Check the tongue for

• Furring, which is a reasonably common presentation and it is of little clinical significance (Swash, 2001). However, anxious patients often attribute it to HIV infection, concerned that it is either oral Candida or oral hairy leukoplakia. This furring is common in smokers (Swash, 2001) and can be caused by patients sleeping with their mouth open, causing their saliva to dry on the tongue. This can easily be removed with a toothbrush.

• Oral hairy leukoplakia: this is normally on the underside of the tongue. It appears as whitish opaque areas of thickened epithelium (Swash, 2001), the patches being of various sizes (Walsh et al., 1999). It is considered pre-malignant (Walsh et al., 1999), and can be an indication of HIV (Pratt, 2003).

Finally, inspect the tonsillar bed and oropharynx for erythema, exudates or postnasal discharge. The tonsils and the lymphoid follicles on the back of the oropharynx are often prominent in young subjects. If this is occluded ask the patient to say 'Ah': this will increase visibility (Swash, 2001; Walsh et al., 1999). Unilateral vesicles may indicate Herpes zoster. A hole in the hard palate may indicate tertiary syphilis (Swash, 2001). Ulcers on the tonsils may be suggestive of glandular fever, streptococcal tonsillitis, thrombocytopenia, rubella or diphtheria (Swash, 2001). If an abscess is noted it could be quinsy (Swash, 2001; Walsh et al., 1999).


This is probably the most common presentation (Hopcroft & Forte, 2003).

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