An eighteen year old white male comes to your office complaining of persistent tonsillitis after being treated with antibiotics (Z-pack) the week before by his local medical doctor. His temperature is 100.3 degrees F. Both tonsils are beefy red and are 4-plus enlarged. The right tonsil is pushing on the uvula. He has tender and enlarged anterior cervical nodes, especially on the right side. His rapid strep test is negative. He is seen by the college physician and is treated with 1 Gram of Rocephin IM. The student returns to your office the next day, complaining of fever, myalgia, and increased throat pain. His temperature is 101.6. The right tonsil has increased in size and is pushing on the uvula even more. The right anterior cervical node has increased in size. The student just happens to mention that when he was gargling with warm salt water this morning that he had difficulty opening his mouth.
WHAT DO YOU THINK HE HAS? If you said PERITONSILLAR ABSCESS, you are correct!
According to the Merck Manual, a peritonsillar abscess is "An acute infection located between the tonsil and the superior pharyngeal constrictor muscle." It is most common in young adults (many of whom are college students). The most common symptoms include: severe pain when swallowing, fever, holding the head tilted toward the side of the abscess, and trismus (difficulty opening the mouth). The tonsil is displaced medially and often displaces the uvula. The soft palate is erythematous and swollen. (1)
As the above student was not responding to the antibiotics, he was referred to an ENT surgeon and underwent a "quinsy" tonsillectomy later in the day. The student did quite well post-operatively. After a 23-hour stay in the hospital, he returned to campus and to class. In fact, he was seen eating in the cafeteria on his first post-op day and became rather famous around campus for his rapid recovery.
In addition to the case described, I have seen this condition two other times in the ten years that I have been in college health. One student underwent an incision and drainage in an ENT surgeon's office. The other was treated surgically with a tonsillectomy.
Peritonsillar abscesses require immediate attention and with just a little knowledge and experience, a college health nurse can assess students with this condition and make the proper referral.
Editor's Note:
The
Merck Manual is available for
free on the
World
Wide Web (WWW) at
http://www.merck.com/pubs/
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