What is the most important step in evaluating a patient with a 3-day history of fever, sore throat, decreased oral intake, difficulty swallowing solid food, and a palpable 2 cm cervical lymph node?

Lateral Neck Radiograph is the Most Important Initial Step

In a patient presenting with fever, sore throat, dysphagia, and cervical lymphadenopathy, the most important initial evaluation step is a lateral neck radiograph (Option B) to rule out retropharyngeal abscess or other deep neck space infection requiring urgent surgical intervention.

Clinical Context and Differential Diagnosis

This presentation suggests an acute infectious process rather than malignancy:

• The 3-day duration of fever with sore throat indicates an acute infectious etiology 1
• Difficulty swallowing solids specifically raises concern for retropharyngeal or deep neck space abscess 2, 3
• The 2 cm cervical lymph node is likely reactive lymphadenopathy associated with pharyngitis 4
• Subcentimeter to 2 cm nodes with acute infectious symptoms are typically benign and reactive 4

Why Lateral Neck Radiograph is Most Important

Lateral neck radiograph is the critical first imaging study because:

• It rapidly identifies retropharyngeal abscess, which presents with dysphagia and can cause airway compromise 1
• Plain radiography can detect prevertebral soft tissue swelling and abnormal air collections indicating deep neck infection 3
• This is a time-sensitive emergency - missing a deep neck abscess can lead to airway obstruction, mediastinitis, or sepsis 2
• It is immediately available, inexpensive, and does not delay treatment 1

Why Other Options Are Less Appropriate

Chest radiograph (Option A) is not indicated as the primary study:

• No respiratory symptoms or signs of thoracic pathology are described 1
• Would not evaluate the neck pathology causing dysphagia 1

Contrast-enhanced CT neck (Option C) is reserved for specific situations:

• CT is indicated when malignancy risk is high (age >40, tobacco use, mass >2 weeks, firm/fixed mass) 1, 5
• This patient has an acute 3-day infectious presentation, not chronic concerning features 1
• CT would be the next step if lateral neck X-ray shows concerning findings or if abscess is suspected but not clearly seen 2, 3
• The positive predictive value of contrast-enhanced CT for deep neck abscess is 82%, but it is not the first-line study in this acute presentation 3

Fine needle aspiration (Option D) is inappropriate at this stage:

• FNA is indicated for persistent masses (>2-4 weeks) or when malignancy is suspected 4, 6
• This 3-day presentation with fever suggests infection, not neoplasm 1, 4
• Aspirating an infected lymph node risks spreading infection and provides no additional diagnostic value 1
• The American Academy of Otolaryngology-Head and Neck Surgery recommends FNA only after appropriate observation period for reactive nodes 4

Clinical Algorithm

Step 1: Obtain lateral neck radiograph immediately 1

• Look for prevertebral soft tissue thickening
• Assess for abnormal air collections
• Evaluate for retropharyngeal widening

Step 2: If lateral neck X-ray is concerning or equivocal, proceed to contrast-enhanced CT neck 1, 2, 3

• CT has 82% positive predictive value for abscess 3
• Air within fluid collections indicates abscess in all cases 3

Step 3: If imaging shows abscess, urgent surgical drainage is required 2, 3

Step 4: If imaging is negative for abscess, treat with antibiotics and reassess within 2 weeks 1, 4

• Reactive lymphadenopathy should resolve with treatment of the underlying infection 4
• Persistent lymphadenopathy beyond 2-4 weeks requires further workup including possible FNA 4

Critical Pitfalls to Avoid

• Do not assume this is simple pharyngitis - dysphagia with fever mandates evaluation for deep neck infection 2
• Do not proceed directly to CT without considering plain radiography first in resource-limited settings 1
• Do not perform FNA on an acutely infected node - this is both non-diagnostic and potentially harmful 1
• Do not miss retropharyngeal abscess - it can rapidly progress to airway compromise 1, 2
• Central necrotic metastatic lymph nodes can mimic pyogenic abscess, but the 3-day acute presentation makes this unlikely 2