What is the best course of treatment for a child or young adult with a history of strep throat who is experiencing significant right neck swelling?

Right Neck Swelling After Strep Throat

Significant neck swelling following strep throat requires immediate evaluation for suppurative complications (deep neck infection, peritonsillar abscess, or descending mediastinitis), which necessitates urgent imaging (CT scan with contrast), ENT consultation, and high-dose intravenous penicillin or clindamycin, with surgical drainage if abscess is confirmed. 1, 2

Immediate Assessment and Diagnosis

Clinical Red Flags Requiring Urgent Evaluation

• Unilateral neck swelling after strep throat is a warning sign for suppurative complications, including retropharyngeal abscess, parapharyngeal abscess, or Lemmiere syndrome 1
• Look specifically for: difficulty swallowing, drooling, trismus (inability to open mouth), respiratory distress, or "hot potato" voice 1, 2
• Fever persisting beyond 48-72 hours of appropriate antibiotic therapy suggests either treatment failure or development of a suppurative complication 3, 2
• Tender anterior cervical lymphadenopathy is expected with strep pharyngitis, but progressive unilateral swelling with induration suggests abscess formation 4, 2

Diagnostic Imaging

• CT scan of the neck with IV contrast is the gold standard for identifying deep neck infections and should be obtained urgently when suppurative complications are suspected 1
• The CT will identify abscess location, extent of inflammation, airway compromise, and potential mediastinal extension 1
• Chest X-ray should be obtained if there is any concern for mediastinal involvement or respiratory symptoms, as descending mediastinitis can complicate deep neck infections 1

Treatment Algorithm

If Imaging Confirms Abscess or Deep Neck Infection

• Immediate ENT consultation for surgical evaluation and drainage - this is not optional, as these infections can rapidly progress to airway compromise or mediastinitis 1
• High-dose intravenous penicillin G (2-4 million units every 4 hours) or ampicillin-sulbactam should be initiated immediately 3, 1
• For penicillin-allergic patients, clindamycin 600-900 mg IV every 8 hours is the preferred alternative 3, 5
• Surgical drainage is typically required for organized abscesses, with placement of draining tubes and irrigation of infected spaces 1
• Hospital admission with close airway monitoring is mandatory 1

If Imaging Shows Cellulitis Without Abscess

• Admit for IV antibiotics (high-dose penicillin or ampicillin-sulbactam) 3, 1
• Serial examinations to monitor for progression to abscess formation 1
• Repeat imaging if clinical deterioration occurs 1

If No Deep Infection but Persistent Symptoms

• Verify that the patient completed a full 10-day course of appropriate antibiotics - treatment failure often results from inadequate duration or non-adherence 3, 5, 6
• Consider repeat throat culture or rapid antigen test to confirm bacterial eradication 3, 4
• If Group A Streptococcus persists, switch antibiotic regimen: first-generation cephalosporin (cephalexin 500mg four times daily for 10 days) or clindamycin (300mg three times daily for 10 days) 3, 5

Antibiotic Selection for Confirmed Strep Pharyngitis

First-Line Treatment

• Penicillin V 500mg orally twice daily for 10 days (adults) or amoxicillin 500mg twice daily for 10 days remains first-line therapy 3, 5, 6
• For children: amoxicillin 45 mg/kg/day divided twice daily for severe infections 6
• The full 10-day course is essential to prevent suppurative complications and rheumatic fever - shorter courses are inadequate 3, 5, 6

Penicillin Allergy Alternatives

• For non-immediate (delayed rash) allergy: cephalexin or cefadroxil for 10 days 5, 7
• For immediate/anaphylactic allergy: clindamycin, azithromycin (5 days), or clarithromycin (10 days) 3, 5
• Macrolide resistance rates are 5-8% in most US areas, making clindamycin preferable when resistance is a concern 5

Critical Pitfalls to Avoid

• Never dismiss unilateral neck swelling as "just lymphadenopathy" - this can be life-threatening deep neck infection requiring surgical intervention 1
• Do not rely on oral antibiotics alone if there is significant neck swelling with systemic toxicity - IV therapy and surgical evaluation are required 1
• Avoid incomplete antibiotic courses - less than 10 days of penicillin/amoxicillin increases risk of treatment failure and complications 3, 5, 6
• Do not use aspirin in children due to Reye syndrome risk 5, 8, 7
• Descending mediastinitis is a rare but potentially fatal complication - maintain high suspicion if chest pain or respiratory symptoms develop 1

Symptomatic Management

• NSAIDs (ibuprofen) or acetaminophen for pain and fever control 5, 8
• Warm salt water gargles for patients old enough to gargle 5, 8
• Corticosteroids are not recommended - they provide minimal benefit (approximately 5 hours of symptom reduction) and potential adverse effects outweigh benefits 8