIDs
Blood disorder- agranulocytosis, leukaemia
Miscellaneous: aphthous ulceration, Bechet’s
syndrome, colloidal bismuth intoxication
Indications for tonsillectomy for recurrent
tonsillitis
sore throats are due to tonsillitis;
the episodes of sore throat are disabling and
prevent normal functioning.
Seven or more episodes in the preceding year
Or five or more episodes of sore throat per
year for 2 years
3 or more episodes for the last 3 years
Asymmetrical adult
For obstructive sleep apnoea (OSA) in children in
conjunction with adenoidectomy is a well-recognized .
In adults with gross tonsil hypertrophy and OSA, or as part
of uvulopalatopharyngoplasty (UPPP) or laser-assisted
uvulopalatoplasty.
Severe haemorrhagic tonsillitis.
Severe infectious mononucleosis with upper airway
obstruction.
Large symptomatic tonsoliths (tonsillar concretions).
As long-term management of IgA nephropathy. The long-
term prognosis is no longer regarded as benign but with
pulsed steroid therapy and tonsillectomy significant
increases in clinical remission rates can be obtained (25
percent with tonsillectomy, 13 percent without) also with
significant increases in renal survival.49, 50, 51, 52
bacterial Group A beta-haemolytic strep
Groups C and G beta haemolytic strep
Arcanobacterium hemolyticum
Neisseria gonorrhoeae
Mycoplasma pneumoniae
Chlaymidia pneumoniae
Corynebacerium diptheriae
Viral Rhonovirus
Corona Virus
Influenza virus
Respiratory Synctal Virus
Para influenza virus
Epstein-Barr Virus
HIV
Funga; Canadida albicans
History of long standing sore throat and
discomfort of variable severity.
Possible aetiology:
Heavy smoking
Chronic rhinosinusitis with increased post
nasal drip
Laryngeal pharyngeal reflux
Poor dental hygiene
Chlamydia pneumonia