stridor or tripod positioning Visualization of the abscess on examination may be difficult, particularly in younger or uncooperative patients In cooperative patients, inspection of the posterior pharyngeal wall with tongue blades and bright headlamp can reveal overt bulging or asymmetry Management and Diagnostic Testing Immediate management should focus initially on maintaining a patent airway If the diagnosis is suspected and the patient is in respiratory distress, emergent otolaryngology consultation is indicated Unless the airway is in immediate jeopardy, vascular access should be secured to administer IV antibiotics If the airway is a significant concern, IV access should be attempted in the operating room given the potential for destabilization and worsening of the upper airway obstruction Laboratory evaluation will often reveal an elevated white blood cell (WBC) count Blood cultures are frequently negative but may be useful in identifying a pathogen Radiographic studies are often essential in the diagnosis of deep space neck infections In stable patients, a lateral neck radiograph is an appropriate initial choice The radiograph shows an increase in the width of the soft tissues anterior to the vertebrae and, on occasion, an air–fluid level In the young child without retropharyngeal infection, the width of the prevertebral space is less than the width of the adjacent vertebral body at the upper cervical vertebrae (C2, C3) if the examination is performed with the neck properly extended For children approaching school age and beyond, the width of this space is typically less than half of the adjacent vertebral body at the mid cervical spine if the neck is properly extended ( Fig 118.4A ) CT of the neck with IV contrast is the best imaging modality to identify a deep space infection However, its use is complicated by the potential for worsening respiratory status when lying supine, coupled with the potential need for sedation to ensure an accurate study This is particularly problematic in patients with potential airway compromise, and consideration should be given to having anesthesia or otolaryngology involved as part of the sedation process CT of the neck, if indicated, can often help differential cellulitis from phlegmon or abscess, as well as the extent of an abscess in the deep neck Features that identify abscess on CT include homogeneity of the fluid collection, scalloping, or irregularity of the abscess wall, and ring enhancement of the abscess wall ( Fig 118.4B ) CT also shows the proximity of the infection to large vessels, which can be compressed by surrounding edema from an infection This is also helpful for potential surgical planning