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Epidemiological Survey of Head and Neck Injuries and Trauma in the United States Rosh K. V. Sethi, Elliott D. Kozin, Peter J. Fagenholz, Daniel J. Lee, Mark G. Shrime and Stacey T. Gray Otolaryngology -- Head and Neck Surgery 2014 151: 776 originally published online 19 August 2014 DOI: 10.1177/0194599814546112 The online version of this article can be found at: http://oto.sagepub.com/content/151/5/776

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Original Research—General Otolaryngology

Epidemiological Survey of Head and Neck Injuries and Trauma in the United States Rosh K. V. Sethi, MD, MPH1,2*, Elliott D. Kozin, MD1,2*, Peter J. Fagenholz, MD3, Daniel J. Lee, MD1,2, Mark G. Shrime, MD, MPH1,2,4, and Stacey T. Gray, MD1,2

Otolaryngology– Head and Neck Surgery 2014, Vol. 151(5) 776–784 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599814546112 http://otojournal.org

No sponsorships or competing interests have been disclosed for this article.

Received April 14, 2014; revised June 20, 2014; accepted July 15, 2014.

Abstract

Introduction

Objective. Head and neck trauma results in a range of injuries, spanning minor lacerations to life-threatening airway compromise. Few studies provide in-depth analysis of injuries to the head and neck (HN). We aim to (1) describe HN injury prevalence in the US and (2) investigate patient disposition and the outcome of mortality.

There are over 50 million trauma-related emergency department (ED) visits in the United States each year that are estimated to cost $406 billion.1,2 The head, neck, and face account for just 12% of total body surface area, yet injuries to these areas are disproportionally represented.3,4 Injuries can range from minor soft tissue lacerations to complex facial fractures, penetrating neck wounds, and cranial nerve injury. The mechanisms of injury in head and neck trauma are diverse and can vary from minor falls to serious assaults and motor vehicle accidents. Prior studies investigating head and neck injury–related visits are limited by their focus on a specific type or mechanism of injury,4-9 reporting of data from a single institution,5,10,11 small patient cohorts,5,8,12 and focus on a specific population10,13 or geographic region.14-16 No single study provides a contemporary, epidemiological analysis of all types of head and neck injuries that are evaluated in the emergency room setting across the US. Existing literature does not provide insight into injury patterns or risk stratification, including predictors of inpatient admission or mortality. Herein we report national estimates for the prevalence and incidence of primary head and neck injuries in children and adults using the largest ED database in the United States, with data from over 131 million ED encounters. We

Study Design. Case series with chart review. Setting. Nationwide emergency department (ED) sample. Methods. The 2011 database was queried for encounters with a primary diagnosis of HN injury, as categorized by the Barell Injury Matrix. Weighted estimates for demographics, injury category, and mechanism were extracted. Predictors of mortality and admission were determined by multivariable regression. Results. We identified 131 million ED encounters. A weighted total of 5,418,539 visits were related to primary HN injuries. Average age was 30 (SE = 0.4), and 56.8% were male. Sixty-four percent of injuries were attributed to fall or blunt trauma. Open wounds comprised 41.8% of injuries. The most common procedure was laceration repair (70%). The majority of patients (97%) were discharged home. Mortality rate was less than 1%. Predictors of admission and mortality (P \ .05) included multiple trauma, vessel trauma, and burns. Other risk factors included foreign-body, older age, and male gender. Conclusions. Primary HN injuries commonly present to emergency rooms in the US. The majority of HN injuries are non–life threatening and do not require admission to the hospital or result in death. These data have implications for HN injury surveillance and may be used to risk-stratify patients who present with injuries in the acute care setting.

Keywords otolaryngology, head and neck, trauma, injury, emergency department

1 Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, USA 2 Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary/Massachusetts General Hospital, Boston, Massachusetts, USA 3 Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA 4 Harvard Interfaculty Initiative in Health Policy, Cambridge, Massachusetts, USA * These authors contributed equally to this article.

Corresponding Author: Elliott D. Kozin, Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles Street, Boston, MA 02114, USA. Email: [email protected]

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Table 1. Barell Diagnostic Injury Matrix ICD-9CM Codes for Head and Neck Region. Region

ICD-9CM Codes

Head (not including traumatic brain injury) Face Neck Head, face, and neck unspecified

873(.0-.1,.8-.9), 941.x6, 951, 959.01 802, 830, 848.0-.1, 872, 873.2-.7, 941(.x1,.x3-.x5,.x7) 807.5-.6, 848.2, 874, 925.2, 941.x8, 953.0, 954.0 900, 910, 920, 925.1, 941.x0, .x9, 947.0, 957.0, 959.09

provide detailed descriptive analysis of patient demographics, visit characteristics, injury type, and mechanism, as well as geocoding analysis to depict variation in injury patterns across the US. We also provide an overview of significant predictors of inpatient admission and death.

Methods This study was exempt from Institutional Review Board approval. The 2011 Nationwide Emergency Department Sample (NEDS), published by the Healthcare Cost and Utilization Project (HCUP) and sponsored by the Agency for Healthcare Research and Quality (AHRQ), was used to estimate the national prevalence of injury to the head and neck region. NEDS is the largest publically available, allpayer ED database in the US. It contains discharge abstracts for 29 million ED visits at 951 hospitals in 30 states and provides a 20% stratified sample of all hospital-based EDs in the country. Individual ED encounters can be weighted according to the sample design, therefore the 2011 NEDS provides a national weighted-sample of over 131 million ED visits. In NEDS, all 15 diagnostic positions were queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM) codes consistent with injury to the head, face, and neck as categorized in the Barell Injury Diagnosis Matrix17 (Table 1). The Barell Matrix, published by the Centers for Disease Control and Prevention (CDC) International Collaborative Effort on Injury Statistics, categorizes injuries by body region and nature of injury using ICD-9CM codes. There are 9 injury categories that contain ICD-9CM codes relevant to the head and neck: fractures, dislocations, sprains and strains (eg, jaw sprain or nasal septum sprain), open wounds, injury to blood vessels, contusions/superficial injury, burns, injury to nerves, and unspecified injuries. Traumatic brain injury and ophthalmologic injuries were excluded. Primary injury to the head and neck was defined as a visit with a relevant injury code listed only in the first diagnostic position. This cohort of ED encounters was used for all subsequent analyses to provide an in-depth survey of primary head and neck injuries. Mechanism of injury is categorized by HCUP in NEDS based on ICD-9CM external causes of injury codes (E-codes) according to established methods.18 There are 11, non–mutually exclusive categories including injury from a sharp object (eg, knife), drowning or submersion, fall, fire/

flame/hot object, firearm, machinery, motor vehicle traffic, natural or environmental causes including stings and bites, poisoning, being struck by or against something (blunt trauma), and suffocation. Descriptive analysis was performed to characterize patient demographics, including national quartile for median household income (as categorized by HCUP according to patient zip code data) and insurance payer, visit characteristics (day of week and month), hospital characteristics (teaching status, trauma designation, and geographic region), and injury characteristics. The 10 most frequent diagnoses were tabulated. The primary, first-listed procedure code for each ED encounter was extracted, if present, and tabulated by frequency. The incidence of head and neck injury per 100,000 US population was calculated using 2011 population estimates obtained from the US Census Bureau Population Estimates Program. NEDS is a stratified 2-stage cluster sample, therefore discharge weights and standard formulas for 2-stage cluster sample were used to generate national estimates and calculate standard errors. Patient demographics, visit, injury, and hospital characteristics were compared by patient disposition (admission vs treatment and release) in bivariable analysis. Differences in proportions and means were assessed using sample design-adjusted statistical tests including the Wald chi-square test (for proportions) and 2-sided unpaired t tests (for means). Significant predictors of admission and mortality were determined in separate multivariable logistic regression models. Each model was inclusive of all independent variables previously listed (patient demographics, visit characteristics, hospital characteristics, and injury characteristics) in order to account for all potential predictors available in NEDS. Statistical significance was determined by a type I error threshold of 0.05. Data linkages and statistical analysis were performed using SAS v.9.3 (SAS Institute, Cary, North Carolina). Survey-weighted commands in SAS were utilized for calculation and comparison of proportions (proc surveyfreq) and means (proc surveymeans) and in logistic regression modeling (proc surveylogistic). A choropleth map, or visually graded representation of frequency within defined geographic areas, was generated to characterize population-adjusted estimates for head and neck injury by region of the United States. Maps were generated using the Epi Info v7.1.3 software published by the CDC.

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Results There was a weighted total of 131,048,605 ED visits in 2011 (unweighted total = 29,421,411 visits). A weighted total of 7,020,455 (standard deviation of weighted frequency [SD] = 143,666) visits were attributed to injury of the head or neck region. A weighted total of 5,418,539 visits (SD = 116,802) were related to primary injury of the head and neck region (defined as Barell Injury Matrix ICD-9CM codes for head or neck injury) and were included in our analysis (4.1% of all ED visits). All values listed hereafter in text and tables represent weighted estimates. There were 1738 ED visits per 100,000 population with an average of 14,845 visits nationwide per day. Nearly all patients were treated and released (97.2%); a minority were admitted (N = 150,148, 2.7%) or died in the ED or hospital (N = 2680, 0.1%). Demographic statistics are summarized in Table 2. The average patient age was 30.0 years (SD = 0.4), 56.8% were male, and the greatest proportion were age 0 to 17 years (43.1%). Seventy percent of patients were treated at a nontrauma or level III trauma hospital. Most visits occurred on a weekday (68.1%), and injury volume was greatest during summer months (June to August) (Figure 1). The highest number of injuries occurred in the geographic south of the US (36.4%) and the least in the geographic west (18.6%) (Figure 2). The majority of injuries were unintentional (89.5%), and 35% of patients had more than 1 injury diagnosis (regardless of body region). Falls (38.9%) and blunt trauma (26.2%) were the most common mechanism of injury (Table 2). Figure 3 illustrates the proportion of injuries by Barell injury diagnosis matrix categories. The most common type of injury was open wound (N = 2,262,298; 42%). More severe injuries, including fractures (N = 260,559; 5%), burns (N = 47,910; 1%), injury to blood vessels (N = 1565; 0.03%), and injury to nerves (N = 598; 0.01%), were less common. The 10 most frequent diagnoses are listed in Table 3. Types of injuries varied by age group; foreign bodies were most common among pediatric patients (50%) and serious injuries including burns, fractures, injury to vessels, and nerve injuries were more common among patients aged 18 to 44 years (Figure 4). Mechanism was also noted to be age dependent (Figure 5). Twenty-four percent of patients underwent a diagnostic or therapeutic procedure in the ED (Table 4). Over half of these patients underwent laceration repair. Complex laceration repair of the eyelid/eyebrow, lip, nose, and external ear was performed in 205,188 patients (15.9% of all patients who underwent a procedure). Nonoperative foreign body retrieval in the ED was performed in 66,001 patients (5.1%). Diagnostic imaging occurred infrequently; computerized axial tomography of the head was obtained in 57,006 patients (4.4%) and plain film X-ray of facial bones was obtained in 6,890 patients (0.5%). Bivariable comparisons for patient demographics, visit, and injury characteristics between patients who were admitted versus patients who were treated and released are

presented in Table 2. Several predictors of inpatient admission were identified in multivariable logistic regression modeling. Odds ratios and significance levels for all independent variables are published online (Supplemental Table S1 available at otojournal.org). Notably, demographic predictors of admission included male gender (odds ratio [OR] = 1.25, 95% confidence interval [CI], 1.22-1.29) and older age (per 1 additional year, OR = 1.01, 95% CI, 1.01-1.01). Visit characteristics that were predictive of admission included weekend visit (vs weekday, OR = 1.05, 95% CI, 1.03-1.08) and level I or II trauma hospital (vs non-trauma or level III trauma hospital, OR = 1.27, 95% CI, 1.03-1.57). Several injury categories predicted inpatient admission (all compared to reference category of open wound): burns (OR = 47.85 95% CI, 37.6-60.96), injury to blood vessels (OR = 57.59, 95% CI, 38.49-86.2), foreign body (OR = 3.10, 95% CI, 2.67-3.62), and fractures (OR = 29.20, 95% CI, 24.98-34.10). Additionally, patients with multiple injuries (OR = 1.62, 95% CI, 1.52-1.74) and patients who did not receive a procedure in the ED (OR = 1.74, 95% CI, 1.43-2.11) were at significantly greater odds of admission. Significant predictors of mortality included male gender (OR = 1.74, 95% CI, 1.45-2.09), older age (per 1 year, OR = 1.02, 95% CI, 1.01-1.03), injuries to blood vessels (OR = 2.95, 95% CI, 1.16-7.53), burns (OR = 6.47, 95% CI, 3.0613.66), injuries resulting from self-harm (OR = 4.57, 95% CI, 2.92-7.14), and injuries resulting from motor vehicle traffic (OR = 3.24, 95% CI, 2.19-4.78), suffocation (OR = 23.26, 95% CI, 15.38-34.48), firearms (OR = 100, 95% CI, 62.5-142.86), and machinery (OR . 100, P \ .0001). All patients with injuries from machinery included in the multivariable model died.

Discussion This study provides a contemporary, landscape analysis of extracranial, primary head and neck injury–related visits to hospital-based EDs in the United States based on data extracted from the largest, all-payer ED database (NEDS). There were over 5 million injuries in 2011, the majority of which were open wounds resulting from falls or blunt trauma, which infrequently resulted in hospital admission or death. Emergency medicine providers and multiple surgical specialties including general surgery, otolaryngology–head and neck surgery, plastic surgery, and oral and maxillofacial surgery are involved in the management of head and neck injuries. While we cannot discern which injuries were managed by an ED physician alone or with the assistance of a surgeon consultant, this study may help focus training for specialties involved in the management of head and neck injuries. Further, this study provides insight into which injuries require immediate transfer to higher level trauma facilities and which ones require follow-up that can be appropriately obtained as an outpatient. Prior studies of head and neck injury–related visits to the ED are limited. In 1995, Sastry et al3 characterized facial trauma in the US using data from the Major Trauma

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Table 2. Characteristics of ED Encounters for Primary Head and Neck–Related Injury, Stratified by Admission versus Treatment and Release. Weighted Frequency, % (Standard Error) Variable Age category 0-17 18-44 45-64 .65 Male gender Patient’s residence Large central, metropolitan Large fringe, metropolitan Median metropolitan Small metropolitan Micropolitan Other Median household income $1-$38,999 $39,000-$47,999 $48,000-$63,999 $64,000 or more Primary payer Private insurance Medicaid Medicare Self-pay Other No charge Weekend visit (Sat or Sun) Injury characteristics Unintentional Assault Intended self-harm Multiple injuries Injury mechanismb Fall Blunt trauma Motor vehicle trafficc Naturec Cut or piercing Fire Suffocation Firearm Machinery Poisoning Drowning or submersion Hospital trauma designation: Trauma level I or II Non–trauma or level III Hospital teaching status: Nonteaching, metropolitan Teaching, metropolitan Nonmetropolitan

Total (N = 5,418,539)

Admitted (N = 150,148)

Treated and Released (N = 5,265,712)

P Valuea \.0001

43.1 (0.9) 28.5 (0.5) 15.1 (0.3) 13.2 (0.2) 56.8 (0.1)

20.7 32.8 19.1 27.4 63.4

(1.2) (0.8) (0.4) (0.9) (0.5)

43.8 (0.9) 28.4 (0.5) 13.0 (0.2) 14.8 (0.3) 56.6 (0.2)

27.1 (1.3) 24.5 (1.3) 21.2 (1.2) 8.9 (0.9) 11.3 (0.5) 6.9 (0.3)

33.4 21.7 17.1 6.9 11.6 9.3

(2.6) (1.3) (1.4) (0.7) (0.8) (0.6)

27.0 (1.3) 24.6 (1.3) 21.7 (1.3) 9.0 (0.9) 11.6 (0.8) 6.8 (0.3)

27.5 (0.9) 25.2 (0.8) 25.0 (0.7) 22.2 (1.0)

29.7 24.9 24.3 21.1

(1.6) (0.9) (0.9) (1.5)

27.4 (0.9) 25.2 (0.8) 25.1 (0.7) 22.2 (1.0)

36.6 (0.6) 26.9 (0.5) 16.4 (0.4) 13.7 (0.3) 6.1 (0.2) 0.3 (0.1) 31.9 (0.1)

30.1 19.1 28.5 14.2 7.2 0.7 33.9

(1.9) (0.8) (0.9) (0.8) (0.5) (0.2) (0.3)

36.8 (0.6) 27.2 (0.5) 16.1 (0.4) 13.7 (0.3) 6.0 (0.2) 0.3 (0.1) 31.8 (0.1)

\.0001

89.5 (1.0) 9.9 (0.3) 0.2 (0.01) 35.3 (0.5)

85.6 16.9 1.9 56.9

(1.3) (0.8) (0.1) (1.2)

89.6 (1.0) 9.7 (0.3) 0.2 (0.01) 34.7 (0.5)

\.0001 \.0001 \.0001 \.0001

38.9 (0.5) 26.2 (0.4) 7.0 (0.1) 2.9 (0.1) 2.8 (0.1) 0.8 (0.02) 0.4 (0.03) 0.1 (0.01) 0.1 (0.01) 0.1 (0.01) 0.02 (0.01)

31.8 16.3 11.6 2.4 3.6 4.4 3.2 1.6 0.2 0.3 0.01

(0.9) (1.0) (0.5) (0.1) (0.2) (0.5) (0.2) (0.2) (0.03) (0.03) (0.01)

39.1 (0.5) 26.5 (0.4) 6.8 (0.1) 2.9 (0.05) 2.8 (0.1) 0.7 (0.02) 0.3 (0.03) 0.1 (0.01) 0.1 (0.01) 0.1 (0.01) 0.02 (0.01)

\.0001 \.0001 \.0001 .0006 \.0001 \.0001 \.0001 \.0001 \.0001 \.0001 .3226 \.0001

30.3 (1.1) 69.7 (1.1)

41.3 (2.4) 58.7 (2.4)

29.9 (1.1) 70.1 (1.1)

42.7 (1.1) 39.6 (1.1) 17.6 (0.6)

38.4 (3.0) 44.4 (2.6) 17.1 (1.1)

42.8 (1.1) 39.5 (1.1) 17.7 (0.6)

\.0001 \.0001

.2146

\.0001

.0993

a P value denotes level of significance for comparison between admitted and discharged patients. For independent variables with mutually exclusive categories, P value denotes results of a chi-square test of independence. b May not add to 100% as patients may have had none or more than 1 type of injury mechanism. c Motor vehicle traffic = injury involving motor vehicle traffic, including occupant of a car, motorcyclist, pedal cyclist, pedestrian, or unspecified person; nature = injury involving natural or environmental causes, including bites and stings. Downloaded from oto.sagepub.com at Dicle Ãœniversitesi on November 2, 2014

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Figure 1. Monthly variation in volume of primary head and neck injury–related visits to hospital-based emergency departments in the United States in 2011. Error bars denote standard deviation of weighted frequency.

Outcome Study (1982-1987). Of the 87,174 trauma patients in the database, one third had facial trauma, including fractures, blunt injuries, and penetrating wounds, most resulting from motor vehicle accidents. Recent estimates suggest the burden of trauma may be significantly greater; Allareddy et al9 identified 407,157 facial fracture–related ED visits in the United States in 2007, the majority of which were nasal fractures. Penetrating neck injuries have been noted to account for 5% to 10% of traumatic injuries in adults.12 External laryngeal trauma is estimated to occur with an incidence of 1 in every 137,000 emergency department visits.8 Taken together,

these reports provide a limited view of isolated head and neck injuries and largely focus on facial fractures. We provide a comprehensive survey of primary head and neck injuries and trauma. Several epidemiological patterns were observed. As expected, head and neck injuries occur more frequently among males and in the spring and summer months. These data are consistent with gender biases and seasonal variation observed in general trauma studies1 and epidemiological surveys of traumatic brain injury.19 This report finds, not surprisingly, that minor injuries such as lacerations are common and typically occur from unintentional falls and blunt trauma. This is consistent with studies surveying head and neck injuries in the United Kingdom,5 2010 injury statistic data compiled by the CDC National Center for Injury Prevention and Control,20 as well as survey responses on trauma practice patterns reported by academic and private-practice otolaryngologists.21 Geographically, the incidence of head and neck injuries was greatest in the South, which may reflect increased injury burden or variable ED utilization patterns. More severe trauma (burns, fractures, injury to blood vessels and nerves) comprised less than 7% of all injuries. Our data may underestimate the total number of injuries resulting from penetrating neck trauma involving the carotid artery or jugular vein or injuries from hanging and strangulation as many of these patients are dead on arrival to the ED12 or have other predominate injuries. The prevalence of facial fractures is lower than reported by Allareddy et al6; in their analysis of the 2007 NEDS database, they identified craniofacial fractures coded in any of the 15 diagnostic columns provided and did not exclude intracranial injuries. However, the present report performed detailed analysis

Figure 2. National weighted estimates for incidence of primary head and neck injuries per 100,000 population by census-defined regions of the United States. Downloaded from oto.sagepub.com at Dicle Ãœniversitesi on November 2, 2014

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Figure 3. Frequency of primary head and neck injuries by Barell Injury Matrix category.

only of primary injuries attributed to the head, face, or neck to ensure regression results predicting mortality and admission could be attributed solely to head and neck injuries. Over 1.6 million head and neck injuries were identified that were not coded in the primary position, and it is possible that many of these constitute serious injuries associated with other major trauma that was preferentially coded in a higher position. Predictors of mortality have been studied in general trauma patients, however they have not been reported for head and neck injuries specifically. Injury to blood vessels and burns were identified as significant predictors of death.

The association between burns and death may reflect concomitant smoke inhalation injury, which is independently associated with morbidity and mortality.22 Extracranial head and neck vascular injuries can occur by blunt or penetrating mechanisms. Blunt cerebrovascular injury (including carotid and vertebral artery dissection) is more common than penetrating injury. Most injuries are low grade, but severe injuries typically result in morbidity or mortality due to ischemic cerebrovascular accident. In contrast, penetrating injury to neck vessels more commonly cause death due to exsanguination.12 Although patients with these injuries comprise only a small portion of our study cohort, the association with mortality reinforces the importance of well-understood screening, diagnostic, and treatment algorithms for vascular neck injuries.23-25 The mechanism of injury is important to ascertain. Motor vehicle accidents, suffocation, firearm, or machinery-related injuries are associated with greater odds of death. Socioeconomic factors were not associated, despite evidence of disparities in general trauma series.26 Older age and male gender were associated with increased mortality, consistent with general trauma studies.27 Predictors of admission were less discrete. Several demographic factors were associated including male gender, older age, rural residence, and insurance type. Rural residents may have a higher likelihood of admission due to convenience rather than acuity of injury. Notably, uninsured self-pay patients were at significantly lower odds of admission than patients insured with Medicare, which suggests that financial barriers may prevent additional medical care. Patients who visited the ED on the weekend (vs Monday through Friday) were also at higher odds of admission. A possible explanation is that higher acuity injuries occurred during the weekend when a large proportion of the population is away from work and school, or it may reflect inadequate surgical staffing in the ED. Patients assessed at level I or II trauma hospitals were more likely to be admitted, likely because they had higher acuity injuries and were intentionally transported to these facilities for advanced care. Hospital teaching status was not associated with significant disparities in care.

Table 3. List of 10 Most Common Diagnoses among Patients with Primary Head and Neck Injuries. All Patients N = 5,418,539 Diagnosis (ICD-9CM) Unspecified head injury (959.01) Contusion of face, scalp, or neck (920) Open wound of forehead (873.42) Open wound of scalp (873.0) Open wound of lip (873.34) Abrasion of head (910.0) Open wound of jaw (874.44) Nasal bone fracture, closed (802.0) Open wound of face, not otherwise specified (873.40) Foreign body in ear (931)

Weighted Frequency

Percentage (SE)

1,155,519 960,261 647,369 527,249 285,701 212,287 179,424 132,915 127,580 114,772

21.3 (0.5) 17.7 (0.3) 11.9 (0.1) 9.7 (0.1) 5.3 (0.1) 3.9 (0.1) 3.3 (0.1) 2.5 (0.1) 2.4 (0.1) 2.1 (0.1)

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Figure 4. Frequency of primary head and neck injury categories by age group.

Figure 5. Frequency of primary head and neck injury mechanism by age group.

Our results suggest that emergency medicine physicians and consulting surgeons may benefit from focused training on complex facial laceration repair, fracture management, and foreign body removal as these were among the most common injuries. Clinicians should also anticipate investing greater time and effort in triaging and managing patients with burns, injury to blood vessels or nerves, and fractures. Additionally, increased resources and attention should be given to patients with injuries incurred by self-harm, suffocation, firearms, or machinery as these have a higher risk of

mortality. Finally, taking into consideration the breadth of diagnoses, it is clear that primary extracranial head and neck injuries are typically not life threatening. There are several limitations to this study. Injuries are classified according to the Barell Injury Diagnosis Matrix that precludes a more detailed analysis of injury types. Injury diagnoses clinically relevant to the head and neck may have been excluded from analysis because of how they are categorized in the Barell Matrix. Skull base fractures, for example, are categorized as traumatic brain injury and were therefore not included.

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Table 4. List of Top 10 Non-Imaging Procedures Performed in the ED. All Patients Who Underwent Procedure in ED N = 1,293,887 Procedure (ICD-9CM code)

Weighted Frequency

Percentage (SE)

702,843 85,476 77,923 34,325 23,786 18,003 15,293 9347 9503 8058

54.3 (1.4) 6.6 (0.3) 6.0 (0.3) 2.7 (0.1) 1.8 (0.1) 1.4 (0.1) 1.2 (0.1) 0.7 (0.06) 0.7 (0.05) 0.6 (0.1)

Laceration repair of open wound (86.59) Laceration repair of eyelid/eyebrow (08.81) Laceration repair of lip (27.51) Intraluminal foreign body removal (98.11) Laceration repair of nose (21.81) Laceration repair of external ear (18.4) Removal of foreign body from nose (98.12) Application of splint (93.54) Esophagogastroduodenoscopy (45.13) Other repair and reconstruction of skin and subcutaneous tissue (86.89)

However, for such a broad overview study we felt the Barell Matrix was an appropriate method for communicating and simplifying national injury patterns. Use of this classification scheme, endorsed by the CDC, also permits compatibility with existing injury surveillance systems and allows for comparability with future publications. Further, as we attempted to look only at primary head and neck injuries, this study underestimates head and neck trauma that may be associated with other injuries subsequently listed as a secondary diagnostic code. Additionally, severe injuries resulting in pre-hospital mortality were not included, thus potentially skewing the results. As with all large, retrospective database studies, this study is limited in its ability to account for unknown confounders. Finally, discharge abstracts are interpreted and coded by independent reviewers and are subject to their individual biases, however these individuals are highly trained and their work is validated.

Conclusions This study provides a landscape analysis of head and neck injuries in the US. In 2011, there were over 5 million primary head and neck injuries that ranged in severity from minor lacerations to penetrating wounds. These injuries infrequently result in admission to a hospital and overall mortality is low. Significant predictors of inpatient admission or death include injury to blood vessels, burns, motor vehicular trauma and injury from machinery, male gender, and older age. These data have implications for head and neck injury surveillance and may be used to risk-stratify patients who present with injuries in the acute care setting. Author Contributions Rosh K.V. Sethi, conception, design, acquisition of data, analysis, drafting, final approval; Elliott D. Kozin, conception, design, acquisition of data, analysis, drafting, final approval; Peter J. Fagenholz, conception, design, drafting, final approval; Daniel J. Lee, conception, drafting, final approval; Mark G. Shrime, conception, design, drafting, final approval; Stacey T. Gray, conception, design, drafting, final approval.

Disclosures Competing interests: None. Sponsorships: None. Funding source: None.

Supplemental Material Additional supporting information may be found at http://otojournal .org/supplemental.

References 1. Mackenzie EJ, Rivara FP, Jurkovich GJ, et al. The National Study on Costs and Outcomes of Trauma. J Trauma. 2007;63: S54-S67. 2. Corso P, Finkelstein E, Miller T, et al. Incidence and lifetime costs of injuries in the United States. Inj Prev. 2006; 12:212-218. 3. Sastry SM, Sastry CM, Paul BK, et al. Leading causes of facial trauma in the major trauma outcome study. Plast Reconstr Surg. 1995;95:196-197. 4. Wade AL, Dye JL, Mohrle CR, et al. Head, face, and neck injuries during Operation Iraqi Freedom II: results from the US Navy-Marine Corps Combat Trauma Registry. J Trauma. 2007;63:836-840. 5. Hussain K, Wijetunge DB, Grubnic S, et al. A comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34-47. 6. Allareddy V, Nalliah R, Lee MK, et al. Impact of facial fractures and intracranial injuries on hospitalization outcomes following firearm injuries. JAMA Otolaryngol Head Neck Surg. 2014;140:303-311. 7. McMullin BT, Rhee JS, Pintar FA, et al. Facial fractures in motor vehicle collisions: epidemiological trends and risk factors. Arch Facial Plast Surg. 2009;11:165-170. 8. Jewett BS, Shockley WW, Rutledge R. External laryngeal trauma analysis of 392 patients. Arch Otolaryngol Head Neck Surg. 1999;125:877-880. 9. Allareddy V, Allareddy V, Nalliah R. Epidemiology of facial fractures. J Oral and Maxillofac Surg. 2011;69:2613-2618.

Downloaded from oto.sagepub.com at Dicle Ãœniversitesi on November 2, 2014

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10. Lim LH, Kumar M, Myer CM III. Head and neck trauma in hospitalized pediatric patients. Otolaryngol Head Neck Surg. 2004;130:255-261. 11. Gassner R, Tuli T, Hachl O, et al. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg. 2003;31:51-61. 12. Demetriades D, Skalkides J, Sofianos C, et al. Carotid artery injuries: experience with 124 cases. J Trauma. 1989;29:91-94. 13. Imahara SD, Hopper RA, Wang J, et al. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg. 2008;207: 710-716. 14. Bring G, Bjornstig U, Westman G. Gender patterns in minor head and neck injuries: an analysis of casualty register data. Accid Anal Prev. 1996;28:359-369. 15. Bener A, Rahman YS, Mitra B. Incidence and severity of head and neck injuries in victims of road traffic crashes: in an economically developed country. Int Emerg Nurs. 2009;17:52-59. 16. Zargar M, Khaji A, Karbakhsh M, et al. Epidemiology study of facial injuries during a 13 month of trauma registry in Tehran. Indian J Med Sci. 2004;58:109-114. 17. Barell V, Aharonson-Daniel L, Fingerhut LA, et al. An introduction to the Barell body region by nature of injury diagnosis matrix. Inj Prev. 2002;8:91-96. 18. Finkelstein E, Corso P, Miller T. Incidence and Economic Burden of Injuries in the United States. New York, NY: Oxford University Press; 2000.

19. Bruns J Jr, Hauser WA. The epidemiology of traumatic brain injury: a review. Epilepsia. 2003;44(suppl 10):2-10. 20. CDC. National estimates of the 10 leading causes of nonfatal injuries treated in hospital emergency departments, United States—2010. http://www.cdc.gov/injury/wisqars/pdf/National_ Estim_10_Leading_Causes_Nonfatal_Injuries_Tx_Hospital-ED_ US2010-a .pdf. Accessed March 14, 2014. 21. McCusker SB, Schmalbach CE. The otolaryngologist’s cost in treating facial trauma: American Academy of Otolaryngolog— Head and Neck Surgery survey. Otolaryngol Head Neck Surg. 2012;146:366-371. 22. Cancio LC. Airway management and smoke inhalation injury in the burn patient. Clin Plast Surg. 2009;36:555-567. 23. Bromberg WJ, Collier BC, Diebel LN, et al. Blunt cerebrovascular injury practice management guidelines: the Eastern Association for the Surgery of Trauma. J Trauma. 2010;68:471-477. 24. Tisherman SA, Bokhari F, Collier B, et al. Clinical practice guideline: penetrating zone II neck trauma. J Trauma. 2008; 64:1392-1405. 25. Wood J, Fabian TC, Mangiante EC. Penetrating neck injuries: recommendations for selective management. J Trauma. 1989; 29:602-605. 26. Haider AH, Chang DC, Efron DT, et al. Race and insurance status as risk factors for trauma mortality. Arch Surg. 2008; 143:945-949. 27. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma. 1995;38:185-193.

Downloaded from oto.sagepub.com at Dicle Ãœniversitesi on November 2, 2014

Epidemiological survey of head and neck injuries and trauma in the United States.

Head and neck trauma results in a range of injuries, spanning minor lacerations to life-threatening airway compromise. Few studies provide in-depth an...
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