What is the most appropriate next diagnostic step for a 14-year-old boy presenting with severe pharyngitis, fever, dysphagia, otalgia, and a deviated uvula, with physical examination findings of a large right tonsil, swelling of the right soft palate, and tender cervical lymphadenopathy?

From the Guidelines

The most appropriate next step in diagnosis for this 14-year-old boy is A. CT scan of the neck. This patient presents with classic signs of peritonsillar abscess, including progressive sore throat, difficulty swallowing, muffled voice, fever, and examination findings of uvular deviation, asymmetric tonsillar enlargement, and soft palate swelling. A CT scan of the neck with contrast is the preferred imaging modality as it can confirm the diagnosis by visualizing the abscess collection, determine its exact location and extent, and help differentiate peritonsillar abscess from other deep neck space infections like retropharyngeal or parapharyngeal abscesses. This distinction is crucial for proper management, which typically involves drainage of the abscess along with antibiotic therapy, as recommended by the Infectious Diseases Society of America guidelines for the diagnosis and management of group A streptococcal pharyngitis 1. While lateral neck radiographs might show soft tissue swelling, they lack the sensitivity and specificity of CT. The clinical presentation is not consistent with infectious mononucleosis or lymphadenopathy requiring biopsy, making Monospot test and lymph node biopsy inappropriate, as stated in the guidelines for the diagnosis of group A streptococcal pharyngitis 1. Additionally, proceeding without further diagnostic testing would be inadequate given the potential severity of deep neck infections and their complications, including airway compromise. The patient's symptoms and examination findings are consistent with a bacterial pharyngitis, and the guidelines recommend laboratory testing to confirm the diagnosis of group A streptococcal pharyngitis, but in this case, a CT scan is necessary to evaluate the extent of the infection and guide management. The guidelines also emphasize the importance of accurate diagnosis and appropriate antimicrobial therapy to prevent complications such as acute rheumatic fever and suppurative complications, and to reduce the risk of transmission to others 1. In this case, the patient's clinical presentation and examination findings suggest a peritonsillar abscess, and a CT scan is the most appropriate next step in diagnosis to confirm the diagnosis and guide management.

From the Research

Diagnostic Approach

The patient's symptoms, such as a sore throat, fever, difficulty swallowing, and a muffled voice, suggest a peritonsillar abscess or another deep neck infection. To confirm the diagnosis, imaging studies can be useful.

• The patient's presentation is consistent with a peritonsillar abscess, which can be diagnosed using imaging techniques 2, 3.
• A lateral neck radiograph can be used to evaluate the patient's neck and detect any signs of abscess or other complications 4, 5.
• However, a CT scan of the neck is generally more accurate for confirming the presence of deep neck abscesses, including peritonsillar abscesses 2.

Next Steps

Given the patient's symptoms and physical examination findings, the most appropriate next step in diagnosis would be to obtain imaging studies to confirm the presence of an abscess.

• Option B, lateral neck radiographs, may be a reasonable initial step, but it may not provide enough information to confirm the diagnosis 4, 5.
• Option A, CT scan of the neck, is likely the most appropriate choice, as it can provide more detailed information about the presence and extent of any abscess 2.
• Options C, D, and E are not directly relevant to the diagnosis of a peritonsillar abscess or other deep neck infections in this patient.