Evaluation and Management of Tonsillar Swelling with Voice Change
A patient presenting with tonsillar swelling and voice change requires immediate assessment for peritonsillar abscess and expedited laryngeal evaluation to exclude serious pathology, particularly if there are red flag features such as asymmetric tonsillar enlargement, trismus, or respiratory compromise.
Immediate Assessment Priorities
Red Flag Identification
- Assess for peritonsillar abscess by examining for ipsilateral soft palate swelling, uvular deviation, trismus (less common in children), and "hot potato" voice quality, which indicates a gradually worsening odynodysphagia requiring urgent intervention 1, 2.
- Evaluate for airway compromise by observing for respiratory distress, stridor, difficulty swallowing, or change in voice quality that suggests laryngeal involvement 3.
- Examine for asymmetric tonsillar enlargement, as unilateral tonsillar hypertrophy requires assessment to exclude malignancy, particularly in adults with tobacco or alcohol use 3, 4.
Physical Examination Specifics
- Perform complete head and neck examination including palpation for neck masses, assessment of tonsillar size using the Brodsky grading scale, and evaluation of the oropharynx with tongue depressor (without tongue protrusion to optimize visualization) 3.
- Document voice quality changes through perceptual evaluation, noting characteristics such as muffled quality, hot potato voice, or hoarseness 3, 1.
- Assess for concomitant symptoms including fever >101.5°F, hemoptysis, dysphagia, odynophagia, otalgia, or neurologic symptoms that warrant expedited laryngeal evaluation 3.
Diagnostic Algorithm
When to Pursue Expedited Laryngeal Evaluation
Clinicians should visualize the larynx or refer for laryngoscopy when voice changes are accompanied by:
- History of tobacco abuse or alcohol use 3
- Concomitant neck mass 3
- Respiratory distress or stridor 3
- Recent surgical procedures involving head, neck, or chest 3
- Professional voice user status 3
- Voice changes persisting beyond 3 months (though earlier evaluation is appropriate based on clinical presentation) 3
Imaging Considerations
- Obtain CT scan with contrast if peritonsillar abscess is suspected clinically, as imaging can differentiate intratonsillar abscess, peritonsillar abscess, phlegmon, and extension into parapharyngeal or retropharyngeal spaces 5, 6.
- Consider polysomnography when there is discordance between tonsillar size and severity of obstructive symptoms, or when obesity, craniofacial abnormalities, or neuromuscular disorders are present 3, 4, 7.
Management Based on Diagnosis
Peritonsillar Abscess
Immediate drainage is required through needle aspiration, incision and drainage, or abscess tonsillectomy, combined with antibiotic therapy effective against Group A Streptococcus and oral anaerobes 2, 8.
- First-line antibiotics should include clindamycin (preferred in penicillin-allergic patients due to coverage of Fusobacterium necrophorum, which is present in 23-58% of peritonsillar abscesses) or ampicillin/sulbactam 5, 8.
- Abscess tonsillectomy should be preferred when complications have occurred, alternative procedures have failed, or bilateral peritonsillar abscess is present 8.
- Corticosteroids may be helpful in reducing symptoms and speeding recovery 2.
Isolated Intratonsillar Abscess or Phlegmon
Clinically stable patients respond to intravenous antibiotic therapy without surgical drainage 6.
- Surgical drainage is indicated only with airway compromise, combination of intra- and peritonsillar abscess, or unresponsiveness to medical treatment 6.
Tonsillar Hypertrophy with Obstructive Symptoms
Tonsillectomy is indicated when tonsillar hypertrophy (Brodsky grade 3-4) causes confirmed obstructive sleep apnea, recurrent infections meeting Paradise criteria, or significantly impaired quality of life 4, 7.
- Complete tonsillectomy is preferred over partial tonsillotomy because residual lymphoid tissue may harbor crypts contributing to ongoing symptoms 4.
- Intraoperative dexamethasone (0.5 mg/kg, maximum 8-25 mg) should be administered to decrease postoperative pain, nausea, vomiting, and time to oral intake 3.
Self-Limited Viral Laryngitis
Most dysphonia related to upper respiratory infection resolves in 7-10 days regardless of treatment when accompanied by rhinitis, fever, and fatigue 3.
- Observation is appropriate if symptoms are of recent onset with typical viral features 3.
Critical Pitfalls to Avoid
- Never delay evaluation of unilateral tonsillar enlargement, as asymmetric enlargement requires exclusion of malignancy 3, 4.
- Do not assume all voice changes are benign laryngitis—delays in diagnosis of laryngeal cancer beyond 3 months lead to higher disease stages and worse prognosis 3.
- Avoid interval tonsillectomy after peritonsillar abscess, as this approach is not supported by contemporary clinical studies and recurrences after needle aspiration or incision and drainage are rare 8.
- Do not overlook airway compromise—all patients with oropharyngeal or laryngeal involvement should be observed in a facility capable of intubation or tracheostomy 3.
- Never assume tonsillectomy will completely resolve obstructive sleep apnea in obese patients, as resolution occurs in only 10-25% compared to 70-80% in normal-weight children 3, 4.