Page 135 - Journal of Special Operations Medicine - Winter 2014

What would you want to look for on exam? severe pharyngitis can be caused by Epstein-Barr virus
(mononucleosis); the presence of swollen posterior cer-
You examine the patient. You find a 21-year-old man vical nodes is typical for this. 1
who is sitting upright. His voice is somewhat muffled,
but he appears in no respiratory distress. His neck is Peritonsillar abscess or PTC refers to an infection in-
supple, but he has tender left anterior cervical adenopa- volving the space between the tonsil and the pharyngeal
thy. His heart rate, respiratory rate, and blood pressure muscles and palate. It is thought to arise as a compli-
are normal. He has an Spo of 98% and a temperature cation of a streptococcal infection. In PTC, there is an
2
of 38.0ºC. Examination of his pharynx reveals pharyn- infection in this space with swelling, whereas PTA refers
geal swelling (Figure 1). You note that there is a minimal to infection with defined collection(s) of pus.
degree of trismus.
In this case, a 21-year-old has already demonstrated
helpfulness to your team and is now seeking medical
attention. It is reasonable to treat him if his condition
is amenable to your medical resources and allows the
continuance of a productive relationship in your mis-
Figure 1 sion environment. A thorough history and physical ex-
Pharyngeal swelling amination allow for the narrowing of your differential,
on examination. arriving at a likely diagnoses of PTC/PTA. Further clari-
fication of the patient’s dysphagia may be of importance
as hydration and oral intake may be of equal importance
to the infection, dependent on environmental factors.
Social aspects such as smoking, drug use, and dental
care may also be factors that affect treatment outcomes.

What is your next step?
“Trismus” is a term that can be used to describe
restriction in mouth opening. Your attention must now focus on determining the sta-
bility of this patient with regards to your current opera-
tional environment and resources at your disposal. The
You review your differential diagnoses.
primary issue is the presence of airway impairment. If
the patient is in respiratory distress, is drooling, or has
Epiglottitis is a potentially life-threatening infection of significant trismus, then you may need to seek help rap-
the epiglottis. In Western society, it was historically seen idly or secure the airway. Intubation can prove difficult
affecting children, but with the advent of the HiB vac- even in experience hands so an emergent cricothyroid-
cine it is far less common. It is still seen in adults and otomy may be necessary.
children, and needs to be considered and respected.
In this case the patient has swelling and is in pain but
Retropharyngeal abscess is an infection typically seen appears to be at no immediate risk. In addition, your
in children. This usually occurs deeper down in the current operating conditions do not permit immediate
pharynx. Patients often have normal-appearing palates evacuation. What next?
and tonsils but may have stridor and/or neck stiffness
to flexion. Lateral soft tissue neck radiographs may be The treatment for PTC is intravenous antibiotics and
helpful if available. Consider this diagnosis in ‘croupy’ supportive care.
children who don’t respond to inhaled epinephrine.
Antibiotics
Ludwig’s angina is usually caused by a dental infection Antibiotics are an important part of the therapy for PTA
that forms an abscess and swelling under the tongue or and PTC. In fact, an initial 24-hour trial of antibiot-
mandible. It can cause airway obstruction due to pro- ics (intravenous [IV]) for presumed PTC patients who
trusion of the tongue superiorly and posteriorly. Typi- show no signs of airway compromise is quite reason-
cally, physical examination will demonstrate submental able. A variety of choices are available, but with the
2
swelling and lymphadenopathy. international prevalence of penicillin-resistant organ-
isms, clindamycin or ampicillin/sulbactam are reason-
Tonsilitis is a common infection caused by group A strep- able choices. Often, the IV delivery of these antibiotics
tococci bacteria. The tonsils can be quite large and even is preferable to rapidly achieve and maintain therapeutic
appear to “kiss” in the midline. It typically responds to serum drug levels. Intravenous therapy also allows for
antibiotics and/or steroids. In some case, tonsillitis or increased patient compliance and daily follow-up. This

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