Oropharyngeal Bee,Hornet,Yellow Jacket,and Wasp Stings: A National Electronic Injury Surveillance System Analysis and Scoping Review

Abstract

Introduction

It is estimated that up to 94.5% of the adult population has received at least 1 Hymenoptera sting in their lifetime, which includes stings from bees, hornets, yellow jackets, or wasps. This study describes the epidemiology of oropharyngeal stings due to bees, hornets, yellow jackets, and wasps in the United States between 2004 and 2023.

Methods

This study used data from the National Electronic Injury Surveillance System to describe patients with stings who presented to US hospitals for treatment. It then contextualized these findings through a scoping review of case reports of oropharyngeal stings published on Scopus and PubMed, with particular attention to the hospital disposition of cases.

Results

The National Electronic Injury Surveillance System analysis found that an estimated 5% of all stings involved the oropharyngeal region. The rate of oropharyngeal stings has varied over time, and an estimated 2% of victims were admitted to the hospital for any reason. This finding stands in contrast to the review of case reports, in which 64% of victims were hospitalized.

Conclusions

Oropharyngeal stings present a unique risk of airway compromise and merit conservative treatment, which may include hospitalization.

Keywords

Hymenoptera stings oropharyngeal stings bees wasps publication bias

Introduction

It is estimated that up to 94.5% of the adult population has received at least one Hymenoptera sting in their lifetime, which includes stings from bees, hornets, yellow jackets, or wasps.^1,2 Mild pain and redness at the site of the sting are common, although up to 26% of adults respond with symptoms of a large local allergic reaction, which involves increased pain and swelling >10 cm lasting longer than 24 h.^3,4 More severe systemic allergic reactions, with symptoms ranging from urticaria to anaphylaxis, occur in up to 5.0% of adults.^3–5

The bodily location of a sting has been examined as a potential situational risk factor for more severe sting reactions.^6,7 Meanwhile, Castagnoli et al⁸ mentioned that stings to the oropharyngeal region (eg, tongue, soft palate, throat, uvula, etc) can be fatal due to upper airway obstruction caused by localized edema. Indeed, The Lancet published a case report in 1873 of a 74-y-old male who died following a wasp sting to the tongue and localized swelling of the tongue and epiglottis.⁹ Yet, despite a long history of these stings occurring, because they are also rare, there is no consensus on how to manage them.⁸

As a result, this study had the following aims: 1) to describe the epidemiology of oropharyngeal stings due to bees, hornets, yellow jackets, and wasps in the United States between 2004 and 2023 and 2) to conduct a scoping review to analyze these findings in light of published case reports on oropharyngeal stings, with particular attention to the hospital disposition of these cases.

Methods

Aim 1

For the first aim of this study, the National Electronic Injury Surveillance System (NEISS) was queried. The NEISS is affiliated with the US Consumer Product Safety Commission and gathers data on emergency department visits from a nationally representative sample of 100 US hospitals that have 6 or more beds and an emergency department.¹⁰ The NEISS was queried for all cases between 2004 and 2023 that were coded as “Other (71),” the NEISS diagnostic category that includes cases of stings. This dataset included persons presenting to the emergency department with all conditions categorized as “Other,” including but not exclusive to cases of stings. The dataset was then filtered to include only patients whose diagnoses included the terms “bee,” “hornet,” “yellow jacket,” or “wasp” and that involved a stinging injury.

Then the dataset was filtered with respect to the primary body part involved in the stinging injury. The NEISS codes both primary and secondary body parts involved in an injury using a predetermined list of 30 codes corresponding to major anatomic areas (eg, “Upper Trunk,” “Shoulder,” “Ankle,” “Mouth,” “Internal,” “Other,” etc). This study was interested in cases of stings to the oropharyngeal region (eg, the tongue, soft palate, throat, uvula, etc). As a result, the dataset was filtered to include cases that were coded with “Mouth” as the primary body part stung. Because there was no code for any subanatomic site in the oropharynx (eg, tongue, uvula, etc), cases that were coded with “Internal” or “Other” as the primary body part stung also were included and then manually reviewed to determine whether these involved oropharyngeal stings. Cases involving stings to the lips were excluded because the lips are part of the external mouth. For cases in which any secondary body part was involved, case narratives were manually reviewed and included only if the secondary body part described was part of the oropharynx. For example, a patient who inhaled a bee through a straw and was stung in the throat was coded with primary body part “Mouth” and secondary body part “Internal” and was therefore included in the analysis. This filtering was done to ensure that cases included in the analysis involved incidents of oropharyngeal stings only.

All data analysis was performed using R and the srvyr package for complex survey design.¹¹ Descriptive statistics were run for the rate of reports to the NEISS over time as well as for cross-tabulations of reports by patient age and gender, hospital disposition, and the circumstances of the sting. Given that the NEISS dataset is a sample of US hospitals, the results are referred to here as estimates and presented with 95% confidence intervals. The NEISS is also a weighted dataset, meaning that there are unweighted counts of observations reported to the NEISS but that each observation also has a statistical weight that is proportional to the number of people the observation represents in the population and that is meant to be applied during any analysis.¹² All national injury estimates were calculated using these weights. National estimates were included in the results if they met the Consumer Product Safety Commission criteria for stability, including that the unweighted count of observations was >20, the weighted count was >1200 observations, and the coefficient of variation was <33%.¹² For calculation of rates, US population figures were gathered from the United Nations Department of Economic and Social Affairs.¹³

Aim 2

For the second aim of this study, two databases—Scopus and PubMed—were searched for case reports of oropharyngeal stings using the following title, abstract, and keyword search terms: (“Hymenoptera” OR “Hymenoptera-sting”) OR (“Bee” OR “Hornet” OR “Yellow jacket” OR “Wasp” AND (“sting” OR “stinger”)) AND (“Anaphylaxis” OR “Anaphylactic shock” OR “Oropharynx” OR “Oropharyngeal” OR “Odynophagia” OR “Supraglottis” OR “Supraglottic” OR “Uvula” OR “Intubation” OR “Trachea” OR “Larynx” OR “Pharynx” OR “Oral cavity”) AND (“Case” OR “Case report” OR “Case series”). Databases were last searched on September 16, 2024. For this study, records were included if they were case reports or case series of oropharyngeal stings involving the interior of the mouth and oropharynx. Studies were excluded if they involved stings to the lips, if the sting site was not clearly identified, if the patient received stings anywhere else on the body, and if the publication was not a case report or case series.

We collaborated to conduct article reviews and synthesize findings. Case reports were searched for data regarding patient age and gender, history of sting allergy or systemic reaction, symptoms for the current sting incident, circumstances of the sting, hospital disposition, whether any form of intubation was performed, and whether the outcome of the sting was fatal. If no mention was made of the patient having a history of sting allergy or systemic reaction, this was coded as the patient having no such history. These findings are summarized in Tables 1 and 2. A comparison of select demographic and outcome measures across the NEISS analysis and case reports is provided in Table 3.

Table 1.

Sting characteristics.

Source	Patient age (y)	Patient gender	Circumstances of sting	Site of injury
Paparella²⁴ (1964)	21	Male	Drinking from a beverage	Larynx
Jones and Joy²⁵ (1988)	56	Male	Drinking from a beverage	Oral cavity, unspecified
Hoang and Martin²⁶ (1995)	41	Male	Drinking from a beverage	Supraglottic region, unspecified
Smoley²⁷ (2002)	29	Male	Drinking from a beverage	Throat
Tome et al²⁸ (2005)	7	Male	Not specified	Tongue
Tome et al²⁸ (2005)	2	Female	Not specified	Tongue
Feltracco et al²⁹ (2012)	45	Male	Paragliding	Oral cavity, unspecified
Chouake et al³⁰ (2017)	“Adolescent”	Male	Not specified	Epiglottis
Kourelis et al³¹ (2022)	13	Male	Riding a bicycle	Supraglottic larynx
Singer and Lande³² (2022)	15	Female	Ziplining	Uvula
Seyoum et al³³ (2023)	42	Male	Drinking from a beverage	Throat

Table 2.

Patient history, symptoms, and course of treatment.

Source	History of allergy or systemic reaction	Patient symptoms	Hospital disposition	Intubation performed	Fatal
Paparella²⁴ (1964)	No	Edema of the left arytenoid	Held for observation overnight	No	No
Jones and Joy²⁵ (1988)	Yes	Restlessness, hypotension, periorbital edema, anaphylactic shock, acute myocardial infarction	Initially treated and released; returned 10 days later	No	No
Hoang and Martin²⁶ (1995)	No	Erythema and edema of the right arytenoid, progressive dysphagia	Held for observation overnight	No	No
Smoley²⁷ (2002)	No	Progressive hoarseness, painful swallowing, edema adjacent to the left arytenoid cartilage	Held for observation overnight	No	No
Tome et al²⁸ (2005)	No	Edema of the tongue, face, and eyelids, breathing difficulty	Hospitalized for 10 days	Yes	No
Tome et al²⁸ (2005)	No	Edema of the tongue and lips, breathing difficulty	Hospitalized for 2 days	Yes	No
Feltracco et al²⁹ (2012)	Yes	Swelling of the face, tongue, and soft glottis	Dead on EMS arrival	No	Yes
Chouake et al³⁰ (2017)	No	Throat pain, right-sided otalgia	Treated in office setting	No	No
Kourelis et al³¹ (2022)	No	Edema and erythema of the left aryepiglottic fold	Held for observation overnight	No	No
Singer and Lande³² (2022)	No	Dyspnea, dysphonia, odynophagia, drooling; edema of the uvula, anterior pillars of the tonsils, and soft palate	Treated and released	No	No
Seyoum et al³³ (2023)	No	Severe sore throat, difficulty swallowing, difficulty breathing	Hospitalized for 7 days	Yes	No

Table 3.

Select demographics and outcomes across datasets.


Source	Median age (y)(interquartile range)	Male (%)	Hospitalized (%)	Fatal (%)
NEISS dataset	39 (22–51)	61.02	1.92	0.00
Case reports	25 (11.5–42.75)	82.00	64.00	9.09

NEISS, National Electronic Injury Surveillance System

Ethical Considerations

This study was reviewed by the Thomas Jefferson University Institutional Review Board and determined not to constitute human subjects research.

Results

Aim 1

Between 2004 and 2023, there were an estimated 3890 (95% CI, 2458.55–5320.79) people with oropharyngeal stings from bees, hornets, yellow jackets, or wasps in the United States who presented to emergency departments. Stings to the oropharyngeal region represented an estimated 5.08% (95% CI, 3.59–6.56) of all stings. Overall, the rate of oropharyngeal stings appears to have fluctuated over time between 2004 and 2023, with peaks in 2010, 2016, and 2023 (Figure 1). The median age of patients with oropharyngeal stings was 39 years (interquartile range [IQR], 22–51). Most oropharyngeal stings occurred in adults (84.78% of stings; 95% CI, 75.37–94.19) and in males (61.02% of stings; 95% CI, 50.58–71.46). Based on the NEISS product codes tagged to each case and the associated case narratives, the most common scenario for oropharyngeal stings involved a drinking vessel such as a cup, jar, mug, or straw (83.39% of stings; 95% CI, 75.78–91.20). Among cases of oropharyngeal stings in this dataset, there were no recorded fatalities. Overall, 98.08% (95% CI, 94.25–100.00) of victims of oropharyngeal stings were not admitted to the hospital.

Figure 1.

Estimated rate of oropharyngeal stings in the United States per 100,000,000 population between 2004 and 2023.

Aim 2

The Scopus search yielded 914 preliminary results, whereas the PubMed search yielded 351 preliminary results, of which 212 were duplicates. Of the 1053 remaining articles, 1029 were excluded after title and abstract review. In total, 24 articles were sought for full text review. During this stage of review, 4 articles were excluded due to no full text being available, leaving 20 for full text review. Jones et al,¹⁴ Casale and Burkes,¹⁵ and Farhat et al¹⁶ were excluded because they described stings to the lip, not the interior mouth. Vaughn and Koch¹⁷ were excluded due to ambiguity about the sting site. Ellis and Day,¹⁸ Forthal et al,¹⁹ Butterton and Clawson-Simons,²⁰ and Hoffman and Miller²¹ were excluded due to not being case reports. Viswanathan et al²² and Singh et al²³ were excluded due to presentations of cases of mass envenomation in which the mouth was neither the only nor the primary site of stings. After full-text review, 10 case reports were included in the study.^24–33 The results of the search process are summarized in Figure 2.

Figure 2.

Scoping review search process.

The sting characteristics of case reports are summarized in Table 1. The publication dates for the case reports ranged from 1964 to 2023, with most (n=7) published since 2000. Overall, the reports described 11 patients across 7 countries: the United States (n=4), United Kingdom (n=1), Israel (n=2), Costa Rica (n=1), Ethiopia (n=1), Greece (n=1), and Italy (n=1). Overall, 82% of patients (n=9) were male. Excluding Chouake et al,³⁰ who did not specify the patient's age, the median patient age was 25 y (IQR, 11.5–42.75). The most common circumstance of a sting was drinking from a beverage that a bee or wasp had entered (n=5), followed by an outdoor activity in which the patient was moving rapidly and had their mouth open (n=3). Compared with the NEISS dataset, case reports described the subanatomic site of the sting with greater specificity (eg, “epiglottis,” “larynx,” “uvula,” etc), with no single site implicated in a majority of patients. Only 2 patients were described as having a history of allergy or systemic reaction, yet 7 patients were hospitalized and 3 were intubated (Table 2). One case of an oropharyngeal sting was fatal and involved a patient with a prior history of anaphylaxis (Table 2). Overall, 64% of victims (n=7) were admitted to the hospital, making admission the most common hospital disposition, whereas 1 patient was treated in an office setting (Table 2).

Discussion

Although uncommon, oropharyngeal stings from Hymenoptera such as bees, hornets, yellow jackets, or wasps do occur. Based on the NEISS data, the incidence of oropharyngeal stings varied from year to year between 2004 and 2023. The observed variability may be an artifact of small sample size in any given year (ie, <1200 weighted observations), although it also may reflect changes in other factors such as hospital participation in the NEISS sampling frame, weather patterns, and human behavior. Nonetheless, it is important for clinicians to be familiar with these cases of sting because the proximity of the sting site involves the patient's airway regardless of a history of anaphylaxis. Although no reports of fatal stings were made to the NEISS, 1 case report from the literature review did describe such a case.²⁹ This finding confirms the warning by Castagnoli et al⁸ that, while rare, oropharyngeal stings may be fatal.

Results of this study's analysis of NEISS data and case reports demonstrated that these stings happened most commonly in the context of a bee or wasp entering the patient's drinking vessel without their knowledge. The patient then drank from the vessel, providing the bee or wasp entry into the patient's mouth. In both the NEISS dataset and the case reports, patients were most commonly males and adults, although the median age from the NEISS data was higher (39 vs 25 y).

Notably, the NEISS analysis indicated that only an estimated 2% of people with oropharyngeal stings due to bees, hornets, yellow jackets, and wasps were admitted to the hospital, whether for observation, treatment, or transfer. This finding stands in contrast to the findings from the review of case reports, which suggested that even when a person has no history of sting allergy, no history of systemic reaction, and no symptoms of systemic reaction, admission still may be warranted, and intubation may be indicated. Among the case reports, several authors expressed concern that oropharyngeal stings may lead to airway compromise.^{24–28,30–33} These findings underscore the consideration to treat oropharyngeal stings conservatively.

In addition, although specialized testing in the emergency setting is not often considered, the physician has the unique opportunity to catch mast cell disorders, such as hereditary alpha tryptasemia and mastocytosis. If an acute tryptase concentration is determined within 4 h of exposure, it may help the outpatient allergist differentiate between mast cell causes (whether allergic or nonallergic) and non-mast-cell causes (ie, direct toxicity and/or mechanical injury to the tissue). A growing body of literature has shown that an acute tryptase level determination may be helpful in making such a differential diagnosis.^34–37

Limitations

This study contained the following limitations. First, the NEISS dataset was limited by reporting bias because not all people with oropharyngeal stings may present to the emergency department. Second, this study was limited by sampling bias because not all hospitals in the United States are eligible to participate in the NEISS sampling frame, namely those that have fewer than 6 beds or lack an emergency department. Third, given the rarity of oropharyngeal stings overall, the precision of the NEISS estimates was reduced, and not all cross-tabulations of interest could be reliably calculated. Fourth, this study was limited by the use of common names in the NEISS to identify the organisms responsible for stings, with this naming (eg, bee or wasp, etc) depending on either physician or patient report. As a result, this study could not reliably undertake comparisons of the proportions of stings attributed to each organism. Fifth, the specificity used to classify sting sites varied between case reports and the NEISS cases, preventing comparison of subanatomic locations between datasets. Lastly, this study was limited by publication bias because published case reports may be biased toward those cases that are more severe.

Footnotes

Author Contribution(s)

Andrew Huff: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Validation; Visualization; Writing – original draft; Writing – review & editing.

Lara Phillips: Conceptualization; Project administration; Formal analysis; Supervision; Writing – review & editing.

Scott W. Keith: Methodology; Writing – review & editing.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Andrew Huff

Scott W. Keith

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