Hot Seat #171: Toddler with neck swellingPosted on: May 6, 2021, by : Mary Beth Howard
Walt Palmer, MD, Children’s National Medical Center
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.
- Born full term without complications
- Fully immunized
- No chronic medical problems or meds at home
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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