Management of Pediatric Head and Neck Infections in the Emergency Department (Infectious Disease CME and Pharmacology CME) -

Management of Pediatric Head and Neck Infections in the Emergency Department (Infectious Disease CME and Pharmacology CME)
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Publication Date: November 2020 (Volume 17, Number 11)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 11/01/2023.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 1 Pharmacology CME credits, subject to your state and institutional approval.


Samira Abudinen-Vasquez, MD
Department of Pediatrics, Icahn School of Medicine at Mount Sinai - Elmhurst Hospital, Elmhurst, NY
Michelle N. Marin, MD, FAAP
Assistant Professor of Pediatrics and Emergency Medicine, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY

Peer Reviewers

Coburn H. Allen, MD, FAAP, FACEP, FPIDS
Distinguished Teaching Professor, Pediatric Emergency Medicine, Fellowship Director, Pediatric Infectious Dis-eases, University of Texas at Austin Dell Medical School; USACS National Director of Pediatric Services, Austin, TX
Susan Fraymovich, DO
Assistant Professor of Clinical Emergency Medicine, Assistant Professor of Clinical Pediatrics, Division of Pediatric Emergency Medicine, New York-Presbyterian/Weill Cornell Medical Center, New York, NY


Head and neck infections can spread to nearby structures, compromising the airway and progressing to life-threatening events. Pediatric head and neck infections can be difficult to recognize; emergency clinicians must know the signs and symptoms of head and neck infections for early diagnosis and urgent management in order to prevent complications and decrease hospitalization rates. This issue reviews presenting signs and symptoms of pediatric head and neck infections, discusses when diagnostic studies are indicated, and offers evidence-based recommendations for management. Conditions reviewed include mastoiditis, sinusitis, Ludwig angina, peritonsillar abscess, retropharyngeal abscess, Lemierre syndrome, and acute suppurative thyroiditis.

Excerpt From This Issue

A previously healthy 2-year-old girl is brought to the ED by her mother for noisy breathing and limited neck movement. The patient had fever to 39°C (102.2°F) for 2 days and a week of rhinorrhea prior to the onset of fever. The mother says the girl has been drooling for the past day. The girl's physical examination is notable for an anxious-appearing toddler with a temperature of 39°C, heart rate of 195 beats/min, blood pressure of 90/60 mm Hg, respiratory rate of 60 breaths/min, and oxygen saturation of 89%. You note stridor at rest, with supraclavicular and subcostal retractions. The girl refuses to look toward her right side. You put the child on a nonrebreather and prepare for intubation. Given the child’s symptoms, you are highly concerned that she may have an infectious process causing significant airway obstruction. With this concern, you have some trepidation in managing her airway and start to consider who to call in order to prevent any further complications, and which airway adjuncts to use when managing this difficult airway…

A 15-year-old boy with history of type 1 diabetes and poor dentition comes in via EMS. The boy is drooling and has trismus. His voice is so hoarse that all of his medical information is obtained through his mother. For the past 2 weeks he has been experiencing some pain from his left second and third mandibular molars, which has gotten progressively worse. For the past 2 days, he has had fever to 40°C (104°F), rigors, and has been sleeping more than usual. Today he awoke with an enlarged tongue, drooling, and a hoarse voice, which prompted them to come to the ED. His vital signs are notable for fever to 40°C, heart rate of 120 beats/min, blood pressure of 100/55 mm Hg, respiratory rate of 30 breaths/min, oxygen saturation of 95%, and a finger-stick glucose level of 600 mg/dL. On physical examination, you note an adolescent boy in moderate distress who is continuously expectorating sputum, with elevation of the floor of the mouth and fullness and crepitus of the bilateral submandibular area. You also note inspiratory stridor with mild supraclavicular retractions. You are concerned he is septic, with significant airway compromise, and you immediately place him on a nonrebreather, order laboratory tests, give IV fluids, and administer broad-spectrum antibiotics. You are concerned about his significant upper airway obstruction and wonder if you should prepare for a surgical airway…

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