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Wohlford L, Trotter Z, Connell M, Bhattarai B, Pandya S. The Role of Ultrasound in Pediatric Peritonsillar Infection: A Descriptive Analysis. Clin Pediatr (Phila) 2024:99228241265174. [PMID: 39056382 DOI: 10.1177/00099228241265174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
In this study, we describe the role of ultrasound in diagnosing pediatric peritonsillar abscesses (PTAs). A retrospective chart review was conducted on 54 children aged 4 to 17 years who had an ultrasound performed for suspected PTA. Based on ultrasound imaging, the patients were classified into 2 groups: PTA-positive (8, 14.8%) and PTA-negative (46, 85.2 %). Trismus was significantly associated with PTA (50% vs. 13%, P = .03). PTA-positive patients were more likely to be given steroids, be admitted, and have extended hospital stays (P = .04, .004, and .002, respectively). The 2 groups had no significant difference in computed tomography (CT) acquisition, surgical intervention, and return visits (P = .92, .17, and .97, respectively). Larger abscesses trended toward surgical treatment (P = .087). Ultrasound is an efficient diagnostic modality for suspected peritonsillar infections in children, with similar clinical outcomes for PTA-positive and PTA-negative groups.
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Affiliation(s)
- Luke Wohlford
- Department of Emergency Medicine, The University of Vermont Medical Center, Burlington, VT, USA
| | - Zola Trotter
- Department of Pediatric Emergency Medicine, Valleywise Health Medical Center, Phoenix, AZ, USA
| | - Mary Connell
- Department of Radiology, Valleywise Health Medical Center, Phoenix, AZ, USA
| | | | - Siddharth Pandya
- Department of Radiology, Valleywise Health Medical Center, Phoenix, AZ, USA
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Kadrie A, Ward C, Chanamolu M, Berry J, Gillespie MB. Peritonsillar Abscess Outcomes with and Without Computed Tomography: A Retrospective Cohort Study. Laryngoscope 2024. [PMID: 38973624 DOI: 10.1002/lary.31629] [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: 03/15/2024] [Revised: 06/17/2024] [Accepted: 06/28/2024] [Indexed: 07/09/2024]
Abstract
OBJECTIVES Peritonsillar abscess (PTA) is a common deep space head and neck infection, which can be diagnosed with or without computed tomography (CT). CT poses a risk for false positives, leading to unnecessary abscess drainage attempts without benefit, whereas needle or open aspiration without imaging could potentially lead to missed abscess in need of treatment. This study considered the utility and impact of obtaining CT scans in patients with suspected PTA by comparing outcomes between CT and non-CT usage. METHODS Retrospective cohort analysis using TriNetX datasets compared the outcomes of two cohorts: PTA without CT and PTA with CT. Measured outcomes included incision and drainage; quinsy adenotonsillectomy; recurrent PTA; airway emergency/obstruction; repeat emergency department (ED) visits; and need for antibiotics, opiates, or steroids. Odds ratios (OR) were calculated using a cohort analysis. RESULTS The CT usage group had increased odds of receiving antibiotics (OR 3.043, [2.043-4.531]), opiates (OR 1.614, [1.138-1.289]), and steroids (OR 1.373, [1.108-1.702]), as well as a higher likelihood of returning to the ED (OR 5.900, [3.534-9.849]) and developing a recurrent PTA (OR 1.943, [1.410-2.677]). No significant differences were observed in the incidence of incision and drainage, quinsy adenotonsillectomy, or airway emergency/obstruction. CONCLUSION Our study indicated that CT scans for PTA diagnosis were associated with increased prescription of antibiotics, opioids, steroids, return ED visits, and recurrent PTA. Future prospective trials are needed to determine if the use of CT scans indicates higher patient acuity that explains the potential negative outcomes. LEVEL OF EVIDENCE Level II Laryngoscope, 2024.
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Affiliation(s)
- A Kadrie
- School of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
| | - C Ward
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
| | - M Chanamolu
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
| | - Joseph Berry
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, U.S.A
| | - M B Gillespie
- Department of Otolaryngology-Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A
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Tüchert SE, Vollert K, Schuster T, Kröncke T. Use of CEUS for Imaging Evaluation of Pediatric Peritonsillar Abscess. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:631-636. [PMID: 36690031 DOI: 10.1055/a-2017-7172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
PURPOSE Peritonsillar abscess can be diagnosed by B-mode ultrasound and cross-sectional imaging. The latter (with MRI being the modality of first choice in children) is associated with higher effort and risk for pediatric patients due to the administration of X-rays and/or the need of sedation. The purpose of this study is to evaluate whether the introduction of CEUS into the diagnostic algorithm for suspected pediatric peritonsillar abscess is suitable and advantageous. MATERIALS AND METHODS Single-institution retrospective review of data of pediatric patients who were presented to the department of pediatric radiology for sonographic evaluation under the suspicion of peritonsillar abscess. Diagnostic performance of CEUS was evaluated by using surgical exploration or clinical follow-up as the reference standard. RESULTS 284 children included in the study underwent B-mode ultrasound. Mean age of all patients was 6,23 years. Peritonsillar abscess was the diagnosis in 42 patients. Diagnosis of peritonsillar abscess was made by B-mode ultrasound alone in 13 of 42 patients (31 %). In 17 of 42 patients (40 %), diagnosis was made by a combination of B-mode ultrasound and CEUS. Sensitivity rose from 37 % to 86 % in cases where B-mode ultrasound remained unclear and CEUS was used. CONCLUSION Contrast-enhanced ultrasound (CEUS) is suitable and efficient for the diagnosis of peritonsillar abscess in pediatric patients. It increases the sensitivity for the diagnosis of peritonsillar abscess and thereby reduces the need of additional cross-sectional imaging for the pediatric patients.
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Affiliation(s)
- Stefanie Eliane Tüchert
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Kurt Vollert
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Tobias Schuster
- Department of Pediatric Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Thomas Kröncke
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
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Eliason MJ, Wang AS, Lim J, Beegle RD, Seidman MD. Are Computed Tomography Scans Necessary for the Diagnosis of Peritonsillar Abscess? Cureus 2023; 15:e34820. [PMID: 36919070 PMCID: PMC10008127 DOI: 10.7759/cureus.34820] [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: 02/04/2023] [Indexed: 02/11/2023] Open
Abstract
Background Peritonsillar abscess is one of the most common deep-space infections of the head and neck, accounting for significant healthcare costs in the United States. Contributing to this expenditure is the trend of increased usage of computed tomography (CT), particularly in the emergency department. However, CT can be falsely positive for peritonsillar abscess, prompting unnecessary drainage attempts that yield no purulence. The false positive findings question the accuracy of CT in diagnosing peritonsillar abscess. Objectives The objective of the study was to compare the accuracy of CT with clinical exam to assess if CT is warranted in peritonsillar abscess diagnosis. Methods A retrospective study was performed of patients presenting to eight Orlando emergency departments with throat pain from January 1, 2013, to April 30, 2013. Patients with clinical diagnoses of peritonsillar abscesses were reviewed. A note was made whether CT was performed and if peritonsillar abscess was seen. The reads were compared to the results of procedural intervention for abscess drainage to assess the accuracy of CT in diagnosing peritonsillar abscess. Results There were 116 patients diagnosed with peritonsillar abscess, of which 99 underwent CT scans to aid in diagnosis. Among these 99 patients, 23 received procedural intervention, with 16 having a return of purulence (69.6%), and seven remaining without purulence (30.4%). Conclusion This study highlights the potential inaccuracies of CT scan in diagnosing peritonsillar abscess, as 30.4% of scans interpreted as abscess lacked purulence on intervention. Given these findings, clinicians could serve as better fiscal stewards by using history and exam to guide management in the majority cases with infectious processes of the oropharynx.
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Affiliation(s)
| | - Andy S Wang
- Internal Medicine, Westchester Medical Center, Valhalla, USA.,Surgery, University of Central Florida College of Medicine, Orlando, USA
| | - Jihoon Lim
- Medical Student, University of Central Florida College of Medicine, Orlando, USA
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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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Gilley DR, Virdi GS, Namin AW, Dooley LM. Utility of CT in the workup of adults with sore throat in the emergency department. Am J Emerg Med 2021; 50:739-743. [PMID: 34879496 DOI: 10.1016/j.ajem.2021.09.063] [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: 03/24/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The goal of this study was to determine if computed tomography (CT) added any clinical information that was incorporated into the decision regarding treatment for patients who presented to the Emergency Department (ED) with sore throat. METHODS A retrospective chart review of adult patients who presented to the ED with a chief complaint of sore throat who subsequently underwent CT during that ED visit between 1/1/18 and 12/31/18 at our tertiary academic health center was performed. The association between palatal bulge on Otolaryngology physical exam with successful drainage procedure was examined. The mean Hounsfield units (HU) and maximum dimension of measurable fluid collection on CT were compared between patients who underwent a successful drainage procedure and those who did not undergo a drainage procedure or attempted drainage was unsuccessful. RESULTS Ninety-four patients met inclusion criteria, with 53% (50/94) men. Of the 22 patients with a palatal bulge on physical examination by Otolaryngology, 86% (19/22) underwent a successful drainage procedure (p < 0.001) when compared to those not undergoing successful drainage. Notably, 56% (53/94) of CT scans were interpreted as normal or tonsillitis. The mean HU was 42.0 in those patients who underwent a successful drainage procedure and 74.1 in those who did not undergo a drainage procedure (p < 0.001). Overall, 21/35 fluid collections had a palatal bulge (p < 0.001). CONCLUSION Palatal bulge is a reliable finding in identifying patients with a drainable peritonsillar abscess, and CT scans could largely be avoided in patients without physical exam findings suggestive of more extensive deep neck space abscesses. If a CT scan is obtained, HU should be measured and incorporated into the shared decision-making process with the patient.
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Affiliation(s)
- David R Gilley
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA.
| | - Gurpal S Virdi
- University of Missouri School of Medicine, Degree Program, Columbia, MO, USA
| | - Arya W Namin
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
| | - Laura M Dooley
- Department of Otolaryngology - Head and Neck Surgery, University of Missouri School of Medicine, Columbia, MO, USA
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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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Soldatskiy YL, Bulynko SA, Denisova OA, Edgem SR, Kovalets ES. [Features of the clinic, diagnosis and treatment of parapharyngeal abscesses in children: analysis of 121 observations]. Vestn Otorinolaringol 2021; 86:62-68. [PMID: 34964332 DOI: 10.17116/otorino20218606162] [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] [Indexed: 06/14/2023]
Abstract
UNLABELLED Parapharyngeal and retropharyngeal abscesses (PPA) in children are a rare pathology, for the diagnosis of which it is necessary to use additional instrumental examination methods. The tactics of treating patients remains a subject of discussion. OBJECTIVE To analyze the features of the clinic, diagnosis and treatment of PPA in children. MATERIAL AND METHODS According to the hospital database, a retrospective analysis of the medical histories of children discharged from the clinic with a diagnosis of "J39.0 Retropharyngeal and parapharyngeal abscess" was carried out in the period from 01.01.14 to 31.12.19. In all cases, the diagnosis was confirmed by computed tomography (CT) data with contrast enhancement. Complaints at the time of treatment, anamnesis and instrumental diagnosis data, clinical features of the course of the disease and the effectiveness of treatment were analyzed. RESULTS 121 children were treated for PPA (average age 73±41 months; Me=52.5 months), which is 0.4% of all hospitalized in the otorhinolaryngological department, 0.7% of the number of emergency hospitalizations, 0.8% of the number of hospitalized children with pharyngeal diseases, and 8.3% of the number of patients with pharyngeal abscess. Abscesses were more often localized in the upper pharynx, at the level of the I-II cervical vertebrae (49.6% of all observations); abscesses were found least often in the pharyngeal space (5.8%), there was no statistically significant difference between the right-sided and left-sided location: 47.9% and 46.2%, respectively. Surgical treatment was performed in 98 (81%) patients in the presence of an abscess capsule or an abscess diameter of more than 2 cm according to CT; the remaining 23 (19%) children were treated conservatively. The opening of the abscess was performed endopharyngeal, in the case of a pronounced deep lateral location of the abscess and its proximity to large blood vessels - with access through the tonsillar niche after preliminary tonsillectomy (19.4% of those operated). CONCLUSION The final diagnosis of parapharyngeal and retropharyngeal abscess can be established by contrast-enhanced computed tomography. Conservative treatment is indicated for a limited group of patients at the initial stages of the disease, most patients need surgical treatment.
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Affiliation(s)
- Yu L Soldatskiy
- Morozovskaya Children's City Clinical Hospital, Moscow, Russia
| | - S A Bulynko
- Morozovskaya Children's City Clinical Hospital, Moscow, Russia
| | - O A Denisova
- Morozovskaya Children's City Clinical Hospital, Moscow, Russia
| | - S R Edgem
- Morozovskaya Children's City Clinical Hospital, Moscow, Russia
| | - E S Kovalets
- Morozovskaya Children's City Clinical Hospital, Moscow, Russia
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Floriani ID, Borgmann AV, Barreto MR, Ribeiro ER. EXPOSURE OF PEDIATRIC EMERGENCY PATIENTS TO IMAGING EXAMS, NOWADAYS AND IN TIMES OF COVID-19: AN INTEGRATIVE REVIEW. REVISTA PAULISTA DE PEDIATRIA 2020; 40:e2020302. [PMID: 33331510 PMCID: PMC7747787 DOI: 10.1590/1984-0462/2022/40/2020302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 09/12/2020] [Indexed: 11/22/2022]
Abstract
Objective: To analyze literature data about unnecessary exposure of pediatric emergency patients to ionizing agents from imaging examinations, nowadays and during times of COVID-19. Data sources: Between April and July 2020, articles were selected using the databases: Virtual Health Library, PubMed and Scientific Electronic Library Online. The following descriptors were used: [(pediatrics) AND (emergencies) AND (diagnostic imaging) AND (medical overuse)] and [(Coronavirus infections) OR (COVID-19) AND (pediatrics) AND (emergencies) AND (diagnostic imaging)]. Inclusion criteria were articles available in full, in Portuguese or English, published from 2016 to 2020 or from 2019 to 2020, and articles that covered the theme. Articles without adherence to the theme and duplicate texts in the databases were excluded. Data synthesis: 61 publications were identified, of which 17 were comprised in this review. Some imaging tests used in pediatric emergency departments increase the possibility of developing future malignancies in patients, since they emit ionizing radiation. There are clinical decision instruments that allow reducing unnecessary exam requests, avoiding over-medicalization, and hospital expenses. Moreover, with the COVID-19 pandemic, there was a growing concern about the overuse of imaging exams in the pediatric population, which highlights the problems pointed out by this review. Conclusions: It is necessary to improve hospital staff training, use clinical decision instruments and develop guidelines to reduce the number of exams required, allowing hospital cost savings; and reducing children’s exposure to ionizing agents.
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