Risk Factors for Pediatric Deep Neck Infection Revisit After Emergency Department Discharge for Pharyngitis or Localized Neck Symptoms

Comprehensive Summary

Jafari et al. ​​examined emergency department (ED) visits preceding pediatric deep neck space infection diagnoses and identified factors associated with return admissions after ED discharge for pharyngitis/tonsillitis or localized neck symptoms. The authors conducted a multistate cross-sectional analysis using the HCUP State Emergency Department and State Inpatient Databases from six U.S. states (2018-2019), including patients younger than 18 years. Among 799 pediatric deep neck space infection admissions, 18.3% had at least one treat-and-release ED visit within the preceding 10 days. The most frequent discharge diagnoses at these initial visits were fever, pharyngitis/tonsillitis, and localized neck symptoms. Among 419,660 ED visits for pharyngitis/tonsillitis and 58,478 visits for localized neck symptoms, 10-day return admissions for deep neck space infection were rare (0.01% and 0.07%, respectively). For patients presenting with localized neck symptoms, younger age, fever diagnosis, and neck imaging at initial visit predicted return admission. For patients presenting with pharyngitis/tonsillitis, localized neck symptoms, absence of upper respiratory infection diagnosis, and neck imaging predicted return admission.

Outcomes and Implications

Deep neck space infections in children, while uncommon, can rapidly progress to life-threatening complications including airway obstruction, mediastinitis, and sepsis, making early recognition critical. However, these infections present a diagnostic challenge because early symptoms overlap substantially with common, benign conditions like viral pharyngitis and cervical lymphadenitis. This study reveals that nearly one in five pediatric deep neck space infections were preceded by an ED visit within the preceding 10 days where the diagnosis was missed, representing a potential opportunity for earlier intervention. However, the extremely low incidence of deep neck space infections among all pharyngitis (0.01%) and localized neck symptom (0.07%) presentations highlights the needle-in-a-haystack nature of this diagnostic challenge. For emergency clinicians, the identified risk factors provide guidance for heightened suspicion: younger children with fever and localized neck symptoms appear at higher risk, while the absence of typical upper respiratory infection features in patients presenting with pharyngitis may warrant closer evaluation. The association between neck imaging at the initial visit and subsequent deep neck space infection admission is particularly intriguing and could reflect two scenarios: either imaging was obtained because clinicians appropriately had heightened suspicion but early disease was not yet visible, or imaging results were misinterpreted. This underscores the importance of clinical follow-up and careful imaging interpretation in high-risk presentations. The practical challenge is balancing appropriate vigilance against overtesting and overdiagnosis in conditions where serious disease is rare. Given the low absolute risk, routine imaging of all pediatric pharyngitis or neck symptoms is not justified, but selective use in high-risk presentations (young children with fever and localized findings, or pharyngitis without typical URI features) may be warranted. Important limitations include the administrative database design lacking clinical details such as physical examination findings, vital signs, pain severity, and duration of symptoms. The study cannot assess whether initial management was appropriate or whether earlier imaging would have changed outcomes. Coding errors may have misclassified some cases. Future research should prospectively validate these risk factors using detailed clinical data and examine whether clinical decision rules incorporating these predictors can improve early detection without excessive imaging in low-risk patients.