What is the most important step in evaluating a pediatric patient with fever, sore throat, decreased oral intake, difficulty swallowing, and a palpable cervical lymph node?

Lateral Neck Radiograph is the Most Important Initial Step

For a 4-year-old with fever, sore throat, dysphagia, and cervical lymphadenopathy, a lateral neck radiograph (Option B) is the most appropriate initial imaging evaluation to rule out potentially life-threatening deep neck space infections, particularly retropharyngeal abscess.

Clinical Reasoning

This presentation raises concern for retropharyngeal infection (RPI) or deep neck space infection, which can present with:

• Fever and sore throat 1
• Difficulty swallowing (dysphagia) 2
• Cervical lymphadenopathy 3
• Decreased oral intake 1

While these symptoms could represent simple pharyngitis with reactive lymphadenopathy, the combination—particularly the dysphagia with solid foods—warrants imaging to exclude a more serious process 2.

Why Lateral Neck Radiograph is Most Appropriate

High Diagnostic Utility

• Lateral neck radiography has 84.3% sensitivity and 93.7% specificity for diagnosing retropharyngeal infection in pediatric patients presenting to the emergency department 2
• It provides good detection rates (72.5%) when pathology is located in the hypopharynx and cervical esophagus 4
• This imaging modality is particularly useful as an initial screening tool before considering more invasive or expensive studies 5, 2

Cost-Effective and Readily Available

• Lateral neck radiographs are widely available, quick to obtain, and involve minimal radiation exposure compared to CT 5
• They serve as an appropriate first-line imaging study in the emergency/acute care setting 2

Why Other Options Are Less Appropriate

Chest Radiograph (Option A)

• Not indicated in this clinical scenario 6
• The American College of Emergency Physicians recommends chest radiography for febrile children only when there are respiratory signs such as cough, hypoxia, rales/crackles, or high fever >39°C with suspected pneumonia 1
• This patient's symptoms localize to the oropharynx and neck, not the chest 1

Contrast-Enhanced CT Neck (Option C)

• While CT has 100% sensitivity for deep neck infections and is superior to plain radiography 7, it should be reserved for cases where lateral neck radiograph is positive, indeterminate, or when clinical suspicion remains very high despite negative plain films 7
• CT involves significantly higher radiation exposure in a pediatric patient 6
• The ACR Appropriateness Criteria support starting with less invasive imaging when appropriate 6

Fine Needle Aspiration (Option D)

• Completely inappropriate as an initial diagnostic step 3, 8
• FNA is indicated for persistent lymphadenopathy (>2-4 weeks) when malignancy is suspected, not for acute febrile illness 3
• The 2 cm cervical lymph node in this acute febrile context is most likely reactive lymphadenopathy secondary to pharyngitis or deep neck infection 3
• Performing FNA without imaging would miss a potentially dangerous retropharyngeal abscess that requires urgent surgical drainage 2, 7

Clinical Algorithm

Step 1: Obtain lateral neck radiograph immediately 2

Step 2: Interpret findings:

• If positive for retropharyngeal thickening or abscess: Proceed to contrast-enhanced CT neck for surgical planning and obtain urgent ENT consultation 7
• If negative but high clinical suspicion persists: Consider CT neck with contrast, as lateral neck films can miss up to 17% of deep neck infections 2, 7
• If negative with low clinical suspicion: Manage as reactive lymphadenopathy with close follow-up 3

Critical Pitfalls to Avoid

• Do not assume this is simple viral pharyngitis with reactive adenopathy without imaging, given the dysphagia and decreased oral intake—these symptoms suggest potential airway compromise 2
• Do not proceed directly to FNA of the lymph node, as this could be reactive to a deeper infection and aspiration would miss the primary pathology 3, 8
• Do not skip imaging in favor of empiric antibiotics alone, as retropharyngeal abscesses require surgical drainage and can lead to airway obstruction, mediastinitis, or sepsis if untreated 2, 7
• Recognize that RPI incidence is increasing in children, and drug-resistant organisms like MRSA are becoming more common, making timely diagnosis critical 2