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1.
Ann R Coll Surg Engl ; 2022 Apr 21.
Article in English | MEDLINE | ID: covidwho-1808509

ABSTRACT

INTRODUCTION: Adenotonsillectomy is commonly performed for recurrent tonsillitis and obstructive sleep apnoea. These conditions may improve with age. The COVID-19 pandemic led to all UK elective surgery being suspended. This study aimed to determine whether delaying surgery had any effect on a patient's symptoms using the validated T-14 paediatric throat disorders outcome test. METHODS: Patients completed a T-14 questionnaire when the child was listed for surgery; this was repeated on the revised surgery date and a paired t test was used to compare the responses. RESULTS: Questionnaires were completed by 29 patients a mean of 6.4 months apart. There was a significant improvement in scores (p<0.02) for five domains: eating habits, visits to a doctor/A&E, antibiotics for less than 2 weeks, chronic infections and school missed due to sore throats. CONCLUSIONS: This study demonstrates that following delays resulting from the COVID-19 pandemic, paediatric patients experienced an improvement in some aspects of their quality of life while awaiting tonsillectomy and/or adenoidectomy. This was most apparent in quality-of-life measures relating to recurrent tonsillitis, namely visits to a doctor/A&E, antibiotics for less than 2 weeks, chronic infections and school missed due to sore throats. Patients may experience an improvement in some of their individual symptoms, in particular their infective symptoms, during an observation period.

2.
Cureus ; 14(2): e22271, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1776610

ABSTRACT

Peritonsillar abscess (PTA) is a common deep tissue infection of the head and neck. In the literature, most cases demonstrate PTA following acute tonsillitis; however, less documented are cases arising in post-tonsillectomy patients. Here, we report a 45-year-old woman with a history of tonsillectomy 16 years prior, who presented to the emergency department with signs and symptoms consistent with PTA, including sore throat and the presence of a right-sided abscess in the posterolateral oropharynx with apparent pus. The patient reported three previous episodes of right-sided PTA, all of which were addressed via drainage and antibiotic treatment. This episode was treated similarly; cultures from the abscess revealed no growth of organisms. The patient was started on a short course of clindamycin and discharged to follow-up with her primary care physician. Several theories for the etiology of PTA development in post-tonsillectomy patients exist. One theory suggests that PTA may develop in this group of patients due to imperfect margins during the initial surgery, with residual tonsil tissue serving as a nidus for abscess development. Other theories suggest that a congenital fistula may exist in these patients, which, when occluded by scar tissue following a tonsillectomy, may lead to PTA development. Similarly, occlusion of minor salivary ducts has also been suggested to play a role in this unique pathophysiology. Overall, documenting rare cases of PTA development in post-tonsillectomy patients serves as a means of better understanding the complicated etiology behind PTA development and may be able to guide treatment in the future.

3.
British Journal of Surgery ; 109(SUPPL 1):i37-i38, 2022.
Article in English | EMBASE | ID: covidwho-1769139

ABSTRACT

Aim: In June 2020, and after the first wave of the COVID outbreak has settled, we resumed operating in our trust for elective surgery in three different hospitals. However, it was thought that the number of posttonsillectomy complications had increased. We performed an audit to evaluate the rate of post-tonsillectomy complications in our trust and investigate possible causes. Method: We measured the rates of patients who developed complications post-operatively during the period from June to November 2020 and compared it to the rates in the pre-COVID year and the national rate. Moreover, we scrutinized retrospectively the operative notes of each patient presenting with a post-tonsillectomy complication and identified risk factors. Results: In the study period, we performed 129 tonsillectomies. Of these patients, 14 presented with complications;11of which had bleeding, while 3 had post-operative pain. Two patients needed to return to the theatre to control the bleeding. During the same period in 2019, 28 patients had complications out of a total of 199 patients. The rate of complications in 2020 was 10% which compared favourably with the previous year (14%). The highest number of patients (9/14) was in a hospital which posed a new environment to our surgeons. Dissection by Bipolar diathermy was the most contribute factor for bleeding in most patients (11/14). Conclusions: The disruption caused by the pandemic situation did not influence overall rates of complications. However, the hospital which presented a new operating environment had the highest rate.

4.
J Laryngol Otol ; : 1-2, 2022 Mar 21.
Article in English | MEDLINE | ID: covidwho-1751639

ABSTRACT

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.

5.
Eur Arch Otorhinolaryngol ; 2022 Feb 26.
Article in English | MEDLINE | ID: covidwho-1712236

ABSTRACT

PURPOSE: To longitudinally evaluate the impact of the COVID-19-pandemic on the incidence of inpatient tonsil surgery and outpatient primary care of sore throat in Germany. METHODS: A retrospective interrupted time-series analysis was conducted. The national database of the Hospital Remuneration System was used to retrieve the number of operations performed between January 2019 and September 2021 including elective and non-elective cases with the exception of malign diseases. Three episodes were compared on a weekly basis: before, during, and after the first national lockdown (March 16-May 3, 2020). We also analysed the number of outpatient doctor contacts of sore throat patients in 2019 and 2020. RESULTS: Overall, 144,069 surgical cases were included in the analysis. The first lockdown resulted in an abrupt and significant decrease of all types of tonsil surgery (p < 0.01). The incidence of tonsillectomy decreased from 556 (before) to 111 (during) and 326 (after) cases per week (relative risk 0.24; 95% CI 0.19-0.30, and 0.82; 95% CI 0.73-0.92). After the lockdown, the incidence persisted on a lower level compared to 2019. The number of doctor contacts decreased from 2,967,322 in 2019 to 1,976,617 in 2020 (- 33.4%). CONCLUSIONS: The first lockdown was associated with a significant decrease of all types of tonsil surgery. A return to pre-pandemic surgical activity was not identified. The findings were accompanied by a significant decrease of outpatient doctor contacts of sore throat patients in primary care, particularly in the subgroup of children and adolescents. The impact of the second lockdown, starting in December 2020, was by far not comparable.

6.
Laryngoscope Investig Otolaryngol ; 7(1): 43-46, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1669593

ABSTRACT

OBJECTIVE: To compare the degree of particle aerosolization with the use of several energy devices used in tonsillectomy and other common upper airway procedures. METHODS: Three different energy devices were measured. These included (a) monopolar electrocautery, (b) bipolar electrocautery, and (c) thermal welding device (TWD). Each device was applied to fresh cadaveric cow tongue and porcine nose. Aerosolized particles produced by these devices were measured using a calibrated electronic particle counter. Measurements were recorded over the course of 3 minutes. Particle sizes were measured at 0.3, 0.5, 1.0, 5, and 10 µm. RESULTS: In comparing types of tissues and particle sizes, TWD had the lowest aerosolizing burden among the three devices. By analyzing the highest particle value of TWD against both monopolar and bipolar, monopolar electrocautery proved to have the highest aerosolization exposure with statistical significance at 0.5 and 10 µm. No statistical significance was found when comparing TWD against monopolar electrocautery. DISCUSSION: Our study demonstrates there is a difference in aerosolization burden dependent on the type of device utilized. TWD proved to have the lowest burden whereas monopolar electrocautery had the highest. CONCLUSION: TWD produces less aerosolization than conventional monopolar electrocautery when cauterizing or ablating tissue in an experimental setting. The degree of aerosolization was comparable to bipolar electrocautery. LEVEL OF EVIDENCE: 2.

7.
British Journal of Surgery ; 108(SUPPL 6):vi195, 2021.
Article in English | EMBASE | ID: covidwho-1569616

ABSTRACT

Introduction: Good Surgical Practice from RCS England encourages the use of e-health records and detailed typed operative notes. The Covid- 19 pandemic has led to multi-site operating. ENT operations in our trust were split over three sites including the private sector leading to potential disruption in continuity of patient care. Physical operation notes are difficult to access in emergencies, telephonic clinics or for audit purposes. We aim to have operative notes available on patients' erecords which adhere to RCSEng guidelines. Method: In this QIP, we reviewed all ENT operations over a retrospective one-month period recording percentage of notes uploaded to patient e-record and the number of surgeons in theatre. We created two novel RCSEng compliant e-operative notes with a user guide, generic and tonsillectomy-specific, and prospectively collected data to complete the cycle. Results: 261 patients were included in both study periods. Only 36/ 134(27%) had e-operative pre-intervention improving to 71/127(56%) post-intervention. In the latter period, 76% of operations included a registrar and were more likely to have e-operative notes(72%) compared to when a consultant was operating alone(6%). There was low uptake of our tonsillectomy e-proforma(33%). Conclusions: Our QIP has already proved effective with our templates increasing operative documentation on e-records. Increased use of etemplate was more likely with the presence of a registrar in theatre. Room for improvement remains and we will re-audit after the introduction of further user-friendly operative templates and IT training. This QIP has also revealed additional operative training opportunities of which registrars can take advantage.

8.
Otolaryngol Head Neck Surg ; : 1945998211064275, 2021 Dec 07.
Article in English | MEDLINE | ID: covidwho-1556869

ABSTRACT

OBJECTIVE: To offer pragmatic, evidence-informed advice on administering corticosteroids in otolaryngology during the coronavirus disease 2019 (COVID-19) pandemic, considering therapeutic efficacy, potential adverse effects, susceptibility to COVID-19, and potential effects on efficacy of vaccination against SARS-CoV-2, which causes COVID-19. DATA SOURCES: PubMed, Cochrane Library, EMBASE, CINAHL, and guideline databases. REVIEW METHODS: Guideline search strategies, supplemented by database searches on sudden sensorineural hearing loss (SSNHL), idiopathic facial nerve paralysis (Bell's palsy), sinonasal polyposis, laryngotracheal disorders, head and neck oncology, and pediatric otolaryngology, prioritizing systematic reviews, randomized controlled trials, and COVID-19-specific findings. CONCLUSIONS: Systemic corticosteroids (SCSs) reduce long-term morbidity in individuals with SSNHL and Bell's palsy, reduce acute laryngotracheal edema, and have benefit in perioperative management for some procedures. Topical or locally injected corticosteroids are preferable for most other otolaryngologic indications. SCSs have not shown long-term benefit for sinonasal disorders. SCSs are not a contraindication to vaccination with COVID-19 vaccines approved by the US Food and Drug Administration. The Centers for Disease Control and Prevention noted that these vaccines are safe for immunocompromised patients. IMPLICATIONS FOR PRACTICE: SCS use for SSNHL, Bell's palsy, laryngotracheal edema, and perioperative care should follow prepandemic standards. Local or topical corticosteroids are preferable for most other otolaryngologic indications. Whether SCSs attenuate response to vaccination against COVID-19 or increase susceptibility to SARS-CoV-2 infection is unknown. Immunosuppression may lower vaccine efficacy, so immunocompromised patients should adhere to recommended infection control practices. COVID-19 vaccination with Pfizer-BioNTech, Moderna, or Johnson & Johnson vaccines is safe for immunocompromised patients.

9.
Otolaryngol Head Neck Surg ; 164(6): 1186-1192, 2021 06.
Article in English | MEDLINE | ID: covidwho-1455831

ABSTRACT

OBJECTIVE: To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation. STUDY DESIGN: Randomized double-blinded clinical trial based on prospective parallel design. SETTING: Academic medical center and tertiary children's hospital between March 2018 and July 2019. METHODS: Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events. RESULTS: Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13). CONCLUSIONS: As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.


Subject(s)
Adenoidectomy/methods , Electrocoagulation , Radiofrequency Ablation , Tonsillectomy/methods , Adolescent , Child , Child, Preschool , Double-Blind Method , Female , Humans , Male , Prospective Studies , Treatment Outcome
10.
Acta Otolaryngol ; 141(9): 857-859, 2021 Sep.
Article in English | MEDLINE | ID: covidwho-1390257

ABSTRACT

BACKGROUND: Due to many different reasons such as possible coronavirus colonization in tonsillar tissue, decreased enzymatic antiviral activity, decreased cytokine activity from palatine tonsil tissue and reduced humoral and cellular immune response, tonsillectomy may alter the incidence of Covid-19. AIMS/OBJECTIVES: To reveal the frequency of Covid-19 in patients who underwent tonsillectomy and to analyze the effect of tonsillectomy on the severity of the disease. MATERIALS AND METHODS: Patients aged between 15 and 65 and had a history of tonsillectomy were compared with control group in terms of incidence and severity of Covid-19 disease. RESULTS: A 4% Covid rRT-PCR test positivity rate was detected in patients with tonsillectomy whereas; it was 6.8% in the control group with a statistically significant difference. However, in terms of disease severity there was no difference between the two groups. CONCLUSIONS AND SIGNIFICANCE: It has been proven that tonsillectomy surgery does not pose an additional risk in terms of COVID 19 disease severity. The positive effect of tonsillectomy in terms of disease frequency has been even demonstrated for the first time in the literature.


Subject(s)
COVID-19/epidemiology , Tonsillectomy , Tonsillitis/surgery , Adolescent , Adult , Aged , COVID-19/diagnosis , COVID-19 Nucleic Acid Testing , Case-Control Studies , Female , Humans , Incidence , Male , Middle Aged , Prognosis , Reverse Transcriptase Polymerase Chain Reaction , Tonsillitis/diagnosis , Tonsillitis/etiology , Turkey , Young Adult
11.
Otolaryngol Head Neck Surg ; : 1945998211037707, 2021 Aug 17.
Article in English | MEDLINE | ID: covidwho-1360602

ABSTRACT

The "tonsil riots" of 1906 were panics that developed at several public schools in historically immigrant-dominated neighborhoods of New York City (NYC). Per archived newspaper articles, several NYC public schools asked for parental consent to have Board of Health physicians come and perform tonsillectomy and adenoidectomy on their students. When children subsequently returned home from school "drooling mouthfuls of blood and barely able to speak," mothers reacted with panic and flocked to the schools demanding the safe return of their children. Police, ultimately, had to be called in to manage the crowds, and the events of 1906 largely faded from the public eye. However, these events can offer important lessons in communication and cultural humility as the United States continues its mass vaccination against coronavirus disease 2019.

12.
World J Otorhinolaryngol Head Neck Surg ; 7(3): 174-178, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-1253736

ABSTRACT

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.

13.
Acta Otorhinolaryngol Ital ; 41(3): 197-205, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1222316

ABSTRACT

OBJECTIVE: Interactions between SARS-CoV-2 and pharyngeal associated lymphoid tissue are thought to influence the manifestations of COVID-19. We aimed to determine whether a previous history of tonsillectomy, as a surrogate indicator of a dysfunctional pharyngeal associated lymphoid tissue, could predict the presentation and course of COVID-19. METHODS: Multicentric cross-sectional observational study involving seven hospitals in Northern and Central Italy. Data on the clinical course and signs and symptoms of the infection were collected from 779 adults who tested positive for SARS-CoV-2, and analysed in relation to previous tonsillectomy, together with demographic and anamnestic data. RESULTS: Patients with previous tonsillectomy showed a greater risk of fever, temperature higher than 39°C, chills and malaise. No significant differences in hospital admissions were found. CONCLUSIONS: A previous history of tonsillectomy, as a surrogate indicator of immunological dysfunction of the pharyngeal associated lymphoid tissue, could predict a more intense systemic manifestation of COVID-19. These results could provide a simple clinical marker to discriminate suspected carriers and to delineate more precise prognostic models.


Subject(s)
COVID-19 , Palatine Tonsil , Tonsillectomy/adverse effects , Adult , Aged , COVID-19/epidemiology , Cross-Sectional Studies , Female , Humans , Italy/epidemiology , Male , Middle Aged , Palatine Tonsil/surgery , Pandemics , SARS-CoV-2
14.
Laryngoscope ; 131(6): E2074-E2079, 2021 06.
Article in English | MEDLINE | ID: covidwho-908740

ABSTRACT

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.


Subject(s)
Adenoidectomy , Air Microbiology , Ambulatory Surgical Procedures , Respiratory Tract Infections/microbiology , Surgical Wound Infection/microbiology , Tonsillectomy , Adolescent , Child , Child, Preschool , Cohort Studies , Double-Blind Method , Female , Humans , Infant , Male , Nasopharynx/microbiology , Prospective Studies , Risk , Risk Factors
15.
Eur Arch Otorhinolaryngol ; 278(7): 2631-2636, 2021 Jul.
Article in English | MEDLINE | ID: covidwho-800731

ABSTRACT

PURPOSE: Otorhinolaryngological surgeries being highly aerosol-generating carry the risk of transmission of SARS-CoV-2. Most centers have canceled elective surgeries. Surgical demonstration and hands-on training of postgraduate residents are challenging during the COVID-19 pandemic. Continued training of residents is of utmost importance in terms of time and skill development. Tonsillectomy is one of the most common and important surgeries in ENT. Resident training of tonsillectomy is essential. Here, we present a simple, inexpensive model for tonsillectomy hands-on training addressing critical steps of the surgery. METHODS: An oropharynx and tonsil model is prepared using easily available materials, such as a small plastic tub, gauze pieces, ribbon gauze, and rubber strips. The junior residents are trained in all the critical steps of tonsillectomy using routine tonsillectomy instruments. CONCLUSION: This model for tonsillectomy is a simple, inexpensive model for training postgraduate residents during and after the COVID-19 pandemic. We hope that this model can help young residents to get trained in critical steps of tonsillectomy, in a closely simulated environment and help them develop confidence and skills in managing live patients.


Subject(s)
COVID-19 , Internship and Residency , Tonsillectomy , Humans , Pandemics , SARS-CoV-2
16.
Am J Otolaryngol ; 41(6): 102737, 2020.
Article in English | MEDLINE | ID: covidwho-799098

ABSTRACT

PURPOSE: Surgeons resuming elective procedures during the COVID-19 pandemic should consider strategies to mitigate risk of exposure. For otolaryngologists performing surgery on children, unique vulnerability to SARS-CoV-2 results from a regular interface with the upper respiratory tract mucosa. A growing interest in perioperative application of povidone­iodine (PVP-I) to the nasopharynx and oropharynx has emerged. The purpose of this review is to provide an evidence-based assessment of PVP-I in pediatric oral, nasal and pharyngeal surgery. METHODS: A contemporary literature review with algorithmic approach to the potential use of PVP-I in pediatric mucosal surgery. RESULTS: Several formulations of PVP-I have shown rapid in vitro virucidal activity against SARS-CoV-2. Antisepsis using 1.0% PVP-I mouthwash and 0.45% PVP-I throat spray can occur after 30 seconds of contact time. To date, in vivo effectiveness of PVP-I against SARS-CoV-2 has yet to be established and possible risks of its direct use on upper aerodigestive mucosa of children must be weighed. CONCLUSION: Further research is required prior to strongly recommending PVP-I use in preparation for nasal, oral or pharyngeal surgery in children.


Subject(s)
Anti-Infective Agents, Local/administration & dosage , Coronavirus Infections/prevention & control , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Otorhinolaryngologic Surgical Procedures , Pandemics/prevention & control , Pneumonia, Viral/prevention & control , Povidone-Iodine/administration & dosage , Betacoronavirus , COVID-19 , Child , Coronavirus Infections/epidemiology , Coronavirus Infections/transmission , Humans , Nasopharynx , Oropharynx , Pneumonia, Viral/epidemiology , Pneumonia, Viral/transmission , SARS-CoV-2
17.
Am J Otolaryngol ; 41(5): 102583, 2020.
Article in English | MEDLINE | ID: covidwho-457319

ABSTRACT

During an ongoing pandemic of COVID-19, controlling the oropharyngeal bleeding, such as post-tonsillectomy hemorrhage, with cauterization is considered a very vulnerable procedure for medical staff because of high probability of exposure to aerosolized secretion. The authors aimed to introduce an appropriate treatment protocol for oropharyngeal bleeding that provides first aid to patients while protecting medical staff at high-risk of infection such as COVID-19.


Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Coronavirus Infections/prevention & control , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Pandemics/prevention & control , Pneumonia, Viral/epidemiology , Pneumonia, Viral/prevention & control , Postoperative Hemorrhage/therapy , Tonsillectomy/adverse effects , COVID-19 , Coronavirus Infections/transmission , Humans , Pneumonia, Viral/transmission , Postoperative Hemorrhage/etiology , SARS-CoV-2
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