Pediatric deep space neck infections in U.S. children, 2000–2009

https://doi.org/10.1016/j.ijporl.2014.02.024Get rights and content

Abstract

Objective

Deep space neck infections (DNI) are common pediatric illnesses, which can lead to significant morbidity and healthcare expenditures. Recent studies suggest that the incidence of pediatric DNI in the United States is increasing, but no nationally representative studies exist. This study sought to characterize pediatric DNI at the national level over the past decade and to determine whether U.S. incidence of pediatric DNI and associated resource utilization changed from 2000 to 2009.

Methods

The Kids’ Inpatient Database (KID) was used to evaluate pediatric DNI incidence, demographics, and outcomes from 2000 to 2009. Cases were identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes for peritonsillar abscess (475), parapharyngeal abscess (478.22), and retropharyngeal abscess (478.24). Regression analyses within each year and across the entire study period were performed on variables of interest including performance of imaging studies, operative intervention, length of hospital stay and total hospital charges.

Results

The incidence of retropharyngeal abscess increased significantly from 0.10 cases per 10,000 in 2000 to 0.22 in 2009 (p = 0.02). There was no significant change during this time period in the incidence of combined DNI (1.07–1.37 cases per 10,000, p = 0.07), peritonsillar abscess (0.82–0.94 cases per 10,000, p = 0.12) or parapharyngeal abscess (0.08–0.14 cases per 10,000, p = 0.13). The percentage of retropharyngeal abscess patients managed surgically decreased (48–38%, p = 0.04) and the average length of hospital stay also decreased during this time (4.6–3.9 days, p = 0.03). There was a marked increase in the total inflation-corrected hospital charges per case for all DNI ($9,486–16,348, p = 0.005).

Conclusions

The incidence of pediatric retropharyngeal abscess has increased significantly from 2000 to 2009, without concurrent increases in the incidence of combined DNI, peritonsillar, or parapharyngeal abscesses. There has been a change in management of retropharyngeal abscesses during this time with a decrease in operative intervention and a decrease in the length of hospital stay. Hospital charges associated with all pediatric DNI have nearly doubled during this timeframe, warranting future epidemiologic resource utilization studies in this population.

Introduction

Deep space neck infections (DNI) are a significant clinical entity in the pediatric population, commonly affecting the retropharyngeal, parapharyngeal, or peritonsillar spaces [1]. While most pediatric DNI respond to intravenous antibiotics and surgical incision and drainage, rare cases can lead to life-threatening complications. Pediatric DNI have been associated with mediastinitis, jugular vein thrombosis, and airway obstruction [2], [3].

There has been concern that the incidence of DNI in children is increasing [4], [5], [6]. Widespread use of antibiotics in the primary care setting has contributed to an increase in drug-resistant bacterial strains in normal oropharyngeal flora. Methicillin-resistant Staphylococcus aureus (MRSA) is becoming a more common organism isolated from head and neck aspirates [7], [8], [9], [10], [11], [12], [13].

Although it has been demonstrated that the nature of pediatric DNI is changing, there has not been a study at the national level to determine if the incidence of pediatric DNI has changed over the past decade. The purpose of this study was to use a nationally representative database to examine this phenomenon, as well as to determine whether DNI incidence varies based on geographic and socioeconomic factors. We also studied resource utilization and hospital charges associated with treating DNI.

Section snippets

Methods

The Healthcare Cost and Utilization Project – Kids’ Inpatient Database (KID) from the Agency for Healthcare Research and Quality was the data source for this project. The KID is a national all-payer inpatient care database that includes children less than 20 years old at the time of admission. The database includes both public and private hospitals and is available every 3 years. The 2009 database included data from approximately 2–3 million pediatric hospitalizations occurring in 44 states [14]

Demographics

There were 41,483 total patients presenting with DNI during the study period. The average age of patients presenting with DNI was 11.3 years, which did not change significantly over the study period (p = 0.43). Age was analyzed by subtype of DNI, which demonstrated a significantly lower average age for retropharyngeal abscesses compared to peritonsillar abscess or parapharyngeal abscess (5.0 vs. 13.6 and 6.6 years, respectively; p < 0.001 and p < 0.01, respectively) (Fig. 1). On average, 34% of the

Discussion

DNI represent a major source of morbidity and healthcare expenditures in children. It has been suggested that the incidence of DNI in children is increasing, but epidemiological studies are rare. This study analyzes the incidence and management of pediatric DNI nationally over the past decade. While there has been an increase in health services research in the otolaryngology literature over the last 10 years, this still represents a fertile area of study [20]. In the case of pediatric DNI,

Conflicts of interest

There were no conflicts of interest reported by Drs. Novis, Pritchett, or Thorne. At the time of manuscript preparation, Dr. Sun was a Robert Wood Johnson Foundation Clinical Scholar supported by the U.S. Department of Veterans Affairs. Dr. Sun is now an employee at Partnership for Health Analytic Research, LLC in Beverly Hills, CA and a general otolaryngologist at the UCLA Arthur Ashe Student Health & Wellness Center in Los Angeles, CA.

Acknowledgments

Funding/support: At the time of manuscript preparation, Gordon H. Sun was a Robert Wood Johnson Foundation Clinical Scholar supported by the U.S. Department of Veterans Affairs.

Sarah J. Novis and Gordon H. Sun had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Previous presentation: This study was presented as a poster presentation at the Annual Meeting of the American Society of Pediatric Otolaryngology,

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