What is the likely diagnosis and initial management for acute anterior neck pain that started after a painful swallow with neck rotation?

Acute Anterior Neck Pain After Painful Swallow with Neck Rotation

The most likely diagnosis is calcific tendinitis of the longus colli muscle (also called retropharyngeal tendinitis), and initial management consists of NSAIDs (ibuprofen 400–800 mg every 6–8 hours) with reassurance that symptoms typically resolve within 10–15 days. 1

Clinical Presentation and Diagnosis

This classic triad—acute anterior neck pain, odynophagia (painful swallowing), and cervical spine stiffness following neck rotation—strongly suggests calcific tendinitis of the longus colli muscle rather than mechanical neck pain. 1

Key Diagnostic Features

• Acute onset of severe anterior neck pain triggered by a specific neck movement (rotation during swallowing) 1
• Odynophagia as a prominent symptom distinguishes this from simple mechanical neck pain and indicates involvement of structures adjacent to the pharynx 2, 1
• Cervical spine stiffness accompanies the pain 1
• Symptoms typically occur without fever initially, though low-grade fever may develop 1

Critical Red-Flag Screening

Before proceeding with conservative management, you must systematically exclude serious pathology:

• Constitutional symptoms (fever >38°C, unexplained weight loss, night sweats) require urgent MRI cervical spine without contrast 3
• Progressive neurological deficits (weakness, sensory changes, gait disturbance, bowel/bladder dysfunction) mandate immediate MRI within 12–24 hours 3
• History of malignancy, immunosuppression, or IV drug use necessitates urgent imaging to exclude metastatic disease, infection, or epidural abscess 3, 4
• Intractable pain despite appropriate analgesia is a red flag 3
• Vertebral body tenderness on palpation suggests metastatic disease or osteomyelitis 3

Diagnostic Workup

Initial Laboratory Testing

• Complete blood count (CBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) to assess for inflammatory or infectious processes 5, 4
• Elevated inflammatory markers in the context of this presentation warrant further investigation but do not automatically indicate infection 4

Imaging Strategy

If no red flags are present:

• Plain cervical radiographs (lateral view) may reveal retropharyngeal calcification anterior to C1-C2, which is pathognomonic for longus colli tendinitis 1
• However, plain films have limited sensitivity and CT cervical spine with contrast is the definitive imaging modality 1

CT findings diagnostic of longus colli tendinitis:

• Retropharyngeal calcification (hydroxyapatite deposits) anterior to the odontoid process of C2 1
• Retropharyngeal edema without abscess formation 1
• Absence of fracture or arterial dissection 1

If any red flags are present:

• Urgent MRI cervical spine without contrast is mandatory to exclude serious pathology including retropharyngeal abscess, vertebral osteomyelitis, epidural abscess, or metastatic disease 3, 4

Important Differential Diagnoses to Exclude

The combination of anterior neck pain and odynophagia requires consideration of several serious conditions 2:

• Retropharyngeal or prevertebral abscess: Presents with fever, dysphagia, and may show fluid collection on imaging 5, 2
• Esophageal perforation: Suggested by history of foreign body ingestion, instrumentation, or severe retching; requires urgent CT with oral contrast 5
• Cervical arterial dissection: Presents with unilateral headache and neck pain; requires CT angiography 3
• Thyroid cartilage fracture: History of direct trauma 2
• Vertebral osteomyelitis/discitis: Fever, elevated inflammatory markers, risk factors for infection 3, 4

Initial Management Protocol

Pharmacologic Therapy

NSAIDs are first-line treatment:

• Ibuprofen 400–800 mg orally every 6–8 hours (maximum 3200 mg/day) 6, 1
• Take with food or milk to minimize gastrointestinal side effects 6
• Use the lowest effective dose for the shortest duration 6

Adjunctive analgesics if needed:

• Acetaminophen may be added when NSAIDs alone provide insufficient relief 7
• Avoid opioids for this condition as the risk-benefit profile is unfavorable 3
• Short-term muscle relaxants may be considered for severe muscle spasm, but avoid benzodiazepines (e.g., diazepam) as they are associated with delayed recovery 7

Non-Pharmacologic Measures

• Activity modification: Avoid extreme neck rotation and positions that exacerbate pain 7
• Heat application may provide symptomatic relief 7
• Soft diet during the acute phase to minimize odynophagia 1
• Reassurance that this is a self-limited condition 1

Expected Clinical Course and Follow-Up

Natural History

• Favorable evolution within 10–15 days is typical with conservative management 1
• Improvement should be evident within 3–5 days 7

Follow-Up Strategy

• Reassess in 3–5 days if symptoms are not improving 7
• If symptoms persist beyond 2 weeks or worsen, obtain CT cervical spine with contrast (if not already done) or MRI cervical spine without contrast to exclude alternative diagnoses 3, 1
• Consider referral to otolaryngology or spine specialist if diagnosis remains uncertain or symptoms are refractory 1

Critical Pitfalls to Avoid

• Do not dismiss odynophagia as a minor symptom—it is a key clinical feature that distinguishes serious pathology from simple mechanical neck pain 2
• Do not assume mechanical neck pain when odynophagia is present; the differential diagnosis includes life-threatening conditions such as esophageal perforation and retropharyngeal abscess 5, 2
• Do not delay imaging if red flags emerge during the clinical course 3
• Do not order MRI immediately in the absence of red flags, as most cases of longus colli tendinitis resolve with conservative therapy and imaging can be deferred if clinical improvement occurs 3, 1
• Watch for development of fever, progressive dysphagia, or respiratory symptoms, which would indicate potential abscess formation or other serious complications requiring urgent re-evaluation 5, 3