10.23 Diseases of the Throat

Recognise and distinguish the common causes of oral ulceration
Assoc w systemic disorder
 IBD (Crohns / UC)
 Coeliac disease
 Systemic / discoid lupus
 Behçets disease
 Neutropenia
 Immunideficiency
 Reiters disease
 Stevens-Johnsons syndr
 Starchans syndrome
Assoc w dermatologic dis.
 Lichen planus
 Dermatitis herpetiformis
 Erythema multiforme
major
 Toxic epidermal necrolysis
 Pemphigus vulgaris
 mucous membr pemphigoid
Assoc. w viral infection
 Herpes simplex I/II
 Coxsackie (hand, foot and
mouth disease)
 Zoster (chickenpox)
 Cytomegalovirus
Assoc w drugs
 antimalarials
 Methyldopa
 Tolbutamide
 Penicillamine
 Gold salts
Assoc w deficiency
 Iron
 B12
 Folate
 Vitamin C
Others
 Syphilis infection
 Tuberculosis infection
 Trauma (ill-fitting
dentures, toothbrushing,
sharp teeth)
 Neoplasm (SCC)
Those in bold are more likely to be causes of oral ulceration
History: GI symptoms, rashes, drug history, dietary history, dentures, fever / sweats etc.
Examination: rashes, pallor, oral cavity including floor of mouth and entire surface of tongue.
SCC produces indurated aphthous ulcers with raised and rolled edges, usually on the floor of the
mouth or lateral borders of the tongue.
Background box: diseases causing oral ulceration
Behcet's syndrome is a chronic multisystem venulitis of unknown aetiology. It is characterised by:
recurrent oral and genital ulcers, arthritis, iritis, and neurological disease. It is three times more
common in males than females.
Pemphigus: This is a group of conditions that are characterized by the formation of blisters within the
epidermis of both skin and mucous membranes. Current evidence suggests that there is an
autoimmune basis. Incidence is slightly higher in women, and in Asians and Jews. Peak onset is
between 60 and 70 years of age.
Reiters disease is a reactive arthritis and comprises a triad of symptoms: urethritis, conjunctivitis and
a seronegative arthritis. Two broad subtypes are recognised: an enteric form related to
gastrointestinal infection and a genital form related to sexual activity.
Erythema multiforme is a term describing target lesions - circular lesions often with central blister with
a symmetrical peripheral distribution, usually on limbs.
Stevens Johnson syndrome is a severe and sometimes fatal form of erythema multiforme. There are
often mouth, genital and eye ulcers and fever. There is a higher incidence in children and young
adults, and it is twice as common in males than females. There may be pulmonary, gastrointestinal,
cardiac or renal involvement.
Strachans syndrome is the combination of: orogenital ulceration, sensory neuropathy, and amblyopia.
The aetiology is unknown.

Recognise and manage tonsillitis
The tonsils and adenoids are aggregates of
lymphatic tissue within the oral cavity - they form
what is known as Waldeyers ring (see pic right).
Tonsillitis may occur at any age but is most
common under 9 years old, in winter and spring.
Spread is by droplet infection with 50-85% of cases
probably being viral.
Symptoms include: sore throat and dyspahgia;
earache (referred otalgia); headache and malaise.
Signs include: Pyrexia (may be high); enlarged
hyperaemic tonsils (may exude pus); inflamed
pharyngeal mucosa; foetor; and cervical
lymphadenopathy.
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The management of tonsillitis is as follows
Bed rest
High fluid intake
Soluble paracetamol (or aspirin in adults) held in
the mouth and then swallowed.
Antibiotics if severe. Injected penicillin followed
by 10 days orally is usual treatment of choice.
Important differentials include: infectious
mononucleosis, scarlet fever, diphtheria, HIV.
Sore throat + malaise + pyrexia
+/- cervical nodes
 odynophagia/ dysphagia
Pain may be referred to the ear via the glossopharyngeal nerve
Halitosis
Mouth breathing
If dysphagia is severe & limiting oral intake of food/liquid ADMIT
If TRISMUS/ Drooling/ Hot potato voice = peritonsillar abscess
Organisms
Viral (~70%):
 HSV (red, swollen tonsils. May have aphthous ulcers on their surfaces)
 Cytomegalovirus
 Adenovirus
 Measles virus
 EBV (with palatal petechiae) may cause tonsillitis in the absence of mononucleosis. Common
in young children. A grey membrane may cover tonsils
Consider infectious mononucleosis (MN) due to EBV in adolescents/ young children with acute
tonsillitis, particularly when tender cervical, axillary, and/or inguinal nodes; splenomegaly; severe
lethargy and malaise; and low-grade fever accompany acute tonsillitis.
Bacterial (~15-30%)
 Group A ß haemolytic Strep (pyogenes)
 Strep pneumonia
 H. influenzae
 S. aureus
 Bacteriodes fragilis (recurrent tonsillitis)
Viral & bacterial causes difficult to discern clinically
Tonsils may be covered in white plaques in bacterial infections
Differential
Peritonsillar abscess
Infectious mononucleosis
Diphtheria
Scarlet fever (RARE): Strep tonsillitis + punctuate erythematous rash, whiteness around mouth +
strawberry & cream tongue)
Investigations
Blood: FBC, WCC, ESR, U&E
Throat swab
Monospot test
Blood culture
Rx.
Rest
Encourage fluids
Soluble paracetamol
Penicillin 500mg TDS 10days
NOT AMOXICILLIN: this causes a rash in infectious mononucleosis
Admit if fluid & oral intake is significantly restricted or quinsy present
Inpatient Rx
IV FLUIDS
Analgesia
Oral morphine
Ibuprofen
Paracetamol (IV if necessary)
ABx: Benzylpenicillin 1.2mg QDS (<300mg/min) & Metronidazole (500mg/8hs)
Steroids: Prednisolone/IV hydrocortisone if necessary
Recurrent tonsillitis
Likely to be disrupting school/ ADL (takes up to 2 weeks to fully recover)
Long term low dose ABx: (250mg penicillin) or start course with each cold if child always gets
tonsillitis with colds
Tonsillectomy if:
 7 attacks in 1 year
 5 in each of the last 2 years
 3 in each of the last 3 years
 Airway obstruction
 Quinsy
Discuss pros & cons with patient/parents
Complications
 Hemorrhage
 Infection of tonsillar fossa
 Otitis media
(Pulmonary abscess/ Pneumonia)
Due to aspiration of blood/tissue (RARE)

Recognise quinsy
Quinsy is the name given to a peritonsillar abcess
(see pic right). This abcess is usually a complication
of acute tonsillitis and is more common in adults. Pus
collects in the space between the tonsil and the
pharyngeal tonsil and causes:
 fever
 pain
 dysphagia
 referred otalgia
 trismus (difficulty opening the mouth).
Note the displaced uvula (which may be very
oedematos) and tonsil.
Systemic antibiotic is strongly indicated without
delay together with incision to drain the abcess if
much trismus is present. In young children this should
be done under general anaethesia. A tonsillectomy is
often carried out six weeks post drainage.
Pus outside the tonsillar capsule. Complication of
strep tonsillitis
Severe tonsillitis + trismus +/- halitosis & drooling
Hot potato voice due to pharyngeal oedema
Patient continues to become more ill despite ABx.
Severe dysphagia (sometimes unable to swallow
saliva)
Referred earache common
Complications: parapharyngeal abscess 
mediastinitis
Rx
Admit to hospital  drainage (never attempt in GP due to proximity of the external carotid artery)
IV Fluids & solid food when able
IV Penicillin/erythromycin + metronidazole (usually marked improvement in 12 hrs)
Consider tonsillectomy in 6 weeks