ENT Note

Chief Complaint

Chief Complaint: Left-sided odynophagia and trismus

Assessment

Marcus Vance is a 34-year-old male with a history of recurrent acute tonsillitis, presenting with severe left-sided sore throat, dysphagia, and muffled voice. Examination is notable for right-sided uvular deviation, left peritonsillar fullness, and mild trismus, endoscopy shows a patent airway without epiglottitis or supraglottic oedema, laboratory testing is significant for leukocytosis (WBC 16,200 /µL), and imaging demonstrates a 2.4 cm rim-enhancing fluid collection in the left peritonsillar space on contrast-enhanced CT neck. The overall clinical picture is consistent with a left peritonsillar abscess although deep neck space infection (parapharyngeal or retropharyngeal abscess) and severe exudative tonsillitis with peritonsillar cellulitis remain in the differential diagnosis.

Plan

• Bedside needle aspiration and incision and drainage (I&D) of the left peritonsillar abscess performed under local anaesthesia; 6 mL of purulent fluid evacuated
• Send evacuated purulent fluid for aerobic and anaerobic bacterial cultures and sensitivity
• Administer ampicillin/sulbactam (Unasyn®) 3 g IV once in ED, dexamethasone (Decadron®) 10 mg IV once, then transition to amoxicillin/clavulanate (Augmentin®) 875 mg/125 mg PO BID for 10 days and paracetamol (acetaminophen, Tylenol®) 1,000 mg PO Q6H PRN pain
• Counselled patient on strict airway precautions, maintaining oral hydration, and warm salt water gargles; cleared for discharge after tolerating PO fluids in the ED
• Follow up as an outpatient with Otolaryngology - Head & Neck Surgery in 1 week
• Follow-up instructions were included in the patient's discharge paperwork; arrange follow-up unless it is considered as needed
• Discussed with Dr. Eleanor Rostova (Attending Otolaryngologist), who agrees with the plan above

Subjective

History of Presenting Illness

Marcus Vance is a 34-year-old male presenting with the chief complaint above, for which Otolaryngology has been consulted.

• Evaluation of severe left-sided throat pain, difficulty swallowing, and voice changes
• Symptoms began 4 days ago as a generalised sore throat, localising to the left side 48 hours ago; pain is sharp, constant, rated 8/10, and radiates to the left ear
• Worsened by swallowing solids and liquids; minimally relieved by over-the-counter ibuprofen 400 mg PO
• Rapidly progressive over the past 24 hours, with new-onset difficulty opening the mouth fully and pooling of saliva
• History of 2–3 episodes of streptococcal pharyngitis per year over the last 3 years, previously managed successfully with oral penicillin; no prior peritonsillar abscesses
• Unable to tolerate solid food or attend work as a warehouse supervisor for the past 2 days due to pain and fatigue
• Associated subjective fevers, chills, left-sided otalgia, and a muffled "hot potato" voice; denies dyspnoea, stridor, or neck stiffness
• Completed a 3-day course of azithromycin prescribed at an urgent care clinic 2 days ago without clinical improvement
• Current everyday smoker (0.5 packs/day for 10 years); social alcohol use (2–3 beers on weekends); denies illicit drug use
• Non-contributory; no family history of bleeding disorders or head and neck malignancies
• Denies recent sick contacts, recent travel, or known tuberculosis exposure
• Up to date on childhood immunisations including Tdap; received annual influenza vaccine on 15/10/2023
• Patient expresses interest in discussing elective tonsillectomy at his outpatient follow-up given the frequency of his throat infections

Objective

Physical Examination

Examination Exceptions and Pertinent Positives/Negatives

• Voice is muffled ("hot potato" quality). Mild trismus present with inter-incisor distance of approximately 2.5 cm. Asymmetry of the oropharynx with significant erythema, oedema, and inferior-medial displacement of the left palatine tonsil. Uvula is oedematous and deviated to the right. Tender, mobile 1.5 cm left jugulodigastric lymph node palpated.

Examination with the Above Corrections

General: No acute distress Voice: Muffled ("hot potato" voice), no stridor Head & Face: Normocephalic, atraumatic Eyes: EOMI, PERRL, no APD, moist conjunctivae Ears: Auricles normal in appearance. No masses, lesions, or scars. EACs patent AU. Nose: No external abnormality. Septum non-deviated. Turbinates non-erythematous and non-swollen, without pus. No masses or polyps. Mucosa healthy. Oral Cavity: Mild trismus (inter-incisor distance 2.5 cm). Mucosa moist, without lesions. Lips without masses or lesions. Oral tongue without masses or lesions, with normal mobility. Dentition good. FOM soft, non-tender, without abnormality. Oropharynx: Left peritonsillar bulging and erythema with inferior-medial displacement of the left tonsil. Uvula deviated to the right. Right tonsil 1+ without exudate. Posterior pharynx symmetric. Neck: Soft. Tender 1.5 cm left Level II cervical lymphadenopathy; no supraclavicular or auricular LAD. Trachea midline. Laryngeal framework palpable. Thyroid without masses or fullness. PULM: No IWOB CV: RR, pulse without abnormality ABD: Soft, NT/ND Skin: No lesions MSK: Moves all four extremities NEURO: Cranial Nerves II - XII grossly intact, HB 1/6 bilaterally

Flexible Fiberoptic Laryngoscopy with Corrections Below

After verbal consent was obtained, the nasal passage(s) were treated with a topical combination of 4% lidocaine and 0.05% oxymetazoline. The flexible endoscope was then passed through the right naris, which appeared grossly normal. The nasopharynx was grossly normal, without a mass or lesion. The posterior pharynx was symmetric, without a mass or lesion. The base of the tongue was normal and symmetric. The vallecula was clear. The epiglottis and aryepiglottic folds were crisp, without a mass or lesion. The supraglottic inlet was unobstructed. The true vocal folds were fully mobile and symmetric, without a mass or lesion. The visualised subglottis was patent. The pyriform sinuses were clear, without pooling of secretions. The patient tolerated the procedure well, without complication.

• Bulging of the left lateral pharyngeal wall superiorly consistent with the inferior extent of the left peritonsillar abscess; airway remains completely patent at the level of the glottis and supraglottis with no laryngeal oedema.