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What is Cobblestone throat?

in:Coronavirus COVID-19published:03 Dec 2020, last updated:04 Feb 2021

Cobblestone throat refers to "lumpy" or rough surface at the back of the throat (see image as example). Cobble stone throat is a potential finding on clinical examination when a doctor examines the back of the throat. This is associated with Pharyngitis, that is inflammation of this area. It can lead to swelling of the lymphatic tissue (a component of the immune system) deep in this area that leads to the rough appearance on the surface. Possible causes for cobblestone throat include Infections, Allergies, Irritants, Acid reflux, and others. Read on to find out more about each of these.

1. Infection

These are a common cause of cobblestone throat, out of which viral infections are the commonest type as opposed to others such as bacterial and/or fungal infections. Often a period of rest and actively hydrating with lots of water will provide great relief for most viral infections and antibiotics are not useful. However, if the symptom persists for more than 2-3 days of rest and hydration, it would be pertinent to get an examination with your doctor for a check-up to ensure there are no features of certain severe viruses (such as Ebstein Barr) and/or others such as bacteria, and treatment would be tailored accordingly (may include antibiotics, depending on examination findings)

2. Allergy

Often wake up in the morning with a runny or blocked nose, with sensations of mucus trickling backwards down your throat (post-nasal drip)? Or perhaps you develop these symptoms on exposure to certain triggers like dust or cold air? This may mean you have allergic rhinitis, another cause of "cobblestoning" of the throat. Here, the underlying cause being the allergy for the inflammation and swelling of tissue at the back of your throat. This may need specific treatment such as anti-histamine tablets and/or nasal sprays which your doctor can prescribe.

3. Irritants

Prolonged/excessive exposure to airborne irritants can also lead to inflammation and cobblestone throat, such as smoking, vaping and/or air pollution.

4. Acid 

Ever feel like there may be sourish fluid from your tummy that finds its way back into your mouth, or a burning sensation in your throat/tummy? These are possible symptoms of gastro-esophageal reflux disease (GERD) which can also be a cause for inflammation and irritation in the throat. You can read more about GERD at the link above!

5. Thicker mucous

This would be diagnosis of exclusion, and you would need to have a review with your doctor to ascertain none of the other possible causes are leading to the irritation. With thicker mucous, there are reports that irritation in the throat can develop. This may arise as a result of inadequate hydration and/or certain medications. Once again, a period of rest and hydration may provide relief, but if symptoms persists for more than 2-3 days, do visit your doctor for an examination.

6. Others 

Finally, as with most medical issues, occasionally there can be more insidious causes of a given finding which your doctor would look out for. In the case of cobblestone throat, these include certain growths and or blood cell disorders that can be and early sign of potentially serious diseases.


Ultimately, as you probably gathered above, a period of rest and increased water intake will provide significant relief of cobblestone throat arising from most common causes. 

However, if you find your symptoms are persisting more than 2-3 days, or developing with other concomitant problems such as painful lumps in the neck, ear discomfort, or blood in your phlegm, do have an early review with your family doctor. Depending on his findings, he would be able to offer tailored therapy or, if required, a referral to a specialist colleague for further assessment. The latter may be a specialist from Otolaryngology (or "Ear, Nose, Throat (ENT)") for further evaluation and consideration if a scope may be required.

For greater convenience, you may consider having an initial consultation online via video call with a doctor to assess whether you really need to make that trip down. Several of these applications also provide specialist referrals and/or medication delivery to your home as well.

Author's Profile

Dr. Dinesh MBBS (NUS) is a licensed general practitioner (GP) in Singapore with a passion for sustainable initiatives that improve the quality, affordability, and accessibility of healthcare. Dr. Dinesh has managed complex initiatives from health promotion/community-based screening programs in underprivileged populations, to multinational health technology research spanning across industries, by leading multidisciplinary teams to execute aligned objectives. His current scientific research interests include Ophthalmology, Infectious Disease, Public Health, and Medical Technology.

He is experienced in project management and multinational applied clinical research having served as Head (Health Informatics) of the Collaborative Ocular Tuberculosis Study (COTS) group (2011-2019). COTS is a cloud computing-enabled study involving over 30 hospitals from 10 countries to better understand ocular tuberculosis (TB), a prevalent infectious disease that disproportionately affects the poor, as an early opportunity to address TB infection using big data.

Within Singapore, he was conferred the NUS Student Leadership award and 2019 Young Alumnus (Medicine) of the year award for multidisciplinary collaborations across faculties of Medicine, Nursing, Pharmacy and others to organise technology-enabled grassroots health promotion campaigns and free annual health screenings for underprivileged communities in Kallang, Geylang, Chinatown, and Macpherson.

Credentials And Achievements

Awards:  2019 NUS Young Alumnus (Medicine) of the Year; Commonwealth Fellow (Innovation); National Youth fund award, Singapore.

10 Publications:
1) Gunasekeran DV. Technology and chronic disease management. Lancet Diabetes Endocrinol. 2018 Feb;6(2):91. Article.
2) Gunasekeran DV. Invited Commentary: Treating the Patient with Uveitis as an Individual – Not a Disease. JAMA Ophthalmol. 2019;137(2):206-207. Article.
3)  Gunasekeran DV* and Liu ZH*, Tan WJ, Koh J, Cheong CP, Tan LH, Lau CS, Phuah GK, Manuel ND, Chia CC, Seng GS, Tong N, Huin MH, Dulce SV, Yap S, Ponampalam K, Ying H, Ong MEH, R P. Safety and Efficacy of telereview in patients with Abdominal Pain Using Video Consultation: a randomised controlled trial evaluating digital telereview (SAVED). J Med Internet Res. e-pub ahead of print. Article.
4)  Weiling LL, Ming Kai AC, Gunasekeran DV. Digital health for patients with chronic pain during the COVID-19 pandemic. Br J Anaesth. 2020 Aug 10. Epub ahead of print. Article.
5) Gunasekeran DV, Wong TY. Artificial Intelligence in Ophthalmology in 2020: A Technology on the Cusp for Translation and Implementation. Asia Pac J Ophthalmol. 2020;9(2):61-66. Article.
6)  DS Ting, Gunasekeran DV, Wickham L, TY Wong. Next generation telemedicine platforms to screen and triage. Br J Ophthalmol. e-pub ahead of print. Article.
7)  Agrawal R* and Gunasekeran DV*, Grant R, Agarwal A, Onn MK, Nguyen QD, Pavesio C, Gupta V, COTS-1 Study Group. Clinical features and outcomes of patients with TB uveitis treated with anti-tubercular therapy (ATT) in COTS-1. JAMA Ophthalmol. 2017 Dec;135(12):1318-1327. Article.
8)  Z Liu, M Ng, DV Gunasekeran, H Li, K Ponampalam, R Ponampalam. Mobile technology: Usage and perspective of patients and caregivers presenting to a tertiary care emergency. World J Emerg Med. 2020;11(1):5-11. Article.
9)  Chia KJW, Gunasekeran DV, Laude A. The Impact of Switching Anti-Vascular Endothelial Growth Factor Therapy in the Management of Exudative Age-Related Macular Degeneration. Ophthalmic Surg Lasers Imaging Retina. 2017 Oct;48(10):859-869. Article.
10)  Bansal S, Gunasekeran DV, Ang B, Lee J, Khandelwal R, Sullivan P, Agrawal R. Controversies in Pathology and Management of Hyphema. Surv Ophthalmol. 2016 May-Jun;61(3):297-308. Article

Financial Declaration

DVG reports equity investment in AskDr, Doctorbell (acquired by MaNaDr, Mobile Health), VISRE, and Shyfts. 

Accepted Insurance

CHAS, Cigna, Bupa, Aetna

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  2. 2. Wheatley LM, Togias A. Clinical practice. Allergic rhinitis. N Engl J Med. 2015 Jan 29;372(5):456-63. doi: 10.1056/NEJMcp1412282.
  3. 3. Richter JE, Rubenstein JH. Presentation and Epidemiology of Gastroesophageal Reflux Disease. Gastroenterology. 2018 Jan;154(2):267-276. doi: 10.1053/j.gastro.2017.07.045. Epub 2017 Aug 3.
  4. 4. Spurling GK, Del Mar CB, Dooley L, Foxlee R, Farley R. Delayed antibiotic prescriptions for respiratory infections. Cochrane Database Syst Rev. 2017 Sep 7;9(9):CD004417.
  5. 5. La Mantia I, Andaloro C. Cobblestone Appearance of the Nasopharyngeal Mucosa. Eurasian J Med. 2017 Oct;49(3):220-221.


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