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.
A variety of terms deserve attention in the description and management of neck pain symptoms. Neck stiffness refers to an abnormal preferred position of the neck or a normal position with restricted range of motion. Meningismus indicates neck stiffness related to meningeal irritation or inflammation. Torticollis (Latin for “twisted neck”) refers to neck stiffness associated with the child holding his or her head to the side with the chin rotated in the opposite direction. Trismus refers not to neck stiffness, but stiffness and limited opening of the jaw.
Various neck spaces or potential spaces deserve description (Figure 33-1), as infection of a certain space often indicates likely pathophysiology, determines the symptomatology and examination presentation, and dictates treatment of the disorder. The sublingual space (supramylohyoid space, a subdivision of the submandibular space) is that space beneath the tongue, medial to the body of the mandible and superior to the myelohyoid muscle. The peritonsillar space is a potential space between the capsule of the pharyngeal or palatine tonsil and the superior constrictor muscle of the pharynx. The danger space is a potential space that is bound superiorly by the skull base, anteriorly by the alar fascia, and posteriorly by the prevertebral fascia, extending down to the diaphragm. The retropharyngeal space is anterior to the danger space and posterior to the visceral space containing the esophagus and trachea. It potentially communicates laterally with the parapharyngeal and danger spaces.1 The parapharyngeal space (also pharyngomaxillary space or lateral pharyngeal space) is best described as an inverted pyramid with the base at the skull base and the apex at the greater cornu of the hyoid bone, lateral to the superior pharyngeal constrictors, medial to the parotid gland, mandible, and lateral pterygoid muscles, anterior to the prevertebral fascia, and posterior to the pterygomandibular raphe.
General definitions applicable to a description of infections anywhere in the body include cellulitis, phlegmon, and abscess. Cellulitis is a superficial infection, usually with signs of induration, erythema, and warmth. A phlegmon is an infection deeper in tissue with signs including induration, edema of surrounding tissues on imaging, possible necrosis of tissues within a given area, but no clearly-defined capsule or enhancing rim on contrast imaging. It may or may not be possible to obtain fluid from a phlegmon using needle or open techniques. An abscess is a walled-off collection of necrotic tissue and purulent material which typically exhibits an enhancing rim on imaging.