Delayed Recognition and Drainage of a Pediatric Retropharyngeal Abscess with Parapharyngeal Extension in a...

Deep neck space infections in children can deteriorate quickly, especially when diagnosis and source control are delayed. We describe a 4-year-old boy admitted on 28 March 2026 with 4 days of progressive right lateral neck swelling, fever, muffled voice, and breathing difficulty. Ultrasonography showed a right cervical inflammatory mass with moderate upper-airway compression but was reported as Ludwig's angina, which did not match the lateral clinical findings. Needle aspiration yielded no pus, contrast-enhanced computed tomography was not obtained, and surgical drainage was not performed at that stage. The child deteriorated and required emergency tracheostomy with parapharyngeal incision and drainage on 1 April; approximately 20 mL of pus was evacuated. Persistent illness and delayed lateral neck radiography later identified a retropharyngeal component, prompting wider drainage of both spaces on 11 April. Gram stain and pus and blood cultures were negative. He improved after definitive drainage, airway care, antimicrobial escalation, and nutritional support and was discharged on hospital day 20. This course highlights the clinical cost of delayed anatomic definition and source control. In a child with progressive neck swelling and airway symptoms, a negative aspiration or discordant ultrasound should prompt urgent cross-sectional imaging where feasible or operative reassessment; early multidisciplinary action may prevent avoidable airway deterioration.