Urgent Evaluation for Peritonsillar Abscess
This child requires immediate evaluation for peritonsillar abscess (PTA), as increasing uvula deviation despite clinical improvement on antibiotics is a classic warning sign of this serious complication. 1
Immediate Clinical Assessment
Examine specifically for:
- Uvular displacement toward the opposite side from the affected tonsil 1
- Unilateral tonsillar bulging with edema and erythema 1
- Trismus (difficulty opening mouth) 1
- "Hot potato" voice or drooling 1
- Asymmetry of the soft palate 1
The classic presentation is progressive sore throat despite antibiotics, with edema of the affected tonsil and uvular displacement—exactly what this child is demonstrating. 1
Diagnostic Approach
For cooperative older children:
- Perform fine needle aspiration of the affected tonsil for prompt diagnosis 1
- This allows immediate confirmation of PTA and provides material for culture 1
If PTA is confirmed or highly suspected:
- Consider imaging (CT with contrast) if the diagnosis is uncertain or if deeper neck space involvement is suspected 1
Treatment Algorithm
Antibiotic Management
Switch from amoxicillin to a cephalosporin immediately 1
- Cephalosporins achieve high tissue concentrations within inflamed peritonsillar tissue 1
- This addresses the polymicrobial nature of PTA (including anaerobes and beta-lactamase producers) that amoxicillin alone cannot adequately cover 1
Definitive Treatment
Quinsy tonsillectomy (immediate tonsillectomy) is the definitive treatment 1
- This approach not only drains the abscess but eliminates potential for occult inferior pole or contralateral abscess 1
- It spares the child a future hospitalization and surgical procedure 1
- This is particularly important in children, where PTA can occur even at young ages (average age 8 years in reported series) 1
Critical Pitfall to Avoid
Do not continue amoxicillin monotherapy and observe. The increasing uvular deviation indicates progression despite antibiotic therapy, which is a hallmark of PTA development. 1 Progressive symptoms despite antibiotics should heighten suspicion for this complication, not reassure you that treatment is working. 1
Why This Matters
While the tonsillectomy guidelines focus on recurrent infections and sleep-disordered breathing 2, they specifically identify history of peritonsillar abscess as a modifying factor that favors tonsillectomy—particularly if more than one episode occurs. 2 This child's presentation suggests the first episode is developing now, requiring urgent intervention to prevent complications and potentially qualifying them for future tonsillectomy consideration.