What is the likely cause of anterior neck muscle pain that worsens with swallowing, and how should it be evaluated and managed?

Anterior Neck Muscle Pain with Swallowing

The most likely cause is acute calcific tendinitis of the longus colli muscle, which presents as anterior neck pain triggered by swallowing and requires CT neck with contrast to confirm the diagnosis and exclude more serious conditions like retropharyngeal abscess or esophageal perforation. 1, 2

Differential Diagnosis Priority

The combination of anterior neck muscle pain worsening with swallowing demands immediate consideration of several time-sensitive conditions:

Most Common: Longus Colli Tendinitis

• Acute calcific tendinitis of the longus colli muscle is a self-limiting condition caused by calcium hydroxyapatite deposition in the prevertebral space that causes pharyngeal swelling and impaired swallowing. 2
• Presents with acute onset anterior neck pain, odynophagia (painful swallowing), dysphagia, and neck stiffness 1, 2
• This is the most frequently missed diagnosis because it mimics more serious infections 2

Life-Threatening Conditions to Exclude

• Retropharyngeal or prevertebral abscess requires urgent differentiation, as these demand surgical drainage while longus colli tendinitis requires only conservative management. 1, 2
• Esophageal perforation presents with anterior neck pain, dysphagia, and can rapidly progress to mediastinitis 1
• Aortic dissection can present with anterior neck pain and dysphagia from mass effect 1

Other Structural Causes

• Cervical spine degenerative changes with anterior osteophytes can mechanically compress the esophagus, causing dysphagia and referred anterior neck pain 3
• Glossopharyngeal neuralgia presents as severe oropharyngeal pain triggered by swallowing, typically from neurovascular compression 4

Initial Diagnostic Approach

Imaging: CT Neck with IV Contrast

CT neck with contrast is the initial imaging modality of choice because it can identify retropharyngeal fluid collections, abscesses, prevertebral calcifications (diagnostic of longus colli tendinitis), and hardware displacement. 4

• Contrast is strongly preferred for soft tissue characterization and to differentiate inflammatory conditions from infectious processes. 4
• CT delineates deep space neck masses, identifies calcifications in the longus colli tendon, and evaluates for skull base erosion 4
• Thin-cut high-resolution imaging through the cervical spine should be obtained 4

When to Consider MRI

• MRI cervical spine with and without contrast is indicated if CT is equivocal or if there is concern for epidural abscess, spinal cord involvement, or glossopharyngeal nerve pathology. 4
• MRI is superior for detecting intraparenchymal lesions affecting cranial nerve IX, leptomeningeal disease, and soft tissue abnormalities 4

Red Flags Requiring Urgent Imaging

• Fever, elevated inflammatory markers (ESR, CRP), or immunocompromised state suggest infection requiring immediate CT with contrast 4
• Progressive dysphagia with weight loss mandates urgent endoscopy to exclude malignancy 5, 6
• Neurologic symptoms (altered taste, loss of gag reflex, tongue weakness) suggest cranial nerve involvement requiring MRI 4

Clinical Examination Priorities

History Details to Elicit

• Acute onset (hours to days) with low-grade fever suggests longus colli tendinitis, while high fever with toxic appearance suggests abscess. 1, 2
• Trauma history, recent cervical spine surgery, or instrumentation raises concern for iatrogenic injury 4, 1
• Chronic progressive symptoms suggest degenerative cervical spine disease or malignancy 3

Physical Examination Findings

• Palpable anterior neck tenderness over the prevertebral muscles suggests longus colli tendinitis 2
• Limited cervical range of motion, particularly rotation and extension, is common in both infectious and inflammatory conditions 1, 2
• Assess for cranial nerve IX dysfunction: test gag reflex, posterior tongue sensation, and taste on posterior one-third of tongue. 4

Management Algorithm

If Longus Colli Tendinitis Confirmed (Prevertebral Calcification on CT)

• Conservative management with NSAIDs and activity modification is sufficient, as this is a self-limiting condition resolving in 1-2 weeks. 2
• No antibiotics or surgical intervention required 2
• Reassure patient and provide symptomatic relief 2

If Retropharyngeal Abscess Identified

• Urgent ENT/surgical consultation for drainage is mandatory, as this is a surgical emergency. 1
• Broad-spectrum IV antibiotics covering oral flora 4
• Airway monitoring in ICU setting 1

If Cervical Spine Degenerative Disease

• Physical therapy with manual therapy, soft tissue techniques, and mobilization of facet joints can improve swallowing capacity in cervicogenic dysphagia. 3
• Consider referral to speech-language pathologist if dysphagia persists 3

If Glossopharyngeal Neuralgia Suspected

• CT neck should include imaging of the pharynx and larynx to exclude mucosal neoplasm, and evaluate the stylohyoid ligament for calcification. 4
• MRI orbits, face, and neck with contrast is complementary to assess the glossopharyngeal nerve course 4

Critical Pitfalls to Avoid

• Do not empirically treat as simple pharyngitis or muscle strain without imaging—missing retropharyngeal abscess or esophageal perforation can be fatal. 1, 2
• Do not assume post-surgical dysphagia is "normal" without imaging verification of hardware position, as late migration can occur years after surgery. 7
• Do not rely on clinical examination alone to exclude aspiration risk—up to 55% of dysphagic patients have silent aspiration without protective cough. 7, 6
• Do not order plain radiographs as the initial test—they have insufficient sensitivity for soft tissue pathology and will delay definitive diagnosis 4