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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