What is the appropriate management for a patient with unilateral upper palate swelling following a 1-week history of sore throat and cough?

Unilateral Upper Palate Swelling After 1 Week of Sore Throat and Cough

This patient requires urgent evaluation for peritonsillar abscess (PTA), which is the most likely diagnosis given the unilateral palatal swelling following a week of pharyngitis symptoms. 1, 2

Immediate Clinical Assessment

Examine for these specific red flags that indicate peritonsillar abscess:

• Unilateral soft palate swelling with uvular deviation away from the affected side 2, 3
• Trismus (difficulty opening the mouth) - though this may be less prominent in some patients 2
• "Hot potato" voice (muffled speech quality) 2, 3
• Progressively worsening odynophagia (painful swallowing) rather than improvement 2
• Ipsilateral tender anterior cervical lymphadenopathy 4

Life-Threatening Complications to Exclude

Immediately assess for signs requiring emergency intervention:

• Difficulty swallowing with drooling - suggests impending airway compromise 4, 1
• Neck tenderness or swelling - raises concern for parapharyngeal abscess or Lemierre syndrome 4, 1
• Respiratory distress or stridor - indicates upper airway obstruction 5
• High persistent fever with severe systemic symptoms in adolescents/young adults - consider Fusobacterium necrophorum infection and Lemierre syndrome 1, 6

Diagnostic Approach

If peritonsillar abscess is suspected based on unilateral palatal swelling:

• Perform needle aspiration of the swollen soft palate - this is both diagnostic and therapeutic 2
• If pus is obtained, the diagnosis is confirmed and surgical drainage is required 2, 3
• Culture the aspirate - Fusobacterium necrophorum is recovered in up to 58% of PTA cases and Group A Streptococcus in approximately 20% 6

Note: Peritonsillar abscess is a clinical diagnosis based on examination findings; imaging is not required for typical presentations 3

Management Algorithm

If pus is confirmed on needle aspiration:

1. Surgical drainage via either incision and drainage under local anesthesia OR acute tonsillectomy (à chaud) 2, 3
2. Antibiotic therapy effective against Group A Streptococcus and oral anaerobes 3
3. Consider clindamycin as first-line therapy given the high prevalence of Fusobacterium necrophorum, which is resistant to macrolides 6
4. Corticosteroids may reduce symptoms and speed recovery 3
5. Ensure adequate hydration and pain control 3

If no pus is obtained but clinical suspicion remains high:

• Consider parapharyngeal abscess - 52% of parapharyngeal abscesses have concomitant PTA 6
• Obtain CT imaging with contrast to evaluate deep neck spaces 6

Important Clinical Context

Peritonsillar abscess is the most common deep neck infection and typically affects young adults, though it can occur at any age 6, 3. The infection develops in the space between the tonsillar capsule and pharyngeal constrictor muscle 6.

The 1-week duration of symptoms is consistent with PTA, as it typically develops as a complication of acute tonsillitis after several days of pharyngitis 2, 7.

Critical Pitfalls to Avoid

• Do not dismiss unilateral palatal swelling as simple viral pharyngitis - this finding mandates evaluation for abscess 2, 5
• Do not prescribe antibiotics alone without drainage if PTA is present - abscess drainage is essential for treatment 2, 3
• Do not delay evaluation for bilateral involvement - bilateral PTA is rare but catastrophic and requires immediate intervention 5
• Do not use macrolides (azithromycin, clarithromycin) as monotherapy - Fusobacterium necrophorum is resistant, and this organism is highly prevalent in PTA 6

When to Hospitalize

Most patients can be managed in the outpatient setting after drainage and initiation of antibiotics 3. However, admit patients with:

• Signs of airway compromise 5, 3
• Inability to maintain oral hydration 3
• Suspected extension into deep neck spaces 6, 3
• Severe systemic toxicity suggesting Lemierre syndrome 1, 6