17-year-old with severe pharyngitis, fever, and dysphagia

THE CASE: A 17-year-old boy has had severe pharyngitis, fever, and dysphagia for the past 2 days. Although he took an NSAID and tried gargling with hydrogen peroxide, he obtained no relief.

What is the most likely cause of the patient’s symptoms?

• Mononucleosis
• Peritonsillar abscess
• Ludwig angina
• Epiglottitis

The patient has a peritonsillar abscess, an inflammatory process of the throat and tonsils first described in the 14th century. Also known as quinsy, this infection is one of the most common inflammatory processes of the head and neck region; the highest incidence occurs in persons between the ages of 30 and 40 years. Peritonsillar abscess formation is thought to result from a suppurative tonsillitis with an accumulation of pus in the peritonsillar tissues. Some evidence suggests that the infection develops without any history of tonsillitis.

Symptoms, which usually manifest several days before the patient seeks medical advice, include a unilateral sore throat, otalgia, neck discomfort, headache, dysphagia, malaise, and a “hot potato” voice. Oropharyngeal examination usually reveals asymmetry of the soft palate; contralateral displacement of the uvula; and an enlarged, erythematous tonsil that often is covered with an exudate. Other findings may include trismus, drooling, adenopathy, fever, fetid breath, tachycardia, anxiety, and signs of dehydration.

Laboratory and imaging studies (plain films, ultrasonography, or CT) are usually unnecessary unless the diagnosis is not evident or if deep space infections of the neck are a concern.

Mixed aerobic and anaerobic organisms are responsible for most cases of peritonsillar abscess. Streptococcus pyogenes is the most commonly reported aerobic organism; peptostreptococcal organisms are the most frequently identified anaerobes.

Antibiotics are the mainstay of therapy, although incision and drainage may be necessary if the patient appears toxic or has significant swelling of the oral cavity. Admit patients who appear toxic or who exhibit any signs of potential complications, such as airway obstruction. A combination of a penicillin and metronidazole is often recommended as initial therapy because of the significant risk of streptococcal resistance and the presence of mixed flora. Supportive therapy with oral and parenteral analgesics, antipyretics, and hydration is indicated. Some experts recommend corticosteroids to reduce discomfort and edema.

Patients with mononucleosis often are between 15 and 25 years old, although this infection may affect younger persons as well as elderly ones. Most cases are caused by infection with the Epstein-Barr virus. Patients typically have pharyngitis, fever, and lymphadenopathy that follows a 1- to 2-week prodrome of malaise, fatigue, and myalgia. Pharyngitis may be severe and is considered a cardinal symptom of mononucleosis. Physical examination may reveal tonsillar erythema and edema with an exudate, cervical adenitis, splenomegaly, and a morbilliform or papular erythematous eruption on the trunk or an upper extremity rash.

Laboratory results that may be helpful in making the diagnosis include a white blood cell count and differential that demonstrate atypical lymphocytes, elevated liver enzymes, and a positive heterophile test. Supportive therapy is the mainstay of treatment; analgesics, antipyretics, and bed rest are recommended.

Ludwig angina is a rapidly progressive cellulitis that involves the submental, sublingual, and submandibular spaces. The soft tissue is often described as board-like. Secondary elevation and edema of the tongue result in drooling and airway obstruction. Most of these infections are thought to have an odontogenic origin; the second and third molars are the most common nidus of infection.

Ludwig angina is thought to be caused by hemolytic Streptococcus organisms, although a mixed Staphylococcus- Streptococcus infection or combination of aerobic and anaerobic organisms may be involved. Drainage and removal of necrotic material may be warranted if antibiotic therapy is unsuccessful.

Epiglottitis results from an acute inflammation of the epiglottis and surrounding soft tissue, including the vallecula, aryepiglottic folds, and arytenoids. Haemophilus influenzae and group A streptococci are the most common causal organisms in adults. This disease has historically been seen in adults (average age, 45 years), although in previous decades, it was more commonly described in children aged 3 to 7 years. With the advent of the H influenzae type B vaccine, the incidence in children has declined significantly.

Onset is acute. Symptoms, which progress rapidly, include dysphagia, pharyngitis, and hot potato voice in a patient with no history of upper respiratory tract infection. Other findings may include drooling, adenitis, stridor, toxic appearance, fever, and tripod posturing.

Empiric antibiotic therapy is instituted for coverage of group A streptococci, Staphylococcus pyogenes, and H influenzae. Intubation equipment should be at the bedside and an otolaryngologist or anesthesiologist contacted emergently. If the patient is stable, lateral radiographs may help to delineate the clinical diagnosis. Visualization of the airway should never be attempted in a child, because this may cause acute airway obstruction resulting from laryngospasm.