Differential diagnoses - Oral and throat infections

Dr Nigel Stollery compares four presentations and offers clues for their diagnosis.

Oral thrush


  • Thick white plaques on the buccal mucosa
  • Contact bleeding seen when removal attempted
  • May affect any area of the mouth or throat
  • More common in patients who are immunocompromised
  • Often associated with steroid inhaler use
  • If diagnosis is in doubt, a swab can be helpful


  • Treatment is usually with a topical antifungal preparation
  • If related to inhaler use, rinsing or a spacer can be helpful
  • If recurrent, check immune status, HIV and fasting blood sugar level

    Bacterial tonsillitis


    • Very common throat infection caused by streptococcus
    • Most common in five to 10 and 15-25 year age groups
    • Most cases present with pain, often referred to the ears, problems swallowing, lymphadenopathy and headache
    • Children may also complain of abdominal pain


    • Centor criteria may aid diagnosis: fever, exudates, anterior cervical nodes, no cough
    • Paracetamol and ibuprofen can be helpful
    • NICE advises antibiotics if marked systemic upset, unilateral peritonsillitis, history of rheumatic fever, diabetic or immunocompromised



      • Inflammation of the throat, most commonly caused by adenovirus
      • 40-80% caused by viruses
      • May be accompanied by systemic illness, with fever, cough, abdominal pain
      • Very common condition, especially in winter months
      • If aetiology is in doubt, a throat swab can be helpful to detect presence of streptococcus


      • Treat symptomatically with analgesia and fluids
      • Topical analgesia can be helpful, for example, spray or lozenges
      • In severe cases, steroids can be helpful

        Glandular fever


        • Signs can be very similar to those of tonsillitis
        • Caused by Epstein-Barr virus
        • Lymphadenopathy may be present in sites away from the cervical chain
        • Fever may last 10-14 days
        • Chronic fatigue common (may last >1 month in 9-22% of cases)
        • Spread by saliva, so outbreaks and contacts often reported
        • Most common in children and younger adults


        • Self-limiting condition
        • Symptomatic treatment may be helpful, including paracetamol and ibuprofen

        Dr Stollery is a GP in Kibworth, Leicestershire, and clinical assistant in dermatology at Leicester Royal Infirmary

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