You are seeing a 2 year old boy with a high fever who is irritable and refuses to look up. His parents think he has a sore throat. You are appropriately worried about a retropharyngeal cellulitis/abscess and obtain the following X-Ray.

Widened prevertebral soft tissue space consistent with a retropharyngeal cellulitis/abscess

Fortunately he is adequately protecting his airway. What if he wasn’t? How would you know? Keep in mind that a child with an impending airway disaster will maintain a position of comfort even if they have stridor (really bad croup), or drooling (epiglottitis). Patients with any of the following signs/symptoms deserve a detailed workup including labs (CBC and blood culture at least) plus imaging starting with plain radiographs, the CT with contrast. All of this is proceeded by a careful evaluation of the patient’s ability to protect and maintain their airway.

Red Flags Suggesting a Deep Space Infection Involving the Upper Airway

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  • Fever > 2 weeks
  • Symptom duration >2 wks
  • Trismus
  • Drooling
  • Asymmetric tonsillar swelling or adenopathy
  • Swelling in floor of mouth or lateral neck/jaw swelling
  • Dysphonia
  • Pain out of proportion to clinical findings
  • Airway obstruction, dyspnea
  • Inability to lay supine
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