A 3-year-old is toxic, drooling and holding the neck extended. There is inspiratory stridor and increasing recession. Contrast CT, obtained while stable, shows a 3.5 cm retropharyngeal collection compressing the airway. What is the best next step?
The immediate threat is loss of airway; controlled airway management with surgical backup must precede definitive drainage and antimicrobial therapy.
A. Attempt awake transoral needle aspiration in the emergency department: Distress, poor access and loss of airway control make this hazardous.
B. Give oral antibiotics and review the following morning: A large abscess with systemic illness and evolving obstruction requires inpatient emergency treatment.
C. Secure the airway in theatre with senior paediatric anaesthetic and ENT teams, then drain the collection and give IV antibiotics: Airway control precedes drainage when obstruction is impending; spontaneous rupture and aspiration must be anticipated.
D. Repeat CT under sedation before escalation: Sedation can precipitate obstruction and repeat imaging adds no decisive information.
E. Perform blind nasotracheal intubation on the ward: Blind instrumentation risks trauma, rupture and complete obstruction.
If the child had no airway signs and only a small phlegmon without a drainable collection, closely monitored IV antibiotics could be tried first.
Independent Clinora educational preparation material; not official JCIE content, an accredited programme, or a substitute for local policy and specialist clinical judgement.
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