Pediatric Sore Neck: Recommended Treatment Approach
For a pediatric patient with a sore neck, the initial management depends on the underlying cause, which is most commonly traumatic (62%) or infectious (19%), with most cases resolving with conservative outpatient treatment within 2 weeks. 1
Initial Clinical Assessment
The evaluation should focus on identifying red flag features that distinguish benign from serious pathology:
Key Historical Features to Elicit
- Trauma history: Blunt neck trauma can cause laryngeal injury requiring urgent intervention 2
- Fever and systemic symptoms: Suggests infectious etiology 3, 1
- Duration and severity: Acute versus chronic presentation guides imaging decisions 4
- Age: 75% of retropharyngeal abscess cases occur in children under 5 years 3
Critical Physical Examination Findings
- Limitation of neck extension (45% of retropharyngeal abscess cases): This is the most common finding in deep neck infections 3
- Torticollis (36.5% of cases): Suggests muscular or infectious pathology 3, 1
- Neck mass or swelling: Requires imaging evaluation 4
- Respiratory distress or stridor: Rare (1.5%) but indicates potential airway compromise 3
Diagnostic Imaging Strategy
When to Image
Do not routinely image all pediatric neck pain. 4 Imaging is indicated when:
- Red flag symptoms are present (trauma, suspected malignancy, infection, neurological deficits) 4
- Deep neck infection is suspected 4
- Limitation of neck movement persists 3
Imaging Modality Selection
For suspected deep neck infections:
- Ultrasound is first-line for superficial lesions and differentiating solid from cystic masses 4
- CT with IV contrast is appropriate when deep neck infection requires surgical evaluation, with shorter examination time reducing sedation needs 4
- CT revealed pathologic findings in 6 of 9 children imaged for neck complaints 1
For traumatic injuries:
- Plain radiographs showed significant abnormalities in only 6 of 60 children (10%) 1
- MRI of cervical spine should be performed in suspected or confirmed abusive head trauma to evaluate for ligamentous injury 4
Treatment by Etiology
Traumatic Neck Pain (62% of cases) 1
- Most cases managed conservatively as outpatients with complete recovery in less than 2 weeks 1
- NSAIDs are effective for acute neck pain 5
- Muscle relaxants can be used for acute presentations 5
- One case of posttraumatic torticollis recovered in 7 weeks with conservative management 1
Infectious Causes (19% of cases) 1
Retropharyngeal cellulitis/abscess:
- Antibiotic therapy alone is successful in 58% of cases, including 37% of patients with defined abscess on CT 3
- No treatment failures occurred in either antibiotic-only or antibiotic-plus-surgery groups 3
- Surgical drainage is indicated when CT shows defined abscess with clinical deterioration 3
- Hospital admission required in only 3 of 33 infectious cases, with 2 requiring emergency surgical drainage 1
Viral infections (16.5% of cases): Supportive care 1
Postural/Muscular Causes (17.6% of cases) 1
- Conservative management with reassurance 1
- Heat application (warm compresses, heating pads) may help relax muscles 6
- Complete recovery typically within 2 weeks 1
Common Pitfalls to Avoid
- Do not assume respiratory distress is always present in serious neck pathology: Only 1.5% of retropharyngeal abscess cases presented with stridor 3
- Do not over-image: Plain radiographs have low yield (10% abnormality rate) in pediatric neck complaints 1
- Do not delay CT when deep infection is suspected: CT provided definitive diagnosis when signs and symptoms suggested emergent cause 1
- Do not routinely perform surgery for retropharyngeal abscess: 37% of CT-confirmed abscesses resolved with antibiotics alone 3