Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Peritonsillar Abscess - The Sore Throat Emergency

Patient Demographics

• Age: 24 years
• Sex: Male
• Occupation: College student

Chief Complaint

"I can barely swallow and my throat is killing me."

History of Present Illness

A 24-year-old male presents with severe sore throat for 5 days. He was diagnosed with strep throat 4 days ago and started amoxicillin but has progressively worsened. He now has severe odynophagia (9/10), drooling, and difficulty opening his mouth fully. He reports muffled voice and pain radiating to his right ear. He has not been able to eat or drink much for the past 2 days.

Initial Assessment

ESI Level: 2 - Potential airway emergency

First Impression:

• Appearance: Ill-appearing, drooling, "hot potato" muffled voice
• Work of breathing: Slightly labored, mild stridor noted
• Circulation: Flushed

Vital Signs:

• Heart rate: 112 bpm
• Blood pressure: 128/78 mmHg
• Respiratory rate: 18 breaths/min
• SpO2: 96% on room air
• Temperature: 38.9C (102.0F)
• GCS: 15

Airway Assessment

Critical Question: Is the airway threatened?

Warning Signs:

• Stridor: Mild inspiratory stridor - CONCERNING
• Drooling: Present - unable to swallow secretions
• Voice: Muffled "hot potato" voice
• Trismus: Present - limited mouth opening
• Position: Sitting forward, reluctant to lie flat

Decision: Airway currently stable but at risk; avoid any intervention that might obstruct airway (no blind nasopharyngeal procedures)

Primary Survey

Airway: Patent but potentially compromised; prepare for difficult airway Breathing: Mild increased work, audible stridor Circulation: Tachycardic, well-perfused Disability: Alert, anxious Exposure: No external abnormalities

Physical Examination

Oropharyngeal Exam (performed carefully):

• Severe trismus (inter-incisal distance 2cm)
• Muffled voice
• Deviation of uvula to the LEFT
• Right tonsillar bulging and erythema
• Right soft palate fullness
• Right anterior pillar displacement
• Purulent exudate on right tonsil
• Tender right submandibular lymphadenopathy

Classic PTA Findings:

• Unilateral tonsillar bulge
• Uvula deviation AWAY from affected side
• Trismus
• "Hot potato" voice

Diagnosis

Right Peritonsillar Abscess (PTA)

Secondary Survey

SAMPLE History:

• Symptoms: Severe sore throat, odynophagia, trismus, fever, ear pain
• Allergies: None
• Medications: Amoxicillin (started 4 days ago)
• PMH: Prior tonsillitis x2, otherwise healthy
• Last Meal: Yesterday (unable to eat)
• Events: Progressive worsening despite antibiotics

Management

Preparation:

• Difficult airway equipment at bedside
• ENT consultation requested
• IV access obtained (hydration, antibiotics)

Imaging:

• CT neck with contrast (if diagnosis uncertain or concern for deep space infection)
• This patient: Clinical diagnosis clear; CT to assess for extension to parapharyngeal space

CT Findings:

• 2.5cm right peritonsillar abscess
• No extension to parapharyngeal or retropharyngeal space
• Airway patent but narrowed

Treatment Options

This Patient:

• ENT performed needle aspiration at bedside
• 8mL of purulent material aspirated
• Immediate relief of symptoms

Procedure: Needle Aspiration

Technique:

1. Position patient upright
2. Topical anesthesia (lidocaine spray + pledget)
3. 18g needle on 10mL syringe
4. Insert at point of maximal fluctuance
5. Aspirate while withdrawing
6. May require multiple passes

Results:

• 8mL thick purulent drainage
• Sent for culture

Antibiotic Therapy

IV Antibiotics (initially):

• Ampicillin-sulbactam 3g IV q6h OR
• Clindamycin 900mg IV q8h (if penicillin allergic)

Oral Antibiotics (discharge):

• Amoxicillin-clavulanate 875mg PO BID x 10 days

Why amoxicillin alone failed:

• PTA often has mixed flora including anaerobes
• Anaerobes produce beta-lactamases
• Need beta-lactamase inhibitor coverage

Culture Results

Aspirate culture:

• Streptococcus pyogenes (Group A Strep)
• Fusobacterium necrophorum
• Prevotella (anaerobe)

Polymicrobial infection typical of PTA

Clinical Course

After Drainage:

• Immediate improvement in pain
• Trismus resolved within 24 hours
• Able to drink fluids
• Fever resolved

Observation:

• Observed for 6 hours in ED
• Tolerated oral intake
• Discharged with oral antibiotics

Disposition

• Discharged home after observation
• Oral antibiotics x 10 days
• ENT follow-up in 1 week
• Return if worsening symptoms
• Discussion of elective tonsillectomy (given history of recurrent tonsillitis)

Complications to Consider

1. Airway obstruction - most immediate concern
2. Parapharyngeal/retropharyngeal extension - deep space infection
3. Lemierre syndrome - septic thrombophlebitis of internal jugular vein (F. necrophorum)
4. Mediastinitis - descending infection
5. Aspiration of abscess contents

Teaching Points

1. PTA is a clinical diagnosis: Uvular deviation, tonsillar bulge, trismus, hot potato voice
2. Airway first: Prepare for difficult airway; avoid interventions that may worsen obstruction
3. Needle aspiration is first-line: Effective, can be done at bedside, avoids incision
4. Antibiotics need anaerobic coverage: Amoxicillin-clavulanate, ampicillin-sulbactam, or clindamycin
5. Consider Lemierre syndrome: If F. necrophorum isolated or patient has neck pain/swelling
6. Recurrent PTA: Consider tonsillectomy; 10-15% recurrence rate
7. Trismus may limit exam: CT useful if unable to adequately visualize oropharynx

Clinical Image

Image Description: Intraoral photograph demonstrating a right peritonsillar abscess with uvular deviation to the left, right soft palate and tonsillar bulge, and erythema consistent with PTA.

Attribution: Image from Wikimedia Commons, Peritonsillar abscess. Licensed under CC BY-SA 3.0. Source: https://commons.wikimedia.org/wiki/File:PeriijTomsillitis.jpg

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