What is the recommended treatment for a patient with severe throat pain, painful swallowing, right ear pain, unilateral bulging of the soft palate, and enlargement and tenderness of cervical lymph nodes on the right side, accompanied by fever?

Peritonsillar Abscess: Immediate Antibiotic Therapy and Urgent ENT Referral Required

This clinical presentation—unilateral bulging of the soft palate with severe throat pain, dysphagia, referred ear pain, fever, and tender cervical lymphadenopathy—is highly suggestive of peritonsillar abscess, which requires immediate antibiotic therapy and urgent ENT evaluation for possible drainage.

Clinical Recognition and Diagnosis

The constellation of symptoms you describe represents a suppurative complication that extends beyond simple pharyngitis:

• Unilateral soft palate bulging is the hallmark physical finding of peritonsillar abscess, distinguishing it from uncomplicated streptococcal pharyngitis 1
• Severe unilateral throat pain with referred ear pain indicates deep tissue involvement beyond mucosal infection 1
• Tender cervical lymphadenopathy with fever suggests significant bacterial infection requiring immediate treatment 1

This is NOT a case where observation or delayed treatment is appropriate—unlike uncomplicated pharyngitis where testing before treatment is standard practice 1.

Immediate Antibiotic Management

First-line empiric therapy should be high-dose amoxicillin-clavulanate (875-125 mg twice daily for adults, or 90 mg/kg/day of amoxicillin component for children) to cover both Group A Streptococcus and oral anaerobes including Fusobacterium species 1. The addition of clavulanate is critical because peritonsillar abscesses frequently involve beta-lactamase producing organisms that would not respond to penicillin or amoxicillin alone 1.

Alternative Regimens for Penicillin Allergy:

• For non-anaphylactic penicillin allergy: Clindamycin 300-450 mg three times daily (or 20-30 mg/kg/day in children divided into 3 doses) provides excellent coverage of both streptococci and anaerobes 1
• Avoid macrolides (azithromycin, clarithromycin) as monotherapy for suspected abscess, as they have inadequate anaerobic coverage despite being acceptable for uncomplicated streptococcal pharyngitis 1

Critical Next Steps Beyond Antibiotics

Urgent ENT Referral:

Patients with peritonsillar abscess require same-day ENT evaluation for possible needle aspiration or incision and drainage 1. Antibiotics alone may be insufficient, and delayed drainage increases risk of:

• Extension to parapharyngeal or retropharyngeal spaces 1
• Development of Lemierre syndrome (septic thrombophlebitis of the internal jugular vein) 1
• Airway compromise from progressive swelling 1

Warning Signs Requiring Emergency Department Evaluation:

• Difficulty swallowing saliva (drooling) 1
• Trismus (inability to open mouth fully) 1
• Muffled "hot potato" voice 1
• Neck swelling or tenderness suggesting deep space infection 1

Pain Management

Provide aggressive analgesia with acetaminophen or NSAIDs (ibuprofen) for moderate to severe pain 1. The pain from peritonsillar abscess is typically severe and undertreated. Avoid aspirin in children due to Reye syndrome risk 1.

Do NOT use systemic corticosteroids (such as intramuscular Kenalog) as they can mask progression of infection without treating the underlying abscess and may delay recognition of treatment failure 2.

Common Pitfalls to Avoid

Do Not Treat This as Simple Pharyngitis:

• Standard 10-day penicillin or amoxicillin monotherapy is inadequate for peritonsillar abscess due to polymicrobial infection including anaerobes 1
• Do not perform rapid strep testing and wait for results—the unilateral soft palate bulging indicates a surgical emergency requiring immediate empiric treatment 1

Do Not Delay ENT Consultation:

• Antibiotics alone have higher failure rates than combined antibiotic-drainage approaches 1
• Waiting 48-72 hours to reassess (appropriate for uncomplicated pharyngitis) is dangerous with suspected abscess 1

Recognize Lemierre Syndrome Risk:

Recent evidence shows Fusobacterium necrophorum causes 10-20% of pharyngitis in adolescents and young adults and can progress to life-threatening Lemierre syndrome with septic emboli 1. Severe unilateral pharyngitis with neck tenderness warrants urgent evaluation and aggressive treatment 1.

Treatment Duration and Follow-up

• Continue antibiotics for 10-14 days after drainage or until complete clinical resolution 1
• Reassess within 24-48 hours to ensure clinical improvement and absence of complications 1
• If no improvement within 48 hours despite antibiotics and drainage, consider imaging (CT with contrast) to evaluate for deep space infection or alternative diagnosis 1