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Trott S, Burruss CP, Weltzer M, Iverson K, Azbell C, Bush ML. Perioperative factors influencing hospitalization duration for pediatric neck abscesses. Am J Otolaryngol 2023; 44:103967. [PMID: 37454430 DOI: 10.1016/j.amjoto.2023.103967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/20/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
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.
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Affiliation(s)
- Skylar Trott
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, KY, USA
| | | | | | - Kenneth Iverson
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Chris Azbell
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Matthew L Bush
- Department of Otolaryngology, University of Kentucky Medical Center, Lexington, KY, USA.
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Tahir S, Hasanain R, Abuhammour W, Dsouza AP, Lone R, Kherani S. Granulicatella adiacens Causing a Parapharyngeal Abscess in a 10-Month-Old Infant: A Rare-Case Report and Literature Review of Deep Neck Infections (DNIs) in Children. Cureus 2023; 15:e42144. [PMID: 37602014 PMCID: PMC10438130 DOI: 10.7759/cureus.42144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2023] [Indexed: 08/22/2023] Open
Abstract
Granulicatella adiacens is a rare variant of the Streptococcus bacteria. When isolated, G. adiacens has been described in cases of endocarditis and bacteremia, but less commonly seen in isolated pyogenic infections. We report a case of a parapharyngeal abscess caused by G. adiacens in an otherwise healthy 10-month-old infant, which was successfully treated with antibiotics and surgical drainage. To the best of our knowledge, this is the first described case of a pediatric deep soft tissue neck infection caused by G. adiacens with one other report in an adult. Additionally, of all localized infections from this bacteria, this is only the second reported case in the pediatric population. We also include an evidence-based literature review of the clinical presentation, microbiology, imaging modalities, and management approach to deep neck infections (DNIs).
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Affiliation(s)
- Saja Tahir
- Pediatrics, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Rand Hasanain
- Pediatrics, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Walid Abuhammour
- Infectious Diseases, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Ajay P Dsouza
- Radiology, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Rubina Lone
- Laboratory Medicine, Al Jalila Children's Speciality Hospital, Dubai, ARE
| | - Safeena Kherani
- Otolaryngology - Head and Neck Surgery, Al Jalila Children's Speciality Hospital, Dubai, ARE
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3
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Nurminen J, Heikkinen J, Happonen T, Nyman M, Sirén A, Vierula JP, Velhonoja J, Irjala H, Soukka T, Ivaska L, Mattila K, Hirvonen J. Pictorial Review of MRI Findings in Acute Neck Infections in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:967. [PMID: 37371199 DOI: 10.3390/children10060967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Abstract
Pediatric neck infections and their complications, such as abscesses extending to deep neck compartments, are potentially life-threatening acute conditions. Medical imaging aims to verify abscesses and their extensions and exclude other complications. Magnetic resonance imaging (MRI) has proven to be a useful and highly accurate imaging method in acute neck infections in children. Children and adults differ in terms of the types of acute infections and the anatomy and function of the neck. This pictorial review summarizes typical findings in pediatric patients with neck infections and discusses some difficulties related to image interpretation.
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Affiliation(s)
- Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Tatu Happonen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Mikko Nyman
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Aapo Sirén
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jari-Pekka Vierula
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jarno Velhonoja
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Heikki Irjala
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, University of Turku, 20014 Turku, Finland
| | - Lauri Ivaska
- Department of Paediatrics and Adolescent Medicine, InFLAMES Research Flagship Center, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, University of Turku and Turku University Hospital, 20520 Turku, Finland
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4
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Ramazani F, Yunker WK, Liu CC. Sensitivity and Specificity of US and CT as Diagnostic Tools for Pediatric Lateral Neck Abscesses. Otolaryngol Head Neck Surg 2023; 168:1529-1534. [PMID: 36939468 DOI: 10.1002/ohn.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 09/04/2022] [Accepted: 11/02/2022] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Ultrasound (US) and computed tomography (CT) are commonly used in the diagnosis of pediatric neck abscesses. The objective of this study is to determine the sensitivity and specificity of US and CT in the diagnosis of pediatric lateral neck abscesses, with a secondary objective of evaluating the association of specific clinical features with a positive US or CT scan. STUDY DESIGN Retrospective review of pediatric patients admitted to a tertiary care center from January 1, 2011, to December 31, 2020, with neck abscesses. SETTING Tertiary care center. METHODS The sensitivity and specificity of US and CT were calculated by comparing imaging performed within 24 h of incision and drainage (I&D). Multiple regression was used to evaluate the association of clinical features with a true positive US or CT. RESULTS There were 171 patients included in this study, with a median age of 1.5 years (interquartile range [IQR]: 1-5 years). I&D was done in 156 patients (91.2%), while 15 (8.8%) were treated with antibiotics. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of US were 69.5%, 80%, 96.6%, and 24.2%. The sensitivity, specificity, PPV, and NPV of neck CT were 95.5%, 80%, 95.5%, and 57.1%. Length of symptoms, skin erythema, and fluctuance were not significantly associated with a positive US (F(3, 82) = 0.24, p = .9, R2 = 0.01) or CT scan (F(3, 30) = 0.84, p = .5, R2 = 0.08). CONCLUSION Neck US has a low sensitivity for diagnosing pediatric neck abscesses, when compared to CT, but remains a useful initial investigation given its high PPV. Clinicians should have a low threshold for pursuing CT if there is a high suspicion of abscess formation. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Fatemeh Ramazani
- Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Warren K Yunker
- Department of Surgery, Section of Otolaryngology-Head and Neck Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Che Carrie Liu
- Department of Otolaryngology-Head and Neck Surgery, University of Arizona College of Medicine, Tuscon, Arizona, USA
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Hagelberg J, Pape B, Heikkinen J, Nurminen J, Mattila K, Hirvonen J. Diagnostic accuracy of contrast-enhanced CT for neck abscesses: A systematic review and meta-analysis of positive predictive value. PLoS One 2022; 17:e0276544. [PMID: 36288374 PMCID: PMC9604924 DOI: 10.1371/journal.pone.0276544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 10/08/2022] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To review the diagnostic accuracy of contrast-enhanced computed tomography (CT) in differentiating abscesses from cellulitis in patients with neck infections, using surgical findings as the reference standard. MATERIALS AND METHODS Previous studies in the last 32 years were searched from PubMed and Embase. Because of partial verification bias (only positive abscess findings are usually verified surgically), sensitivity and specificity estimates are unreliable, and we focused on positive predictive value (PPV). For all studies, PPV was calculated as the proportion of true positives out of all positives on imaging. To estimate pooled PPV, we used both the median with an interquartile range and a model-based estimate. For narrative purposes, we reviewed the utility of common morphological CT criteria for abscesses, such as central hypodensity, the size of the collection, bulging, rim enhancement, and presence of air, as well as sensitivity and specificity values reported by the original reports. RESULTS 23 studies were found reporting 1453 patients, 14 studies in children (771 patients), two in adults (137 patients), and seven including all ages (545 patients). PPV ranged from 0.67 to 0.97 in individual studies, had a median of 0.84 (0.79-0.87), and a model-based pooled estimate of 0.83 (95% confidence interval 0.80-0.85). Most morphological CT criteria had considerable overlap between abscesses and cellulitis. CONCLUSIONS The pooled estimate of PPV is 0.83 for diagnosing neck abscesses with CT. False positives may be due to limited soft tissue contrast resolution. Overall, none of the morphological criteria seem to be highly accurate for differentiation between abscess and cellulitis.
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Affiliation(s)
- Jon Hagelberg
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
| | - Bernd Pape
- Turku Clinical Research Center, Turku University Hospital, Turku, Finland
- School of Technology and Innovations, University of Vaasa, Vaasa, Finland
| | - Jaakko Heikkinen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Janne Nurminen
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Jussi Hirvonen
- Department of Radiology, Faculty of Medicine and Health Technology and Tampere University Hospital, Tampere University, Tampere, Finland
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
- * E-mail:
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6
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Point-of-Care Ultrasound of the Head and Neck in Children. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Perina V, Szaraz D, Harazim H, Urik M, Klabusayova E. Paediatric Deep Neck Infection—The Risk of Needing Intensive Care. CHILDREN 2022; 9:children9070979. [PMID: 35883963 PMCID: PMC9315740 DOI: 10.3390/children9070979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/19/2022] [Accepted: 06/28/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Vojtech Perina
- Department of Oral and Maxillofacial Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 625 00 Brno, Czech Republic; (V.P.); (D.S.)
| | - David Szaraz
- Department of Oral and Maxillofacial Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Jihlavska 20, 625 00 Brno, Czech Republic; (V.P.); (D.S.)
| | - Hana Harazim
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic;
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Milan Urik
- Department of Paediatric Otorhinolaryngology, University Hospital Brno, Faculty of Medicine, Masaryk University, Cernopolni 9, 662 63 Brno, Czech Republic;
| | - Eva Klabusayova
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic;
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Correspondence: ; Tel.: +420-532-234-693
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Liang J, Jiang L, Li M, Liu L, Li H. Should preoperative computed tomography be routine examination for cervicofacial space infections? BMC Infect Dis 2022; 22:566. [PMID: 35733094 PMCID: PMC9215011 DOI: 10.1186/s12879-022-07545-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 06/16/2022] [Indexed: 02/08/2023] Open
Abstract
Background Cervicofacial space infections are potentially life-threatening, which require accurate diagnosis, early incision, and adequate drainage. The utilization of computed tomography (CT) in cervicofacial space infections has significantly increased for its advantages in the evaluation of abscesses, its availability, and low cost. However, the clinical value of preoperative CT imaging in cervicofacial space infections remains controversial for its poor specificity, radiation exposure, potential complications, and extra cost. We, therefore, investigated whether CT examination should be used as a routine examination in the treatment of patients with cervicofacial space infections. Methods A retrospective study of all patients affected by cervicofacial space infections that received incision and drainage surgery from Jan 2016 to Dec 2020 was performed at West China Hospital of Stomatology at Sichuan University. Patients were divided into two groups: the group with preoperative CT and without preoperative CT. Outcomes, including reoperation rate, missed diagnosis rate, days of symptom relief, length of stay, duration of surgery, and total cost of hospitalization, were analyzed. Results Out of n = 153 patients, 108 patients underwent surgery with preoperative CT and 45 patients without preoperative CT. The reoperation rate in the preoperative CT group (6/108, 5.6%) was significantly lower (P = 0.00) than that in the group without preoperative CT (10/45, 22.2%). Significant reduction of missed diagnosis rate (P = 0.00), days of symptom relief (P = 0.01), length of stay(P = 0.03), and duration of surgery (P = 0.01) were detected in the preoperative CT group. The results demonstrated that the utilization of preoperative CT can reduce the missed diagnosis rate and repeated surgery complications. Conclusions We recommend preoperative CT as a routine examination in cervicofacial space infections.
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Affiliation(s)
- Jiayu Liang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Linli Jiang
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Maoye Li
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Lei Liu
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China
| | - Hui Li
- State Key Laboratory of Oral Diseases and National Clinical Research Center for Oral Diseases, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.
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Retropharyngeal, Parapharyngeal and Peritonsillar Abscesses. CHILDREN 2022; 9:children9050618. [PMID: 35626793 PMCID: PMC9139861 DOI: 10.3390/children9050618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 11/16/2022]
Abstract
Deep neck infections (DNIs) include all the infections sited in the potential spaces and fascial planes of the neck within the limits of the deep layer of the cervical fascia. Parapharyngeal and retropharyngeal infections leading to parapharyngeal abscess (PPA) and retropharyngeal abscess (RPA) are the most common. DNIs remain an important health problem, especially in children. The aim of this narrative review is to describe the management of peritonsillar, retropharyngeal and parapharyngeal abscesses in pediatric age. Despite relatively uncommon, pediatric DNIs deserve particular attention as they can have a very severe course and lead to hospitalization, admission to the intensive care unit and, although very rarely, death. They generally follow a mild upper respiratory infection and can initially present with signs and symptoms that could be underestimated. A definite diagnosis can be made using imaging techniques. Pus collection from the site of infection, when possible, is strongly recommended for definition of diseases etiology. Blood tests that measure the inflammatory response of the patient may contribute to monitor disease evolution. The therapeutic approach should be targeted toward the individual patient. Regardless of the surgical treatment, antibiotics are critical for pediatric DNI prognosis. The diagnostic-therapeutic procedure to be followed in the individual patient is not universally shared because it has not been established which is the most valid radiological approach and which are the criteria to be followed for the differentiation of cases to be treated only with antibiotics and those in which surgery is mandatory. Further studies are needed to ensure the best possible care for all children with DNIs, especially in this era of increased antimicrobial resistance.
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Nurminen J, Heikkinen J, Happonen T, Velhonoja J, Irjala H, Soukka T, Ivaska L, Mattila K, Hirvonen J. Magnetic resonance imaging findings in pediatric neck infections-a comparison with adult patients. Pediatr Radiol 2022; 52:1158-1166. [PMID: 35184213 PMCID: PMC9107440 DOI: 10.1007/s00247-021-05275-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 12/08/2021] [Accepted: 12/21/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Differences in the functioning of the immune system and the anatomical proportions of the neck between children and adults lead to different manifestations of deep neck infections. Magnetic resonance imaging (MRI) may serve as an alternative to computed tomography (CT) as the primary imaging modality. OBJECTIVE To study characteristic MRI findings and the diagnostic accuracy of MRI in pediatric deep neck infections. MATERIALS AND METHODS We retrospectively studied a cohort of pediatric patients who underwent a neck 3-tesla MRI study over a five-year period. Inclusion criteria were: 1) emergency MRI findings indicating an infection, 2) infection as the final clinical diagnosis, 3) diagnostic image quality verified by the radiologist reading the study and 4) age under 18 years. Patient record data, including surgery reports, were compared with the MRI findings. RESULTS Data of 45 children were included and analysed. Compared to adults, children had a higher incidence of retropharyngeal infection and lymphadenitis, and a lower incidence of peritonsillar/parapharyngeal infection. MRI showed evidence of an abscess in 34 children. Of these 34 patients, 24 underwent surgery, which confirmed an abscess in 21 but no abscess in three patients. In addition, three patients underwent surgery without MRI evidence of abscess, and an abscess was found in one of these cases. The measures of diagnostic accuracy among the children were sensitivity 0.96, specificity 0.77, positive predictive value 0.89, negative predictive value 0.91 and accuracy 0.89. Compared with adults, children had lower C-reactive protein, but a similar proportion of them had an abscess, and abscess size and rate of surgery were similar. CONCLUSION Despite the differences in the infection foci, emergency MRI in children had equal diagnostic accuracy to that in adults.
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Affiliation(s)
- Janne Nurminen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland.
| | - Jaakko Heikkinen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Tatu Happonen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Jarno Velhonoja
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Heikki Irjala
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Turku and Turku University Hospital, Turku, Finland
| | - Tero Soukka
- Department of Oral and Maxillofacial Surgery, University of Turku, Turku, Finland
| | - Lauri Ivaska
- Department of Paediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Kimmo Mattila
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
| | - Jussi Hirvonen
- Diagnostic Radiology, University of Turku, Kiinamyllynkatu 4-8, 20520, Turku, Finland
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Heilbronn C, Heyming TW, Knudsen-Robbins C, Schomberg J, Simon D, Bacon K, Huoh K. Features associated with surgically significant abscesses on computed tomography evaluation of the neck in pediatric patients. Int J Pediatr Otorhinolaryngol 2021; 150:110893. [PMID: 34438187 DOI: 10.1016/j.ijporl.2021.110893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/27/2021] [Accepted: 08/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neck-related chief complaints are common in the pediatric Emergency Department (ED), and although the incidence of pathology such as retropharyngeal abscesses is rare, the ability to rule out abscesses requiring surgical/procedural intervention is essential. However, there are no clear clinical guidelines regarding work-up and diagnosis in this population, possibly contributing to an excess use of potentially harmful and costly computed tomography (CT) imaging. OBJECTIVE In this study we sought to identify historical, physical exam, and laboratory findings associated with surgically significant neck abscesses to better delineate CT neck imaging criteria. METHODS We conducted a retrospective chart review of all patients ≤18 years presenting to a pediatric ED between 2013 and 2017 who underwent CT neck imaging. Surgically significant abscesses (SSAs) were defined as abscesses ≥2 cm, retropharyngeal abscesses (RPA), parapharyngeal abscesses (PPA), or peritonsillar abscesses (PTA). Historical factors, physical exam findings, laboratory results, demographics, and CT results were analyzed using univariate statistical analysis and regression models. RESULTS A total of 718 patients received neck CTs and 153 SSAs were identified. In children younger than 6 years, factors associated with statistically significant increased odds of an SSA were reported throat pain (OR 1.18; 95% CI 1.05, 1.33), fussiness (OR 1.18; 1.01, 1.39), lethargy (OR 1.43; 1.07, 1.91), tonsillar enlargement (OR 1.17; 1.02, 1.34), C-reactive protein (CRP) > 10 (OR 1.22; 1.07, 1.40), and an ED visit within the preceding week (OR 1.18; 1.04, 1.33). In children older than 6 years, the factors associated with statistically significant increased odds of an SSA included current antibiotic use (OR 1.12; 1.02, 1.22) and a CRP >10 (OR 1.14; 1.03, 1.26). CONCLUSION Some historical, physical exam, and laboratory findings are associated with SSAs, and while not definitive in isolation, may be beneficial additions to routine SSA assessment, as a supplement to clinical judgement regarding CT and observation decisions. This may potentially allow for the identification of patients requiring CT versus those who may not, and thus the opportunity to safely reduce the use of CT imaging in select patients.
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Affiliation(s)
- Cameron Heilbronn
- Children's Hospital of Orange County, Department of Otolaryngology, Orange, CA, USA
| | - Theodore W Heyming
- Children's Hospital of Orange County, Department of Emergency Medicine, Orange, CA, USA; Department of Emergency Medicine, University of California, Irvine, USA.
| | | | - John Schomberg
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Dina Simon
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Kellie Bacon
- Children's Hospital of Orange County, Research Institute, Orange, CA, USA
| | - Kevin Huoh
- Children's Hospital of Orange County, Department of Otolaryngology, Orange, CA, USA
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A rare case of ectopic parathyroid cyst associated with Hashimoto thyroiditis. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2021. [DOI: 10.1016/j.jecr.2020.100074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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13
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Aulino JM, Kirsch CFE, Burns J, Busse PM, Chakraborty S, Choudhri AF, Conley DB, Jones CU, Lee RK, Luttrull MD, Moritani T, Policeni B, Ryan ME, Shah LM, Sharma A, Shih RY, Subramaniam RM, Symko SC, Bykowski J. ACR Appropriateness Criteria ® Neck Mass-Adenopathy. J Am Coll Radiol 2020; 16:S150-S160. [PMID: 31054741 DOI: 10.1016/j.jacr.2019.02.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 02/08/2019] [Indexed: 11/26/2022]
Abstract
A palpable neck mass may be the result of neoplastic, congenital, or inflammatory disease. Older age suggests neoplasia, and a congenital etiology is more prevalent in the pediatric population. The imaging approach is based on the patient age, mass location, and clinical pulsatility. Underlying human papillomavirus-related malignancy should be considered in all age groups. Although the imaging appearance of some processes in the head and neck overlap, choosing the appropriate imaging examination may allow a specific diagnosis, or a limited differential diagnosis. Tissue sampling is indicated to confirm suspected malignancy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | - Claudia F E Kirsch
- Panel Chair, Northwell Health, Zucker Hofstra School of Medicine at Northwell, Manhasset, New York
| | | | - Paul M Busse
- Massachusetts General Hospital, Boston, Massachusetts
| | - Santanu Chakraborty
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada, Canadian Association of Radiologists
| | - Asim F Choudhri
- Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee
| | - David B Conley
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, American Academy of Otolaryngology-Head and Neck Surgery
| | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | | | | | - Bruno Policeni
- University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Maura E Ryan
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | | | - Aseem Sharma
- Mallinckrodt Institute of Radiology, Saint Louis, Missouri
| | - Robert Y Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | | | - Julie Bykowski
- Specialty Chair, UC San Diego Health Center, San Diego, California
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14
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Lindquist NR, Patro A, Gitomer SA, Cañadas KT. Pediatric acute unilateral suppurative lymphadenitis: The role of antibiotic susceptibilities at a large tertiary pediatric care center. Int J Pediatr Otorhinolaryngol 2019; 120:11-14. [PMID: 30743188 DOI: 10.1016/j.ijporl.2019.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 01/16/2019] [Accepted: 01/16/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Nathan R Lindquist
- Department of Otolaryngology - Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA
| | | | - Sarah A Gitomer
- Department of Otolaryngology - Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA
| | - Karina T Cañadas
- Texas Children's Hospital, Department of Otolaryngology - Head and Neck Surgery at Baylor College of Medicine, Houston, TX, USA.
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15
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Abstract
Infection of the neck is a relatively common emergency department complaint. If not diagnosed and managed promptly, it may quickly progress to a life-threatening infection. These infections can result in true airway emergencies that may require fiberoptic or surgical airways. This article covers common, as well as rare but emergent, presentations and uses an evidence-based approach to discuss diagnostic and treatment modalities.
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Affiliation(s)
- Renjie Michael Li
- Department of Emergency Medicine, Loma Linda University Medical Center, 11234 Anderson Street MC A-108, Loma Linda, CA 92354, USA
| | - Michael Kiemeney
- Department of Emergency Medicine, Loma Linda University School of Medicine, 11234 Anderson Street MC A-108, Loma Linda, CA 92354, USA.
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16
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Quinn NA, Olson JA, Meier JD, Baskin H, Schunk JE, Thorell EA, Hodo LN. Pediatric lateral neck infections - Computed tomography vs ultrasound on initial evaluation. Int J Pediatr Otorhinolaryngol 2018; 109:149-153. [PMID: 29728170 DOI: 10.1016/j.ijporl.2018.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 04/02/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Review the evaluation of children with a deep lateral neck infection and define the impact of initial imaging modality on outcomes and costs. METHOD Case series, pediatric patients <18 years of age admitted to a tertiary care hospital with lateral neck infection between 01/01/14-05/31/16 as identified by ICD-9 and ICD-10 codes: 289.3 (lymphadenitis, unspecified), 682.1 (cellulitis and abscess of neck), 683 (acute lymphadenitis), I88.9 (nonspecific lymphadenitis, unspecified), L02.11 (cutaneous abscess of neck), L03.221 (cellulitis of neck), and L03.222 (acute lymphangitis of neck). Patients were divided into two groups based on initial imaging modality: primary ultrasound or primary computed tomography. Differences in length of stay, type and total number of imaging studies obtained, number of procedures, hospital readmission, and hospital cost were compared between cohorts. RESULTS There were 40 (31%) primary ultrasound and 88 (69%) primary computed tomography patients (128 total). Median length of stay was 46 (IQR: 25,90) hours (1.9 days) for primary ultrasound and 63 (IQR: 39,88) hours (2.6 days) for primary computed tomography patients (p = 0.33). Drainage was performed in 48% of both groups. Additional imaging occurred in 17 (43%) primary ultrasound and 18 (20%) primary computed tomography patients (p = 0.02). Readmission occurred in 8 patients (6.3%). Retropharyngeal infection was encountered in 13 patients (10%); this was only discovered in patients who had a computed tomography performed. Median cost per primary ultrasound patients was $5363 (IQR: 3011, 7920) and $5992 (IQR: 3450, 8060) for primary computed tomography patients. CONCLUSIONS The primary imaging modality (ultrasound or computed tomography) used to work-up children with a lateral neck infection did not impact length of stay or hospital cost. However, a significant subset had a coexisting retropharyngeal infection that was only identified on computed tomography. Future studies are needed to identify appropriate criteria for imaging in the work-up of lateral neck infections.
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Affiliation(s)
- Nicholas A Quinn
- Department of Surgery, Division of Otolaryngology, 50 N Medical Drive, University of Utah, Salt Lake City UT 84132, USA; Primary Children's Hospital, Salt Lake City, UT 84113, USA.
| | - Jared A Olson
- Department of Pharmacy, Primary Children's Hospital, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA; Department of Pediatrics, Division of Infectious Diseases, University of Utah, Salt Lake City, UT 84132, USA
| | - Jeremy D Meier
- Department of Surgery, Division of Otolaryngology, 50 N Medical Drive, University of Utah, Salt Lake City UT 84132, USA; Primary Children's Hospital, Salt Lake City, UT 84113, USA
| | - Hank Baskin
- Intermountain Pediatric Imaging, Intermountain Healthcare, 100 Mario Capecchi Drive, Salt Lake City, UT 84113, USA; Department of Radiology, 50 N. Medical Drive, University of Utah, Salt Lake City, UT 84132, USA
| | - Jeff E Schunk
- Primary Children's Hospital, Salt Lake City, UT 84113, USA; Department of Pediatrics, Division of Emergency Medicine, 50 N Medical Drive, University of Utah, Salt Lake City, UT 84132, USA
| | - Emily A Thorell
- Department of Pediatrics, Division of Infectious Diseases, 50 N Medical Drive, University of Utah, Salt Lake City, UT 84132, USA; Primary Children's Hospital, Salt Lake City, UT 84113, USA
| | - Laura N Hodo
- Department of Pediatrics, Division of Inpatient Medicine, 50 N Medical Drive, University of Utah, Salt Lake City, UT 84132, USA; Primary Children's Hospital, Salt Lake City, UT 84113, USA
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Kimia AA, Rudloe TF, Aprahamian N, McNamara J, Roberson D, Landschaft A, Vaughn J, Harper MB. Predictors of a drainable suppurative adenitis among children presenting with cervical adenopathy. Am J Emerg Med 2018; 37:109-113. [PMID: 29754963 DOI: 10.1016/j.ajem.2018.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/25/2018] [Accepted: 05/05/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES We sought to identify predictors for a drainable suppurative adenitis [DSA] among patients presenting with acute cervical lymphadenitis. METHODS A retrospective cross sectional study of all patients admitted to an urban pediatric tertiary care emergency department over a 15 year period. Otherwise healthy patients who underwent imaging for an evaluation of cervical lymphadenitis were included. Cases were identified using a text-search module followed by manual review. We excluded immunocompromised patients and those with lymphadenopathy felt to be not directly infected (i.e. reactive) or that was not acute (symptom duration >28 days). Data collected included: age, gender, duration of symptoms, highest recorded temperature, physical exam findings, laboratory and imaging results, and surgical findings. A DSA was defined as >1.5 cm in diameter on imaging. We performed binary logistic regression to determine independent clinical predictors of a DSA. RESULTS Three hundred sixty-one patients met inclusion criteria. Three hundred six patients (85%) had a CT scan, 55 (15%) had an ultrasound and 33 (9%) had both. DSA was identified in 71 (20%) patients. Clinical features independently associated with a DSA included absence of clinical pharyngitis, WBC >15,000/mm3, age ≤3 years, anterior cervical chain location, largest palpable diameter on exam >3 cm and prior antibiotic treatment of >24 h. The presence of fever, skin erythema, or fluctuance on examination, was not found to be predictive of DSA. CONCLUSIONS We identified independent predictors of DSA among children presenting with cervical adenitis. Risk can be stratified into risk groups based on these clinical features.
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Xu P, Xia X, Li M, Guo M, Yang Z. Parathyroid cysts: experience of a rare phenomenon at a single institution. BMC Surg 2018; 18:9. [PMID: 29409478 PMCID: PMC5801706 DOI: 10.1186/s12893-018-0340-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 01/22/2018] [Indexed: 01/19/2023] Open
Abstract
Background Parathyroid cysts are relatively uncommon lesions and are often misdiagnosed. We evaluate our experience in the diagnosis of and therapy to correct parathyroid cystic lesions. Methods We retrospectively reviewed a series of 32 patients with parathyroid cysts who were admitted to our department between July 2011 and November 2016. Clinical pathological features of the patients, including age, gender, location, size, ultrasonography, histopathology, surgery, and follow-up, were analyzed. Results There were 22 female and 10 male participants with a median age of 46.7 years old (27–76 years old). Only two cysts were found in the superior mediastinum. The rest were located under the lower pole of the thyroid. All of the patients underwent ultrasonography scans and serum parathyroid hormone (PTH) assays. Three patients had elevated serum PTH levels, and they were further scanned with Tc99m sestamibi as functional cysts. In 29 cases of nonfunctional cysts, 3 cases were preoperatively diagnosed by cystic aspiration with PTH detection. The rest were diagnosed by postoperative immunopathology. All of the patients underwent cystectomy, and 24 patients also underwent thyroidectomy. There was a significant difference in cyst diameter size between the cystectomy alone and cystectomy with thyroidectomy groups (4.0 ± 2.0 vs 1.5 ± 1.0 cm; p < 0.05). No participant experienced recurrence during the median 36 months of follow-up. Conclusions Cystic lesions located under the lower pole of the thyroid gland should be considered to have originated at the parathyroid gland. Cystic aspiration with PTH detection or postoperative immunopathology can lead to a definitive diagnosis. Cystectomy is still a commonly used and effective treatment.
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Affiliation(s)
- Peipei Xu
- Department of General Surgery, Sixth People's Hospital Affiliated Shanghai Jiao Tong University, 600 Yi-Shan Road, Shanghai, 200233, China
| | - Xiaotian Xia
- Department of General Surgery, Sixth People's Hospital Affiliated Shanghai Jiao Tong University, 600 Yi-Shan Road, Shanghai, 200233, China
| | - Meifang Li
- Department of Emergency, Sixth People's Hospital Affiliated Shanghai Jiao Tong University, 600 Yi-Shan Road, Shanghai, 200233, China
| | - Minggao Guo
- Department of General Surgery, Sixth People's Hospital Affiliated Shanghai Jiao Tong University, 600 Yi-Shan Road, Shanghai, 200233, China.
| | - Zhili Yang
- Department of General Surgery, Sixth People's Hospital Affiliated Shanghai Jiao Tong University, 600 Yi-Shan Road, Shanghai, 200233, China.
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19
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Letter to the editor: Response to "KTP laser endoscopic tissue fibrin glue biocauterization for congenital pyriform sinus fistula in children". Int J Pediatr Otorhinolaryngol 2018; 104:230-231. [PMID: 28935275 DOI: 10.1016/j.ijporl.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/02/2017] [Indexed: 11/20/2022]
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20
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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. Int J Pediatr Otorhinolaryngol 2017; 96:89-93. [PMID: 28390621 DOI: 10.1016/j.ijporl.2017.02.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 02/21/2017] [Accepted: 02/25/2017] [Indexed: 11/20/2022]
Abstract
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.
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Ryu YJ, Kim DW, Jeon HW, Chang H, Sung MW, Hah JH. Modified Sistrunk operation: New concept for management of thyroglossal duct cyst. Int J Pediatr Otorhinolaryngol 2015; 79:812-816. [PMID: 25829321 DOI: 10.1016/j.ijporl.2015.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/01/2015] [Accepted: 03/02/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To describe a method of hyoid cartilage division during Sistrunk operation for management of thyroglossal duct cyst (TGDC) and compare postoperative outcomes with those of conventional hyoid bone cutting. METHODS Fifty-nine patients who received operative treatment for TGDC from January 2005 to July 2013 were enrolled. The degree of fusion in the cartilaginous portion of the hyoid was evaluated by preoperative neck computed tomography and classified into (1) non-fusion, (2) partial fusion, and (3) complete fusion. Techniques of hyoid management, division of the cartilaginous portion of the hyoid or conventional hyoid bone cutting, during Sistrunk operation were analyzed according to the fusion classification. RESULTS Of the 59 patients, 27 were pediatric patients and 32 were adults. In 32 adults undergoing TGDC, there were 13 cases (41%) of complete hyoid fusion and 7 (22%) of non-fusion. A total of 20 adult patients (63%) were treated with the cartilage division. Among the pediatric patients, 96% of cases were classified as non-fusion of the hyoid, and all of these were treated with the cartilage division. Patients who were treated with the cartilage division showed better postoperative results. However, there were no statistical differences. CONCLUSIONS Our cartilage division technique at Sistrunk operation for TGDC is feasible and comparable to conventional hyoid cutting with regard to postoperative results.
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Affiliation(s)
- Yoon-Jong Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Dong Wook Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Hyoung Won Jeon
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Hyun Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
| | - Myung Whun Sung
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
| | - J Hun Hah
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea.
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22
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Lee DY, Seok J, Kim YJ, Kim MS, Sung MW, Hah JH. Neck computed tomography in pediatric neck mass as initial evaluation in ED: is it malpractice? Am J Emerg Med 2014; 32:1237-40. [DOI: 10.1016/j.ajem.2014.07.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/25/2014] [Accepted: 07/26/2014] [Indexed: 11/24/2022] Open
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