What is the most likely diagnosis and immediate management for a patient presenting with severe sore throat, inability to swallow, hypotension (blood pressure 88/54 mmHg) and dizziness?

Immediate Diagnosis and Management of Severe Sore Throat with Hypotension

This patient requires immediate emergency evaluation for a life-threatening deep neck space infection or airway compromise, with urgent IV fluid resuscitation and preparation for potential airway intervention.

Most Likely Diagnosis

Peritonsillar abscess, retropharyngeal abscess, or acute epiglottitis are the primary diagnostic considerations given the severe presentation with inability to swallow and hemodynamic instability 1, 2, 3.

• Peritonsillar abscess is the most common deep infection of the head and neck in young adults, presenting with fever, severe sore throat, dysphagia, and "hot potato" voice 1
• The inability to eat or drink combined with hypotension (BP 88/54) and dizziness indicates either severe dehydration from prolonged inability to swallow or systemic sepsis from deep space infection 1, 2
• These are not uncomplicated acute pharyngitis cases covered by standard sore throat guidelines, which explicitly exclude complicated pharyngitis (peritonsillar abscesses, Lemierre disease, severe comorbidity) 4

Immediate Management Algorithm

Step 1: Airway Assessment and Stabilization (First Priority)

• Immediately assess for airway compromise: Look for drooling, stridor, respiratory distress, oxygen desaturation, or inability to handle secretions 5
• If any signs of airway obstruction are present, prepare for emergency airway management with tracheostomy, cricothyrotomy, or endotracheal intubation 2, 5
• Acute epiglottitis can cause sudden upper airway obstruction that may become lethal and must be managed quickly 5
• Even mild initial findings can deteriorate rapidly after hospitalization despite treatment 5

Step 2: Hemodynamic Resuscitation (Concurrent with Step 1)

• Initiate aggressive IV fluid resuscitation immediately to address hypotension (BP 88/54) and dizziness 1
• The hypotension likely represents either severe dehydration from inability to swallow or early septic shock from deep space infection 1, 2
• Establish large-bore IV access and begin crystalloid boluses 1

Step 3: Urgent Diagnostic Evaluation

• Perform fiberoptic laryngoscopy to visualize the epiglottis, aryepiglottic folds, and pharynx for edema, abscess, or obstruction 6, 5
• Obtain CT scan of the neck with IV contrast to identify peritonsillar abscess, retropharyngeal abscess, epiglottic abscess, or extension into deep neck tissues 1, 6
• CT imaging showing air bubbles within swollen tissue confirms necrotizing abscess 6
• Look for unilateral tonsillar swelling with uvular deviation (peritonsillar abscess) or beefy red edematous epiglottis extending to aryepiglottic folds (epiglottitis) 1, 6

Step 4: Empiric Antibiotic Therapy

• Start IV antibiotics immediately without waiting for culture results, as these are potentially lethal infections 1, 2, 3
• Antibiotics must cover group A streptococcus and oral anaerobes, as peritonsillar abscesses are polymicrobial 1
• Ludwig's angina in particular progresses quickly to airway obstruction and requires urgent antibiotics plus surgical drainage 2

Step 5: Corticosteroid Administration

• Administer IV corticosteroids to reduce laryngeal edema and speed recovery 1, 6
• Corticosteroids are helpful in reducing symptoms in peritonsillar abscess and should be given immediately when epiglottitis is suspected 1, 6

Step 6: Surgical Intervention

• Drainage of abscess is a cornerstone of treatment if peritonsillar or epiglottic abscess is confirmed 1, 6
• Surgical drainage plus antibiotics are the mainstays of management for deep neck infections 2
• Under local or general anesthesia, perform puncture and drainage of identified abscess 6

Red Flags Present in This Case

• Inability to swallow (dysphagia) is a critical warning sign of deep space infection or airway compromise 1, 6, 3
• Hypotension (88/54 mmHg) indicates either severe dehydration or septic shock, both requiring immediate intervention 1, 2
• Dizziness suggests inadequate cerebral perfusion from hypotension 1

Common Pitfalls to Avoid

• Do not treat this as simple viral or streptococcal pharyngitis with oral antibiotics and outpatient follow-up—this presentation demands emergency evaluation 4, 1
• Do not delay imaging or specialist consultation while attempting conservative management, as these infections can extend into deep neck tissues and cause airway obstruction 1, 2
• Do not assume stable vital signs will remain stable—patients with acute epiglottitis can deteriorate rapidly even with mild initial findings 5
• Do not perform blind instrumentation of the pharynx without visualization, as this can precipitate complete airway obstruction 2, 5

Disposition

• This patient requires hospital admission for IV antibiotics, hydration, pain control, and close airway monitoring 1, 5
• Most peritonsillar abscess patients can be managed in the outpatient setting after drainage, but this patient's hemodynamic instability mandates inpatient care 1
• If symptoms of laryngeal edema, oxygen desaturation, or dyspnea are present, emergency airway management should be prepared immediately after hospitalization 5