Pediatric Case of the Week 8: Sore Throat and Neck Stiffness

A 4 yo boy presents with worsening sore throat and "neck  stiffness".  5 days earlier he had been seen by his pediatrician for Sore throat, fevers, and body aches.  At the time he had a documented fever of 104.  His parents were told that he had "the flu" and were instructed to treat with over the counter acetaminophen and lots of fluid. His mom called the pediatrician's office today concerned that he had increasing neck stiffness.  The clinic triage nurse recommended he be evaluated in the Emergency Department for meningitis.

VS:  102.2    BP 95/50    HR 101    RR 22    Sat  99%

PE: Tired, non-toxic. Airway is patent and no stridor or drooling present. Tonsils are 2+ with mild erythema and no exudate. Uvula is midline, and his voice in normal (no muffled quality). He has multiple 1 cm firm cervical lymph nodes. No truisms.  Kernig's and Brudzinski's signs are negative. He has some neck discomfort with extension.


What is your differential diagnosis?

Would you LP this child?

Would you image this child...if so, what would you be looking for?

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Differential Diagnosis:

-Viral pharyngitis
-Bacterial pharyngitis (less likely with absence of exudate)
-Retropharyngeal abscess
-Epiglottis (rare)
-Foreign Body

Lumbar Puncture?:  You wouldn't be wrong to LP this child.  Let's assume you do and it's negative. If you do a good history and physical exam, you would probably consider other etiologies first.  Key components of the history that should direct you are sore throat with "neck stiffness."

This case is most concerning for retropharyngeal abscess. The majority of the cases present in kids under 5.  Most kids will be toxic appearing with fever and lymphadenopathy.  Neck stiffness, pain with extension, is a classic finding. Retropharyngeal abscess can also present with torticollis. You may also get a history of painful swallowing (odynophagia).

Less common are pain with mouth opening (trismus), hoarsness, and stridor.  You would be unlikely to see significant tonsillar exudate but you might appreciate fullness in the neck or neck mass.  If you do palpate a neck mass, the likelihood of RPA increases dramatically.

The MISTAKE: do not rely on the presence of respiratory compromise to make the diagnosis of retropharyngeal abscess.  You need to make the diagnosis before the patient's breathing is compromised. In retrospective study of 64 cases, only 1 patient had stridor and 2 had wheezing.

A neck xray may show pre-vertebral edema but it is not a sensitive test.  Prevertebral space measurements > 7mm at C2 or >14 mm at C6 are consistent with RPA.  You could screen with a lateral neck film. If it is negative, and you still have suspicion, get a CT scan.  CT is the test of choice. I would recommend a low threshold to CT if you suspect RPA.  Ultrasound may be used to screen the prevertebral space, but as of now, my impression is that it's use is limited.


Once you've confirmed an RPA, get the bug juice on board.  As with adults, Clindamycin is a good first choice for almost all things ENT.

You'll of course want to consult ENT.  Surprisingly many of these cases are managed medically without drainage of the abscess.  (Particularly if you make the diagnosis early and get the Clindamycin on board.)



Obviously, if at any time the child's airway is compromised, you will need to intubate.

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Resources:

Hawaii Dept of Pediatrics: http://www.hawaii.edu/medicine/pediatrics/pemxray/v5c01.html
Avoiding Common Errors In The Emergency Department; Lippincott
Medscape Pediatric Retropharyngeal Abscess: http://emedicine.medscape.com/article/995851-overview
BMJ Best Practice: http://bestpractice.bmj.com/best-practice/monograph/599/diagnosis/step-by-step.html