A 16-year-old boy comes to the emergency department due to sore throat and fever. He started having a mild sore throat after returning from summer camp about a week ago, and it has worsened in the last 2 days. The patient also has right neck pain and earache but no cough or shortness of breath. He does not use tobacco or illicit drugs and is not sexually active. Temperature is 38.8 C (102 F), blood pressure is 118/74 mm Hg, and pulse is 104/min. Enlarged and tender cervical lymph nodes are present. The patient is not able to fully open his mouth, but examination of the oral cavity shows pooling of saliva, a large right tonsil with swelling of the right soft palate, and deviation of the uvula to the left. Ear examination shows normal tympanic membranes. A rapid test for Streptococcus pyogenes is negative. Which of the following is the most likely diagnosis?

Question

A 16-year-old boy comes to the emergency department due to sore throat and fever.  He started having a mild sore throat after returning from summer camp about a week ago, and it has worsened in the last 2 days.  The patient also has right neck pain and earache but no cough or shortness of breath.  He does not use tobacco or illicit drugs and is not sexually active.  Temperature is 38.8 C (102 F), blood pressure is 118/74 mm Hg, and pulse is 104/min.  Enlarged and tender cervical lymph nodes are present.  The patient is not able to fully open his mouth, but examination of the oral cavity shows pooling of saliva, a large right tonsil with swelling of the right soft palate, and deviation of the uvula to the left.  Ear examination shows normal tympanic membranes.  A rapid test for Streptococcus pyogenes is negative.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d5e3_4144_bc81_91c32ee38327_MD0003_00 This patient has fever, pharyngeal pain, and earache suggesting a possible peritonsillar abscess (PTA). PTA, also known as quinsy, is an acute bacterial infection of the region between the tonsil and the pharyngeal muscles. It begins as persistent tonsillitis/pharyngitis and progresses to cellulitis/phlegmon, with pus collecting into an abscess within a week of symptom onset. PTA is most common in older adolescents and young adults, and drug or alcohol use increases the risk. Examination findings in PTA can include spasm of the jaw muscles (trismus) (which often limits the physical examination), muffled "hot potato" voice, and swelling of peritonsillar tissues with deviation of the uvula to the contralateral side. Treatment involves needle aspiration or incision and drainage plus antibiotic therapy to cover Group A hemolytic streptococci and respiratory anaerobes. (Choice A) Epiglottitis is characterized by high-grade fever, severe sore throat, and odynophagia that can rapidly progress to airway obstruction. Pharyngeal findings in epiglottitis are typically normal. (Choice B) Uncomplicated tonsillitis is characterized by tonsillar erythema and exudates, often with tender anterior cervical nodes and palatal petechiae. However, trismus, pooling of saliva, and uvular deviation are more consistent with PTA. (Choice C) Enlarged adenoids are usually seen in early childhood and regress with age. They are unlikely to cause symptoms in an adolescent but may occasionally obstruct the nasopharynx. (Choice D) Herpangina is caused by the coxsackie A virus and presents with fever, sore throat, and odynophagia. It is most common in children and is characterized by vesicles on the tonsils and soft palate. (Choice E) Infectious mononucleosis is characterized by the triad of fever, pharyngitis, and posterior cervical lymphadenopathy. Mononucleosis is not typically complicated by abscess formation. Educational objective: Peritonsillar abscess is characterized by fever, pharyngeal pain, and earache. Examination findings include trismus, muffled voice, and swelling of peritonsillar tissues with deviation of the uvula. Treatment involves needle aspiration or incision and drainage plus antibiotic therapy. References: Peritonsillar abscess (http://www.ncbi.nlm.nih.gov/pubmed/18246890)

A 16-Year-Old Boy Comes to the Emergency Department Due to Sore