A Stiff Neck in a Four Year Old

1/10/2008

I saw a four year old girl today for follow up from a recent hospitalization. The child originally came to the office with a one day history of fever and “holding her head in a strange way”. The mother could not get a specific complaint from the child. She was very irritable and uncomfortable.

On examination she was noted to have a red throat and a slightly tilted head to one side. The throat exam displayed slightly enlarged tonsils but no other swelling or bulging of the tissues in the area. The blood test performed in the office revealed a very minimally elevated white blood cell count but more specifically the cell types were predominantly bacterial.

I suspected that this child had an infection in the deeper tissues of the throat as she was clearly uncomfortable. A pediatric ENT was kind enough to see her the same day and agreed that her exam was abnormal. He performed a CT scan of the neck which revealed a very early retropharyngeal abscess. This is a bacterial infection of the deep tissue of the back portion of the throat. This infection is notoriously difficult to diagnose at the early stages. The child was treated successfully with a course of intravenous antibiotics followed by oral antibiotics.

This condition is actually quite uncommon. I have only seen a small handful of these over the past twenty plus years. Typically these children present with fever, poor intake of fluids and solids, stiff neck, and drooling or muffled voice (in the late stage). The diagnosis needs to be confirmed by CT or MRI scan in order to specify how extensive the abscess is and to ensure that the diagnosis is correct. There are other bacterial infections of the airway that can mimic this condition (i.e. epiglotitis) While antibiotics are effective, surgery to drain the abscess might be indicated. In this case it was not.

      

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