A 41-year-old man presents with a 4-day history of progressive swelling and pain on the right side of his neck. He complains of difficulty swallowing and mild trismus. On examination, there is a tender, fluctuant mass in the right anterior cervical triangle, with overlying redness and warmth.

Question

A 41-year-old man presents with a 4-day history of progressive swelling and pain on the right side of his neck. He complains of difficulty swallowing and mild trismus. On examination, there is a tender, fluctuant mass in the right anterior cervical triangle, with overlying redness and warmth.
Diagnosis and treatment

GPT-4o mini · Answer

Based on the clinical presentation of the 41-year-old man, the symptoms suggest the presence of an acute infection in the neck, with likely involvement of the deep cervical spaces. The progressive swelling, pain, difficulty swallowing (dysphagia), and trismus (limited mouth opening) are indicative of a potential cervical abscess, likely due to pharyngitis, odontogenic infection, or lymphadenitis.

Likely Diagnosis:

Cervical Abscess or Deep Neck Space Infection (e.g., peritonsillar abscess, retropharyngeal abscess, or submandibular space infection).

Initial Management Steps:

Imaging:
- CT Scan of the Neck: With contrast to delineate the extent of the infection, identify the presence of an abscess, and evaluate surrounding structures.
Antibiotic Therapy:
- Broad-spectrum intravenous antibiotics should be initiated, covering both aerobic and anaerobic organisms. Common regimens include:
  - Piperacillin-tazobactam
  - Ceftriaxone plus metronidazole
  - Clindamycin (if allergic to beta-lactams).
Surgical Intervention:
- If a significant abscess is identified or if there is worsening of the patient’s condition, surgical drainage should be performed. This can include:
  - Incision and drainage of the edema or abscess under local or general anesthesia, depending on the size and location of the infection.
Supportive Care:
- Ensure hydration, pain management, and monitoring of airway patency, especially considering possible worsening of trismus and dysphagia which can threaten airway compromise.
Consults:
- It may be appropriate to involve an ear, nose, and throat (ENT) specialist or a general surgeon, depending on the nature of the infection and required intervention.

Conclusion:

The combination of clinical signs and symptoms points towards a deep neck space infection or abscess, requiring prompt intervention with imaging, antibiotics, potential surgical drainage, and monitoring for complications.