Neck Swelling

Written By Brandon Ho
Case by Sean Mathis & Christopher Sarkis MD

Patient Presentation

23-month-old female presenting with 1 week of fever and neck swelling.  She was seen by her PCP two days prior and prescribed Augmentin. Today, she was noted to have worsening left sided neck swelling and decreased PO.

VS: T 36.5C, HR 115, RR 22, BP 108/70, SpO2 99% on RA

On exam, the patient was noted to have a palpable left-sided mass and decreased range of motion.

Diagnostic Findings

US of the Soft Tissue of the Neck showed a 3cm x 2.2 cm heterogeneous collection concerning for a developing abscess behind the L carotid artery and jugular vein. CT was recommended and revealed a left retropharyngeal abscess with a mass effect on the left internal jugular vein. ENT was consulted and recommended admission for IV antibiotics and reassessment.  She ultimately required the OR on day 2 of admission for drainage.

Retropharyngeal Abscess (RPA)

A retropharyngeal abscess is a collection of pus located in the tissues in the back of the throat, behind the esophagus. This condition is most commonly seen in young children <10 years old (compared to a peritonsillar abscess (PTA) which is most often seen in older children), often resulting from an oral or upper airway infection.

  • Signs of severe airway obstruction:

    • Tripod position

    • Leaning forward with head in the "sniffing position”

    • Retractions

    Features in common with PTA:

    • RAPID High fever

    • Hot potato voice

    • Sore throat, dysphagia, & drooling

    Features discerning for RPA:

    • Inability to extend the neck due to pain

    • Chest pain (mediastinal extension)

    • Tender lymphadenopathy

    Features discerning for PTA:

    • Uvular deviation

    • Trismus

    • +/- lymphadenopathy

  • 1) Lateral neck x-ray: If the prevertebral space is more than half of the size of the C2 vertebra, it may indicate a retropharyngeal abscess.

    • Keep in mind that neck flexion can falsely enlarge the space causing a false positive

    2) Neck CT scan with contrast: If the index of suspicion is high, jump to CT early as lateral neck X-rays can be negative.

    3) Consider CXR in patients with chest pain: The retropharyngeal space sits anterior to a potential space (“danger zone”) connecting to the mediastinum. Retropharyngeal infections can spread via this space to cause mediastinitis

  • 1. If signs of severe airway obstruction: consult anesthesia and ENT to secure the airway.

    2. Consult ENT for possible incision and drainage.

    3. Antibiotics (IV + PO): 10 -14 days

    • Clindamycin 30 mg/kg q8h (max 600 mg/dose)

    • Unasyn

Educational Pearls:

  • Lack of improvement or worsening of infection despite 36-48 hours on antibiotics indicates antibiotic failure and could indicate the need for IV antibiotics.

  • Swelling of the neck, especially with trismus or decreased ROM indicates imaging with concern for deep soft tissue neck infection (retropharyngeal abscess, peritonsillar abscess, Lemierrie’s Syndrome, Ludwig’s Angina)

  • Rapid assessment of the degree of upper airway obstruction is the initial step in the evaluation and signs of severe airway obstruction warrant immediate involvement of airway specialists to secure the airway.

  • Lateral neck X-rays or a neck CT scan with contrast can help make the diagnosis of a retropharyngeal abscess.

  • Management includes I&D and IV antibiotics (Clindamycin or Unasyn)

Brandon Ho
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