What is the best course of treatment for a patient with a swollen throat, swollen tonsils, pain, and lymphadenopathy on one side of the ears, accompanied by feelings of fullness and diarrhea?

Clinical Approach to Unilateral Pharyngotonsillitis with Lymphadenopathy

You should test this patient for Group A Streptococcus using a rapid antigen detection test or throat culture, and if positive, treat with penicillin or amoxicillin; however, the unilateral presentation with ear fullness and diarrhea raises concern for alternative diagnoses that may require different management.

Initial Diagnostic Considerations

The unilateral nature of this presentation is atypical for common viral pharyngitis and warrants careful evaluation. Viral pharyngitis typically presents with bilateral symptoms and is often accompanied by cough, coryza, conjunctivitis, or hoarseness—features that suggest you should NOT pursue bacterial testing 1. The presence of diarrhea actually points away from streptococcal infection and toward a viral etiology 1, 2.

However, several features demand attention:

• Unilateral tonsillar swelling with pain and ipsilateral lymphadenopathy requires exclusion of peritonsillar abscess, which necessitates urgent evaluation and possible surgical drainage 3
• The ear fullness on the same side could represent either referred pain from the pharynx or concurrent otitis externa/media 1, 4
• In sexually active adults, unilateral tonsillitis should prompt consideration of sexually transmitted infections, particularly primary syphilis and gonococcal pharyngitis 1, 5

Examination Priorities

Perform a focused examination looking for:

• Tragal or pinna tenderness, which would indicate otitis externa rather than middle ear disease 1, 4
• Peritonsillar bulging or uvular deviation suggesting abscess formation 3
• Presence or absence of tonsillar exudate, palatal petechiae, and scarlatiniform rash 1
• Tender anterior cervical lymphadenopathy (supports streptococcal infection) versus generalized lymphadenopathy (suggests Epstein-Barr virus/infectious mononucleosis) 1, 6

Testing Strategy Using Modified Centor Criteria

Apply the Centor criteria to determine testing needs 1, 2:

• Fever by history (1 point)
• Tonsillar exudates (1 point)
• Tender anterior cervical adenopathy (1 point)
• Absence of cough (1 point)

• Patients with fewer than 3 Centor criteria do not need streptococcal testing 1
• With 3-4 criteria, perform rapid antigen detection test or throat culture 1, 2
• The presence of diarrhea strongly argues against streptococcal pharyngitis regardless of score 1

Management Based on Streptococcal Testing

If Streptococcal Test is Positive:

Prescribe penicillin or amoxicillin for 10 days to prevent rheumatic fever and suppurative complications 1, 2:

• Amoxicillin 500 mg every 12 hours or 250 mg every 8 hours for adults 7
• Alternative: Benzathine penicillin G as single intramuscular injection 2
• For penicillin allergy: first-generation cephalosporin or erythromycin 2
• Treatment must continue for minimum 10 days even if symptoms resolve earlier to prevent acute rheumatic fever 1, 7

If Streptococcal Test is Negative:

Provide supportive care only—systemic antibiotics are NOT indicated for viral pharyngitis 1. However, the unilateral presentation demands additional consideration:

• If sexually active with oral exposure history, test for syphilis (RPR and T. pallidum antibody) and consider gonococcal pharyngitis 1, 5
• Consider Epstein-Barr virus testing if generalized lymphadenopathy or splenomegaly present 1
• Evaluate for Fusobacterium necrophorum in adolescents/young adults with severe pharyngitis, as this can progress to life-threatening Lemierre syndrome 1

Addressing the Ear Symptoms

The ipsilateral ear fullness requires separate assessment:

• Examine for tragal/pinna tenderness—if present, this indicates otitis externa requiring topical antibiotic drops, NOT systemic antibiotics 1, 4
• Topical therapy delivers 100-1000 times higher antibiotic concentrations than systemic therapy for ear canal infections 4, 8
• Perform pneumatic otoscopy if possible to distinguish acute otitis media (requires systemic antibiotics) from otitis externa 1
• Regional lymphadenitis can occur with otitis externa, so don't assume all postauricular swelling is from pharyngitis 6

Critical Red Flags Requiring Urgent Evaluation

Immediately assess for these life-threatening conditions:

• Difficulty swallowing, drooling, or neck swelling suggesting peritonsillar/parapharyngeal abscess or epiglottitis 1
• Severe unilateral throat pain in adolescent/young adult (Lemierre syndrome risk) 1
• Diabetes or immunocompromised state with ear pain (necrotizing otitis externa risk) 4, 8

Expected Timeline and Reassessment

• Symptoms should improve within 48-72 hours of appropriate antibiotic therapy if bacterial infection present 1, 4, 7
• If no improvement by 48-72 hours, reassess to confirm diagnosis and exclude complications 4
• Consider treatment failure, resistant organisms, abscess formation, or alternative diagnosis 4, 8

Common Pitfalls to Avoid

• Do not prescribe oral antibiotics for uncomplicated viral pharyngitis—this increases resistance without benefit 1, 4
• Do not use systemic antibiotics for otitis externa unless infection extends beyond ear canal 1, 4
• Do not assume bilateral disease—unilateral presentations require broader differential including STIs and abscess 5
• Do not ignore diarrhea as a clinical clue—this strongly suggests viral rather than streptococcal etiology 1, 2