What is the possible diagnosis and concern for a patient with a severe sore throat, odynophagia (pain when eating), muffled voice, new onset of snoring and nocturnal drooling, significantly enlarged tonsils (+3 bilateral), and decreased appetite, without fever or body aches?

Possible Diagnosis: Peritonsillar Abscess or Severe Obstructive Sleep-Disordered Breathing

This patient requires urgent evaluation for peritonsillar abscess, parapharyngeal abscess, or other serious throat infection given the constellation of severe symptoms including muffled voice, drooling, new-onset snoring, and significantly enlarged tonsils, even in the absence of fever. 1

Critical Red Flags Present

This patient exhibits multiple warning signs that distinguish this from simple viral or bacterial pharyngitis:

• Muffled voice (hot potato voice) - suggests significant peritonsillar swelling or abscess 1
• Drooling at night - indicates inability to manage secretions, a sign of severe obstruction 1
• New-onset snoring - suggests acute upper airway obstruction from tonsillar hypertrophy 1
• Odynophagia (pain with eating) - severe enough to cause decreased appetite 1
• Duration of 1.5 weeks - prolonged course suggests complications beyond simple pharyngitis 1

Patients presenting with unusually severe signs and symptoms such as difficulty swallowing, drooling, neck tenderness, or swelling should be evaluated for rare throat infections including peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome. 1

Primary Differential Diagnoses

1. Peritonsillar Abscess (Most Concerning)

• The combination of severe odynophagia, muffled voice, drooling, and +3 bilateral tonsillar enlargement strongly suggests peritonsillar or parapharyngeal abscess 1
• These require urgent surgical drainage under general anesthesia to prevent life-threatening airway obstruction 2
• The absence of fever does NOT rule out abscess formation 1

2. Severe Obstructive Sleep Apnea from Tonsillar Hypertrophy

• New-onset snoring and nocturnal drooling indicate acute upper airway obstruction 1
• +3 bilateral tonsillar enlargement can cause significant airway compromise even without infection 1
• Drooling suggests the patient cannot swallow secretions normally, indicating severe obstruction 1

3. Lemierre Syndrome (Rare but Life-Threatening)

• Should be suspected in patients with severe pharyngitis, particularly adolescents and young adults 1
• Caused by Fusobacterium necrophorum, can lead to internal jugular vein thrombophlebitis and septic emboli 1
• Urgent diagnosis and treatment necessary to preclude complications and death 1

Immediate Management Steps

Urgent Evaluation Required

• Physical examination focusing on:
  • Asymmetry of tonsils or uvular deviation (suggests unilateral abscess) 1
  • Neck tenderness or swelling (suggests deep space infection) 1
  • Trismus (difficulty opening mouth - suggests abscess) 1
  • Assessment of airway patency 1

Diagnostic Testing

• Rapid antigen detection test (RADT) or throat culture for Group A Streptococcus if bacterial infection suspected 3, 4
• However, the severity of symptoms warrants imaging regardless of strep test results 1
• CT scan with contrast if peritonsillar or parapharyngeal abscess suspected to guide surgical drainage 1

Treatment Considerations

If peritonsillar abscess confirmed:

• Requires urgent surgical drainage under general anesthesia 2
• Broad-spectrum intravenous antibiotics 1
• Hospital admission for airway monitoring 2

If severe tonsillar hypertrophy without abscess:

• The American Academy of Otolaryngology recommends tonsillectomy for children with obstructive sleep apnea documented by symptoms of airway obstruction 1
• Given the severity (drooling, new snoring, muffled voice), this patient may require urgent or semi-urgent tonsillectomy 1
• Inpatient admission may be warranted for airway monitoring if severe obstruction present 1

If bacterial pharyngitis without complications:

• Penicillin V 250-500 mg orally 2-3 times daily for 10 days if Group A Streptococcus confirmed 3
• However, the severity of symptoms makes uncomplicated pharyngitis unlikely 1

Critical Pitfalls to Avoid

• Do not dismiss the absence of fever - peritonsillar abscess and severe airway obstruction can occur without fever 1
• Do not treat empirically with oral antibiotics alone - this patient needs urgent evaluation for surgical drainage if abscess present 1, 2
• Do not delay imaging - CT scan is essential if deep space infection suspected 1
• Monitor airway closely - life-threatening obstruction can develop, especially in children with smaller airways 2
• Consider Lemierre syndrome - routine testing for Fusobacterium necrophorum is not recommended, but clinicians must remain vigilant in patients with severe pharyngitis 1

Disposition

This patient requires same-day evaluation by an otolaryngologist or emergency department given the combination of severe symptoms suggesting either deep space infection or critical airway obstruction. 1