What is the appropriate management for a patient with pharyngitis, nasal congestion, cough, left-sided cervical lymphadenopathy, and dysphagia?

Management of Pharyngitis with Cervical Lymphadenopathy and Dysphagia

This patient requires immediate testing for Group A Streptococcus pharyngitis using rapid antigen detection test or throat culture, and urgent evaluation for potential deep space neck infection given the combination of left-sided neck swelling and dysphagia. 1, 2

Immediate Assessment Priorities

Rule Out Life-Threatening Complications

• Assess for airway compromise immediately: Look for drooling, muffled voice ("hot potato voice"), severe odynophagia limiting oral intake, trismus, or respiratory distress—these indicate potential peritonsillar or parapharyngeal abscess requiring urgent imaging and possible surgical drainage. 2
• Examine for deep space infection: Unilateral neck swelling with dysphagia raises concern for peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome (septic thrombophlebitis of internal jugular vein). 2, 3
• Check vital signs: Fever >39°C, tachycardia, or hypotension suggest severe bacterial infection. 1

Physical Examination Red Flags

• Tonsillar asymmetry with one tonsil pushed medially strongly suggests peritonsillar abscess 2
• Neck tenderness or swelling may indicate deep space infection or Lemierre syndrome 2
• Drooling indicates severe pain with swallowing or impending airway obstruction 2
• Muffled voice strongly suggests deep space infection 2

Critical pitfall: The absence of fever does not rule out peritonsillar abscess or severe airway obstruction. 2

Diagnostic Testing Strategy

Test for Group A Streptococcus

Test this patient immediately because they meet criteria for bacterial pharyngitis: 1

• Persistent fever
• Left-sided cervical lymphadenopathy (tender anterior cervical adenitis)
• Sore throat
• Absence of prominent viral features (no rhinorrhea, conjunctivitis, or hoarseness mentioned)

Use rapid antigen detection test (RADT) or throat culture before prescribing antibiotics—microbiological confirmation is mandatory. 1, 4 Clinical features alone cannot reliably differentiate bacterial from viral pharyngitis. 4

When Imaging Is Required

Obtain CT scan of neck with IV contrast urgently if any of the following are present: 2

• Muffled voice
• Drooling
• Severe odynophagia
• Tonsillar asymmetry
• Unilateral neck swelling with dysphagia (as in this patient)

The combination of left-sided neck swelling and dysphagia in this patient warrants imaging to exclude abscess formation. 2, 3

Chest Radiograph Considerations

Obtain chest X-ray if: 1

• Cough persists or worsens
• Concern for aspiration pneumonia (given dysphagia)
• Respiratory symptoms suggest lower respiratory tract involvement

A case report documents pyopneumothorax as a rare but serious complication of streptococcal pharyngitis with neck swelling. 3

Antibiotic Treatment (If GAS Confirmed)

First-Line Therapy

Penicillin remains the treatment of choice for confirmed Group A Streptococcal pharyngitis: 1

• Penicillin V 250 mg orally 2-3 times daily for 10 days, OR
• Amoxicillin 500 mg orally twice daily (or 1000 mg once daily) for 10 days
• Intramuscular benzathine penicillin G for patients unlikely to complete oral therapy

Rationale: Proven efficacy, narrow spectrum, low cost, and no documented penicillin resistance in GAS. 1

Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy: 1

• Narrow-spectrum cephalosporins (cephalexin or cefadroxil) for 10 days

For anaphylactic-type penicillin allergy: 1

• Clindamycin (resistance ~1% in US), OR
• Azithromycin 500 mg day 1, then 250 mg days 2-5 (resistance 5-8% in US)

Important: Avoid tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, and older fluoroquinolones—they are ineffective against GAS. 1

Management of Dysphagia

Swallowing Evaluation

Refer to speech-language pathologist for formal swallowing evaluation if: 1

• Dysphagia persists after acute pharyngitis resolves
• Patient reports coughing or choking while eating/drinking
• Concern for aspiration risk

Do not perform swallowing evaluation if respiratory rate >35 breaths/min—this indicates severe respiratory compromise requiring stabilization first. 5

Aspiration Precautions

• Obtain chest radiograph and nutritional assessment in patients with dysphagia and cough to evaluate for aspiration. 1
• Consider videofluoroscopic swallow evaluation (modified barium swallow) or fiberoptic endoscopic evaluation of swallowing (FEES) if aspiration suspected. 1

Symptomatic Management

Offer analgesic therapy to all patients: 1

• Acetaminophen, NSAIDs, or aspirin (adults only)
• Throat lozenges
• Salt water gargles

Reassure patients that typical sore throat resolves in <1 week and antibiotics provide modest benefit (shortening symptoms by 1-2 days) but are necessary to prevent complications when GAS is confirmed. 1

When to Escalate Care

Admit or refer urgently if: 2

• Signs of airway compromise (stridor, severe dyspnea, inability to swallow secretions)
• Suspected deep space neck infection on examination or imaging
• Inability to tolerate oral intake due to severe odynophagia
• Systemic toxicity (high fever, tachycardia, altered mental status)

Follow-up within 24-48 hours if symptoms worsen or fail to improve with appropriate antibiotic therapy. 1