Deep neck space Infections in children: Peritonsillar, retropharyngeal, parapharyngeal, and Ludwig's angina emergencies in the pediatric emergency department

Pediatric deep neck space infections (DNSIs)-peritonsillar, retropharyngeal, and parapharyngeal abscesses and Ludwig's angina-are uncommon but potentially life-threatening due to rapid progression to airway obstruction, sepsis, and mediastinal extension. This narrative review summarizes evidence for emergency clinicians. A literature search of PubMed/Scopus (2000-2025) identified studies on pediatric DNSI epidemiology, imaging, microbiology, and management. DNSIs peak at ages 2-5 years because of prominent retropharyngeal lymph nodes. Nonspecific symptoms (fever, irritability, neck stiffness) often delay diagnosis in young children, while older children present with trismus, dysphagia, and "hot potato" voice. Airway compromise is the highest priority and must be assessed before imaging. Contrast-enhanced CT remains the gold standard for stable patients, but point-of-care ultrasound has high accuracy for peritonsillar abscesses. Microbiology is polymicrobial; methicillin-resistant Staphylococcus aureus is increasingly reported. Empiric broad-spectrum intravenous antibiotics (e.g., ampicillin-sulbactam) should be initiated early, with vancomycin added if MRSA risk factors are present. Surgical drainage is indicated for abscesses >2-2.5 cm, airway compromise, or failure of medical therapy. Multidisciplinary collaboration reduces complications. Early recognition, an airway-first approach, selective imaging, and timely antibiotics improve outcomes. Standardized emergency department (ED) protocols and risk stratification tools are needed to prevent life-threatening complications in this vulnerable group.