What is the most important step in evaluating a patient with 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 with acute fever, sore throat, dysphagia, and cervical lymphadenopathy of 3 days duration, a lateral neck radiograph (Option B) is the most important initial evaluation to rapidly exclude retropharyngeal abscess, which can cause life-threatening airway compromise. 1

Clinical Context: Acute Infection vs. Malignancy

• The 3-day duration of fever with sore throat indicates an acute infectious etiology rather than malignancy, making this presentation consistent with reactive lymphadenopathy associated with pharyngitis 1
• The critical concern is not the 2 cm cervical lymph node itself, but rather the dysphagia (difficulty swallowing solids), which mandates immediate evaluation for deep neck infection 1
• Reactive lymphadenopathy commonly occurs with respiratory infections and typically resolves within days to weeks 2

Why Lateral Neck Radiograph First

• Plain lateral neck X-ray is immediately available, inexpensive, does not delay treatment, and rapidly identifies retropharyngeal abscess by showing prevertebral soft tissue thickening, abnormal air collections, and retropharyngeal widening 1
• Retropharyngeal abscess presents with dysphagia and can rapidly progress to airway compromise, making early detection critical 1
• If the lateral neck radiograph is concerning or equivocal, the next step is to proceed to contrast-enhanced CT neck 1

Why NOT the Other Options

Contrast-Enhanced CT Neck (Option C)

• CT neck is reserved for situations with high malignancy risk: age >40, tobacco use, mass present >2 weeks, or firm/fixed mass 1
• This patient has an acute 3-day infectious presentation without features suggesting malignancy 1
• While CT has high positive predictive value (82%) for deep neck abscess, it should follow plain radiography in the initial algorithm unless there are specific high-risk features 3

Fine Needle Aspiration (Option D)

• FNA on an acutely infected node is both non-diagnostic and potentially harmful 1
• FNA should only be considered if a node persists beyond 2-4 weeks despite appropriate observation and treatment 2
• In this acute infectious presentation, FNA would be premature and inappropriate 1

Chest Radiograph (Option A)

• Chest X-ray has no role in evaluating acute pharyngitis with cervical lymphadenopathy and dysphagia 1
• It would be indicated only if there were concerns for mediastinal involvement or pulmonary pathology, which are not suggested by this presentation

Critical Management Algorithm

1. Obtain lateral neck radiograph immediately to assess for retropharyngeal abscess 1
2. If radiograph shows prevertebral soft tissue thickening or abnormal air, proceed urgently to contrast-enhanced CT neck 1
3. If radiograph is negative, treat with broad-spectrum antibiotics and reassess within 2 weeks 1
4. The 2 cm cervical node should resolve with treatment of the underlying infection; if it persists beyond 2-4 weeks, then consider further workup including possible FNA 2

Key Pitfall to Avoid

The most dangerous error is missing retropharyngeal abscess, which can rapidly progress to airway compromise. 1 Never assume simple pharyngitis when dysphagia is present—this symptom mandates evaluation for deep neck infection with lateral neck radiograph as the critical first step.