Hot Seat #171: Toddler with neck swelling
Posted on: May 6, 2021, by : Mary Beth Howard
Walt Palmer, MD, Children’s National Medical Center
HPI:
A 3-year-old previously healthy boy presents to the Emergency Dept for left-sided neck swelling. Two weeks ago, he presented to another ED for neck swelling in the setting of URI symptoms, diagnosed with reactive lymphadenopathy, discharged home with supportive care instructions. Symptoms (including swelling) soon thereafter resolved.
Now, he presents with 2 days of painless neck swelling. His parent explains that the affected area previously was behind his left ear, but now it is lower, larger, and affecting his neck. He denies difficulty eating, denies fevers, and denies changes in voice or difficulty breathing. No known sick contacts or recent travel.
Review of Systems
Constitutional symptoms: No fever, no fatigue
Skin symptoms: No rash
ENMT symptoms: Mouth: denies pain, Throat: +external neck swelling, denies difficulty swallowing, denies neck stiffness, denies trismus, denies sore throat, denies nasal congestion.
Respiratory symptoms: denies shortness of breath, denies cough, denies stridor.
Cardiovascular symptoms: denies syncope.
Gastrointestinal symptoms: no vomiting, denies diarrhea.
Musculoskeletal symptoms: no Neck pain.
PMHx/PSHx
- Born full term without complications
- Fully immunized
- No chronic medical problems or meds at home
Physical Exam
T 36.8, HR 117, RR 22, SpO2 99% on RA
Wt 12.7 kg
Skin: Warm. dry.
Head: Normocephalic. atraumatic.
Eye: Normal conjunctiva. no discharge.
ENT: Tympanic membranes clear. Oral mucosa moist. 2-3 cm area of swelling posterior and inferior to the left angle of the mandible, mobile, without overlying erythema, nontender to palpation. Both tonsils appear enlarged, mildly erythematous, without exudate. Left tonsil > right.
Cardiovascular: Normal peripheral perfusion
Respiratory: Lungs are clear to auscultation. Respirations are non-labored.
Chest wall: No deformity
Back: Normal alignment
Musculoskeletal: No deformity
Gastrointestinal: Soft, nontender, nondistended
Neurological: Normal speech observed
You obtain a neck ultrasound with the following result:
“Enlarged tonsils, left greater than right, compatible with tonsillitis. Left-sided peritonsillar abscess as above, which extends to the level of the submandibular gland. The inferior extent of the abscess is not completely visualized on this examination. CT head and neck with IV contrast is recommended for further evaluation.”
You send a CBC and blood culture, start Unasyn, and make the patient NPO with maintenance IV fluids while considering your next step.
ENT examines the patient. They obtain a similar examination without seeing an easily drainable peritonsillar abscess, and they, too, recommend a CT with contrast. The patient is getting progressively fussier as his NPO time approaches 8 hours.
Your patient appears to have calmed down after the IV placement and ENT exam, so you send him to radiology without using an anxiolytic or sedative. Radiology calls 20 minutes later explaining that the patient is too agitated and is not tolerating being in the CT scanner.
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Although I understand the theoretical concern about sedating a child with “an incompletely characterized airway infection,” objectively this child does not have any clinical signs of airway compromise (no stridor, no cough, non-labored respirations, normal speech, no neck stiffness, no trismus, no difficult swallowing, no drooling). Hence, we emergency physicians should feel comfortable sedating this child if necessary, and I argue that this practice is well within out scope of practice. If we consult anesthesiology for these airways, we are giving up some of our “turf.” And, such actions may make it even harder for anesthesiology to feel comfortable granting us EM docs sedation privileges for drugs like propofol.
Agree with Dewesh, and additionally- this abscess seems more external than intrinsic to the airway- the tonsils aren’t even that remarkable. Nor is there any noisy breathing.
Pentobarb is a quick and effective agent in this case- fast on, and fast off. Etomidate is also quick but we don’t traditionally use it in the scanner.
It is silly to send a 3 yr to the scanner for an image that requires IV contrast for characterization of the pathology without sedation.
Any time IV contrast is needed, the patient needs to be totally STILL immediately after the contrast is injected, i. e we can’t wait for him to “calm down”. The radiology tech won’t even inject unless that stillness is assured.