At the Bedside

Think of this as an airway-first infection. Start with ABCs and assess for stridor, drooling, muffled “hot potato” voice, tripod positioning, neck stiffness, torticollis, and toxic appearance. Keep the patient upright, minimize agitation, and involve ENT early if there is any concern for airway compromise.

Workup is guided by stability:
  • If unstable/airway concern: do not delay for imaging; call anesthesia/ENT, prepare for difficult airway/awake technique if feasible, and move to OR/controlled airway setting.
  • If stable: CT neck with IV contrast is the usual imaging test in adults and cooperative older children; it helps distinguish cellulitis/phlegmon from drainable abscess and define extent. In younger children, lateral neck radiograph may show widened prevertebral soft tissues, but CT is more definitive.
  • Labs: CBC, CMP, blood cultures if febrile/toxic, lactate if septic. Consider rapid strep/viral testing only if it changes the differential, not management.
Initial treatment:
  • IV broad-spectrum antibiotics covering oral flora, streptococci, staphylococci, and anaerobes.
  • Analgesia, IV fluids if dehydrated.
  • NPO in case operative drainage is needed.
  • ENT consultation for drainage if large abscess, airway symptoms, failure of medical therapy, or significant mass effect.
Disposition:
  • Admit all confirmed cases; many need ICU monitoring if airway risk.
  • Small, early phlegmon without airway compromise may respond to IV antibiotics alone, but still needs close inpatient monitoring.
  • Drainage is indicated when there is a defined abscess, worsening symptoms, or no improvement after 24–48 hours.
A Classic Presentation
A 4-year-old boy presents with fever, drooling, refusal to eat, muffled voice, and neck stiffness after a recent upper respiratory infection. He’s sitting forward, anxious, and won’t extend his neck. Exam shows tender cervical lymphadenopathy and limited neck range of motion without obvious tonsillar asymmetry. CT neck with contrast shows a rim-enhancing retropharyngeal collection with airway narrowing. He is kept upright, given IV ampicillin-sulbactam, and ENT is called for operative drainage and airway planning.
Patient Presentation to Attending
How you’d present this patient on the floor
This is a 4-year-old boy with recent URI symptoms presenting with fever, drooling, muffled voice, and neck stiffness over the last day. My main concern is retropharyngeal abscess because he has classic deep neck space red flags and is now refusing to extend his neck, which raises airway concern. He’s sitting forward and looks uncomfortable; on exam he has limited neck ROM and posterior pharyngeal fullness but no obvious unilateral peritonsillar swelling. I’m less concerned for simple pharyngitis because of the drooling, toxic appearance, and restricted neck motion, and less concerned for epiglottitis because he’s not in severe respiratory distress or tripoding, though airway risk is still real. CT neck with contrast shows a rim-enhancing retropharyngeal collection with some mass effect on the airway. I’ve started IV ampicillin-sulbactam, kept him NPO and upright, and I’ve already paged ENT for likely operative management and close airway monitoring, likely admission.

Study Directive

  • Draw the deep neck space anatomy from memory: retropharyngeal vs parapharyngeal vs peritonsillar spaces.
  • Make a one-page airway algorithm for suspected deep neck infection: stable vs unstable, imaging vs OR.
  • Memorize first-line IV antibiotic choices and when to add MRSA coverage.
  • Review 3 classic pediatric exam findings that distinguish retropharyngeal abscess from simple pharyngitis.

Recent Literature