Ms. L is a 25-year-old woman with no significant past medical history in whom sore throat, fever, and malaise developed 7 days ago. She complains of severe throat pain, more pronounced on the right, and right ear pain. She reports severe pain with swallowing. She also reports that for the past day she has not been able to open her mouth widely.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
PRIORITIZING THE DIFFERENTIAL DIAGNOSIS
The pivotal points, in this case, are the unilateral nature of the throat pain as well as the odynophagia and trismus. This presentation suggests a peritonsillar abscess, classically referred to as quinsy. Peritonsillar abscesses generally form in the area of the soft palate, just above the superior pole of the tonsil.
Peritonsillar abscess is a must not miss diagnosis because if left untreated, it may progress to airway obstruction, abscess rupture, or septic necrosis. Other important diagnoses to consider in this case would be retropharyngeal abscess or epiglottitis. Lemierre disease, a rare disease caused by F necrophorum, must also be considered. Table 30-6 lists the differential diagnosis.
Table 30-6.Diagnostic hypothesis for Ms. L. ||Download (.pdf) Table 30-6. Diagnostic hypothesis for Ms. L.
|Diagnostic Hypotheses ||Demographics, Risk Factors, Symptoms and Signs ||Important Tests |
|Leading Hypothesis |
|Peritonsillar abscess ||Severe unilateral sore throat with fever and muffled voice, unilaterally enlarged, medially displaced tonsil, and deviation of uvula to unaffected side ||Diagnosis is usually clinical |
|Active Alternative—Must Not Miss |
|Epiglottitis ||Sore throat with muffled voice, stridor, drooling, and anterior neck tenderness || |
Lateral neck radiograph
Direct visualization with laryngoscopy
|Retropharyngeal abscess ||Similar to epiglottitis with more prominent neck symptoms (stiffness and pain) ||Lateral neck radiograph or CT scan of the neck |
|Lemierre syndrome ||Pain, swelling and induration at the angle of the mandible with persistent high fevers and trismus ||CT scan of the neck |
On physical exam, she is breathing comfortably. Her vital signs are temperature, 39.0°C; pulse, 102 bpm; BP, 110/70 mm Hg; and RR, 15 breaths per minute. Examination of the oropharynx revealed a markedly enlarged right tonsil with associated swelling of the soft palate uvular deviation to the left. The right tympanic membrane is clear, with good light reflex and no bulging. There is tender anterior cervical lymphadenopathy bilaterally. The lung exam was normal and no stridor was noted.
Is the clinical information sufficient to make a diagnosis? If not, what other information do you need?
The patient’s symptoms of a unilaterally enlarged, medially displaced tonsil with uvular deviation to contralateral side are sufficient to make the diagnosis of peritonsillar abscess. You arrange for ENT evaluation.
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