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If clinical presentation suggests impending airway obstruction, lab work does
little to inform immediate decision making, and the increased stress may convert
a partial obstruction into a critical airway. Oxygenation may be determined
noninvasively by pulse oximetry. Suspicion for traumatic injury warrants cervical
spine immobilization. Definitive airway control prior to full evaluation may be
necessary.

Child With Neck Mass and Respiratory Distress or Systemic
Toxicity
The mechanism and duration of symptoms are crucial elements in the evaluation
of a neck mass. Trauma from vehicular collisions, falls from heights, or sports
injuries may cause formation of a hematoma near vital structures such as the
carotid artery or trachea (see Chapter 112 Neck Trauma ). Allergic reactions
ranging from local bee stings to anaphylaxis may precipitate an acute emergency
if there is enough tissue edema to obstruct the larynx or trachea (see Chapter 85
Allergic Emergencies ).
Local and regional infections may present with cervical lymphadenopathy, but
can have more significant life-threatening aspects. Acute airway obstruction may
result from viral or bacterial infections with associated tonsillar hypertrophy or
laryngocele enlargement. Bacterial pharyngitis occasionally progresses to deep
space neck infections including retropharyngeal abscess, lateral pharyngeal
abscess (LPA), and peritonsillar abscess (PTA). Lemierre syndrome, an
uncommon parapharyngeal infection involving thrombophlebitis of the internal
jugular vein with septic emboli including metastatic pulmonary abscesses, may
manifest as respiratory distress and systemic toxicity in the adolescent with a
history of pharyngitis. Dental infection that spreads to the floor of the mouth (i.e.,
Ludwig angina) and neck may cause cervical swelling and airway compression.
Rarely, epiglottitis may present with associated cervical adenitis or the
appearance of a submandibular mass from ballooning of the hypopharynx.
Concomitant dysphagia, drooling, or stridor would raise suspicion for these
complications. Occasionally, branchial cleft cysts or cystic hygromas can become

infected and progress to abscess formation or rarely to mediastinitis. Children
with human immunodeficiency virus (HIV) infection (see Chapter 94 Infectious
Disease Emergencies ) may present with parotitis or generalized
lymphadenopathy (e.g., axillary, cervical, occipital), particularly visible in the
neck. Children may have hyperthyroid symptoms when a neck mass represents
thyromegaly. Similarly, patients with the mucocutaneous lymph node syndrome