A 19-year-old man has 5 days of sore throat that is now much worse on the right, with pain radiating to the right ear and difficulty swallowing his own saliva. He was started on amoxicillin 3 days ago with no improvement. Temperature is 38.7 C and heart rate is 104/min. His voice is muffled and he is drooling slightly into a cup. He is sitting comfortably and is not stridorous. Which physical examination finding is most likely to be present?
- AA swollen cherry-red epiglottis with a normal oropharynx
- BGrey tonsillar exudate with posterior cervical adenopathy
- CA bulging posterior pharyngeal wall with neck stiffness
- DTender induration beneath the jaw with a raised tongue
- EDeviation of the uvula toward the left with trismus
Reveal answer & full explanation
Correct answer: E — Deviation of the uvula toward the left with trismus
- AA swollen cherry-red epiglottis with a normal oropharynx
- BGrey tonsillar exudate with posterior cervical adenopathy
- CA bulging posterior pharyngeal wall with neck stiffness
- DTender induration beneath the jaw with a raised tongue
- EDeviation of the uvula toward the left with trismus✓
Why Deviation of the uvula toward the left with trismus is correct
- Peritonsillar abscess is the most common deep neck space infection in adolescents and young adults and typically develops as a suppurative complication of tonsillitis that fails to improve on oral antibiotics.
- Pus collects between the tonsillar capsule and the superior constrictor muscle, so the affected tonsil and soft palate are pushed medially and downward and the uvula is displaced toward the opposite side.
- Irritation of the adjacent internal pterygoid muscle produces trismus, and the swollen soft palate gives the characteristic muffled hot potato voice with referred otalgia and drooling.
- Treatment is drainage by needle aspiration or incision plus antibiotics covering group A streptococcus and oral anaerobes, with airway assessment first.
- Deviation of the uvula toward the left with trismus — correct, contralateral uvular displacement with limited mouth opening localizes a right peritonsillar collection.
Why the others are wrong
- Tender induration beneath the jaw with a raised tongue — Ludwig angina, a bilateral cellulitis of the submandibular and sublingual spaces that usually spreads from an infected lower molar; it produces woody floor-of-mouth swelling that elevates the tongue in the midline rather than a unilateral tonsillar bulge following a sore throat.
- Grey tonsillar exudate with posterior cervical adenopathy — infectious mononucleosis, a near-miss because it does not respond to amoxicillin (which often provokes a maculopapular rash), but its tonsillar enlargement is bilateral, with posterior cervical adenopathy, fatigue, and often splenomegaly, and it does not explain pain lateralized to the right with referred otalgia; persistent or worsening unilateral symptoms call for reassessment for a suppurative complication whatever antibiotic has been given.
- A bulging posterior pharyngeal wall with neck stiffness — retropharyngeal abscess, which mainly affects children under 6 and presents with neck extension, torticollis, and midline posterior swelling rather than asymmetric tonsillar bulging.
- A swollen cherry-red epiglottis with a normal oropharynx — adult supraglottitis also causes severe odynophagia, a muffled voice, and drooling with a deceptively normal-looking oropharynx, but it does not displace the uvula or cause trismus, and a sore throat that lateralizes to one side after tonsillitis fails to improve on amoxicillin points to a peritonsillar collection.