Stomatitis caused by herpes simplex virus is usually confined to the anterior buccal mucosa but occasionally may extend to the anterior tonsillar pillars and involve the upper esophagus in immunocompetent patients on rare occasions ( e-Fig 74.1 ) Particularly in more extensive cases, the child may complain of a sore throat Peritonsillar Abscess A peritonsillar abscess may complicate a previously diagnosed infectious pharyngitis or may be the initial source of a child’s discomfort This occurs most commonly in older children and adolescents Trismus is common in these patients The diagnosis is evident from visual inspection, augmented occasionally by careful palpation These abscesses produce a bulge in the posterior aspect of the soft palate, deviate the uvula to the contralateral side of the pharynx, and have a fluctuant quality on palpation ( e-Fig 74.2 ) TABLE 74.1 DIFFERENTIAL DIAGNOSIS OF SORE THROAT IN THE IMMUNOCOMPETENT HOST Infectious pharyngitis Respiratory viruses Group A streptococci Epstein–Barr virus (infectious mononucleosis) Human immunodeficiency virus Neisseria gonorrhoeae Anaerobic bacteria Group C and G streptococci Arcanobacterium haemolyticum Mycoplasma pneumoniae (unconfirmed) Chlamydia pneumoniae (unconfirmed) Francisella tularensis Corynebacterium diphtheriae (diphtheria) Other causes Herpetic stomatitis Irritative pharyngitis Foreign body Peritonsillar abscess Retropharyngeal and lateral pharyngeal abscesses Epiglottitis Kawasaki disease Stevens–Johnson syndrome Chemical exposure Psychogenic pain Referred pain Retropharyngeal and Lateral Pharyngeal Abscesses Retropharyngeal abscess is an uncommon cause of sore throat, usually occurring in children younger than to years Although most children with this disorder often appear toxic and have neck pain and occasionally respiratory distress, a few complain of sore throat and dysphagia without other manifestations early in the course Some infants and young children may also manifest torticollis A young child with a retropharyngeal abscess who presents with a high fever, toxic appearance, and torticollis is sometimes incorrectly suspected to have meningitis A soft tissue lateral neck radiographic examination may demonstrate the lesion, whereas direct visualization is often impossible Unfortunately, flexion (even limited) of the neck during the radiograph may cause a buckling of the retropharyngeal tissues that resembles a purulent collection The clinician must insist on a radiograph with the neck fully extended before hazarding an interpretation If the diagnosis remains uncertain despite adequate radiographs, a computed tomography (CT) scan with intravenous contrast should be obtained TABLE 74.2 COMMON CAUSES OF SORE THROAT Infectious pharyngitis Respiratory viruses Group A streptococci Epstein–Barr virus Irritative pharyngitis Forced hot air heating TABLE 74.3 LIFE-THREATENING CAUSES OF SORE THROAT Retropharyngeal and lateral pharyngeal abscesses Epiglottitis Tonsillar hypertrophy (severe) with infectious mononucleosis Diphtheria Peritonsillar abscess Lemierre syndrome Lateral pharyngeal abscesses manifest in a fashion similar to retropharyngeal infections but occur less often High fever is a common symptom, and both trismus and swelling below the mandible may be seen Lateral neck radiographs are often unrevealing, with no appreciable thickening in the prevertebral space A CT scan helps to confirm the diagnosis The Children’s Hospital of Philadelphia Clinical Pathway ED Clinical Pathway for the Evaluation/Treatment of the Child With a Suspected Deep Neck Space Infection URL: https://www.chop.edu/clinical-pathway/neck-infection-clinicalpathway Authors: R Abaya, MD; M Joffe, MD; L Vella, MD; M Dunn, MD; S MacFarland, MD; M Rizzi, MD; K Shekdar, MD; R Bellah, MD; J Lavelle, MD Posted: February 2017, reviewed October 2019 FIGURE 74.1 Incidence by age of infectious mononucleosis in three large studies Epiglottitis The incidence of epiglottitis, a well-appreciated cause of life-threatening upper airway infection, has declined significantly since the introduction of vaccination against Haemophilus influenzae type b This disease manifests with a toxic