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Dan Med J 2019 Feb;66(2)

Introduction: We aimed to investigate doctors' ad-herence to the local antibiotic guidelines for treatment of patients admitted with acute pharyngeal infections and to identify patient-related risk factors for non-adherence.

Methods: All patients with acute tonsillitis, peritonsillar abscess (PTA), and parapharyngeal abscess admitted to the Ear-Nose-Throat Department, Aarhus University Hospital, in the 2001-2014 period were included in the study.

Results: In total, 2,567 patients were hospitalised with acute pharyngeal infection. Read More

Turk Arch Otorhinolaryngol 2018 Dec 1;56(4):221-225. Epub 2018 Dec 1.

Department of Otorhinolaryngology and Head & Neck Surgery, Şişli Hamidiye Eftal Training and Research Hospital, İstanbul, Turkey.

Objective: Peritonsillar abscess (PTA) is defined as pus accumulation between the tonsillar capsule and constrictor pharyngeal muscle. It can be seen as a complication of acute tonsillitis, but other mechanisms have also been proposed. In this study we aimed to reveal the seasonal variations and epidemiologic features of PTA. Read More

Clin Otolaryngol 2019 Jan 21. Epub 2019 Jan 21.

Mersey ENT Research Collaborative, Merseyside, UK.

Objectives: While uncommon in the population at large, peritonsillar abscess (PTA) is a common subject of ENT referrals. Missed or uncertain diagnosis is a source of concern for non-specialist referrers. In line with the NHS England Second Sepsis Action Plan, we aimed to develop a predictive score for the presence of PTA. Read More

Emerg Med Clin North Am 2019 Feb;37(1):95-107

Department of Emergency Medicine, Loma Linda University School of Medicine, 11234 Anderson Street MC A-108, Loma Linda, CA 92354, USA. Electronic address:

Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. Read More

Emerg Med Clin North Am 2019 Feb;37(1):69-80

Department of Emergency Medicine, Northwestern University, 211 East Ontario - Suite 300, Chicago, IL 60611, USA. Electronic address:

This article reviews the presentation, diagnosis, and management of common and "can't miss" infections of the oropharynx, including streptococcal pharyngitis, infectious mononucleosis, peritonsillar abscess, retropharyngeal abscess, and epiglottitis. Read More

Case Rep Otolaryngol 2018 27;2018:7307290. Epub 2018 Sep 27.

Department of Otorhinolaryngology, Juntendo University Faculty of Medicine, Tokyo, Japan.

Deep neck abscess is a life-threatening infection that causes laryngeal edema and upper airway occlusion. The predominant bacterial species involved in this disorder is group A streptococcus. Group G streptococcus (GGS) constitutes the normal commensal flora of the human upper airway. Read More

J Emerg Med 2018 Dec 17;55(6):841-844. Epub 2018 Oct 17.

University of California San Diego, San Diego, California.

Background: In the winter months, one often sees a large increase in the volume of patients presenting to emergency departments with acute pharyngitis. While most cases of acute pharyngitis are benign, a rare minority can be life threatening.

Case Report: We report a case of epiglottis with a concomitant peritonsillar abscess (PTA) in an adult who presented to the emergency department with a sore throat. Read More

Med Clin North Am 2018 Nov 20;102(6):1109-1120. Epub 2018 Sep 20.

Otolaryngology-Head and Neck Surgery, University of California, San Francisco, 2233 Post Street, 3rd floor, San Francisco, CA 94115, USA.

Infections of the head and neck are common and appropriately managed by primary care providers in most cases. However, some infections are associated with significant morbidity and require urgent recognition and management by specialty services. These include deep neck space infections originating in the oral cavity, pharynx, and salivary glands, as well as complicated otologic and sinonasal infection. Read More

Int J Pediatr Otorhinolaryngol 2018 Nov 5;114:143-146. Epub 2018 Sep 5.

Michigan Medicine, Department of Otolaryngology, Head & Neck Surgery, Ann Arbor, MI, United States.

Objective: To determine the incidence of intratonsillar abscess (ITA) patients within the population of patients diagnosed with peritonsillar abscess (PTA) and to further characterize the differences in symptomatology and successful treatment strategies between the two groups.

Methods: This study is a retrospective chart review of patients diagnosed with PTA or ITA at our institution from 2000 to 2017. Descriptive and inferential statistics are reported, including univariate and multivariate analyses. Read More

Clin Otolaryngol 2019 Jan 25;44(1):7-13. Epub 2018 Oct 25.

Department of Otolaryngology - Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, UK.

Aim: (a) To report national trends for tonsillectomy, tonsillitis, peritonsillar abscess and deep neck space infection in secondary care. (b) To report national trends in sore throat consultations in primary care. (c) To report national trends in antibiotic prescribing in both primary and secondary care between 2011 and 2015. Read More

J Laryngol Otol 2018 Oct 13;132(10):872-874. Epub 2018 Sep 13.

Department of Otorhinolaryngology, Head and Neck Surgery,Medical Faculty,University of Cologne,Germany.

Objective: Smoking is purported to increase the risk of peritonsillar abscess formation, but prospective data are needed to confirm this hypothesis. This prospective study aimed to identify this correlation.

Methods: Fifty-four patients with peritonsillar abscess were prospectively asked about their smoking behaviour using a questionnaire that was designed and approved by the Robert Koch Institute (Berlin, Germany) to analyse smoking behaviour in epidemiological studies. Read More

Pediatr Emerg Care 2018 Sep;34(9):e161-e164

Division of Pediatric Emergency Medicine, Department of Pediatrics, Hamad Medical Corporation.

Neck abscesses such as retropharyngeal, peritonsilar, and lateral pharyngeal are well described, typically cause a characteristic illness, and have a known epidemiology. We present a rare occurrence of case of confluent, mixed retropharyngeal, lateral pharyngeal, and peritonsilar abscess in a 9-month-old female infant. The symptoms at presentation were very mild and not expected in association with this extensive an abscess. Read More

Diagnostics (Basel) 2018 Aug 2;8(3). Epub 2018 Aug 2.

Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Rigshospitalet University Hospital, 2100 Copenhagen, Denmark.

Peritonsillar abscess (PTA) is a common complication to acute tonsillitis. The treatment is drainage of the abscess, but many needle aspirations are unsuccessful due to a low diagnostic accuracy based on oral examination only. In this article, we describe how intraoral ultrasound can be added to improve the diagnostic work-up of PTA and present a novel technique for ultrasound-guided aspiration of PTA, using a small pencil-shaped transducer. Read More

Arch Dis Child Educ Pract Ed 2018 Jul 31. Epub 2018 Jul 31.

Department of Pediatric Endocrinology, Pamukkale University School of Medicine, Denizli, Turkey.

An 11-year-old boy was admitted with mildly painful swallowing. His parents mentioned he had had bad breath for 4 months. He had presented with the same complaint several times at medical centres, and some antibiotics and analgesics were given. Read More

BMJ Case Rep 2018 Jul 24;2018. Epub 2018 Jul 24.

Women's & Children's Hospital, Adelaide, South Australia, Australia.

We report the case of a 14-year-old man with unilateral peritonsillar swelling, airway compromise and fever. On physical examination, the patient was pyrexic with trismus, dysphonia, uvula deviation, exudative unilateral peritonsillar swelling and unilateral cervical lymphadenopathy. Attempts at aspirating the prominent peritonsillar region were unsuccessful. Read More

Dis Markers 2018 28;2018:2040746. Epub 2018 May 28.

Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Münster, Münster, Germany.

Peritonsillar inflammation is a common characteristic of both peritonsillar abscess (PTA) and peritonsillitis (PC). The aim of the present study was to apply the PTA score as an objective criterion to identify patients with peritonsillar inflammation (PI) who might profit from medical treatment. Hence, the recently developed PTA score was applied retrospectively on patients suffering from acute tonsillitis, peritonsillitis, and peritonsillar abscess. Read More

J Laryngol Otol 2018 Jul 11;132(7):615-618. Epub 2018 Jun 11.

Department of Advanced Cardiovascular Therapeutics,Nagoya University Graduate School of Medicine,Japan.

Objective: To assess the diagnostic role of mean platelet volume in tonsillitis with and without peritonsillar abscess.

Methods: Mean platelet volume and other laboratory data were retrospectively investigated.

Results: Mean platelet volume was significantly lower in the tonsillitis group (7. Read More

Jpn J Infect Dis 2018 Sep 31;71(5):365-367. Epub 2018 May 31.

Department of Otolaryngology, National Center for Global Health and Medicine.

Fusobacterium necrophorum has recently been suggested to be associated with tonsillopharyngitis, peritonsillar abscess, and recurrent tonsillitis. Between the 2 subspecies of F. necrophorum, subsp. Read More

Malays Fam Physician 2018 30;13(1):41-44. Epub 2018 Apr 30.

MD, M.Med (ORL-HNS), Department of Otorhinolaryngology-Head & Neck Surgery, Universiti Sains Malaysia Health Campus Kota Bharu, Kelantan, Malaysia.

Peritonsillar abscess, or quinsy, is a rare complication of acute tonsillitis. It usually presents with odynophagia, trismus, and muffled voice, reflecting the space-occupying lesion in the oral cavity. Examination reveals a unilateral swelling on either side of the soft palate, which drains thick pus after an incision is made. Read More

Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2017 May;31(10):794-795

Department of Otorhinolaryngology Head and Neck Surgery, the Sixth Affiliated Hospital of Guangzhou Medical University, the People's Hospital of Qingyuan, Qingyuan, 511518, China.

The aim of this study is to investigate the clinical value of visual analogue scale combined with serum C-reactive protein in evaluating the prognosis of peritonsillar abscess. Thirty-one patients be hospitalized with peritonsillar abscess were enrolled in this study, who were treated by puncture and antibiotic from January 2016 to February 2017. VAS and CRP level were detected on the 1, 3, 5 day of hospitalization for all the patients. Read More

Trop Doct 2018 Jul 14;48(3):179-182. Epub 2018 May 14.

4 Professor, Department of Otorhinolaryngology, Christian Medical College, Vellore.

In order to study the bacteriological profile, antibiotic sensitivity and outcome following empirical therapy with early generation antibiotics in patients with deep head and neck infection, a retrospective review of 42 patients admitted for drainage and intravenous antibiotic therapy was performed. Ludwig's angina was the commonest infection, with the most common organisms isolated being Group F ß-haemolytic (15%) and non-haemolytic (12.5%) streptococcus. Read More

Ann Ital Chir 2018 ;89:70-74

Necrotizing fasciitis is one of the most dangerous complication of an abscess and it is still a disease with a high mortality. In this work, we decided to consider two cases: the first one concerns a male subject, aged 66, deceased because of a fatal necrotizing fasciitis associated to a cervical descending mediastinitis, which evolved from a primary peritonsillar abscess; the second is about a 50-year-old woman with a perineal abscess, then evolved into necrotizing fasciitis associated to a fatal septis shock. After a systematic consideration of necrotizing fasciitis as pathology and an analysis of the possible related risks to a diagnostic or therapeutic delay, we analyzed the particular history of both cases to underline the possible critical issues in professional behavior of the medical staff intervened. Read More

Indian J Pediatr 2018 Oct 15;85(10):911-913. Epub 2018 Mar 15.

Department of ENT, Hindu Rao Hospital & North DMC Medical College, New Delhi, India.

Extracranial carotid artery aneurysms are rare but important entity. Impending rupture of such aneurysms can lead to catastrophic hemorrhage, airway compromise and may prove fatal. The authors report a case of true aneurysm of cervical internal carotid artery in a four-year-old girl who presented with fever and swelling of neck and oropharynx. Read More

West J Emerg Med 2018 Jan 14;19(1):172-176. Epub 2017 Dec 14.

University of Arizona, Arizona Simulation Technology & Education Center, Tucson, Arizona.

Introduction: Peritonsillar abscess (PTA) is the most common deep space infection of the head and neck presenting to emergency departments.1 No commercial PTA task trainer exists for simulation training. Thus, resident physicians often perform their first PTA needle aspiration in the clinical setting, knowing that carotid artery puncture and hemorrhage are serious and devastating complications. Read More

BMJ Case Rep 2018 Jan 17;2018. Epub 2018 Jan 17.

Department of Otorhinolaryngology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK.

A 7-month-old boy presented to the emergency department with reduced oral intake, neck swelling and fever. Clinical examination revealed a 3 cm left parotid and left level I neck swelling with left medialised tonsil but no trismus. Computed imaging confirmed the presence of an abscess in the peritonsillar area with extension into the parapharyngeal space and deep lobe of the parotid gland. Read More

J Ultrasound Med 2018 Jul 23;37(7):1657-1663. Epub 2017 Dec 23.

Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea.

Objectives: Pediatric tonsillar infections are common, particularly in adolescents. Ultrasonography (US) has high sensitivity and specificity for diagnosing peritonsillar abscesses and can diagnose tonsillitis by enlargement of the gland. In this study, we established normal tonsillar measurements and volumes according to age in pediatric populations. Read More

Dis Markers 2017 17;2017:9126560. Epub 2017 Oct 17.

Institute of Immunology, University Hospital Münster, Münster, Germany.

Peritonsillar abscess (PTA) is a very frequent reason for urgent outpatient consultation and otolaryngological hospital admission. Early, correct diagnosis and therapy of peritonsillar abscess are important to prevent possible life-threatening complications. Based on physical examinations, a reliable differentiation between peritonsillar cellulitis and peritonsillar abscess is restricted. Read More

J Paediatr Child Health 2017 Nov;53(11):1065-1070

Otorhinolaryngology, Head and Neck Surgery, Canterbury District Health Board, Christchurch, New Zealand.

Tonsillectomy is one of the most common paediatric surgical procedures performed in Australasia. The aim of this paper is to provide an up-to-date review of the indications for the procedure (and the evidence base for each of these indications), as well as describe the surgical technique and perioperative management and risks for a non-surgical audience. The primary indications for tonsillectomy are obstructive sleep apnoea (OSA) (where it is most commonly performed in association with adenoidectomy) and recurrent pharyngotonsillitis. Read More

BMJ Open 2017 Nov 15;7(11):e016221. Epub 2017 Nov 15.

Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.

Objectives: To investigate if use of antibiotics was associated with bacterial complications following upper respiratory tract infections (URTIs).

Design: Ecological time-trend analysis and a prospective cohort study.

Setting: Primary, outpatient specialist and inpatient care in Stockholm County, Sweden. Read More

Otolaryngol Head Neck Surg 2018 02 7;158(2):280-286. Epub 2017 Nov 7.

1 Department of Otolaryngology/Head and Neck Surgery, Southern California Permanente Medical Group, San Diego, California, USA.

Objective This study was performed to determine whether the efficacy and safety of medical management of uncomplicated peritonsillar abscess (PTA) presenting in the emergency department is equivalent to medical plus surgical therapy. Study Design Case series with chart review. Setting Southern California Permanente Medical Group (SCPMG). Read More

Vestn Otorinolaringol 2017;82(5):12-14

Morozovskaya City Children's Clinical Hospital, Moscow Health Department, Moscow, Russia, 119049.

The present study was undertaken for the purpose of elucidating the specific features of the past medical history and the etiological factors responsible for the development of tonsillogenic pharyngeal abscesses in the children. We performed the retrospective analysis of the medical histories of 291 children presenting with this condition who had been admitted for the treatment to the ENT Department of the Morozovskzya City Children's Clinical Hospital during the period from January till December 2015. The study has demonstrated the following most common shortcomings of the outpatient treatment of the patients suffering from chronic tonsillitis at the stage preceding formation of paratonsillar abscess: inadequate antibacterial therapy of acute chronic tonsillitis or its exacerbation and limited indications for tonsillectomy at the level of the outpatient treatment. Read More

Laryngoscope 2018 04 8;128(4):783-784. Epub 2017 Oct 8.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of New Mexico Hospital, Albuquerque, New Mexico, U.S.A.

Auris Nasus Larynx 2018 Jun 18;45(3):517-521. Epub 2017 Sep 18.

Department of Anatomy and Histology, University of Zaragoza, Spain.

Objective: Tonsillectomy is one of the surgical techniques most practiced by otolaryngologists, and despite being a relatively simple technique; it presents a considerable percentage of complications, such as postoperative bleeding. The aim of this study is to describe the surgical indications and most frequent complications, analyze whether surgical suture of the tonsillar pillars has an influence on bleeding, and study the data of hospital stay and its importance for the control of complications.

Methods: A retrospective study of 326 patients who underwent a tonsillectomy in our Department of Otolaryngology from 2006 to 2014 was conducted. Read More

Case Rep Otolaryngol 2017 21;2017:4670152. Epub 2017 Aug 21.

Department of Otolaryngology, Hospital Infantil Joana de Gusmão, 152 Rui Barbosa St., 88025-301 Florianópolis, SC, Brazil.

Introduction: Peritonsillar abscess is considered a suppurative complication of acute tonsillitis. It is usually unilateral and clinically evident bilateral presentation is uncommon. The condition affects mainly children older than 10 years and young adults. Read More

Eur Arch Otorhinolaryngol 2017 Nov 12;274(11):3997-4001. Epub 2017 Sep 12.

Department of Otorhinolaryngology-Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland.

Peritonsillar abscess (PTA) is traditionally considered only a purulent complication of acute tonsillitis (AT), but may be related to infection of minor salivary glands. We analysed the presence of peritonsillar minor salivary glands and inflammation patterns in 114 adult tonsils representing three patient groups: recurrent AT, chronic tonsillitis (CT), and PTA. Samples acquired from elective tonsillectomies were stored in formalin, and after preparation were microscopically examined for inflammation and fibrotic changes. Read More

PLoS One 2017 6;12(9):e0183214. Epub 2017 Sep 6.

Department of Otorhinolaryngology, Jena University Hospital, Jena, Germany.

The palatine tonsils, localized in the oropharynx, are easily accessible secondary lymphoid tissue in humans. Inflammation of the palatine tonsils, local and chronic in case of chronic tonsillitis (CT) or acute in the presence of a peritonsillar abscess (PTA), ranks among the most common diseases in otolaryngology. However, the functionality of tonsillar immune cells, notably T-cells, in the context of these immune pathologies is poorly understood. Read More

S D Med 2017 Jul;70(7):314-316

Department of Surgery, University of South Dakota Sanford School of Medicine.

Peritonsillar abscess (PTA) is a common pathology in otolaryngology emergency. The treatment of PTA is usually bedside drainage or surgical removal of the tonsils (Quincy tonsillectomy) in combination with antibiotic treatment. However, patients with immune suppression might have a more difficult treatment course. Read More

Laryngoscope 2017 10 7;127 Suppl 5:S1-S9. Epub 2017 Aug 7.

Department of Otolaryngology and Pediatric Otolaryngology, UT Southwestern Medical Center at Dallas and Children's Medical Center Dallas, Dallas, Texas, U.S.A.

Objectives: To determine the demographics and treatment outcomes of patients with a peritonsillar abscess (PTA) and to provide guidance for treatment options.

Methods: The 2012 National Emergency Department Database, 2012 National Inpatient Sample, and 2013 Nationwide Readmissions Database were used to analyze patients with a PTA who presented to emergency departments (ED), were admitted and/or readmitted to hospitals in the United States. Outcomes were used to create a decision model to compare initial medical versus surgical management. Read More

Braz J Otorhinolaryngol 2018 Sep - Oct;84(5):532-539. Epub 2017 Jul 17.

Kaohsiung Veterans General Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Kaohsiung, Taiwan; Tajen University, Department of Pharmacy and Graduate Institute of Pharmaceutical Technology, Pingtung, Taiwan. Electronic address:

Introduction: Peritonsillar abscess is the most common deep neck infection. The infectious microorganism may be different according to clinical factors.

Objective: To identify the major causative pathogen of peritonsillar abscess and investigate the relationship between the causative pathogen, host clinical factors, and hospitalization duration. Read More

Laryngoscope 2018 01 31;128(1):72-77. Epub 2017 May 31.

Norris Medical Library, University of Southern California, Los Angeles, California, U.S.A.

Objectives: This study systematically reviews the existing literature on the efficacy of adjuvant corticosteroids in improving clinical outcomes after peritonsillar abscess (PTA) drainage.

Study Design: Systematic review.

Methods: We performed a literature search of MEDLINE, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Scopus, Embase, and ClinicalTrials. Read More

Laryngorhinootologie 2017 05 17;96(5):276-277. Epub 2017 May 17.

Laryngorhinootologie 2017 05 17;96(5):275-276. Epub 2017 May 17.

Auris Nasus Larynx 2018 Apr 1;45(2):291-294. Epub 2017 May 1.

Bakırköy Dr. Sadi Konuk Training and Research Hospital, Department of Otorhinolaryngology-Head and Neck Surgery, Istanbul, Turkey.

Objective: To investigate the effect of the single systemic use of corticosteroid following drainage procedure in patients with peritonsillar abscess (PTA).

Methods: This retrospective case-control trial included 32 patients with the diagnosis of PTA between December 2013 and January 2016 in our clinic. Patients were divided into two groups based on the approaches of two authors for the treatment after PTA drainage. Read More

Cardiology 2017;137(4):237-243. Epub 2017 May 4.

Department of Pediatrics, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan.

Objectives: Retropharyngeal lesions are often associated with Kawasaki disease (KD). A 4-year-old male first presented a peritonsillar and retropharyngeal abscess-like lesion. Surgical tonsillectomy was performed to avoid a risk of mediastinal abscess, but he fulfilled the diagnostic criteria of KD after the operation. Read More

Clin Otolaryngol 2017 Dec 25;42(6):1358-1362. Epub 2017 May 25.

Department of Otorhinolaryngology - Head and Neck Surgery, Helsinki University Hospital, Helsinki, Finland.

Objectives: To compare the bacterial species and patient clinical features in peritonsillar abscesses between patients who had renewal (renewal group) and those who did not (recovery group).

Design: Prospective comparative aetiological study.

Setting: Tertiary referral centre. Read More

J Laryngol Otol 2017 Jul 2;131(7):627-630. Epub 2017 May 2.

Department of Otolaryngology,Hospital Universitário de Brasília, Universidade de Brasília,Brasília,Brazil.

Background: Peritonsillar abscess is the most common deep infection of the head and neck in young adults. It is considered a purulent complication of acute tonsillitis, but other mechanisms have been proposed. There is no consensus as to whether seasonality affects peritonsillar abscess incidence. Read More

Int J Oral Maxillofac Surg 2017 Sep 29;46(9):1118-1120. Epub 2017 Apr 29.

Department of Otorhinolaryngology/Head and Neck Surgery, Istanbul Training and Research Hospital, Istanbul, Turkey.

Septic arthritis of the temporomandibular joint (TMJ) is a rarely seen clinical condition. Such an infection may be encountered following infections in the head and neck region, with direct or haematogenous spread to the joint. This article presents the case of a patient with tonsillitis leading to septic arthritis of the TMJ and reports the results of a review of the literature. Read More

Braz J Otorhinolaryngol 2018 May - Jun;84(3):305-310. Epub 2017 Apr 9.

Hospital General Universitario Gregorio Marañón, Madrid, Spain.

Introduction: Deep neck infections are defined as suppurative infectious processes of deep visceral spaces of the neck.

Objective: The aim of this study is to review different factors that may influence peritonsillar and deep neck infections and may play a role as bad prognosis predictors.

Methods: We present a retrospective study of 330 patients with deep neck infections and peritonsillar infections who were admitted between January 2005 and December 2015 in a tertiary referral hospital. Read More

Am Fam Physician 2017 Apr;95(8):Online

Am Fam Physician 2017 Apr;95(8):501-506

Broadlawns Medical Center, Des Moines, IA, USA.

Peritonsillar abscess is the most common deep infection of the head and neck, occurring primarily in young adults. Diagnosis is usually made on the basis of clinical presentation and examination. Symptoms and findings generally include fever, sore throat, dysphagia, trismus, and a "hot potato" voice. Read More