Otolaryngology and head and neck surgery underwent drastic changes during the COVID-19 pandemic. Since March 10, the first day of the lockdown in Italy, diagnostic and therapeutic procedures were limited to emergency and oncology cases, while outpatient procedures and clinical examinations were temporarily suspended to limit virus diffusion and to reallocate personnel into wards dedicated to COVID-19. In our otolaryngology unit, between March 10 and April 28, 2020, we performed 96 surgical procedures; they mainly consisted in diagnosis and treatment of malignant tumors of the head and neck (77%), management of acute upper airway obstruction in adults and children (14.7%), drainage of abscesses of the head and neck (6.2%), and treatment of nasal bone fractures (2.1%). When comparing these data with those of the same period in 2019 for emergency and oncology procedures, we noticed a drastic reduction of head and neck abscesses and nasal bone fractures, while oncology surgery remained stable

Candelori, Francesca

Cialente, Fabrizio

de Vincentiis, Marco

Greco, Antonio

Minni, Antonio

Ralli, Massimo

English

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Archivio della ricerca- Università di Roma La Sapienza

CommentaryEffects of COVID-19 Pandemic onOtolaryngology Surgery in Italy: TheExperience of Our University HospitalOtolaryngology–Head and Neck Surgery1–3 American Academy ofOtolaryngology–Head and NeckSurgery Foundation 2020Reprints and permission:sagepub.com/journalsPermissions.navDOI: 10.1177/0194599820928970http://otojournal.orgMassimo Ralli, PhD1, Antonio Minni, MD1,Francesca Candelori, MD1, Fabrizio Cialente, MD1,Antonio Greco, MD1, and Marco de Vincentiis, MD2AbstractOtolaryngology and head and neck surgery underwent dras-tic changes during the COVID-19 pandemic. Since March 10,the first day of the lockdown in Italy, diagnostic and thera-peutic procedures were limited to emergency and oncologycases, while outpatient procedures and clinical examinationswere temporarily suspended to limit virus diffusion and to real-locate personnel into wards dedicated to COVID-19. In ourotolaryngology unit, between March 10 and April 28, 2020, weperformed 96 surgical procedures; they mainly consisted indiagnosis and treatment of malignant tumors of the head andneck (77%), management of acute upper airway obstruction inadults and children (14.7%), drainage of abscesses of the headand neck (6.2%), and treatment of nasal bone fractures (2.1%).When comparing these data with those of the same period in2019 for emergency and oncology procedures, we noticed adrastic reduction of head and neck abscesses and nasal bonefractures, while oncology surgery remained stable.KeywordsCOVID-19, SARS-CoV-2, otolaryngology, head and necksurgeryReceived May 1, 2020; accepted May 1, 2020.The pandemic wrought by severe acute respiratory syn-drome coronavirus 2 (SARS-CoV-2), also known ascoronavirus disease 2019 (COVID-19), has had dramaticeffects on the health care systems of most countries worldwide .1Italy, the country with the second-most COVID-19–relateddeaths, has also undergone profound changes, resulting in amajor decrease of nonurgent outpatient diagnostic visits andexaminations as well as surgical procedures.2,3As with most disciplines, otolaryngology and head andneck surgery activity over the country underwent drasticchanges.4 Since March 10, 2020, the first day of the lock-down in Italy, diagnostic and therapeutic otolaryngologyprocedures were limited to emergency and oncology cases,while outpatient procedures and clinical examinations weretemporarily suspended to limit virus diffusion and to reallo-cate personnel into wards dedicated to COVID-19.5The aim of this work is to report and discuss the changesin the surgical activity of the otolaryngology unit of thePoliclinico Umberto I of Rome, Italy, belonging to the third-largest university hospital in Italy, during the pandemic.Particular attention was given to the number of proceduresand type of surgery performed during the pandemic, and datawere compared with the same period in 2019.Surgical Activity in Our OtolaryngologyUnitDuring the COVID-19 pandemic, per national regulations,only emergency and oncology cases were treated in our unit.Urgent conditions were represented by respiratory distress,epistaxis, head and neck abscesses, sudden sensorineuralhearing loss, and acute vertigo attacks.Surgical procedures performed in our unit during the pan-demic principally consisted in tracheostomies; pharyngeal,nasal, and laryngeal oncology diagnostic biopsies performedas open surgery through microlaryngoscopy or endoscopy;and open head and neck oncologic procedures.In all cases, specific COVID-19–related symptoms in theprevious 2 weeks or direct exposure to SARS-CoV-2 wasinvestigated before admission, with special attention to cough,fever, and anosmia and dysgeusia.6 Also, a nasopharyngealswab for SARS-CoV-2 was performed before hospitalization,and body temperature was measured before entering the oper-ating room. Because of the potential transmission of SARS-CoV-2 through aerosol7 and the contiguity of physician andpatient during surgical procedures, personal protective equip-ment was used by all personnel in the operating room, includ-ing FFP2 masks covered by a surgical mask, cap and shoecovers, surgical goggles, gloves, and double gowns.8From March 10 to April 28, 2020, we performed 96 surgi-cal procedures: 74 (77%) for diagnosis and treatment ofmalignant tumors of the head and neck, 14 (14.7%) for the1Department of Sense Organs, Sapienza University of Rome, Rome, Italy2Department of Oral and Maxillofacial Sciences, Sapienza University ofRome, Rome, ItalyCorresponding Author:Massimo Ralli, PhD, Department of Sense Organs, Sapienza University ofRome, Viale del Policlinico 155, Rome, 00186, Italy.Email: massimo.ralli@uniroma1.itmanagement of acute upper airway obstruction in adults andchildren (tracheostomies, aspirated foreign body extraction,laryngeal postoperative bleeding), 6 (6.2%) to drainabscesses of the head and neck (retropharyngeal, peritonsil-lar, parapharyngeal, submandibular, parotid, and floor ofmouth), and 2 (2.1%) for nasal bone fractures (Figure 1).Other emergency conditions encountered in our unit duringthis period, such as epistaxis, did not require surgery.Figure 2 shows details of the oncologic procedures per-formed in our unit during the pandemic. Most were diagnos-tic microlaryngoscopy procedures for laryngeal cancer (n =38, 51.4%), followed by total laryngectomies (n = 7, 9.4%),parotid gland tumor surgery (n = 7, 9.4%), endoscopic sur-gery for nasal and paranasal sinus cancer (n = 6, 8.1%), oralcancer surgery (n = 5, 6.8%), neck dissection (n = 4, 5.3%),subtotal laryngectomies (n = 3, 4.1%), thyroidectomies (n =2, 2.7%), rhinopharynx cancer endoscopic biopsies (n = 1procedure, 1.4%), and external ear canal carcinoma biopsy(n = 1, 1.4%).Figure 3 shows a comparison of these data with the sameperiod in 2019. From March 10 to April 28, 2019, we performed195 surgical procedures. Most were procedures for diagnosisand treatment of malignant tumors of the head and neck (41%),followed by elective surgery (30.3%), upper airway manage-ment (12.8%), head and neck abscess drainage (9.7%), andnasal bone fracture (6.2%). Except for elective surgery, whichhas been suspended, the main changes during the 2020 pan-demic were found for head and neck abscesses (a decrease of68.4%) and nasal bone fractures (a decrease of 83.3%).DiscussionDuring the COVID-19 pandemic, the activity of our otolar-yngology unit underwent profound changes still ensuring thediagnostic and therapeutic procedures for emergency andoncology cases. When comparing current data for emergencyand oncology procedures to the same period in 2019, wenoticed a 50.77% decrease of the overall number of surgicalprocedures, mainly due to the reduction of beds to avoid conta-gion (1 patient/room), the reduction of available operatingrooms and sessions, and the reallocation of nursing and supportstaff to COVID-19 wards. However, we observed a drasticreduction of head and neck abscesses and nasal bone fractures.In 2019, infectious abscesses represented a frequent cause ofsurgical urgency in our unit, while their number decreasednearly 70% during the pandemic. A possible explanation couldFigure 1. Dot plot showing the main areas of surgical proceduresperformed in our otolaryngology unit during the COVID-19pandemic.Figure 2. Oncologic surgical procedures performed in our unitduring the pandemic (reference period: March 10 to April 28,2020). EAC, external auditory canal.Figure 3. Comparison between surgical procedures performed inour unit during the pandemic and the same period in 2019.2 Otolaryngology–Head and Neck Surgerybe the interruption of nonurgent dental activities (endodontictreatment, implantology, and dental extractions) for odonto-genic abscesses9 and the decreased number of tonsillitis follow-ing reduced interpersonal relationships during lockdown forperitonsillar abscesses. The drastic reduction of nasal bone frac-tures (nearly 85%) could be attributable to the cessation ofsporting and recreational events and to the reduction of caraccidents during the lockdown.10ConclusionThe COVID-19 pandemic had a drastic effect on the activityof our otolaryngology unit. Surgical activity was limited toemergency and oncology cases, with a severe impact onother conditions. As the current measures of the lockdowncontinue, it will be difficult to perform scheduled and newexaminations in a timely manner, causing the risk of diag-nostic delays with severe impact on patients’ health.Author ContributionsMassimo Ralli, substantial contributions to the conception of thework, revising the work critically, final approval of the version tobe published, agreement to be accountable for all aspects of thework; Antonio Minni, substantial contributions to the design ofthe work, revising the work critically, final approval of the versionto be published, agreement to be accountable for all aspects of thework; Francesca Candelori, substantial contributions to the acqui-sition of the data, drafting the work, final approval of the versionto be published, agreement to be accountable for all aspects of thework; Fabrizio Cialente, substantial contributions to the analysisof the data, drafting the work, final approval of the version to bepublished, agreement to be accountable for all aspects of the work;Antonio Greco, substantial contributions to the interpretation ofthe data, revising the work critically, final approval of the versionto be published, agreement to be accountable for all aspects of thework; Marco de Vincentiis, substantial contributions to the inter-pretation of the data, revising the work critically, final approval ofthe version to be published, agreement to be accountable for allaspects of the work.DisclosuresCompeting interests: None.Sponsorships: None.Funding source: None.Availability of Data and MaterialsThe data sets used and/or analyzed during the current study areavailable from the corresponding author on reasonable request.References1. Arshad Ali S, Baloch M, Ahmed N, Arshad Ali A, Iqbal A.The outbreak of coronavirus disease 2019 (COVID-19)—anemerging global health threat. J Infect Public Health. Publishedonline March 19, 2020. doi:10.1016/j.jiph.2020.02.0332. Armocida B, Formenti B, Ussai S, Palestra F, Missoni E. TheItalian health system and the COVID-19 challenge. LancetPublic Health. Published online March 25, 2020. doi:10.1016/S2468-2667(20)30074-83. Santacroce L, Bottalico L, Charitos IA. The impact of COVID-19 on Italy: a lesson for the future. Int J Occup Environ Med.Published online March 30, 2020. doi:10.34172/ijoem.2020.19844. Kowalski LP, Sanabria A, Ridge JA, et al. COVID-19 pan-demic: effects and evidence-based recommendations for otolar-yngology and head and neck surgery practice. Head Neck.Published online April 9, 2020. doi:10.1002/hed.261645. Ralli M, Greco A, de Vincentiis M. The effects of the COVID-19/SARS-CoV-2 pandemic outbreak on otolaryngology activityin Italy. Ear Nose Throat J. Published online 2020. doi:10.1177/01455613209238936. Ralli M, Di Stadio A, Greco A, de Vincentiis M, Polimeni A.Defining the burden of olfactory dysfunction in COVID-19patients. Eur Rev Med Pharmacol Sci. 2020;24(7):3440-3441.7. Wang J, Du G. COVID-19 may transmit through aerosol. IrJ Med Sci. Published online March 24, 2020. doi:10.1007/s11845-020-02218-28. Givi B, Schiff BA, Chinn SB, et al. Safety recommendations forevaluation and surgery of the head and neck during the COVID-19 pandemic. JAMA Otolaryngol Head Neck Surg. Publishedonline March 31, 2020. doi:10.1001/jamaoto.2020.07809. Guo H, Zhou Y, Liu X, Tan J. The impact of the COVID-19 epi-demic on the utilization of emergency dental services. J Dent Sci.Published online March 16, 2020. doi:10.1016/j.jds.2020.02.00210. Randelli PS, Compagnoni R. Management of orthopaedic and trau-matology patients during the Coronavirus disease (COVID-19) pan-demic in northern Italy. Knee Surg Sports Traumatol Arthrosc.Published online April 25, 2020. doi:10.1007/s00167-020-06023-3Ralli et al 3

Effects of COVID-19 pandemic on otolaryngology surgery in Italy: the experience of our university hospital

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Effects of COVID-19 pandemic on otolaryngology surgery in Italy: the experience of our university hospital

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