An Adopted 43-Year-Old With Bad Breath, Dyspnea, Dysphagia

Alexander B. Norinsky, DO; Andrew Caravello, DO; James Espinosa, MD


July 14, 2022

Physical Examination and Workup

The patient is a well-nourished male sitting upright in the stretcher. Upon initial triage and evaluation, he is in no obvious distress but appears somewhat uncomfortable and is cooperative with the examination. His blood pressure is 156/95 mm Hg, his pulse is 112 beats/min with a regular rhythm, his respiratory rate is 18 breaths/min, and his temperature (measured orally) is 98.5°F (36.9°C).

Physical examination findings are significant for an erythematous posterior pharynx without exudates. No trismus or stridor is present, and the patient is not in the tripod position, preferring to remain erect. He has poor dentition, with a foul-smelling odor. A hoarse voice is noted. No visible or palpable intraoral abscesses are observed; however, examination is somewhat limited secondary to poor patient compliance.

The uvula is midline and nonedematous. No tongue or sublingual elevation is noted, nor is any brawny edema observed on examination of neck. Several anterior cervical lymph nodes are identified bilaterally, as well as tenderness to palpation, with swelling around the left side of the upper neck and mandibular angle. Thyromegaly is not observed. The patient exhibits full range of motion of the neck; his cardiopulmonary and abdominal examination, along with the other systems, is unremarkable.

Flexible fiberoptic nasolaryngoscopy is immediately performed at bedside, revealing an injected oropharynx with a fair amount of parapharyngeal and retropharyngeal swelling with airway deviation. Given his relative comfort level after administration of intravenous fluids, dexamethasone, and morphine, as well as several sets of stable vital signs and concerning but stable nasolaryngoscopic examination findings, the decision is made to fully image the airway and surrounding structures with a CT scan of the neck and soft tissues with intravenous contrast (Figures 1-4).

Figure 1.

Figure 2.

Figure 3.

Figure 4

Bloodwork is significant for mild leukocytosis (white blood cell count, 11,800/µL; reference range, 3700-10,500/µL) with neutrophilic predominance (9900/µL; reference range, 2100-6700/µL). Outside of that finding, the complete blood count, basic metabolic panel, coagulation profile, and lactate findings are within normal limits. Throat and blood cultures are obtained as well.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.