A 28-year-old man presents to the ENT clinic with a 5-day history of severe sore throat, fever (38.9°C), and difficulty swallowing. On examination, the right tonsil is enlarged, erythematous, with yellowish exudate. The uvula is pushed to the left. Intraoral palpation reveals a bulge in the soft palate above the tonsil. The patient has trismus and a muffled voice. Which of the following is the most appropriate immediate management?

Explanation

## Diagnosis: Peritonsillar Abscess **Key Point:** The clinical presentation—severe unilateral throat pain, fever, trismus, uvula deviation, and a bulge in the soft palate—is pathognomonic for peritonsillar abscess (PTA), a suppurative complication of acute tonsillitis. ### Clinical Features of PTA | Feature | Significance | |---------|-------------| | Unilateral severe pain | Distinguishes PTA from bilateral acute tonsillitis | | Uvula deviation (away from affected side) | Indicates mass effect from abscess | | Intraoral bulge above tonsil | Abscess collection in peritonsillar space | | Trismus | Involvement of muscles of mastication | | Muffled voice ("hot potato voice") | Soft palate edema and abscess mass effect | ### Management Algorithm ```mermaid flowchart TD A[Peritonsillar Abscess Suspected]:::outcome --> B[IV Antibiotics Initiated]:::action B --> C{Needle Aspiration}:::decision C -->|Pus Obtained| D[Incision and Drainage]:::action C -->|No Pus| E[Continue IV Antibiotics + Supportive Care]:::action D --> F[Send Pus for Culture]:::action E --> G[Reassess in 24-48 hrs]:::decision G -->|Improvement| H[Continue IV Antibiotics]:::action G -->|Worsening| I[Repeat Aspiration/Drainage]:::action H --> J[Switch to Oral Antibiotics after 48-72 hrs]:::action J --> K[Tonsillectomy after 6 weeks if recurrent]:::action ``` **High-Yield:** Needle aspiration (18G needle) is both diagnostic and therapeutic. If pus is obtained, immediate incision and drainage (I&D) under local or general anaesthesia is indicated. Pus should be sent for culture and sensitivity. **Clinical Pearl:** IV antibiotics must be started immediately (e.g., ceftriaxone 1–2 g BD + metronidazole 500 mg TDS) even before drainage, as PTA is a medical emergency with risk of airway compromise, mediastinitis, and sepsis. ### Why Immediate Drainage? 1. **Airway risk:** Abscess can expand and obstruct the airway. 2. **Sepsis risk:** Untreated PTA can lead to bacteremia and systemic toxicity. 3. **Source control:** Drainage is the definitive treatment; antibiotics alone have high failure rates (~30%). **Warning:** Oral antibiotics alone (option B) are insufficient for established PTA with pus collection. Delayed drainage increases morbidity and mortality. **Tip:** Tonsillectomy is NOT performed acutely during PTA (option C). It is reserved for recurrent PTA (>2 episodes) and is done 6 weeks after resolution to allow inflammation to settle. [cite:Park 26e Ch 16]