Pediatric ENT Consultation Note

Reason for consultation: Evaluation of right-sided neck mass and progressive dysphagia.

Assessment

Liam Carter is a 4-year-old male with a history of recurrent acute otitis media, presenting with 5 days of fever, odynophagia, and decreased oral intake, with examination notable for trismus, muffled voice, and right-sided cervical lymphadenopathy, endoscopy showing asymmetrical bulging of the right posterior pharyngeal wall with a patent glottic airway, laboratory testing notable for leukocytosis (WBC 18,400 /uL) and elevated CRP (85 mg/L), and imaging demonstrating a 2.4 cm rim-enhancing fluid collection in the right retropharyngeal space. The clinical picture is consistent with right retropharyngeal abscess although suppurative cervical lymphadenitis and parapharyngeal space phlegmon remain in the differential diagnosis.

Plan

• Admit to pediatric inpatient service; NPO for planned transoral incision and drainage in the OR today.
• Obtain blood cultures and send intraoperative purulent fluid for aerobic/anaerobic cultures and Gram stain.
• Start clindamycin 13 mg/kg IV q8h and dexamethasone 0.5 mg/kg IV x 1 dose; maintenance IV fluids (D5NS at 65 mL/hr) and paracetamol (acetaminophen, Tylenol®) 15 mg/kg IV q6h PRN pain/fever.
• Continuous pulse oximetry monitoring and airway precautions at bedside; counsel parents regarding surgical risks and airway management.
• Follow up as an outpatient with Otolaryngology - Head & Neck Surgery in 2 weeks.
• Follow-up instructions were placed in the patient's discharge paperwork; follow-up will be requested unless it is considered as needed
• Discussed with Dr. Sarah Jenkins (Attending Pediatric Otolaryngologist), who agrees with the above

Subjective

History of Presenting Illness

Liam Carter is a 4-year-old male presenting with the chief complaint above, for which Otolaryngology has been consulted.

• Mother brings patient to ED for worsening neck stiffness, persistent fevers, and refusal to eat or drink; ED requested ENT consult for deep neck space infection.
• Symptoms began 5 days ago with rhinorrhea and sore throat; right neck pain and swelling developed 48 hours ago, described as constant, severe, and localized to the right upper neck.
• Pain worsens with neck extension and swallowing; ibuprofen 100 mg PO provided temporary fever reduction but minimal relief of dysphagia.
• Symptoms have progressively worsened over the past 24 hours, with new onset of drooling and muffled "hot potato" voice this morning.
• No prior episodes of deep neck space infections or peritonsillar abscesses.
• Unable to attend preschool; completely refusing solid foods and taking only minimal sips of water since yesterday.
• Associated with fevers up to 39.4 °C, drooling, decreased urine output, and lethargy; denies stridor, cyanosis, or dyspnea at rest.
• History of 4 episodes of AOM in the past year managed medically; no prior surgeries.
• Lives at home with parents and 6-year-old sister; attends daycare 5 days a week; no passive smoke exposure.
• No family history of immunodeficiency, recurrent deep infections, or bleeding disorders.
• Sister recently recovered from an upper respiratory tract infection last week; negative rapid strep test at pediatrician's office 3 days ago.
• Immunisations are fully up to date per CDC schedule, including PCV13 and Hib.
• Last oral intake was 4 ounces of water at 06:00 today (currently NPO > 6 hours).

Objective

Physical Examination

General: Mild distress secondary to pain, sitting upright, drooling intermittently

Head & Face: Atraumatic, non-syndromic features, mild right facial asymmetry due to upper neck fullness

Eyes: EOMI, no APD, no periorbital edema or proptosis

Ears: Auricles without abnormality, EACs patent AU, TMs clear and mobile bilaterally without middle ear effusion

Nose: No external abnormality, septum non-deviated, turbinates mildly congested, clear rhinorrhea bilaterally, no pus

Oral Cavity: Mucosa slightly dry, lips, FOM, and oral tongue without abnormality, tongue normal mobility, dentition good, mild trismus (interincisal opening ~20 mm)

Oropharynx: Soft palate normal midline elevation, tonsils 2+ bilaterally without exudate, mild erythema and anterior bulging of the right posterior pharyngeal wall

Neck: Right level II/III fullness and tenderness to palpation, palpable 2 cm firm mobile lymph node on the right, limited range of motion strictly on neck extension

PULM: No IWOB, no stridor, no stertor, lungs clear to auscultation bilaterally

CV: RR

ABD: Soft

Skin: No lesions

MSK: Moves extremities

NEURO: Cranial nerves grossly intact on limited evaluation

Flexible Fiberoptic Nasopharyngolaryngoscopy

After signed consent was obtained from the patient's guardian, a timeout was completed to verify the procedure, and respiratory therapy was present at the bedside, the flexible endoscope was passed through the right naris, which was grossly normal with mild mucosal congestion. The nasopharynx was grossly normal without mass or lesion, with small non-obstructing adenoid pad. The posterior pharynx was asymmetric with smooth submucosal bulging of the right posterior pharyngeal wall extending inferiorly toward the hypopharynx. The base of tongue was normal and symmetric. The vallecula was clear. The epiglottis and aryepiglottic folds were crisp and without mass or lesion, with no edema. The supraglottic inlet was unobstructed. The true vocal folds were fully mobile and symmetric without mass or lesion. The visualised subglottis was patent. The pyriform sinuses were clear with mild pooling of saliva on the right. Overall, the airway was not concerning for acute impending compromise, though moderately narrowed at the level of the oropharynx. The patient tolerated the procedure well without complication.

Imaging

CT Neck Soft Tissue with IV contrast

• 2.4 x 1.8 x 3.1 cm well-defined, rim-enhancing hypodense fluid collection in the right retropharyngeal space extending from C2 to C4.
• Mild anterior displacement of the right posterior pharyngeal wall and mild mass effect on the airway without critical stenosis.
• Multiple reactive right-sided level II and III cervical lymph nodes; patent bilateral internal jugular veins without thrombosis.