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

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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.

Introduction

Pediatric patients commonly present with superficial soft tissue infections of the face and neck. Some soft tissue infections will develop into an abscess that may benefit from surgical treatment. However, surgical complications include neurovascular damage, wound infections, scarring, and complications from exposure to anesthesia [1]. It is important to accurately distinguish those infectious processes for which surgery is necessary in order to avoid exposing children to unnecessary surgical risks; this is achieved with thorough physical examination combined with imaging.

Historically, computed tomography (CT) was considered the mainstay investigation for head and neck infections due to superior morphological characterization of the infection and excellent visualization of surrounding anatomy. As a result, the use of CT in pediatrics rose significantly over the last two decades. However, with this rise in CT use, the concern for radiation exposure and resultant carcinogenic potential, particularly in children has also increased [2], [3], [4], [5]; this movement resulted in the creation of the Alliance for Radiation Safety in Pediatric Imaging, a 13-member organization consisting of leading medical societies determined to increase awareness and education about radiation dose reduction for CT scans in children [6]. Furthermore, previous reports have suggested that a third of pediatric CT scans are unnecessary. Theoretically, by reducing the number of unnecessary CT scans, the risk of CT-induced cancers should decrease by a similar amount [2], [7].

In many cases, head and neck ultrasound (US) is a reasonable first line alternative and is more frequently being used to evaluate children. US reveals the nature, size, and extent of a mass, defines the relationship of the mass to major vessels and the trachea, and allows for surface marking that can be used to identify the site of the infectious process during surgery [8]. A major benefit of US includes a lack of potentially harmful early radiation exposure. Other benefits include elimination of any need for sedation and lower cost [9], [10], and comparable sensitivity of US in determining whether a soft tissue infectious process requires surgical drainage [11], [12].

The objective of this study was to determine whether routine use of head and neck US would result in decreased reliance on CT imaging without negatively impacting clinical outcome. We hypothesize that primary use of head and neck US will result in a reduction of CT dependence with no change in the rate of failed therapy and with the downstream benefit of reduction in radiation exposure.

Section snippets

Materials and methods

This study is a retrospective chart review of children who presented with a soft tissue infection of the face or neck, were evaluated by a pediatric otolaryngologist at Nationwide Children's Hospital in Columbus, Ohio between January 2006 and December 2013, and underwent surgical and/or medical management following evaluation including imaging. Institution review board approval was obtained prior to study initiation.

Criteria for inclusion included patients aged 0–18 years at time of diagnosis

Results

Three hundred seventy three patients were evaluated with superficial soft tissue infections of the face or neck; 114 patients presented during the pre-implementation period and 259 patients presented in the current protocol period. Table 1 presents patient characteristics separated by period of treatment (pre-implementation vs current protocol). There were no significant differences in demographics or prior medical and surgical history between the two groups. There was no difference in the

Discussion

Evaluation of pediatric neck swelling begins with obtaining an accurate clinical history and physical examination. To improve diagnostic accuracy, most patients will undergo further evaluation with imaging which provides additional value in diagnosing the lesion as an infectious process, determining the location and involvement of adjacent structures, and evaluating for abscess formation [11], [13], [14], [15]. For those patients who require imaging as part of their evaluation, CT has

Conclusions

Increased use of US for initial evaluation of superficial soft tissue infections of the face and neck results in decreased use of CT without changes to treatment strategy or rate of treatment failures. Serial use of US for repeat evaluation following trial inpatient observation did not reduce CT utilization, change treatment selection, or reduce treatment failure. This initiative minimized early exposure to potentially harmful radiation associated with CT use without negatively affecting

Funding support

This project is supported by intramural funding from the Department of Otolaryngology at Nationwide Children's Hospital and the Center for Surgical Outcomes Research at The Research Institute at Nationwide Children's Hospital. The authors have no financial conflicts of interest to disclose.

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