Adenotonsillectomy in high risk patients: Hematologic abnormalities and COVID-19 considerations.

Adenotonsillectomy is one of the most common surgical procedures performed by otolaryngologists. It is vital that surgeons are aware of the risks in performing this surgery especially during the COVID-19 pandemic and in children with hematologic disorders. In this review we describe common hematologic disorders often noted in pediatric patients undergoing this procedure, as well as proper screening and management of these patients. In addition, we also address the impact of the COVID-19 pandemic and some measures to help mitigate the risks of this procedure during this time.

Impact of a History Tonsillectomy and Adenoidectomy on COVID-19 Hospitalization and ICU Admission

Introduction: It is hypothesized that tonsils and adenoids could be target organs for the SARS-CoV-2 virus. This study sought to exam the impact of a history of tonsillectomy and adenoidectomy (T&A) on COVID-19 hospitalization and intensive care unit admission (ICUA) and develop a predictive model. Method(s): One thousand COVID-19 positive (COVID+) and 1000 COVID-19 negative (COVID-) tested patients, randomly selected from a single institution from March to May 2020, were included. Patient demographics and clinical data were extracted. Chi-square, Fisher exact, and Wilcoxon rank sum tests were used for group comparisons. Multivariate (MV) logistic regression models built stepwise using Akaike information criterion were used to assess factors associated with hospitalization and ICUA in COVID+ patients. Result(s): COVID+ patients had statistically significant lower rates of T&A (19.9% vs 15.8%, P=.016), had a higher mean age (51.8 vs 54.5 years, P=.002), rate of African American race (19.3% vs 27.4%, P<.001), and male gender (38.2% vs 46.4%, P=.0008) compared with COVID- patients. Variables predictive of hospital admission for COVID+ patients included age (hazard ratio 1.5, P<.0001), African American race (2.1, P=.0008), immunosuppressive disease (2.3, P=.0025), male gender (2, P=.0008), and diabetes (1.9, P=.0050), along with asthma and heart disease in the MV model. Variables predictive of ICUA for COVID+ patients included age (1.3, P=.013), heart failure (2.8, P=.0059), and diabetes (3.5, P<.0001) in addition to tonsillectomy, immunosuppression, and COPD/ asthma in the MV model. Tonsillectomy appeared to have a covariate-adjusted association with reduced odds of ICUA but was not significant (0.5, P=.057). Conclusion(s): COVID+ patients had statistically significant lower rates of T&A in this study when compared with COVID- patients. Male gender and African American race were associated with increased odds of hospitalization, which warrants further investigation into a cause and the potential influence of health care disparities. Tonsillectomy appeared to have a covariate-adjusted association with reduced likelihood of ICUA but did not reach significance.

Utility of the Pediatric Smell Wheel in Children During the COVID-19 Pandemic

Introduction: Measuring pediatric odor detection in a COVID-19-impacted context is important. Our goal was to determine whether the Pediatric Smell Wheel (PSW) can be used effectively in this clinical setting. Method(s): Consecutive patients at a pediatric otolaryngology clinic who were aged 5-17 years were recruited. Demographics including gender, race, use of nasal topical medications, previous nasal surgery, and previous COVID-19 infection were collected. Each child performed a test of their sense of smell using the PSW (Sensonics International) under direct supervision, and scores were compared. Result(s): Forty-three children were included;mean age was 9.1 years (95% CI, 8.0-10.1);19 (44.2%) were female and 24 (55.8%) male. Thirteen (30.2%) used nasal sprays, 10 (23.2%) had undergone adenoidectomy, and 4 (9.3%) had other nasal surgery. Twenty (46.5%) had a previous COVID-19 infection. Mean and median PSW score out of 11 was 7 (95% CI, 6.4-7.7), ranging from 2 to 10. There was no significant difference in scores based on age, gender, race, use of nasal topicals, previous nasal surgery, or previous COVID-19 infection. Children were able to perform the task as directed. Percentage correct for each odorant on the PSW ranged from 86% for identifying the onion scent to 27.9% for identifying the popcorn scent. Cronbach alpha was 0.54, and deleting any individual item did not improve it above 0.57, indicating low internal consistency of the PSW. Conclusion(s): During the COVID-19 pandemic, children performed more poorly identifying odors on the PSW than previously reported. The reliability of the PSW may not be adequate in today's context.

The impact of national lockdown due to COVID-19 pandemic on frequency of occurrence of secretory otitis media in children - our experience

Objective: To present the impact of national lockdown due to COVID-19 pandemic on the incidence of persistent secretory otitis media in children. Patients: Children aged from four to 13 years who were surgically treated from 1st January 2017 to 31th December 2020 at the University Department of Otolaryngology, Head and Neck Surgery, University Hospital Center Osijek. Methods: Patients underwent otomicroscopy, tympanometry, tone audiometry and fiberendoscopy of the epipharynx. After confirmation of the existence of secretory otitis the children were treated surgically, using adenotomy and myringotomy by inserting ventilation tubes in the equilateral ear. Results: This study included 107 children who were surgically treated with adenotomy and myringotomy by inserting ventilation tubes. The results showed a significant decline in the number of operations in 2020 compared to the previous three years, presumably due to national lockdown closures. We recorded the largest difference comparing 2018 and 2020, when the number of operations decreased by 87%. Conclusions: Drastic reduction of activities during the national lockdown closure, schooling from home and emphasizing the proper and regular implementation of personal hygiene have contributed to reducing the incidence of one of the most common infections in children. Lower frequency of acute otitis media has a positive effect on reducing the frequency of development of secretory otitis in children. Compared to the previous three years, there has been a significant decline in the number of children requiring surgical treatment. This is the first retrospective study on the impact of national lockdown on reducing the need for surgical treatment of persistent secretory otitis in children. © 2022 Hrvatski Lijecnicki Zbor. All rights reserved.

Medical management of severe obstructive sleep apnoea in two cases during the coronavirus disease 2019 pandemic.

OBJECTIVE: Severe paediatric obstructive sleep apnoea in typically developing children with adenotonsillar hypertrophy is primarily managed surgically. Non-emergency ENT surgery was paused early in the coronavirus disease 2019 pandemic and children were offered medical management for obstructive sleep apnoea. METHODS: A service evaluation was performed to assess the impact of continuous positive airway pressure alongside medical management for severe obstructive sleep apnoea. RESULTS: Over 5 months during 2020, in a tertiary care setting, two children (one boy and one girl), aged 2.7 years and 4.1 years, were offered continuous positive airway pressure and medical treatments for severe obstructive sleep apnoea whilst surgery was paused during the coronavirus disease 2019 pandemic. Both children failed to establish continuous positive airway pressure therapy because of ongoing disturbed sleep on ventilation, and they proceeded to adenotonsillectomy. Sleep-Related Breathing Disorder scale scores improved following surgical intervention. CONCLUSION: Continuous positive airway pressure therapy is poorly tolerated in children with severe obstructive sleep apnoea secondary to adenotonsillar hypertrophy. Surgery remains the most appropriate treatment.

Preoperative SARS-CoV-2 Screening Fails to Detect Viral Particles Prior to Airway Surgery.

OBJECTIVES/HYPOTHESIS: Children have higher rates of asymptomatic SARS-CoV-2 infections or milder courses of infection, and their carrier status may potentially impact viral transmission to those providing them care. The aim of this study is to compare the existing COVID-19 preoperative screening protocols to the detection of SARS-CoV-2 viral particles in surgical samples. STUDY DESIGN: Cross-sectional study. METHODS: We conducted a prospective study with consecutive convenience sampling of children undergoing adenoidectomy between January and April 2021. Total nucleic acid was extracted from adenoid tissue and real-time reverse transcription-polymerase chain reaction was conducted to test for the presence of SARS-CoV-2 viral particles. Univariate logistic regression was used to summarize the effect size of variables of interest on the odds of having SARS-CoV-2 positive adenoid tissue. RESULTS: Forty adenoid samples were collected and 11 (27.5%) had a positive SARS-CoV-2 reverse transcriptase-polymerase chain reaction. Patients with positive adenoids were older (11.8 vs. 7.9 years, odds ratio: 1.3, P = .01) and more likely to have had a positive nasopharyngeal swab in the previous 90 days (4/11 or 36% vs. 0). CONCLUSION: These data are the first report on the presence of SARS-CoV-2 particles in pediatric adenoidectomy specimens, with a high percentage of patients showing evidence of viral particles within the adenoid. This finding calls in to question the utility of preoperative COVID screening protocols which have yet to be rigorously validated in asymptomatic patients and have the potential to delay patients' surgical care. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:1665-1667, 2022.

Detection of Respiratory Pathogens Does Not Predict Risks After Outpatient Adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To determine whether the presence of detectable upper respiratory infections (URIs) at the time of adenoidectomy/adenotonsillectomy is associated with increased morbidity, complications, and unexpected admissions. STUDY DESIGN: Prospective double-blinded cohort. METHODS: In this prospective cohort study, nasopharyngeal swabs were obtained intraoperatively from 164 pediatric patients undergoing outpatient adenoidectomy/tonsillectomy with or without pressure equalization tubes (PETs) and were analyzed with PCR for the presence of 22 known URIs, including SARS-CoV-2. Surgeons and families were blinded to the results. At the conclusion of the study, rates of detectable infection were determined and intraoperative and postoperative events (unexpected admissions, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, and postoperative presentation to an emergency department) were compared between infected and uninfected patients. RESULTS: Of the 164 patients (50% male, 50% female, ages 8 mo-18 y), 136 patients (82.9%) tested positive for one or more URI at the time of surgery. Forty one patients (25.0%) tested positive for three or more URIs concurrently, and 11 (6.7%) tested positive for five or more URIs concurrently. There were no significant differences in admission rates, length of PACU stay, rates of laryngospasm/bronchospasm, oxygen desaturation, bradycardia, or postoperative presentation to an emergency department between positive and negative patients. No patients tested positive for SARS-CoV-2. CONCLUSIONS: A recent positive URI test does not confer any additional intraoperative or postoperative risk in the setting of outpatient adenoidectomy/tonsillectomy in healthy patients. There is no utility in preoperative URI testing, and delaying surgery due to a recent positive URI test is not warranted in this population. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2074-E2079, 2021.

ENT management of children with adenotonsillar disease during COVID-19 pandemic. Ready to start again?

Clinical manifestations of COVID-19 in children are milder, but the real burden of disease is unknown. After the lockdown, in our Region Lombardia we have been requested to progressively resume medical services including outpatient assessment and priority surgery. Therefore, we screened surgical waiting lists with identification of 47 children candidates to priority surgery (among 358). No homogeneous national health surveillance/screening programs are ongoing or have been conceived to test susceptible population among children/healthcare workers in preparation of coming down to routinely daily activities, and diagnostic strategies are not completely accurate in children. So, restoring medical services now might be untimely.