A patient presents with progressive dysphagia, 'hot potato' voice, drooling, and neck stiffness. Lateral neck X-ray shows widening of the prevertebral soft tissue shadow. The most appropriate immediate investigation and management is:

• A Urgent direct laryngoscopy to visualise supraglottic swelling
• B Nasopharyngoscopy to evaluate hypopharyngeal mass
• C Barium swallow to confirm the site of dysphagia
• D CT neck with contrast to assess retropharyngeal abscess extent, followed by surgical drainage ✓

Explanation

Widening of the prevertebral soft tissue shadow on lateral neck X-ray (>7 mm at C2, >22 mm at C6 in adults) with bulging symptoms indicates a retropharyngeal abscess. CT neck with contrast delineates the extent, identifies whether loculation is present, and guides the surgical approach. Treatment is IV antibiotics and transoral or external surgical drainage. Direct laryngoscopy is dangerous as it may precipitate complete airway obstruction by rupturing the abscess.

Reference: Dhingra Diseases of Ear, Nose and Throat, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.