Abstract
Rationale and objective
To determine if patient demographic data, medical history, physical examination, and laboratory tests will help predict likelihood of imaging-based diagnosis using CT of the neck performed in the ED for a chief complaint of throat pain.
Material and methods
Single institutional, retrospective review of 367 CT scans of the neck performed for the evaluation of throat pain in the ED from August 2013 to September 2019. Patients’ clinical history, physical exams, lab findings, and imaging results were recorded.
Results
A total of 367 CT scans of the neck performed for the evaluation of throat pain included a recorded exam and clinical history. Of these cases, we noted that the presence of cervical lymphadenopathy (OR = 2.69; 95% CI, 1.37–5.49), tonsillar findings (OR = 2.94; 95% CI, 1.4–6.57), increased white blood cell count (OR = 1.08; 95% CI, 1.02–1.15), and temperature (OR = 1.94; 95% CI, 1.1–3.6) were associated with increased likelihood of obtaining a diagnostic CT scan.
Conclusion
Consideration of tonsillar abnormalities, lymphadenopathy, body temperature, and measured leukocyte count prior to ordering CT scans of the neck for throat pain may increase the diagnostic yield of such exams and decrease CT utilization in the ED.
1
Introduction
Throat pain is a common presentation for patients in ambulatory settings, with reports estimating 11 million annual outpatient and emergency department (ED) visits in 2018, which constitutes 1.2% of all ambulatory visits [ ]. Potential underlying causes of throat pain are broad, and include both benign, self-limiting entities such as gastroesophageal reflux disease and viral pharyngitis, to more actionable or even life-threatening pathologies such as malignancy or peritonsillar abscess (PTA) with deep space infection [ ].
By far, the most common cause of sore throat is pharyngitis, or inflammation of the pharynx, which is often secondary to viral infection in 50–80% of cases [ ]. In addition to viruses, group A beta-hemolytic streptococci is one of the most common bacterial infections causing pharyngitis, accounting for up to 36% of cases [ ] Though both viral and bacterial etiologies of throat pain may present similarly on history and clinical examination, they are managed differently. Viral cases are often treated with supportive care, while bacterial cases are treated with antibiotic therapy, with possible procedural intervention depending on severity [ ]. Therefore, it is imperative to promptly and accurately diagnose the cause of sore throat in order to prevent short-term and long-term sequela [ ]. Though pharyngitis and other causes of sore throat are diagnosed clinically using history, physical examinations, and non-invasive laboratory tests, CT evaluation of the neck is the first-line imaging modality to aid in diagnosis when there is uncertainty [ ].
CT imaging of the neck is especially useful and often used to evaluate for many severe etiologies of sore throat such as descending necrotizing mediastinitis and retropharyngeal space infections [ ]. Moreover, studies have shown that contrast-enhanced CT of the neck has an approximate specificity of 75% and sensitivity of 100% for the detection of peritonsillar abscess [ ]. However, not all patients with sore throat in the ED will have pathology necessitating CT imaging. With the growing usage of CT utilization in the ED disproportionate to the growth in ED patient volume, many patients will receive unwarranted imaging that may not necessarily provide additional diagnostic information [ ]. Ionized radiation, associated with CT of the neck, can measure as much as 60 mGy [ ]. At the same time, CT utilization varies widely between institutions; for instance, reported CT imaging rates among patients with PTA ranges from 1% to 65% (12). Prior studies have studied physical examination characteristics that are predictive of peritonsillar abscess in an effort to improve CT utilization efficiency and reduce ionizing radiation exposure [ ]. To our knowledge, no studies exist investigating the utilization of CT for evaluation of throat pain in the emergency room setting. Our study aims to determine the diagnostic yield of CT of the neck performed in the ED setting for the indication of sore throat and identify clinical predictors of an imaging-based diagnosis. We hypothesize that patient demographic data, components of patient history, physical examination, and laboratory tests will help to predict likelihood of imaging-based diagnosis.
2
Methods
This was a IRB-approved, HIPAA compliant retrospective cohort study examining all patients presenting to the Emergency Department at NewYork-Presbyterian Hospital between August 2013 to September 2019 with the chief complaint of “throat pain”.
2.1
Selection of participants
Patients included in the study were all patients who underwent contrast-enhanced CT or non-contrast enhanced CT of the neck for the evaluation of throat pain in the ED setting based on ICD9/10 diagnosis codes and CPT procedure codes between August 2013 and September 2019. Repeat examinations in patients undergoing serial studies and examinations that were negative due to technical factors (motion degradation or streak artifact) were excluded.
2.2
Data collection
Patient demographic data including age and sex, components of patient’s HPI, physical exam results, and laboratory data were obtained through retrospective chart review of their initial encounter in the emergency department. Scans were categorized as positive if a cause of throat pain was identified based on radiographic findings and negative if no cause was identified on imaging. Furthermore, scans were sub-classified according to category of disease based on etiology.
2.3
Statistical analysis
Mean and standard deviations were calculated for demographic data. Bivariate analysis comparing aforementioned clinical variables between positive and negative CT exams were tested using Wilcoxon rank-sum test for continuous variables or Chi-sq for discrete variables with an α = 0.05.
Given the large pool of variables and potential for confounders and spurious significance, we performed post-selection inference utilizing the LASSO (least absolute shrinkage and selection operator) technique. The algorithm performs variable selection and identifies select variables from our data set with strong association to response. LASSO-adjusted significance test will compare the influence of these select variables on the likelihood of a diagnostic imaging exam.
3
Results
3.1
Demographics
Between August 2013 to September 2019, a total of 367 CTs were performed in the ED with a recorded exam and lab findings. Demographic data of these 367 patients are summarized in Table 1 . Patient age ranged from 2 to 92 at the time of imaging with 44.4% being males. Imaging-based diagnosis was achieved in 248 (67.6%) of these patients. Etiology for diagnosed throat pain by imaging was predominantly infectious (64.5%), however, it included inflammatory (19.8%), foreign body (7.7%), trauma (4.4%), and malignancy (3.2%).
| Imaging Based Diagnosis ( n = 247) | Non-Imaging Based Diagnosis ( n = 120) | Total ( n = 367) | |
|---|---|---|---|
| Gender (% Male) | 47.2% | 38.7% | 44.4% |
| p -value = 0.12 | |||
| Age (Years) | 38.2 | 43.5 | 40.0 |
| p-value = 0.005 |
3.2
Clinical factors associated with diagnosis
Clinical variables were subdivided into recorded clinical symptoms, physical exam, and lab findings. Regarding patients’ clinical presentation, we noted that the presence of cough ( p = 0.009), foreign body sensation ( p < 0.001), and dysphagia ( p = 0.04) were significantly associated with diagnostic images. On physical examination, presence of tonsillar erythema ( p = 0.004)/exudate ( p = 0.001), uvular deviation ( p < 0.001), trismus (p = 0.001), cervical (p < 0.001)/submandibular ( p = 0.04) lymphadenopathy, and increased temperature ( p < 0.001) were significant in patients with diagnostic images. Lastly, on blood work, increased white blood cell counts (p < 0.001) correlated with diagnostic yield of imaging. Recorded clinical findings for both positive and negative imaging results are summarized: categorical ( Table 2 ) and continuous ( Table 3 ) variables.
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