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least briefly consider several more serious disorders ( Fig. 74.2 ). Conditions that
have immediate life-threatening potential include epiglottitis, retropharyngeal and
lateral pharyngeal abscesses, peritonsillar abscess, severe tonsillar hypertrophy
(usually as an exaggerated manifestation of infectious mononucleosis), and
diphtheria. Generally, ill appearance, stridor, and signs of respiratory distress
accompany the complaint of sore throat in epiglottitis and in some cases of
retropharyngeal abscess. Drooling and voice changes are common in children
with these two conditions, as well as in patients with peritonsillar abscess and
severe infectious tonsillar hypertrophy. In cases of epiglottitis or retropharyngeal
abscess that are not clinically obvious, a lateral neck radiograph, obtained under
appropriate supervision can be confirmatory. Peritonsillar abscess and tonsillar
hypertrophy are diagnosed by visual examination of the pharynx. Diphtheria is
rarely a consideration except in unimmunized children, particularly those from
underdeveloped nations.
The next phase of the evaluation of the child with a complaint of sore throat
hinges on a careful physical examination, particularly of the pharynx ( Fig. 74.3 ).
The appearance of vesicles on the buccal mucosa anterior to the tonsillar pillars
points to a herpetic stomatitis or noninfectious syndromes such as Behỗet or
StevensJohnson syndrome (erythema multiforme). Uncommonly, a small,
pointed foreign body, most commonly a fishbone, becomes lodged in the mucosal
folds of the tonsils or pharynx; usually, the history suggests the diagnosis, but an
unanticipated sighting may occur in the younger child. Significant asymmetry of
the tonsils indicates a peritonsillar cellulitis or, if extensive, an abscess. Clinically,
the diagnosis of an abscess is reserved for the tonsil that protrudes beyond the
midline, causing the uvula to deviate to the uninvolved side in a patient with
trismus. Kawasaki disease produces a systemic syndrome with a prolonged fever
and other characteristic findings that are usually more prominent than the
pharyngeal involvement.
The remaining organic diagnoses, once those already discussed have been
eliminated by history, physical examination, and occasionally imaging, include
referred pain, irritative pharyngitis, and infectious pharyngitis. Sources of referred

pain (e.g., otitis media, dental abscess, and cervical adenitis) are usually identified
during the examination. Irritative pharyngitis seen most commonly during the
winter among older children who live in homes with forced hot-air heating,
produces minimal or no pharyngeal inflammation. It often is transient, appearing
upon awakening and resolving by midday.
Infectious pharyngitis ( Fig. 74.3 ) evokes a spectrum of inflammatory
responses that range from minimal injection of the mucosa to beefy erythema