A 30-year-old school teacher presents with a three-day history of fever, chills, and sore throat. He also complains of difficulty swallowing that started yesterday. He denies any cough, chest pain, or difficulty breathing. He is married and denies any new sexual encounters. His temperature is 39.8° C (102.2° F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 19/min. On examination, his voice is muffled. Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated to the right. What is the most appropriate treatment for this patient?

Question

A 30-year-old school teacher presents with a three-day history of fever, chills, and sore throat.  He also complains of difficulty swallowing that started yesterday.  He denies any cough, chest pain, or difficulty breathing.  He is married and denies any new sexual encounters.  His temperature is 39.8° C (102.2° F), blood pressure is 118/76 mmHg, pulse is 102/min, and respirations are 19/min.  On examination, his voice is muffled.  Enlarged, tender cervical lymph nodes are palpated on the left, and his uvula is deviated to the right.  What is the most appropriate treatment for this patient?

Quizplus · Accepted Answer

This patient's symptoms are most likely secondary to a peritonsillar abscess. Although the three-day history of fever, chills, and sore throat were most likely secondary to tonsillitis, his muffled or "hot potato voice" and deviation of the uvula suggest that a peritonsillar abscess has developed as a complication of his tonsillitis. Patients with a peritonsillar abscess typically have prominent unilateral lymphadenopathy, as seen in this patient. This condition can be fatal secondary to either airway obstruction or spread of the infection into the parapharyngeal space, which may lead to involvement of the carotid sheath. Initial treatment consists of aspiration of the peritonsillar abscess and initiation of intravenous antibiotics. Surgical intervention may be necessary if the purulent material cannot be removed with aspiration alone. (Choice A) Throat swabs and oral antibiotics are the usual treatment of tonsillopharyngitis, but this patient's muffled voice and deviation of his uvula suggest that a more complicated infection is present. (Choice B) This patient's unilateral lymphadenopathy, deviation of his uvula, and muffled voice are not consistent with mononucleosis. (Choice C) Emergency laryngoscopy is typically required in patients with epiglottitis to ensure adequate protection of the airway. Epiglottitis can present with difficulty swallowing and a muffled voice similar to that seen in this patient, but the unilateral lymphadenopathy and deviation of the uvula are more suggestive of a peritonsillar abscess. In addition, the epiglottis is located more distal in the airway and is not adjacent to the uvula. (Choice D) Cricothyroidotomy is used as a last resort in patients who are unable to protect their airway. This patient, however, is not complaining of any difficulty breathing at this time. Educational objective: A muffled voice should make one consider a diagnosis other than uncomplicated pharyngitis or tonsillitis. A peritonsillar abscess is a potential complication of tonsillitis and requires both intravenous antibiotic therapy and urgent drainage of the abscess. Deviation of the uvula and unilateral lymphadenopathy can be helpful in distinguishing a peritonsillar abscess from epiglottitis.

A 30-Year-Old School Teacher Presents with a Three-Day History of Fever