A 3-year-old boy has four days of high fever, muffled voice, drooling, and torticollis with the neck held in extension. There is fullness behind the pharyngeal wall on oral examination. A lateral neck radiograph shows prevertebral soft tissue thickening exceeding 7 mm at the level of C2. What is the most appropriate next investigation?

• A Flexible fibreoptic laryngoscopy in clinic
• B Barium swallow
• C Contrast enhanced CT scan of the neck ✓
• D Magnetic resonance angiography of the head and neck

Explanation

Retropharyngeal abscess in a young child presents with fever, drooling, torticollis, and widened prevertebral soft tissue, normally less than 7 mm at A2. Contrast enhanced CT of the neck is the standard next step because it defines the extent of the collection, identifies ring enhancement suggesting a drainable abscess versus cellulitis, and detects mediastinal extension through the danger space. Barium swallow adds nothing and clinic laryngoscopy risks rupture of the abscess into the airway.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.