Kawasaki Disease: Unusual Presentation with Retropharyngeal Involvement.

Background: Kawasaki disease is an acute febrile generalized vasculitic syndrome of childhood of unknown ethology. The most severe complication may involve the hearth and include acute myocarditis with hearth failure, arrythmia, and coronary artery aneurism. The typical clinical symptoms are fever, conjunctivitis, rash, cervical lymphadenopathy, and mucocutaneous changes, and the diagnosis is made by the clinical criteria. Early use of aspirin and immunoglobuline improves symptoms and prevent heart complications. Case Presentation. A 4-year-old male presented to our attention for multiple unilateral laterocervical lymphadenopathies, odynophagia, and neck stiffness, initially treated with IV antibiotic therapy with partial resolution of symptoms. After four months he made a new ER access for cervicalgia, tonsils asymmetry, trismus, stiff neck, lameness, and phalanx hyperaemia and increase in the size of cervical lymph nodes. Radiology showed increase of lymphnodes dimension and retropharyngeal space asymmetry. The same day heart murmur appeared, so the patient underwent cardiological evaluation that documented dilation of the coronary arteries. This sign made it possible to place the diagnostic suspicion of Kawasaki disease and to start IV immunoglobulins and acetylsalicylic acid administration with prompt response. Conclusions: Kawasaki disease presents with a range of symptoms which, taken individually, are very common in childhood. One of these symptoms is represented by the swollen of neck lymph nodes. It is only clinical reasoning that leads to the correct diagnosis, and therefore, to the correct setting of the therapy, reducing the risk of complications.

Aerosolization risk during endoscopic transnasal surgery: a prospective qualitative and quantitative microscopic analysis of particles spreading in the operating room.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic represents the greatest public health emergency of this century. The primary mode of viral transmission is droplet transmission through direct contact with large droplets generated during breathing, talking, coughing, and sneezing. However, the virus can also demonstrate airborne transmission through smaller droplets (< 5 µm in diameter) generated during various medical procedures, collectively termed aerosol-generating procedures. The aim of this study was to analyze droplet contamination of healthcare workers and splatter patterns in the operating theater that resulted from endoscopic transnasal procedures in noninfected patients. METHODS: A prospective nonrandomized microscopic evaluation of contaminants generated during 10 endoscopic transnasal procedures performed from May 14 to June 11, 2020, in the same operating theater was carried out. A dilution of monosodium fluorescein, repeatedly instilled through nasal irrigation, was used as a marker of contaminants generated during surgical procedures. Contaminants were collected on detectors worn by healthcare workers and placed in standard points in the operating theater. Analysis of number, dimensions, and characteristics of contaminants was carried out with fluorescence microscopy. RESULTS: A total of 70 samples collected from 10 surgical procedures were analyzed. Liquid droplets and solid-tissue fragments were identified as contaminants on all detectors analyzed. All healthcare workers appeared to have been exposed to a significant number of contaminants. A significant degree of contamination was observed in every site of the operating room. The mean (range) diameter of liquid droplets was 4.1 (1.0-26.6) µm and that of solid fragments was 23.6 (3.5-263.3) µm. CONCLUSIONS: Endoscopic endonasal surgery is associated with the generation of large amounts of contaminants, some of which measure less than 5 µm. All healthcare workers in the surgical room are exposed to a significant and similar risk of contamination; therefore, adequate personal protective equipment should be employed when performing endoscopic endonasal surgical procedures.

Performing otolaryngological outpatient consultation during the Covid-19 pandemic.

BACKGROUND: The Covid-19 pandemic has had a profound impact on the Otolaryngology outpatient clinical practice, which is at high risk of respiratory viral transmission due to the close contact between the examiner and the patient's airway secretions [1]. Moreover, most otolaryngological procedures, including oropharyngoscopy, generate droplets or aerosols from high viral shedding areas [1]. Thus, only non-deferrable consultations were performed in the outbreak's acute phase. Along with the re-opening of elective clinical services and the impending second wave of the outbreak, a reorganization is necessary to minimize the risk of nosocomial transmission [1]. METHODS: This video (Video 1) shows how to safely conduct an outpatient Otorhinolaryngological consultation, focusing on complete ear, nose and throat examination, according to evidences from the published literature and Otolaryngological societies guidelines [2,3]. RESULTS: After telephonic screening, patients reporting Covid-19 symptoms or closecontact with a Covid-19 case within the last 14 days are referred to telehealth services [1-3]. To avoid crowding, the patient is admitted alone, after body temperature control, except for underage or disabled people [1]. The waiting room assessment must guarantee a social distance of 6 ft [1-3]. The consultation room is reorganized into two separate areas (Fig. 1): 1) a clean desk area, where an assistant wearing a surgical mask and gloves, handles the patient's documentation and writes the medical report, keeping proper distance from the patient, and 2) a separate consultation area, where the examiner, equipped with proper personal protective equipment (Fig. 2) [3,4], carries out the medical interview and physical examination. Endoscopic-assisted ear, nose and throat inspection using a dedicated monitor allows the examiner to maintain an adequate distance from the patient throughout the procedure while providing an optimal view (Figs. 3-6) [3]. Recent evidence shows that nasal endoscopy does not increase droplet production compared to traditional otolaryngological examination [5]. When necessary, nasal topic decongestion and anesthesia must be performed using cottonoids rather than sprays [3]. The patient keeps the nose and mouth covered throughout the consultation, lowering the surgical mask on the mouth for nasal endoscopy and removing it only for oropharyngoscopy. After the consultation, the doffing procedure must be carried out carefully to avoid contamination [4]. All the equipment and surfaces must undergo high-level disinfection with 70% alcohol or 0.1% bleach solutions [3]. Proper room ventilation must precede the next consultation [3]. CONCLUSIONS: The hints provided in this video are useful to ensure both patient and examiner safety during Otolaryngological outpatient consultations and to reduce SARS-CoV-2 transmission.

Elective Tracheostomy During Mechanical Ventilation in Patients Affected by COVID-19: Preliminary Case Series From Lombardy, Italy.

The COVID-19 outbreak poses continued struggles due to the unprecedented number of patients admitted to intensive care units and the overwhelming need for mechanical ventilation. We report a preliminary case series of 32 patients with COVID-19 who underwent elective tracheostomies after a mean intubation period of 15 days (range, 9-21 days). The procedure was performed with percutaneous (10 cases) and open (22 cases) surgical techniques. Neither procedure-related complications nor viral transmission to health care workers was observed. Our preliminary experience supports the safety of tracheostomy, provided that appropriate protocols are strictly followed. The postoperative care is still debated, and, prudentially, our protocol includes tracheal tube change not before 2 weeks after tracheostomy, with cuff deflation and decannulation deferred until confirmation of negative SARS-CoV-2 test results. This is the first case series to report on such a rapidly evolving issue and might represent a source of information for clinicians worldwide who will soon be facing the same challenges.

Strategies to overcome limitations in Otolaryngology residency training during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has produced an unequaled human crisis forcing a radical reorganization in the healthcare system. Otolaryngologists are at high risk of exposure, and changes in medical and surgical activities have reduced the learning opportunity for residents and fellows. We believe that even during COVID-19 crisis it is mandatory to guarantee an optimal training, and here, we propose some strategies, based on our experience, to further increase our trainees' learning curve. METHODS: We asked our trainees to fill out an electronic survey about several aspect of their training: a first section focused on the reduction of clinical activities and the perceived impact of the pandemic on residents' skills; the second part outlined the type of attended training activity and the perceived benefit. RESULTS: Surgical training has been reported by our residents as the activity perceived to be the most contracted during the pandemic. According to residents' opinion the most useful activities were dissection (n = 8, 53.4% residents) and online journal clubs/webinars (n = 7, 46.6% of residents). Residents' suggestions included actively participating to tracheostomy procedures on SARS-CoV-2 positive patients, attending lessons held by senior consultants on basic ENT topics and promoting collegial discussion of inpatient clinical cases. CONCLUSION: Building on this dramatic experience, we must be ready for a global restructuring of the residency program to provide an adequate trainee education for the future surgeons.

Changes in the use of Otorhinolaryngology Emergency Department during the COVID-19 pandemic: report from Lombardy, Italy.

PURPOSE: This paper aims to report the impact of COVID-19 outbreak on Emergency Ear nose and Throat (ENT) activity, in Lombardy (Italy), during COVID-19 pandemic. METHODS: The number of accesses to Emergency Department requiring ENT consultations between February 21st and May 7th, 2020, was retrospectively collected, along with the conditions treated. Data were stratified in 1-week time spans, to evaluate the evolving trends during the on-going epidemic and a comparison with the two previous years was performed. RESULTS: A significant reduction in the number of consultations performed during the pandemic was observed, as high as - 91% compared to the same period of 2018. CONCLUSION: Multiple reasons can explain such a reduction of Emergency ENT consultations, not least the fear of potentially being infected by SARS-CoV-2 by while accessing the hospital. The analysis performed might be useful as a starting point for a future reorganization of first aid consultations once the epidemic will be resolved.

Changing paradigms in sinus and skull base surgery as the COVID-19 pandemic evolves: Preliminary experience from a single Italian tertiary care center.

BACKGROUND: Italy was the first European country suffering from COVID-19. Health care resources were redirected to manage the pandemic. We present our initial experience with the management of urgent and nondeferrable surgeries for sinus and skull base diseases during the COVID-19 pandemic. METHODS: A retrospective review of patients treated in a single referral center during the first 2 months of the pandemic was performed. A comparison between the last 2-month period and the same period of the previous year was carried out. RESULTS: Twenty-four patients fulfilled the inclusion criteria. A reduction of surgical activity was observed (-60.7%). A statistically significant difference in pathologies treated was found (P = .016), with malignancies being the most frequent indication for surgery (45.8%). CONCLUSIONS: Although we feel optimistic for the future, we do not feel it is already time to restart elective surgeries. Our experience may serve for other centers who are facing the same challenges.

Skull-base surgery during the COVID-19 pandemic: the Italian Skull Base Society recommendations.

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is highly contagious with devastating impacts for healthcare systems worldwide. Medical staff are at high risk of viral contamination and it is imperative to know what personal protective equipment (PPE) is appropriate for each situation. Furthermore, elective clinics and operations have been reduced in order to mobilize manpower to the acute specialties combating the outbreak; appropriate differentiation between patients who require immediate care and those who can receive telephone consultation or whose treatment might viably be postponed is therefore crucial. Italy was 1 of the earliest and hardest-hit European countries and therefore the Italian Skull Base Society board has promulgated specific recommendations based on consensus best practices and the literature, where available. Only urgent surgical operations are recommended and all patients should be tested at least twice (on days 4 and 2 prior to surgery). For positive patients, procedures should be postponed until after swab test negativization. If the procedure is vital to the survival of the patient, filtering facepiece 3 (FFP3) and/or powered air purifying respirator (PAPR) devices, goggles, full-face visor, double gloves, water-resistant gowns, and protective caps are mandatory. For negative patients, use of at least an FFP2 mask is recommended. In all cases the use of drills, which promote the aerosolization of potentially infected mucous particles, should be avoided. Given the potential neurotropism of SARS-CoV-2, dura handling should be minimized. It is only through widely-agreed protocols and teamwork that we will be able to deal with the evolving and complex implications of this new pandemic.