PANCE Blueprint EENT (7%)

47-year-old with pharyngitis and difficulty swallowing

Patient will present as → a 19-year-old male who you are seeing for follow-up from the urgent care, where he was seen 2 days earlier with a sore throat. The patient is febrile (102°F), has a muffled (hot potato) voice, and has extreme difficulty opening his mouth (trismus). He opens it just far enough for you to note uvular deviation.

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A peritonsillar abscess is a complication of tonsillitis and occurs when a collection of pus forms and spreads beyond the tonsils into the tissues of the throat next to one of the tonsils. Swollen tissues can block the airway

• A peritonsillar abscess can present with a significant sore throat, pain with swallowing, trismus (inability to open the mouth normally), deviation of the soft palate/uvula, and muffled “hot potato” voice
• Deviation of the soft palate and an asymmetric rise of the uvula is highly suggestive of abscess
• Also known as “Quincy's” abscess
• It usually involves multiple bacteria. Streptococcus and Staphylococcus are the most frequent aerobic pathogens, whereas Bacteroides sp is the predominant anaerobic pathogen

Xray, CT, or ultrasonography of the neck (which would show the collection of pus within the tissue) can help confirm the diagnosis when the physical examination is difficult, or the diagnosis is in doubt, particularly when the condition must be differentiated from a parapharyngeal infection or other deep neck infection

• All such patients require needle aspiration of the tonsillar mass and cultures. Aspiration of pus differentiates abscess from cellulitis

Treatment is surgical drainage, antibiotics, and steroids, particularly in situations where there is a lot of inflammation that obstructs the airway

• An initial 24-hour trial of appropriate parenteral antimicrobials (without surgical drainage) is justifiable in patients with presumed peritonsillar cellulitis who show no evidence of airway compromise, septicemia, severe trismus, or other complications
  • Examples of antimicrobial therapy include parenteral ampicillin-sulbactam and IV clindamycin
  • In less severe cases, oral antibiotics can be used for 7 to 10 days (i.e., amoxicillin, amoxicillin-clavulanate, clindamycin)
• Secure the airway early in a severe infection
• Tonsillectomy may also be considered in about 10% of patients (and those with recurrent peritonsillar abscess)