22 month old girl presenting with concern for right sided neck swelling.  Mother states she noticed the swelling about 2 or 3 days ago, but it became acutely worse today, which prompted this ED visit.  The child was seen by her pediatrician yesterday and started on cefdinir for presumed infection at the site of swelling.  Child’s mother states she particularly became concerned about her daughter’s breathing today, and noticed that it was very noisy. The child was febrile to 103.9 at home prior to coming to the ED. On PE, the child is mildly febrile with a HR 159. She had noisy breathing with sturdor and copious nasal discharge. She also had a 3-4 cm mobile mass at right lateral neck, inferior to angle of mandible and 1 cm soft, mobile lymph node just posterior to the mass, without  erythema, tenderness, or warmth.

A bedside ultrasound using the superficial linear probe shows the mass of interest, which has a stalk-like appearance when color flow is added.  The mass is seen compressing the adjacent vessel.

CT performed in the ED showed “Extensive lymphadenopathy and adenitis. No drainable fluid collection. No abscess. No nodal necrosis.  Moderate to marked narrowing of the nasal pharynx and mild narrowing of the hypopharynx (on the right side). The airway remains patent.  Marked narrowing of the left internal jugular vein and moderate to marked narrowing of the right internal jugular vein, but both are patent, with no thrombosis.  Likely inflammatory/infectious in etiology rather than neoplastic, but needs follow up to clear.”

Child’s respiratory distress worsened in the ED despite racemic epinephrine and dexamethasone, she was ultimately placed on high flow nasal cannula and admitted to the PICU.  ENT was consulted, but no surgical intervention was deemed necessary.  She was placed on ampicillin-sulbactam and vancomycin on admission.  She then was transferred to the pediatric floor within 24 hours of admission, and her antibiotic regimen was changed to clindamycin monotherapy.