What is the best course of treatment for an elderly patient with a unilaterally enlarged and swollen tonsil, causing significant oropharyngeal obstruction, difficulty swallowing, and a history of mild fever?

Urgent ENT Referral and Airway Assessment Required

This elderly patient with acute unilateral tonsillar enlargement causing significant oropharyngeal obstruction requires immediate ENT evaluation to rule out malignancy, peritonsillar abscess, or other serious pathology—this is NOT a typical infectious tonsillitis scenario and demands urgent specialist assessment. 1

Critical Red Flags Present

The unilateral presentation is the most concerning feature here:

• Unilateral tonsillar enlargement in an adult is suspicious for malignancy until proven otherwise, particularly oropharyngeal squamous cell carcinoma or lymphoma 1
• Tonsil asymmetry or mass is explicitly listed as a suspicious sign requiring specialist evaluation 1
• The 2-day timeline with 50% oropharyngeal obstruction represents a rapidly progressive process that is atypical for simple infectious tonsillitis 1

Immediate Management Priorities

Airway Assessment

• Evaluate for signs of impending airway obstruction: muffled voice, stridor, tripod positioning, or respiratory distress 2
• The absence of drooling is reassuring but does not exclude significant obstruction 2
• Patients with upper airway obstruction from oropharyngeal edema can deteriorate rapidly and may require urgent airway intervention 3, 2

Urgent ENT Consultation

• Complete oropharyngeal examination by ENT specialist is mandatory to assess the full extent of obstruction and identify the underlying pathology 1
• Flexible laryngoscopy may be needed to fully visualize the base of tongue and assess airway patency 1
• The physical examination may be limited without specialized equipment, and incomplete examination should prompt immediate referral 1

Differential Diagnosis Considerations

Malignancy (Primary Concern)

• Unilateral tonsillar mass in elderly patients raises strong suspicion for oropharyngeal cancer 1
• HPV-related oropharyngeal cancer and lymphoma are both possibilities 1
• Rapid growth over 2 days would be unusual for malignancy but doesn't exclude it

Peritonsillar Abscess

• Can present with unilateral swelling, dysphagia, and fever 4
• However, the resolution of fever is somewhat atypical for untreated abscess
• If abscess is confirmed, treatment includes drainage plus antibiotics (clindamycin or amoxicillin-clavulanate) 4

Severe Unilateral Tonsillitis

• Less likely given the degree of asymmetry and rapid progression
• Simple tonsillitis guidelines apply to pediatric recurrent infections, not acute unilateral adult presentations 1

Treatment Approach

Do NOT Treat as Simple Tonsillitis

• The pediatric tonsillectomy guidelines 1 are not applicable to this acute adult presentation with unilateral pathology
• Watchful waiting is inappropriate given the airway compromise and concerning features 1

Empiric Antibiotics May Be Considered

• If peritonsillar abscess is suspected, empiric broad-spectrum antibiotics covering streptococcus and anaerobes can be initiated pending ENT evaluation 4
• Clindamycin or amoxicillin-clavulanate are appropriate choices 4
• However, antibiotics should not delay urgent specialist assessment

Hospital Admission Likely Required

• Given the degree of oropharyngeal obstruction (50%), hospital admission for airway monitoring is strongly recommended 2
• Patients with significant upper airway obstruction require close monitoring in a setting where emergency airway management is available 2, 5

Critical Pitfalls to Avoid

• Do not dismiss unilateral tonsillar enlargement as "just tonsillitis"—this presentation pattern demands investigation for malignancy 1
• Do not delay ENT referral for imaging or other workup if the airway is compromised 2
• Do not discharge home without ensuring airway stability and arranging urgent follow-up 2
• Do not apply pediatric tonsillectomy guidelines to acute adult unilateral presentations 1

Definitive Diagnosis Required

• Tissue diagnosis via biopsy will likely be needed if malignancy is suspected 1
• Imaging (CT with contrast) may be indicated to assess extent of disease and rule out deep space infection 1
• The priority is securing the airway and establishing the diagnosis, not empiric treatment of presumed infection 1, 2