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Reprinted by permission of Laryngoscope. 2016; 126(8):1753-1760.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

The Impact of Delayed Surgical Drainage of Deep Neck Abscesses in Adult and Pediatric Populations

John D. Cramer, MD; Matthew R. Purkey, BS; Stephanie Shintani Smith, MD MS; James W. Schroeder, Jr. MD

Objectives/Hypothesis: The conventional treatment for deep neck abscesses in adults is antibiotic therapy with surgical drainage, whereas in children there is debate about the role of surgical drainage versus conservative therapy. It is presently unclear if delayed surgical drainage negatively affects outcomes. Study Design: We performed a multicenter, prospective, risk-adjusted cohort study of adult and pediatric patients with deep neck abscess who received incision and drainage within 7 days of admission in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2013 (adults) and from 2012 to 2013 (pediatrics). Methods: Patients were compared based on age ( 18 years, > 18 years), timing of surgical drainage (day 0, day 1–2, or day 3–7), and complication rates (specifically, abscess-specific morbidity and mortality [M&M]). Multivariate regression was performed to control for preoperative differences. Results: A total of 1,012 cases of deep neck abscess were identified (347 adult, 665 pediatric). In adults, delay in surgi- cal drainage was associated with increased abscess-specific M&M, from 11.5% (day 0) to 17.3% (day 1–2) to 25.0% (day 3– 7) ( P 5 0.02). On multivariate regression, delay in drainage of 3 days in adults was associated with a 2.38-fold increase in M&M (95% confidence interval 1.01–5.59, P 5 0.019). In pediatrics, there was no association between surgical delay and increased abscess-specific M&M, with rates of 5.0% (day 0), 4.0% (day 1–2), and 4.8% (day 3–7) ( P 5 0.68). Conclusion: In adults, delay in surgical drainage of deep neck abscess is associated with increased M&M. There is no association between timing of drainage and M&M in children. Key Words: Deep neck abscess, retropharyngeal abscess, parapharyngeal abscess, National Surgical Quality Improve- ment Program, ACS–NSQIP, complications, pediatrics. Level of Evidence: 2c. Laryngoscope , 126:1753–1760, 2016

INTRODUCTION Management of deep neck infections includes prompt and adequate treatment, with control of the air- way, effective antibiotic therapy, and timely surgical intervention when indicated. Convention dictates that deep neck abscesses in adults require surgical drainage Additional supporting information may be found in the online version of this article. From the Northwestern University Feinberg School of Medicine ( M . R . P .); the Department of Otolaryngology–Head and Neck Surgery ( J . D . C ., S . S . S ., J . W . S .); the Center for Healthcare Studies, Feinberg School of Medicine ( S . S . S .), Northwestern University Feinberg School of Medicine; and the Division of Pediatric Otolaryngology–Head and Neck Surgery, Ann and Robert H. Lurie Children’s Hospital ( J . W . S .), Chicago, Illinois, U.S.A. Editor’s Note: This Manuscript was accepted for publication November 27, 2015. S . S . S . is supported by the Triological Society Research Career Development Award. The American College of Surgeons National Surgi- cal Quality Improvement Program (ACS–NSQIP), its companion pediat- ric database ACS–NSQIP Pediatric (ACS–NSQIPP), and the hospitals participating in the ACS–NSQIP and ACS–NSQIPP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to John D. Cramer, MD, Department of Oto- laryngology–Head and Neck Surgery, Northwestern University Feinberg, School of Medicine, 675 N. St. Clair Street, Suite #1325, Chicago, IL 60611. E-mail: john.cramer@northwestern.edu

on an urgent basis, applying the adage “never let the sun go down on undrained pus.” 1 The urgency of surgi- cal drainage contained in this maxim has limited evi- dence basis, and urgent surgical treatment versus a trial of conservative treatment for children has long been debated. In children, some studies suggest that conserv- ative management may be successful for select patients. 2 No study has specifically examined if delay in surgical drainage affects clinical outcomes. Nonetheless, many recommend urgent drainage because infection from deep neck abscesses can spread and cause life-threatening consequences, including acute upper airway obstruction, mediastinitis, sepsis, epidural abscess, and death. 3–6 It is unknown whether delaying drainage of deep neck abscesses during a trial of conservative treatment increases the chances of potential spread of infection. In much of the existing literature, it is unclear if the patients with successful resolution following medical therapy alone were accurately diagnosed in the first place. In one sys- tematic review of pediatric deep neck abscesses (n 5 94), 52% of patients treated medically improved without drainage. However, the radiologic criteria for diagnosis in these studies varied widely, 2 and many cases diagnosed as abscess likely represent an earlier stage of infection. 5,6 We compare the composite rate of abscess-specific morbidity and mortality (M&M) for adult and pediatric patients with deep neck abscess based on the timing of

DOI: 10.1002/lary.25835

Laryngoscope 126: August 2016

Cramer et al.: Delay in Drainage of Deep Neck Abscess

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