What are the differential diagnoses and recommended management for a patient with unilateral tonsillar white or yellow exudate, foreign-body sensation on swallowing, and mild sore throat?

Unilateral Tonsillar Exudate with Foreign Body Sensation

This presentation requires immediate consideration of peritonsillar abscess (quinsy) as the primary diagnosis, given the unilateral nature and foreign body sensation, which should prompt urgent evaluation and possible drainage before initiating antibiotics. 1

Differential Diagnosis

Most Likely (Requires Urgent Action)

• Peritonsillar abscess: The unilateral exudate combined with foreign body sensation is highly suggestive of abscess formation, which represents the most common deep space infection of the head and neck 1
• This is a suppurative complication that requires different management than simple pharyngitis 2

Other Bacterial Causes

• Group A Streptococcal pharyngitis: Can present with tonsillar exudate, though typically bilateral, and accounts for 5-15% of adult pharyngitis cases 2, 3
• Groups C and G streptococci: Can cause exudative tonsillitis with anterior cervical adenopathy 4
• Arcanobacterium haemolyticum: Particularly in teenagers and young adults, often with scarlet fever-like rash 2

Viral Causes (Less Likely Given Exudate)

• Epstein-Barr virus (infectious mononucleosis): Can present with tonsillar exudate, generalized lymphadenopathy, and splenomegaly 2
• Adenovirus, influenza, parainfluenza: Though viral causes account for 70-95% of tonsillitis overall, exudate is less common 3, 5

Critical Clinical Assessment

Red Flags for Peritonsillar Abscess

• Unilateral tonsillar swelling with deviation of uvula away from affected side 1
• "Hot potato" voice or muffled speech 1
• Trismus (difficulty opening mouth) 1
• Severe dysphagia beyond what mild sore throat would suggest 1

Risk Stratification for Streptococcal Infection

Use modified Centor criteria if abscess is ruled out 6, 7:

• Tonsillar exudate (1 point)
• Tender anterior cervical lymphadenopathy (1 point)
• Fever >38°C/100.4°F (1 point)
• Absence of cough (1 point)

Score of 3-4 indicates 28-56% probability of Group A streptococcal infection 6, 7

Recommended Management Algorithm

Step 1: Rule Out Peritonsillar Abscess

• Examine for unilateral tonsillar bulge, uvular deviation, and trismus 1
• If present: Urgent ENT referral for needle aspiration or incision and drainage 1
• Abscess requires drainage before or concurrent with antibiotics for optimal outcomes 1

Step 2: If No Abscess - Obtain Microbiological Confirmation

• Perform rapid antigen detection test (RADT) immediately - specificity ≥95% 7
• Do NOT treat based on clinical findings alone, as this leads to unnecessary antibiotic use 6
• If RADT negative and clinical suspicion remains high, obtain throat culture 2

Step 3: Antibiotic Treatment (Only if Positive Testing)

First-line for confirmed Group A Streptococcal infection:

• Penicillin V 250-500 mg orally 2-3 times daily for 10 days 7
• Alternative: Amoxicillin 500 mg twice daily for 10 days (better compliance with twice-daily dosing) 6

For penicillin allergy:

• Azithromycin 500 mg day 1, then 250 mg daily days 2-5 6

For recurrent/treatment failure cases:

• Amoxicillin-clavulanate 875/125 mg twice daily - provides coverage against beta-lactamase producing organisms 2
• Clindamycin - high rates of pharyngeal eradication in persistent cases 2

Step 4: Symptomatic Management (Regardless of Etiology)

• Ibuprofen or acetaminophen for pain relief 7
• Adequate hydration 1, 5
• Throat lozenges for additional symptom relief 7

Common Pitfalls to Avoid

• Missing a peritonsillar abscess: The unilateral presentation and foreign body sensation are atypical for simple pharyngitis and warrant careful examination for abscess 1
• Treating without microbiological confirmation: Clinical diagnosis alone is only 80% accurate, leading to overuse of antibiotics 6
• Assuming mild symptoms rule out serious pathology: Even with "mild" sore throat, an abscess can be present and requires drainage 1
• Overlooking infectious mononucleosis: Consider if patient has generalized lymphadenopathy or splenomegaly, as steroids may be needed and ampicillin should be avoided (causes rash) 2

Expected Course and Follow-up

• Most viral and bacterial pharyngitis resolves within 7 days 7
• Antibiotics shorten symptom duration by only 1-2 days even with confirmed streptococcal infection 7
• Return immediately if: worsening dysphagia, drooling, respiratory difficulty, or inability to open mouth - these suggest abscess formation or other complications 1