Although neck pain is a common presenting symptom, it is rarely a discharge diagnosis. Estimates of the incidence of neck pain necessitating admission to a hospital do not exist, but data from a regional children’s hospital with 40,000 emergency department visits per year suggest that less than 10% of patients seen with a complaint of neck pain are admitted. This chapter emphasizes the most common diagnoses associated with neck pain that result in hospital admissions for children.

Neck pain can be caused by various pathologies. Because of the complicated anatomy and diverse structure in the neck, diseases of widely different etiologies may present with similar symptoms and can include infectious, vascular, inflammatory, neoplastic, iatrogenic, congenital, autoimmune, traumatic, neurologic, and idiopathic etiologies (Table  33-1).

The diagnostic evaluation of neck pain is guided by findings from the history and physical examination. The need for and direction of more urgent evaluation is often evident on initial assessment. In cases involving stridor or respiratory distress (posturing, drooling, accessory muscle use, retractions), specialty evaluation by otolaryngology, airway films, or fluoroscopy may be warranted. With fever, lethargy, and/or meningismus, lumbar puncture with or without preceding head computed tomography (CT) to identify cases of increased intracranial pressure related to meningitis should be considered. In cases of trauma, existing protocols, mechanism of injury, and examination findings dictate the initial steps taken. If there is altered mental status and/or cranial neuropathy, gait abnormality, or hemiparesis, then urgent CT or MR angiography or other modality may be warranted to rule out stroke or vessel dissection.

Additional laboratory studies including blood cultures, complete blood count, erythrocyte sedimentation rate, and C-reactive protein may be helpful for suspected infectious or inflammatory problems. If indicated by examination, rapid strep antigen test, throat culture, or culture of purulent drainage from a lymph node, ear, or other non-oral source may be helpful prior to initiation of antibiotic therapy.

Radiologic studies are often helpful in the diagnosis of neck pain. Depending on the history and physical examination findings, a cervical spine series can identify any fracture, dislocation, or instability. A CT scan with contrast is useful for evaluating the soft tissue structures of the neck and can suggest a diagnosis of phlegmon or abscess. Lateral neck films can also serve as an initial screening tool when retropharyngeal abscess or even epiglottitis/supraglottitis is suspected, as they may reveal widening of the retropharyngeal space, or a thumbprint sign from a thickened, edematous epiglottis. Widening can also be seen in normal patients with inadequate neck extension or inspiration, so the finding should be interpreted in the proper clinical context. Following trauma, in addition to identifying fractures or dislocations and evaluating for soft tissue injury, a CT scan can identify or raise suspicion of injury to the trachea or esophagus although crepitus, respiratory distress, and other history and examination findings are at least as important in alerting the practitioner to these entities. MRI is indicated if cervical osteomyelitis is suspected and for the evaluation of certain tumors.

A thorough history and physical examination are warranted in all children presenting with neck pain. A few pieces of information from the history can quickly guide the examiner. Specifically, the presence or absence of fever and related complaints such as a sore throat, ear pain, dental pain, headache, or vomiting might point one toward an infectious or inflammatory cause. Important information in the history of present illness includes the temporal onset of pain, whether it is progressive or static, location of pain, radiation of pain, and presence of associated neurologic symptoms, including bowel or bladder dysfunction, gait disturbance, or mental status change. Often a history of trauma is obvious or known, but eliciting a history of more subtle trauma is important. Systemic findings such as weight loss, fatigue, or night sweats can be suggestive of oncologic problems. Family history can be helpful in some cases if the cause is rheumatologic or vascular. Because of the known associations among some conditions or syndromes, it is important to obtain a thorough past medical and surgical history, including medication use, genetic syndromes, bleeding disorders, and immunodeficiency.

On inspection, it is important to note the general appearance of the patient, including his or her position of comfort. Signs of respiratory distress could include difficulty managing saliva and other secretions, stridor, posturing such as tripod posture with trunk leaning forward and neck extended, retractions, and paradoxical movement of the abdomen.

Asymmetry in the neck, face, or any paired structures should be noted and investigated. Eye examination should include taking note of pupils, conjunctivae, extraocular movements, and gross visual acuity when possible. Oral examination includes assessment of jaw opening, teeth and gums, the floor of examination, tonsils, posterior oropharynx, uvula and palate. External ear (including position with notation of proptosis or mastoid tenderness), ear canal, and middle ear assessment should be completed. Inspection of the nasal tissues should be performed with an otoscope. Neck examination should assess for decreased mobility, torticollis, head tilt, stiffness, meningeal irritation, masses, lymphadenopathy, crepitus, fluctuance, tenderness, bruits, sterdor or stridor, and skin lesions.

Finally, a complete neurologic examination is important to rule out mental status changes, nerve palsy, motor weakness, sensory deficit, and gait abnormality.

When neck pain is a presenting symptom, the underlying cause must be determined to guide diagnostic studies and appropriate consultation or treatment (Table 33-1). Diagnostic considerations and treatment recommendations can include the following.

INFECTIOUS CAUSES

Cervical Lymphadenitis