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Research

Original Investigation

Trends in Orbital Complications of Pediatric Rhinosinusitis


in the United States
Gregory Capra, MD; Bryan Liming, MD; Mark E. Boseley, MD; Matthew T. Brigger, MD, MPH

IMPORTANCE Several studies have documented the prevalence and treatment of orbital
complications secondary to pediatric rhinosinusitis, but to our knowledge, none have
investigated the national health care burden of this disease since the introduction of the
heptavalent pneumococcal vaccine (PCV-7).

OBJECTIVE To identify the current public health burden of orbital complications of pediatric
rhinosinusitis, and to determine if the introduction of the PCV-7 has resulted in a change in
national practice patterns.

DESIGN, SETTING, AND PARTICIPANTS Population-based study using the 2000 and 2009 Kids’
Inpatient Databases to gather data on a sample of all pediatric discharges in the United States
during the years 2000 and 2009. Children diagnosed as having orbital complications of
sinusitis were identified by corresponding International Classification of Diseases, Ninth
Revision (ICD-9) codes. Database analyses generated national estimates of summary statistics
and comparison of trends over the 9-year period.

INTERVENTIONS Database analysis.

MAIN OUTCOMES AND MEASURES National health care trends according to year. End points
assessed included prevalence, age, sex, length of hospital stay, and treatment of disease.

RESULTS The estimated prevalence of orbital complications of sinusitis requiring


hospitalization in the United States has slightly decreased from 5338 (95% CI, 4956-5720)
admissions in 2000 to 4511 (95% CI, 4165-4858) in 2009. However, the mean age has
increased from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-6.26) years. The
proportion of children undergoing surgical treatment increased from 0.108 (95% CI,
0.093-0.123) to 0.195 (95% CI, 0.176-0.213). Total charges increased from $4 140 000 (95%
CI, $3 440 000-$4 830 000) to $10 000 000 (95% CI, $8 480 000-$11 600 000) with a
mean charge per admission increasing from $8390 (95% CI, $7096-$9685) in 2000 to
$22 656 (95% CI, $19 997-$25 314) in 2009. The mean length of stay remained stable at 3.67
(95% CI, 3.37-3.97) to 4.05 (95% CI, 3.81-4.29) hospital days.

CONCLUSIONS AND RELEVANCE The public health impact of orbital complications of pediatric
rhinosinusitis continues to be substantial. Since the institution of the PCV-7 vaccine, national
trends demonstrate a slightly decreased prevalence of hospital admissions. However, there is
a shifting trend toward an older age at admission and a higher proportion of children
undergoing surgical treatment. Author Affiliations: Department of
Otolaryngology–Head and Neck
Surgery, Naval Medical Center San
Diego, San Diego, California (Capra,
Brigger); Department of
Otolaryngology–Head and Neck
Surgery, Madigan Army Medical
Center, Tacoma, Washington
(Liming, Boseley).
Corresponding Author: Matthew T.
Brigger, MD, MPH, Department of
Otolaryngology–Head and Neck
Surgery, Naval Medical Center San
Diego, 34800 Bob Wilson Dr, San
JAMA Otolaryngol Head Neck Surg. 2015;141(1):12-17. doi:10.1001/jamaoto.2014.2626 Diego, CA 92134 (matthew.brigger
Published online October 23, 2014. @med.navy.mil).

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Orbital Complications of Pediatric Rhinosinusitis Original Investigation Research

O
rbital complications are known sequelae of pediatric
rhinosinusitis. In fact, published clinical practice Methods
guidelines for the diagnosis and treatment of pediat-
ric acute bacterial sinusitis recognize that intraorbital compli- This study was approved by the institutional review board of
cations are the most common complication of acute bacterial the Naval Medical Center San Diego. The data are from the Kids’
sinusitis.1 The ethmoid sinus is the nidus of orbital spread in Inpatient Database (KID), Healthcare Cost and Utilization Proj-
most cases, with the frontal and maxillary sinuses the source ect (HCUP), Agency for Healthcare Research and Quality
less frequently.2-5 One study6 found that 100% of patients with (AHRQ).17 The 2000 and 2009 KIDs were used to gather data
subperiosteal abscesses (SPAs) demonstrated concurrent si- on a sample of all pediatric discharges younger than 18 years
nusitis in at least 1 sinus, while 63% had multiple sinus in- in the United States during 2000 and 2009. These data are a
volvement. Theories suggesting why a sinus infection causes representative sample of discharges occurring in the United
a subsequent postseptal orbital complication generally re- States during those years. The sampling strategy is single stage
volve around the ease by which infection and inflammation and is designed to select 10% of uncomplicated in-hospital
can traverse the lamina papyracea. This thin bony septa be- births as well as 80% of complicated births and other pediat-
tween the orbit and the paranasal sinus is naturally porous, is ric admissions from each frame hospital. Discharge weights
susceptible to congenital dehiscences, has large vascular fo- were according to AHRQ protocol using poststratification of 6
ramina, and has the potential for open suture lines. All of these characteristics of each hospital (ownership or control, bed size,
properties have been implicated as possible routes of infec- teaching status, rural or urban location, and US region, free-
tious transmission between the paranasal sinuses and orbit.4,5 standing children’s hospital) in order to calculate national es-
In contrast, preseptal disease is commonly a complication of timate data. The 2000 KID includes 2784 hospitals from 27
trauma or dacrocystitis.2 states, and the 2009 KID includes 4121 hospitals from 44 states.
As described by Chandler et al,7 periorbital and orbital in- Given the known natural association of orbital cellulitis
fections are categorized based on location of infection. The cat- with sinusitis, all children requiring admission with a diagno-
egories represent a progression of severity from mild presep- sis of orbital cellulitis were identified by the International Clas-
tal cellulitis to potentially deadly cavernous sinus thrombosis. sification of Diseases, Ninth Revision (ICD-9) code 37601. Chil-
Given the potential morbidity and even mortality, treatment dren who had a trauma or injury code were excluded from the
strategies include aggressive intravenous antibiotics, topical analysis. The population generated by this search was then
nasal decongestants, and potentially surgical drainage. While stratified according to applicable HCUP Procedure Clinical Clas-
there has been controversy over the evolving roles of surgery sification Software codes for nasal or orbital surgical proce-
vs medical treatment, it is clear that orbital complications of dures. Other information, such as sex, mean total charges, and
rhinosinusitis remain a clinically significant problem.3,8-11 mean length of hospital stay was also obtained. Analysis using
Traditionally, Streptococcus pneumoniae, Haemophilus in- each database’s weighted sampling schema generated na-
fluenzae, and Moraxella catarrhalis have been the most com- tional estimates of summary statistics.
monly implicated pathogens in acute bacterial rhinosinusitis.1
The introduction of the H influenza type b (HiB) vaccine in 1985
altered the landscape of many pediatric infectious diseases.2,4,9
Although HiB has not been completely eradicated, studies have
Results
shown a shift in microbiological trends of acute pediatric in- The national public health burden of pediatric orbital compli-
fections related to epiglottitis, meningitis, rhinosinusitis, peri- cations in 2000 and 2009 is estimated in the Table. Based on
orbital infections, and otitis media.12-16 the weighted estimates, the prevalence of orbital complica-
The heptavalent pneumococcal conjugate vaccine (Prev- tions for the years 2000 and 2009 were 5338 (95% CI, 4956-
nar or PCV-7) was introduced in 2000 for children younger than 5720) and 4511 (95% CI, 4165-4858), respectively, for individu-
24 months. Many authors have studied the effects of the vac- als 18 years or younger. The US census population data
cine on common pediatric diseases. McKinley et al15 discov- estimates of this age group for the years 2000 and 2009 were
ered that few orbital infections were S pneumoniae in origin 72.3 million and 74.5 million, respectively.18,19 This gives an ap-
in the post–PCV-7 population. Similarly, Peña et al16 con- proximate estimate of incidence for these 2 populations of
cluded that fewer S pneumoniae infections occurred, while an nearly 7.38 children per 100 000 in 2000 and 6.05 per 100 000
increase in Staphylococcus aureus prevalence was seen in these in 2009. Mean ages between the 2 groups demonstrated an in-
types of infections. With changing microbiologic characteris- crease from 4.77 (95% CI, 4.56-4.97) years to 6.07 (95% CI, 5.87-
tics of orbital complications secondary to pediatric rhinosinu- 6.26) years over this time span. The median age showed a simi-
sitis over the first decade of the PCV-7 introduction, it could lar trend. Sex distribution remained stable, with a slight male
be expected that the national health care impact of this dis- predominance at 57.6% (CI, 55.4%-59.7%) in 2000 and 59.9%
ease may similarly be affected. The purpose of this study was (CI, 58.1%-61.8%) in 2009.
to examine these national trends with regards to the preva- Children hospitalized in the year 2000 incurred hospital
lence, treatment, and overall charges of orbital complications charges greater than $4 million and accounted for 19 592 (95%
of pediatric rhinosinusitis for the years 2000 and 2009, corre- CI, 17 488-21 696) inpatient days. These charges more than
sponding to the introduction and widespread administration doubled in 2009 to $10 million, although the total inpatient
of the PCV-7 vaccine. days of 18 293 (95% CI, 16 378-20 209) were not significantly

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Research Original Investigation Orbital Complications of Pediatric Rhinosinusitis

of stay between these 2 groups was similar, 6.69 (95% CI, 5.83-
Table. National Estimates for Admissions for Orbital Complications
of Sinusitisa 7.56) and 6.89 (95% CI, 6.14-7.63) days, respectively. Simi-
larly, the length of stay for the medically treated patients was
(95% CI)
not significantly different between the 2 years, with a mean
Characteristic 2000 2009
of 3.21 (95% CI, 2.89-3.52) days in 2000 compared with 3.33 (95%
Patients, total No. 5338 (4956-5720) 4511 (4165-4858)
CI, 3.16-3.49) days in 2009. The total charges for these years
Male sex, % 57.6 (55.4-59.7) 59.9 (58.1-61.8)
were $6371 (95% CI, $5405-$7337) and $15 298 (95% CI, $13 552-
Age, mean, y 4.77 (4.56-4.97) 6.07 (5.87-6.26)
$17 403) in 2000 and 2009, respectively.
Median 3 5
Charges, $
Total 4 140 000 10 000 000 (8 480 000-
(3 440 000-4 830 000) 11 600 000) Discussion
Mean 8390 (7096-9685) 22 656 (19 997-25 314)
The effect of vaccines has been substantial in combatting child-
Median 4586 11 089
hood infectious diseases. This is no more evident than with
Total hospital days 19 592 (17 488-21 696) 18 293 (16 378-20 209)
the introduction of the HiB vaccine.16 However, the overall ef-
Length of stay, d
fect from a national perspective may be difficult to extrapo-
Mean 3.67 (3.37-3.97) 4.05 (3.81-4.29)
late from single-institution studies. Although a vaccine may
Median 3 3
reduce the prevalence of a specific causative pathogen, dis-
Surgically treated, 579 (493-665) 879 (760-998)
total No. ease trends themselves can go unchanged, and vaccines could
Total, % 10.8 (9.3-12.3) 19.5 (17.6-21.3) hasten the emergence of new pathogens. Furthermore, it is im-
Age, mean, y 8.43 (7.72-9.14) 9.02 (8.63-9.41) portant in this era of increased awareness of health care eco-
Length of stay, 6.69 (5.83-7.56) 6.89 (6.14-7.63)
nomics to identify how health care dollars are spent. This
mean, d knowledge will better shed light on allocation of resources and
Charges, mean, $ 25 348 (17 294-33 401) 53 251 (43 881-62 620) the burden with which a disease places on the health system.
Medically treated Large-scale population level databases fill our knowledge gap
Total, % 89.1 (87.6-90.6) 80.5 (78.6-82.3) and are essential in providing accurate epidemiologic data that
Age, mean, y 4.29 (4.08-4.51) 5.33 (5.13-5.52) can be applied toward better understanding national trends.
Length of stay, d 3.21 (2.89-3.52) 3.33 (3.16-3.49) However, they are not without their own limitations. When
Charges, mean, $ 6371 (5405-7337) 15 298 (13 552-17 043) coupled with institutional studies, the information we can
a glean from large databases may shed light on a disease and aid
The data are from the Kids’ Inpatient Database, Healthcare Cost and Utilization
Project, Agency for Healthcare Research and Quality.17 in developing new prevention strategies.
Our goal was to compare pre–PCV-7 era and post–PCV-7 era
hospitalizations related to orbital complications of pediatric
different. Mean charges were substantially more in 2009, with rhinosinusitis in order to detect trends related to the vaccina-
estimates of $22 656 (95% CI, $19 997-$25 314) per hospital- tion for S pneumococcus in the pediatric population. To our
ization compared with $8390 (95% CI, $7096-$9685) in the year knowledge, no prior study has evaluated this relationship on
2000. Despite the differences in total and mean charges per a national level. Using the same rationale described by Peña
hospital stay, the length of stay of 3.67 (95% CI, 3.37-3.97) days et al16 regarding the concept of herd immunity, we chose to
prior to PCV-7 was similar to the post–PCV-7 era at 4.05 (95% compare KID data from 2000 and 2009. Between these years,
CI, 3.81-4.29) days. we found a slight decrease in prevalence of severe rhinosinu-
The data showed an increasing trend toward surgery, sitis resulting in hospital admission for orbital complications
whereby the estimated total number of those surgically treated from 2000 to 2009. It is difficult to impart a definite cause and
increased from 579 (95% CI, 493-665) in 2000 to 879 (95% CI, effect relationship between the decrease in S pneumoniae in-
760-998) in 2009. This represents an increase from 10.8% (95% fections and the decrease in severe pediatric orbital compli-
CI, 9.3%-12.3%) of patients to 19.5% (95% CI, 17.6%-21.3%) be- cations of rhinosinusitis. It may also depend on specific bac-
tween these years. The surgical age was consistent between terial isolates combined with other factors.1 In fact, the study
the 2 groups, with an average age of 8.43 (95% CI, 7.72-9.14) by Peña et al16 supports this theory. When comparing these 2
years in 2000 and 9.02 (95% CI, 8.63-9.41) years in 2009. In con- eras, they found a 13% rise in cases after the introduction of
trast, a slight increase in age for medically treated patients was the vaccine. Cultures from their patients prior to the vac-
seen. An increase from 4.29 (95% CI, 4.08-4.51) years to 5.33 cine’s introduction predominately demonstrated the pres-
(95% CI, 5.13-5.52) years was observed for the age of medi- ence of S pneumoniae, but this pathogen was absent in all as-
cally treated patients for these years. Across the years, medi- pirates for their post–PCV-7 group. Instead, a dramatic rise in
cally treated patients were younger than the surgical age of pa- S aureus was seen in these patients, with a trend toward a grow-
tients. As would be expected, the total charges for surgical ing percentage of cultures demonstrating methicillin-
patients between these 2 groups were significantly different. resistant S aureus (MRSA). These data are supported by an-
In 2000, mean charges for surgically treated patients were other study,13 which showed S pneumonia to predominate prior
$25 348 (95% CI, $17 294-$33 401), while in 2009 it increased to 2000. However, in the late 2000s, infections caused by S
to $53 251 (95% CI, $43 881-$62 620). However, the mean length pneumoniae have occurred less frequently giving way to more

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Orbital Complications of Pediatric Rhinosinusitis Original Investigation Research

staphylococcal infections, including MRSA.2,8,9,11,20-22 Al- gery, with nonsurgical patients averaging 6.1 years while sur-
though these data suggest that PCV-7 has had a dramatic affect gical patients averaged 10.1 years. Peña et al16 also found that
in the reduction of invasive S pneumoniae infections, other fac- older children were taken back to the operating room earlier
tors may be at work, such as emerging antibiotic resistance, S than younger children, but the exact reason for this was un-
pneumoniae strains not covered by PCV-7, or other uneluci- clear. However, this same study found no significant differ-
dated host factors.16,21 In 2010 the PCV-13 vaccine was made ence in surgery rates (17% and 22%) for the pre–PCV-7 and post–
available, which may ultimately further shift bacterial iso- PCV-7 eras. Garcia and Harris10 showed that children younger
lates. As these data become more widely available, future in- than 9 years were successfully treated medically, while older
vestigations are warranted. children had an increased likelihood of requiring surgical drain-
Historically, males have been more likely than females to age. Our national data support these findings. In both 2000 and
present with orbital complications of rhinosinusitis.9,11,21-23 This 2009, the mean age of surgically treated patients was signifi-
was the case in our data, which showed a male predominance cantly higher than those who were medically treated (Table).
in the pre–PCV-7 and post–PCV-7 eras that has not signifi- In both years the medically treated mean age averaged about
cantly changed. In these 2 groups, males represented 57.6% and age 5 years, while the surgical patient was close to the age of 9
59.9% of the populations for 2000 and 2009. This is consis- years. Although polymicrobial or more virulent infections may
tent with the findings of another database study for 2006,24 account for the age discrepancy, another explanation may lie
which found that males comprised 59.5% of patients, and with in the development of the paranasal sinuses. Dewan et al6
the report by Peña et al,16 who found that males were more found that children with frontal sinusitis or nonmedial SPAs
likely to be affected regardless of the vaccine. were more likely to be older and require surgical treatment
Historically, orbital complications of sinusitis tend to oc- compared with their younger counterparts. This may be ex-
cur in children younger than 10 years.9,11,21 In studies prior to plained by the lack of paranasal sinus development in the
PCV-7 immunizations, Garcia and Harris10 found an average younger population.
age at complications of 7.2 years. In the post–PCV-7 era, Sed- Since the publication of the article by Garcia and Harris10
aghat et al23 found patients had an average age of 8.6 years, in 2000, it has been thought that a shift away from surgical
although they found that age was not associated with in- treatment of orbital complications toward primarily medical
creased complication rates based on multivariate analysis. For treatment of this disease has occurred.3,6,8 These authors10
the years 2000 and 2009, our study demonstrated an in- showed prospectively that 93% of children younger than 9 years
crease in the mean age at presentation from 4.77 to 6.07 years, with small, medial SPAs, no frontal sinusitis, and no visual im-
suggesting a trend of increased age of presentation as more chil- pairment could be safely treated medically. Since its publica-
dren were vaccinated. Likewise, Peña et al16 found that older tion, authors2,8,9,22,29 have sought to better define other char-
children were more commonly affected by orbital complica- acteristics of patients who can be safely treated medically.
tions in the post–PCV-7 era. The exact reason for this dispar- These studies have regularly focused on the radiographic size
ity in age between the years 2000 and 2009 is unclear but once and location of SPAs. In contrast to the perception that pa-
again may have to do with the interaction of bacterial isolate tients are treated more conservatively today than in years past,
and host factors. One could argue that despite the wide- our data suggest that surgical rates have actually increased with
spread dissemination of PCV-7 in 2000, not all children were time. We found that despite stricter criteria for medical treat-
initially vaccinated. Peña et al16 suggested that true herd im- ment, surgical rates nearly doubled from 10.8% in 2000 to
munity did not occur until 2003, and thus it is possible that 19.5% in 2009. This is compared with the study by Mahalingam-
the older age of presentation in the post–PCV-7 group may re- Dhingra et al,28 which showed that surgical rates of 12.4% for
flect children who failed to benefit from herd immunity. An- 2006, which are closer to our pre–PCV-7 data surgical rates. Our
other argument may lie in the type of microbiologic infec- data also are not in agreement with those of Peña et al,16 who
tions in older children. A 2012 study25 of chronic rhinosinusitis found no significant difference in surgical rates between their
aspirates in children found that Staphylococcus species ac- study groups. The reason for this discrepancy remains un-
counted for most cases, of which older children were more clear. Again, this may reflect the age of patients, presumed mi-
likely to experience polymicrobial infections. This is in con- crobiological nature of infection, regional variation in KID data
trast to younger children, who seem to be single nasopharyn- sources, or the sample size.
geal pathogen carriers.26 The companion studies by Gordts et Regardless of the increase in surgical rates between 2000
al13,27 support this theory in their findings prior to 2000. They and 2009, it seems that the length of hospital stays has not
found that middle meatus aspirates in 50 children were most changed over the decade. A direct comparison of children who
likely to be represented by the common upper respiratory tract were surgically treated also showed that they did not have lon-
pathogens H influenzae, M catarrhalis, and S pneumoniae, ger stays, and neither did those medically treated. However,
which represented 50% of cultures. In contrast, only 2% of within each year group, length of stay was significantly differ-
adults had S pneumoniae cultures. Adult pathogens were in- ent between the medical and surgical patient groups. These data
stead highly represented by coagulation-negative Staphylo- are in agreement with those of one study16 that found surgi-
coccus species, Corynebacterium species, and S aureus.27 cally treated patients averaged 7.1 days of hospital admission
Both historically and in these databases, age also seems compared with 3.4 days for their medically treated counter-
to affect the surgical rate of patients with orbital complica- parts. Factors that may affect length of hospital stays are nu-
tions. In one study,28 age was predictive of the need for sur- merous and are not accounted for in this study. A natural con-

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Research Original Investigation Orbital Complications of Pediatric Rhinosinusitis

clusion is that surgically treated patients represent failed medical rate as the data coded. Some patients with inaccurate diagno-
treatment or a more virulent disease process, and therefore their ses may be erroneously included or excluded from this data
length of stay is greater. Abscess reaccumulation may also affect set. Furthermore, the data do not include all 50 states, but in-
length of stay, as Dewan et al6 found in their study. They also stead represent a sample of the population used to make pro-
found that surgical technique influences duration of hospital jections based on a weighted sampling algorithm. As a result,
stay. Those patients with combined endoscopic sinus surgery the health care burden may be inaccurate and may affect the
and SPA drainage had significantly shorter length of stay, likely generalizability of these data. These patients also represent the
related to fewer abscess reaccumulation rates. Another study22 more severe cases of orbital complications that required in-
also noted that hospital stays can be influenced by location of patient admission, and it may reflect a change in criteria for
orbital complications. Ketenci et al22 found that patients with outpatient treatment over time. However, it can be assumed
medial abscesses spent 3 to 9 days as in-patients, whereas those that mildly effected patients likely provide a less significant
with superior abscesses spent 6 to 11 days on average. Finally, burden on our health care system. Finally, hospital charges do
health care administrative factors, such as insurance policies, not necessarily correlate with true health care costs, which can-
may also effect duration of hospital stay. not be accounted for with these data.
To no one’s surprise, health care charges for orbital com-
plications of acute rhinosinusitis have dramatically risen over
the previous decade. This is another important set of infor-
mation that institutional studies fail to discuss. We found that
Conclusions
the rates of charges more than doubled from 2000 to 2009, with The public health impact of pediatric patients with orbital com-
the most recent data showing $10 million in total charges av- plications secondary to rhinosinusitis continues to be sub-
eraging $22 656 per hospital visit. Surgical treatment was more stantial. In the post–PCV-7 era, many of the characteristics of
expensive in 2009 ($53 251) than in 2000 ($25 348). Medical disease remain stable, including a male predominance, a sig-
charges more than doubled from $6371 in 2000 to $15 298 in nificantly older surgical population, and the average length of
2009. However, it is important to acknowledge that although stay. In contrast, the prevalence has slightly decreased, the av-
charges have significantly increased, our analysis did not fo- erage age of patients has increased from 4.77 to 6.07 years, and
cus on the true cost of care or health care dollars collected, surgical rates have nearly doubled from 2000 to 2009. Fi-
which may be markedly different from the amount charged. nally, health care charges have shown a dramatic increase in
As with any database study, there are limitations to the just 9 years, which places an added burden on an already
data. Foremost, the use of ICD-9-CM coding is only as accu- stressed health care system.

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