A patient with streptococcal pharyngitis started on dexamethasone and cephalexin three days ago now has halitosis, muffled “hot‑potato” voice, hoarseness, and left tonsillar enlargement; what is the most likely diagnosis and recommended management?

Peritonsillar Abscess: Immediate Drainage Required

This patient has a peritonsillar abscess (PTA) complicating streptococcal pharyngitis, and requires urgent incision and drainage plus antibiotic escalation—cephalexin is inadequate for this polymicrobial infection. 1

Clinical Diagnosis

The constellation of halitosis, muffled "hot potato" voice, hoarseness, unilateral tonsillar enlargement, and failure to improve after 3 days of antibiotics strongly indicates peritonsillar abscess rather than simple pharyngitis. 2, 3, 1

• Classic PTA presentation includes: fever, severe sore throat, dysphagia, trismus, drooling, muffled voice, and asymmetric tonsillar swelling with deviation of the uvula away from the affected side 2, 1, 4
• Halitosis is a key distinguishing feature that suggests suppurative infection rather than uncomplicated pharyngitis 3
• The left tonsillar asymmetry reflects the space-occupying abscess in the peritonsillar space (between the tonsillar capsule and superior pharyngeal constrictor muscle) 2
• Occult PTA can present with unilateral tonsillar enlargement alone without other acute infectious signs, though this patient has multiple classic features 5

Critical Management Steps

1. Immediate Drainage (First Priority)

Airway management and drainage are the cornerstones of treatment and must be performed urgently. 3, 1

• Needle aspiration or incision and drainage should be performed immediately to decompress the abscess and obtain culture material 1, 4
• Airway assessment is mandatory first because PTA carries risk of impending airway obstruction, aspiration, or extension into deep neck tissues 3, 1
• Most patients can be managed in the outpatient setting with drainage and appropriate antibiotics, though hospitalization may be needed for severe cases 1

2. Antibiotic Escalation (Cephalexin is Inadequate)

Peritonsillar abscesses are polymicrobial infections requiring coverage of Group A Streptococcus AND oral anaerobes—cephalexin monotherapy is insufficient. 1

• First-line antibiotic options include:

  • Amoxicillin-clavulanate (covers both streptococci and β-lactamase-producing anaerobes) 1
  • Clindamycin 300 mg orally three times daily for 10 days (excellent streptococcal and anaerobic coverage, ~1% resistance in US) 6, 1
  • Combination therapy with a penicillin plus metronidazole for anaerobic coverage 1

• Why cephalexin failed: First-generation cephalosporins like cephalexin lack adequate anaerobic coverage for the polymicrobial flora in PTA 1

3. Supportive Care

• Corticosteroids may reduce symptoms and speed recovery in PTA, though dexamethasone was already initiated 1
• Maintain hydration and provide adequate pain control with acetaminophen or NSAIDs 1
• Avoid aspirin in children due to Reye syndrome risk 6

Common Diagnostic Pitfalls

• Bilateral PTA is extremely rare (only 13 cases reported worldwide) and lacks the hallmark asymmetry of unilateral disease, potentially mimicking other conditions 2, 3
• Contrast-enhanced CT should be considered if diagnosis is uncertain or if deep neck space extension is suspected 2
• Do not assume simple treatment failure—lack of improvement after 3 days of appropriate antibiotics for pharyngitis should prompt evaluation for suppurative complications like PTA 7, 1

Follow-Up Considerations

• Culture the drained pus to guide antibiotic therapy; Streptococcus pyogenes is commonly isolated but mixed flora is typical 2, 1
• Interval tonsillectomy (typically 6 weeks post-drainage) should be discussed, especially for recurrent episodes 2
• Hospitalization is warranted if the patient cannot maintain hydration, has airway compromise, or has extension into deep neck spaces 1