What should be done for a patient with severe dysphagia (difficulty swallowing), swollen tonsils, and no fever, who has previously tested negative for strep, COVID-19, and flu?

Severe Dysphagia with Swollen Tonsils and No Fever

This patient requires urgent ENT evaluation to assess for potential airway compromise from peritonsillar abscess, infectious mononucleosis with tonsillar hypertrophy, or other causes of severe pharyngeal obstruction that can progress to life-threatening airway obstruction.

Immediate Assessment Priorities

The severity of dysphagia (10/10 pain with swallowing) combined with tonsillar swelling represents a potential airway emergency, regardless of fever absence. You must immediately assess:

• Ability to handle secretions - drooling, inability to swallow saliva, or "hot potato voice" suggest critical narrowing
• Respiratory status - stridor, tachypnea, use of accessory muscles, or oxygen desaturation indicate impending airway compromise
• Degree of trismus - inability to open mouth >3cm suggests deep space infection
• Uvular deviation or asymmetric tonsillar enlargement - indicates peritonsillar abscess even without fever

Differential Diagnosis and Management Algorithm

If Unilateral Tonsillar Swelling with Uvular Deviation

Peritonsillar abscess remains possible despite negative strep test and absence of fever. Proceed with:

• Immediate ENT consultation for needle aspiration or incision and drainage
• IV antibiotics (ampicillin-sulbactam or clindamycin)
• IV corticosteroids (dexamethasone 10mg) to reduce edema
• Hospital admission for airway monitoring

If Bilateral Symmetric Tonsillar Hypertrophy

Consider infectious mononucleosis (Epstein-Barr virus), which can cause:

• Massive tonsillar enlargement ("kissing tonsils") without fever in some cases
• Severe odynophagia preventing oral intake
• Risk of airway obstruction requiring corticosteroids

Obtain:

• Monospot or EBV serology
• Complete blood count (atypical lymphocytosis)
• Consider corticosteroids (prednisone 40-60mg daily for 5-7 days) if airway compromise threatens

If Post-COVID Context

Given negative COVID test but considering post-viral sequelae, dysphagia can occur from:

• Direct viral neuronal damage to swallowing coordination 1
• Respiratory-swallowing coordination impairment 2
• Persistent inflammation affecting pharyngeal function 3

However, 20% of non-intubated COVID patients develop dysphagia 2, and this can persist for months 3, 4.

Critical Management Steps

Hydration and Nutrition

• NPO status initially if aspiration risk suspected or airway compromise present
• IV hydration immediately - severe odynophagia leads to rapid dehydration
• Consider nasogastric tube if unable to maintain hydration orally and prolonged course expected

Airway Protection

If any signs of respiratory distress develop, prepare for potential emergency airway intervention. Have available:

• Difficult airway cart at bedside
• Anesthesia/ENT immediately available
• Consider elective intubation before crisis if progressive worsening 5

Symptomatic Management

• IV corticosteroids (dexamethasone 8-10mg) to reduce pharyngeal edema regardless of etiology
• IV analgesics - opioids may be necessary given 10/10 severity
• Avoid topical anesthetics that may impair protective reflexes

Imaging

Obtain CT neck with IV contrast if:

• Diagnostic uncertainty exists
• Deep space infection suspected
• Airway assessment needed before potential intervention

Common Pitfalls to Avoid

• Do not dismiss absence of fever - immunocompromised patients, elderly, or those with atypical presentations may lack fever despite serious infection
• Do not delay ENT consultation - airway compromise can develop rapidly with tonsillar pathology
• Do not attempt oral intake without swallow assessment if neurological dysphagia suspected - aspiration risk is significant 1, 6
• Do not assume negative strep test excludes bacterial infection - other organisms (Fusobacterium, anaerobes) cause severe pharyngitis
• Do not send patient home without ensuring adequate hydration - inability to swallow requires IV access

Disposition

Admit for observation and IV therapy given severity of symptoms. Discharge criteria include:

• Ability to swallow liquids without severe pain
• Adequate oral hydration maintained
• No signs of airway compromise
• Clear diagnosis established with appropriate treatment initiated

If post-viral dysphagia confirmed after excluding acute infectious/obstructive causes, implement breathing retraining and swallowing rehabilitation 7, as 83% of patients regain normal swallowing function within 2 months 4.