Risks of radiation versus risks from injury: A clinical decision analysis for the management of penetrating palatal trauma in children. (12th February 2013)

• Record Type: Journal Article
• Authors: Hennelly, Kara E.; Fine, Andrew M.; Jones, Dwight T.; Porter, Stephen
• Is Part Of: Laryngoscope. Volume 123:Number 5(2013:May)
• Page Start: 1279
• Page End: 1284
• Publication Date: 2013-02-12
• Subjects: Otolaryngology -- Periodicals; 617.51005
• DOI: 10.1002/lary.23962
• Languages: English
• ISSNs: 0023-852X

Abstract

<abstract abstract-type="main"> <title> <x xml:space="preserve">Abstract</x> </title> <sec id="lary23962-sec-0001" sec-type="section"> <title>Objectives/Hypothesis</title> <p>Penetrating palatal trauma in children presents a diagnostic dilemma regarding the small but severe risk of injury to carotid vessels. Decisions regarding which children require computed tomography with angiography must be balanced against the risk of radiation‐induced malignancy. Our objectives were to compare outcomes between children with and without computed tomography with angiography in the evaluation of palatal trauma and to identify thresholds where the ideal strategy changes in the management of children with palatal trauma through sensitivity analyses.</p> </sec> <sec id="lary23962-sec-0002" sec-type="section"> <title>Study Design</title> <p>Decision analytic techniques were used to compare management strategies for penetrating palatal trauma.</p> </sec> <sec id="lary23962-sec-0003" sec-type="section"> <title>Methods</title> <p>We assigned utilities to the following outcomes: 1) perfect health, 2) future malignancy, 3) carotid injury diagnosed by computed tomography with angiography, and 4) delayed diagnosis of stroke. We calculated outcomes when the risk of stroke ranged from 0.01% to 5.0% for a hypothetical cohort of 10, 000 injured children.</p> </sec> <sec id="lary23962-sec-0004" sec-type="section"> <title>Results</title> <p>Not obtaining computed tomography with angiography is the optimal strategy when the stroke risk is less than 4.5%. In two‐way sensitivity analyses that consider a range of probabilities of radiation‐induced malignancy and stroke, not obtaining computed tomography with angiography on all patients dominates as a strategy until the risk of stroke exceeds 2.3%, and the risk of malignancy is under 0.24%. Routine imaging would introduce 20 additional malignancies for each additional stroke diagnosed.</p> </sec> <sec id="lary23962-sec-0005" sec-type="section"> <title>Conclusions</title> <p>Routine use of computed tomography with angiography for well‐appearing children with palatal trauma should be reconsidered, as the risk of radiation‐induced malignancy may outweigh the benefit of identifying the rare carotid injury.</p> </sec> <sec id="lary23962-sec-0006" sec-type="section"> <title>Level of Evidence</title> <p>2b.</p> </sec> </abstract>