What is the best course of action for a 52-year-old female with right tonsil swelling and a bluish discoloration behind the right tonsil, who has a negative rapid strep (streptococcal) test?

Urgent Referral for ENT Evaluation

This 52-year-old woman with unilateral tonsil swelling and a bluish discoloration behind the right tonsil requires urgent ENT evaluation to rule out peritonsillar abscess, parapharyngeal abscess, or malignancy—the negative strep test appropriately excludes group A streptococcal pharyngitis, but the asymmetric presentation with unusual discoloration is a red flag that demands specialist assessment. 1, 2

Why This Is Not Simple Pharyngitis

• Unilateral tonsil swelling with bluish discoloration is not consistent with typical viral or bacterial pharyngitis, which generally presents with bilateral involvement 1, 3
• The bluish appearance suggests possible vascular involvement, abscess formation, or neoplastic process that requires direct visualization and potentially imaging 1
• Patients with "unusually severe signs and symptoms" or asymmetric findings should be evaluated for rare but serious throat infections including peritonsillar abscess and parapharyngeal abscess 1

Critical Red Flags Present in This Case

• Asymmetric/unilateral tonsillar enlargement is concerning for abscess or malignancy rather than infectious pharyngitis 1, 4
• Bluish discoloration is not a feature of typical streptococcal or viral pharyngitis and may indicate vascular congestion, hematoma, or other pathology 1
• At age 52, unilateral tonsillar enlargement raises concern for tonsillar malignancy (squamous cell carcinoma or lymphoma), which must be excluded 4

What the Negative Strep Test Tells Us

• A negative rapid strep test in adults is sufficient to rule out group A streptococcal pharyngitis without need for backup culture 2, 1
• The specificity of rapid antigen detection tests is ≥95%, making false positives rare 1, 2
• Antibiotics are not indicated based on the negative test result alone 1, 2

Immediate Management Steps

• Refer urgently to ENT for direct laryngoscopy and evaluation of the tonsillar mass and bluish lesion 1
• Consider CT scan with contrast of the neck if abscess is suspected (severe pain, trismus, difficulty swallowing, or systemic symptoms) 1, 3
• Do not prescribe antibiotics empirically without identifying a specific bacterial pathogen or abscess requiring drainage 1, 2
• Provide symptomatic relief with NSAIDs (ibuprofen) or acetaminophen for pain control while awaiting specialist evaluation 2, 3

Differential Diagnosis Requiring Exclusion

• Peritonsillar abscess: typically presents with severe unilateral throat pain, trismus, "hot potato voice," and uvular deviation—may appear as bulging mass with overlying erythema or bluish hue if there is significant vascular congestion 1, 3
• Parapharyngeal abscess: presents with neck swelling, tenderness, and systemic toxicity 1
• Tonsillar malignancy: unilateral tonsillar enlargement in adults over 40, especially with persistent symptoms, warrants biopsy to exclude squamous cell carcinoma or lymphoma 4
• Lemierre syndrome: rare but life-threatening condition with severe pharyngitis, neck pain/swelling, and potential septic thrombophlebitis—requires urgent diagnosis 1, 3

Common Pitfalls to Avoid

• Do not treat with antibiotics based on appearance alone without laboratory confirmation of bacterial infection or identification of abscess requiring coverage 1, 2
• Do not dismiss unilateral findings as "just pharyngitis"—asymmetry demands investigation 1, 4
• Do not delay ENT referral while attempting empiric antibiotic therapy, as this may mask serious pathology 1
• The bluish discoloration is not a typical feature of any common pharyngitis etiology and should prompt immediate concern 1

If ENT Evaluation Is Delayed

• Reassess within 24-48 hours for development of fever, worsening dysphagia, drooling, neck tenderness, or respiratory compromise 3
• Any progression of symptoms warrants emergency department evaluation for possible surgical drainage 1, 3
• Instruct patient to return immediately if difficulty breathing, inability to swallow secretions, or severe worsening of pain occurs 3