A 57-year-old woman with hypertension, hyperparathyroidism, migraine headaches, and prior gastric bypass surgery presents with progressive swelling from the right ear to the base of the neck, right facial fullness, marked fatigue, night sweats, intermittent nausea, and vertigo. What are the differential diagnoses and what urgent work‑up and management should be pursued?

Urgent Evaluation for Deep Neck Infection or Malignancy

This patient requires immediate CT neck with IV contrast and urgent ENT consultation, as the constellation of unilateral neck swelling from ear to neck base, facial swelling, constitutional symptoms (night sweats, exhaustion), and systemic symptoms suggests either a deep neck infection or a malignant process (lymphoma or parotid malignancy), both of which require emergent evaluation. 1

Immediate Risk Stratification

This presentation demands urgent action because:

• Fever with neck swelling strongly suggests an infectious process that can rapidly progress to airway compromise, mediastinitis, or sepsis 1
• The unilateral distribution from ear to neck base with facial involvement indicates potential parapharyngeal or parotid space involvement 1
• Night sweats and exhaustion raise concern for either systemic infection or lymphoproliferative malignancy
• Her hyperparathyroidism history creates additional diagnostic complexity but should not delay urgent evaluation 2

Critical Initial Workup (Within Hours)

Mandatory Imaging

• CT neck with IV contrast is the gold standard and must be obtained urgently to detect abscess formation (peripherally enhancing collections), early bone changes, osteolysis, or mass lesions 1
• This imaging will differentiate between deep neck infection, lymphadenopathy from lymphoma, or parotid/salivary gland pathology 1

Laboratory Assessment

• Complete blood count with differential (leukocytosis suggests infection; atypical lymphocytes or cytopenias suggest lymphoma)
• Inflammatory markers (ESR, CRP) to support infectious etiology 1
• Comprehensive metabolic panel including calcium and phosphorus (given her hyperparathyroidism) 2
• Blood cultures if febrile 1

Vital Signs Monitoring

• Assess for sepsis indicators: temperature, blood pressure, heart rate, respiratory rate, oxygen saturation 1
• Monitor for signs of airway compromise

Empiric Management Pending Imaging

Initiate broad-spectrum IV antibiotics immediately covering Streptococcus viridans, Klebsiella pneumoniae, Staphylococcus aureus, and oral anaerobes while awaiting CT results 1. Do not delay antibiotics for imaging if deep neck infection is suspected clinically.

Differential Diagnosis Priority

Most Urgent Considerations:

1. Deep neck space infection (parapharyngeal, parotid, or masticator space abscess)

   • Unilateral neck swelling with constitutional symptoms is classic 1
   • Can rapidly progress to airway compromise 1

2. Lymphoma (Hodgkin's or Non-Hodgkin's)

   • Night sweats, exhaustion, and progressive lymphadenopathy are B-symptoms
   • Requires tissue diagnosis but imaging first to guide biopsy

3. Parotid malignancy

   • Unilateral facial and neck swelling from ear region
   • Less likely given acute presentation but must be excluded

Secondary Considerations:

1. Acute parotitis or sialadenitis

   • Can present with facial swelling and systemic symptoms 2
   • Usually more localized to gland

2. Complicated otitis externa progressing to skull base osteomyelitis

   • Her vertigo could suggest inner ear involvement 2
   • Less likely given extensive neck involvement

Special Considerations for This Patient

Hyperparathyroidism Context

• Her known hyperparathyroidism is likely unrelated to the acute presentation but requires consideration 2
• Primary hyperparathyroidism can be associated with pheochromocytoma in MEN2 syndrome, though night sweats from pheochromocytoma would typically include paroxysmal hypertension, headache, and palpitations 2
• Her hyperparathyroidism may be secondary to gastric bypass (calcium malabsorption and vitamin D deficiency are common) 3, 4, 5

Gastric Bypass Implications

• Post-gastric bypass patients have impaired calcium absorption and often develop secondary hyperparathyroidism 3, 4, 5
• This is not causing her acute neck swelling but may complicate management if surgery is needed 6
• Ensure adequate calcium and vitamin D supplementation is documented

Vertigo and Nausea Assessment

• If vertigo is positional and brief, consider benign paroxysmal positional vertigo (BPPV) as a separate issue 2
• However, persistent vertigo with neck swelling raises concern for inner ear involvement from infection or mass effect 2
• Vertebrobasilar insufficiency is unlikely given the acute neck findings 2

Critical Next Steps Algorithm

1. Immediate (within 1-2 hours):

   • Start IV access and broad-spectrum antibiotics 1
   • Obtain CT neck with IV contrast 1
   • Consult ENT urgently
   • Monitor airway and vital signs 1

2. Based on CT findings:

   • If abscess identified: Surgical drainage + continued antibiotics 1
   • If lymphadenopathy without abscess: Urgent biopsy (fine needle aspiration or excisional) for lymphoma workup
   • If parotid mass: ENT evaluation for malignancy workup

3. If imaging equivocal: Consider MRI neck with contrast for better soft tissue characterization

Common Pitfalls to Avoid

• Do not attribute neck swelling to hyperparathyroidism alone—parathyroid adenomas do not cause this degree of swelling 2
• Do not delay imaging for laboratory results—CT is diagnostic and guides all subsequent management 1
• Do not assume benign etiology given constitutional symptoms—night sweats demand exclusion of infection and malignancy
• Do not overlook airway assessment—deep neck infections can rapidly compromise the airway 1
• Do not treat vertigo or migraines until life-threatening causes are excluded 2