Does CT have an additional diagnostic value over ultrasound in the evaluation of acute inflammatory neck masses in children?

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Perioperative factors influencing hospitalization duration for pediatric neck abscesses

PURPOSE

Pediatric neck abscesses are a common pathology seen in an ambulatory setting. Although some pediatric neck abscesses are managed medically with antibiotics, surgical intervention is often required. Given the often non-emergent presentation of many abscesses, a variety of logistical and perioperative factors may delay time to care and subsequently prolong hospital stay. The objective of this study was to examine factors that influence the overall time to surgery (TTS) and hospital length of stay (LOS) in a pediatric population with neck abscesses who ultimately require surgical drainage.

MATERIALS AND METHODS

161 pediatric patients who underwent incision and drainage of a neck abscess over a ten-year period at a tertiary referral children's center were reviewed. Demographic information, radiographic studies, and surgical information were extracted from patient charts. Descriptive statistics, Mann-Whitney U tests, and multivariate analyses were performed.

RESULTS

The most common subcategory location was deep neck abscesses (33.1 %). Computed tomography (CT) was the most common pre-operative imaging modality (54.1 %) followed by ultrasound (US) (49.1 %) and magnetic resonance imaging (2.6 %). US and a combination of multiple preoperative imaging modalities were associated with increased LOS and TTS. Repeat surgery was associated with increased LOS. Pre-admission antibiotic use was associated with increased LOS and TTS. Younger patients were more likely to have a longer LOS.

CONCLUSIONS

A variety of factors can influence TTS, LOS, and time from surgery to discharge including patient age, abscess location, a non-optimized utilization of imaging modalities, the utilization of pre-admission antibiotics, and the need for repeat operations.

Paediatric Deep Neck Infection—The Risk of Needing Intensive Care

Deep neck infections are potentially dangerous complications of upper respiratory tract or odontogenic infections. The pathophysiology, clinical presentation, and potential spreading depend on the complex anatomy of the neck fascia. These infections can lead to severe pathological conditions, such as mediastinitis, sepsis, and especially airway impairment with difficult management. Because of the risk of life-threatening emergency situations and the possible impacts on the overall health status of affected children, their early recognition is of utmost importance. Torticollis, drooling, and stridor are the most common signs of advancing disease. Children presenting with these symptoms should be admitted to the paediatric intensive care unit for vital function monitoring, where the airway could be readily secured if function is compromised.

Evaluation of an imaging protocol using ultrasound as the primary diagnostic modality in pediatric patients with superficial soft tissue infections of the face and neck

OBJECTIVE

To determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT).

METHODS

Children with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006-2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010-2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared.

RESULTS

Three hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p < 0.0001) and less likely to undergo CT (66% vs. 41%, p < 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates.

CONCLUSION

Increased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance.

A clinical decision rule for the use of ultrasound in children presenting with acute inflammatory neck masses

OBJECTIVE

To identify the association between clinical and ultrasound findings and surgical drainage in children with inflammatory neck masses and to create a clinical decision rule that allows for reduction of unnecessary use of ultrasound in inflammatory neck masses.

MATERIALS AND METHODS

We reviewed data on patients ≤18 years who visited our emergency department between 2012 and 2014 with inflammatory neck swelling and who underwent ultrasound examinations of the neck. We used multivariate logistic regression to identify factors associated with drainage within 24 h of ultrasound study (early drainage). Recursive partitioning was used for risk stratification.

RESULTS

Of 341 consecutive patients included in this study, 37 patients underwent early drainage and all had purulent material drained. All patients but one with non-suppurative adenitis and 95% (97/102) of those with suppurative adenitis or early/suspicious abscess on ultrasound were initially treated medically. Of those with a definite diagnosis of abscess/fluid collection, 89% (32/36) underwent early drainage. Patients who underwent drainage were more likely to be younger, female and have a longer duration of neck swelling, with fluctuance and erythema on exam. Recursive partitioning analysis revealed that among children with neck swelling >3 days and ≤3 days, the rate of early drainage was 24.3% and 4.4%, respectively. None of the children >7 months with neck swelling ≤3 days underwent early drainage.

CONCLUSION

Children older than 1 year with inflammatory neck swelling ≤3 days are at low risk of having ultrasound findings that require drainage. In this subgroup of patients, ultrasound could be avoided unless the patient fails to improve after a trial of antibiotic therapy.

A Clinico-Pathological Study of Cervical Lymph Nodes

Cervical lymphadenopathy is one of the commonest presenting complaint of patient in ENT OPD Fine Needle Aspiration Cytology (FNAC) is one of the most reliable, less expensive, and basic diagnostic procedure for the definitive and conclusive diagnosis for the immune system which reciprocates in the form of enlarged lymph nodes. A study was conducted in ENT Department of Santosh Medical College, Ghazibad from August 2015 to May 2016 on 64 patients with enlarged cervical lymph nodes. FNAC was done to make the diagnosis. Out of 64 patients (51.5 %) was reactive non-specific, 28 % tubercular, 3.1 % lymphoma and 17 % were malignant. FNAC is one of the most dependable diagnostic tools in case of cervical lymphadenopathy for early diagnosis and detection for the better management.

Severe neck infections that require wide external drainage: clinical analysis of 17 consecutive cases

Infections in the neck layers and spaces are potentially life-threatening diseases causing further complications, like mediastinitis, airway obstruction, or sepsis. Despite of the need for a conservative approach, they still regularly require surgical intervention. Records of 17 patients with severe neck infections that were treated by wide external incision and open wound management were retrospectively analyzed. The aim of the study was to clinically characterize these most serious neck infections. The most common presenting symptoms were neck pain and tense neck mass (94-94%) regularly with fever (65%), always accompanied by a marked elevation of C reactive protein level (average 192 uG/l). These findings were constant and very similar among both the deep neck infection and necrotizing fasciitis cases. More than half of the patients (53%) had at least one systemic co-morbidity. The parapharyngeal space was most commonly affected (83%), but extended disease involving more than two major neck regions was found in 13 cases (76%). Dental (29%) was the most common primary infection, followed by peritonsillar abscess (23%), Microbiological results showed a wide variety of corresponding bacteria. Mediastinitis was developed in three cases (18%), and airway obstruction requiring tracheostomy in two cases (12%). All the patients survived. Severe neck infections are a heterogenous group of diseases regarding to the primary site of infection, microbiology, localisation and host reaction. However, rapidly developed, painful, tense neck mass with a highly elevated CRP level should always alert for an extended or phlegmonous process in the layers or spaces of the neck.