10.14639/0392-100X-N0832
Objective. The aim of this study was to provide an accurate picture of the changes which have occurred and contributions given by Italian Otolaryngology Units during the COVID-19 pandemic.
Methods. A 28-item questionnaire was completed and returned by 154 Otorhinolaryngology Units across the country. This investigated their geographic distribution involvement, the main changes which occurred in workload management and in clinical and surgical activities, and the screening procedures for COVID-19 in healthcare personnel and patients. &nbsp;
Results. Nearly half of the Otolaryngology Units who responded to the questionnaire were merged with other units, while 22% were converted into COVID-19 units or temporarily closed. A reduction of 8.55% in the number of team members was reported, and about 50% of the departments applied uniform work shifts for all staff. All elective activities were uniformly stopped or delayed, passing from 30,295 (pre-COVID data) to 5,684 (COVID data) weekly procedures, with a mean decrease of 81.24% (p&lt;0.001).
Conclusions. Italian Otolaryngology surgeons have demonstrated a high availability to collaborate with non-surgery colleagues, and most of their elective activities, apart from oncology and emergency medical and surgical procedures, have been suspended.
&nbsp;
application/xml
1827-675X
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Gabriele Molteni
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
pandemic
Impact of COVID-19 pandemic on Italian Otolaryngology Units: a nationwide study
Text.Serial.Journal
https://www.actaitalica.it/
40
COVID-19
2020-09-24
2020-05-07
2020-12-04
2020-12-09
325-331
1
Gabriele Molteni
2020/09/24
10.14639/0392-100X-N0832
325
COVID-19 Task Force of the Young Otolaryngologists of the Italian Society of Otolaryngology Head and Neck Surgery; Otolaryngology, Head and Neck Surgery Unit, University Hospital of Verona Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Italy
1827-675X
5
pandemic
331
Impact of COVID-19 pandemic on Italian Otolaryngology Units: a nationwide study
https://www.actaitalica.it/article/download/832/383
40
ACTA OTORHINOLARYNGOLOGICA ITALICA2020;40:325-331; doi: 10.14639/0392-100X-N0832




COVID-19


Impact of COVID-19 pandemic
on Italian Otolaryngology Units: a nationwide study
Impatto della pandemia COVID-19 sulle Unità Operative di Otorinolaringoiatria in Italia:
uno studio nazionale
Giuditta Mannelli1,2, Massimo Ralli1,3, Marco Bonali1,4, Pasquale Capasso1,5, Pierre Guarino1,6, Valeria Iannini1,7,
Niccolò Mevio1,8, Gennaro Russo1,5, Alfonso Scarpa1,9, Giacomo Spinato1,10, Davide Topazio1,11, Gabriele Molteni1,12
1
  COVID-19 Task Force of the Young Otolaryngologists of the Italian Society of Otolaryngology Head and Neck Surgery;
2
  Head and Neck Oncology and Robotic Surgery, Department of Experimental and Clinical Medicine, University of Florence, Italy;
3
  Department of Sense Organs, Sapienza University of Rome, Italy; 4 Otolaryngology Head and Neck Surgery Department, University of
Modena, Italy; 5 Otolaryngology, Head and Neck Surgery Unit AO dei Colli, Monaldi Hospital, Napoli, Italy; 6 Otorhinolaryngology, Head
and Neck Surgery Unit “Santo Spirito” Hospital of Pescara, Italy; 7 Otolaryngology Department, Dipartimento Strutturale Ospedaliero
Chirurgico di Rovigo ULSS 5, Rovigo, Italy; 8 Department of Otolaryngology Niguarda Hospital, Milano, Italy; 9 Department of Medicine
and Surgery, University of Salerno, Italy; 10 Department of Neurosciences, Section of Otolaryngology and Regional Centre for Head
and Neck Cancer, University of Padova, Treviso, Italy - Department of Surgery, Oncology and Gastroenterology, Section of Oncology
and Immunology, University of Padova, Italy; 11 Otolaryngology Department, Ospedale Mazzini, Teramo, Italy; 12 Otolaryngology, Head
and Neck Surgery Unit, University Hospital of Verona Borgo Trento, Department of Surgery, Dentistry, Paediatrics and Gynaecology,
University of Verona, Italy


SUMMARY                                                                                                 Received: May 7, 2020
Objective. The aim of this study was to provide an accurate picture of the changes which                Accepted: May 21, 2020
have occurred during the COVID-19 pandemic, and the contributions given by Italian                      Published online: September 24, 2020
Otolaryngology Units.
Methods. A 29-item questionnaire was completed and returned by 154 Otorhinolaryngology                  Correspondence
Units across Italy that investigated geographic distribution, the main changes which                    Giuditta Mannelli
                                                                                                        Head and Neck Oncology and Robotic Surgery,
occurred in workload management and in clinical and surgical activities and screening
                                                                                                        Department of Experimental and Clinical Medicine,
procedures for COVID-19 in healthcare personnel and patients.                                           University of Florence, largo Brambillla 3,
Results. Nearly half of the Otolaryngology Units that responded to the questionnaire                    50134 Florence, Italy
were merged with other units, while 22% were converted into COVID-19 units or                           Tel. +39 055 794 5489
temporarily closed. A reduction of 8.55% in the number of team members was reported,                    E-mail: mannelli.giuditta@gmail.com
and about 50% of the units applied uniform work shifts for all staff. Elective activities
were uniformly stopped or delayed, passing from 30,295 (pre-COVID data) to 5,684                        Funding
(COVID data) weekly procedures, with a mean decrease of 81.24% (p < 0.001).                             None.
Conclusions. Most of the elective otolaryngology activities were suspended during
the pandemic; the only procedures were for oncology and emergency patients. Italian                     Conflict of interest
Otolaryngologists have demonstrated a high availability to collaborate with non-surgical                The Authors declare no conflict of interest.
colleagues.
KEY WORDS: COVID-19, otolaryngology, SARS-CoV-2, pandemic                                                 How to cite this article: Mannelli G, Ralli M, Bo-
                                                                                                          nali M, et al. Impact of COVID-19 pandemic on
                                                                                                          Italian Otolaryngology Units: a nationwide stu-
RIASSUNTO                                                                                                 dy. Acta Otorhinolaryngol Ital 2020;40:325-331.
Obiettivo. Fornire un quadro accurato dei cambiamenti che si sono verificati e dei contri-                https://doi.org/10.14639/0392-100X-N0832
buti forniti dalle Unità di Otorinolaringoiatria italiane durante la pandemia COVID-19.
Metodi. Un questionario di 29 domande è stato completato da 154 unità. Sono stati inve-                 © Società Italiana di Otorinolaringoiatria
stigati la distribuzione geografica del loro coinvolgimento, i cambiamenti di gestione del              e Chirurgia Cervico-Facciale
carico di lavoro e delle attività clinico-chirurgiche e le procedure di screening applicate su
personale sanitario e pazienti.                                                                                        OPEN ACCESS
Risultati. Quasi la metà delle Unità che hanno risposto sono state fuse con altre unità opera-          This is an open access article distributed in accordance with
tive, mentre il 22% è stato convertito in unità COVID-19 o temporaneamente chiuso. È stata              the CC-BY-NC-ND (Creative Commons Attribution-Non-
segnalata una riduzione dell’8,55% nel numero dei membri del gruppo di lavoro e circa il 50%            Commercial-NoDerivatives 4.0 International) license. The
                                                                                                        article can be used by giving appropriate credit and mentio-
dei dipartimenti ha applicato turni di lavoro per tutto il personale. Tutte le attività elettive sono   ning the license, but only for non-commercial purposes and
state uniformemente interrotte o ritardate, passando da 30.295 (dati pre-COVID) a 5.684 (dati           only in the original version. For further information: https://
COVID) procedure settimanali, con una diminuzione media dell’81,24% (p < 0,001).                        creativecommons.org/licenses/by-nc-nd/4.0/deed.en




                                                                                                                                                                325
G. Mannelli et al.




Conclusioni. La maggior parte delle attività elettive in otorinolaringoiatria, a parte le procedure oncologiche e di emergenza, sono state
sospese. Gli otorinolaringoiatri italiani hanno dimostrato un’alta disponibilità a collaborare con i reparti di medicina.
PAROLE CHIAVE: COVID-19, otolaringoiatria, SARS-CoV-2, pandemia



Introduction                                                           a questionnaire administered to Italian Otolaryngology
                                                                       Units.
The ongoing pandemic of Severe Acute Respiratory
Syndrome CoronaVirus-2 (SARS-CoV-2) infection, also
known as COVID-19, has spread rapidly worldwide since                  Materials and methods
the first cases in Wuhan, China 1. The first cases in Italy were       This study was performed by the COVID-19 Task Force
diagnosed in Rome on January 29, 2020, when two Chinese                of the Italian Young Otorhinolaryngologists (GOS). On
tourists tested positive for the virus and were hospitalised           April 16, 2020, a 29-item questionnaire was sent by e-mail
and isolated at Spallanzani Hospital. On January 31st, the             to all Otolaryngology Units in Italy (n = 296); each unit was
Italian government declared a national emergency.                      asked to respond within 4 days and the final compilation
Since the first case of an Italian patient affected by                 deadline was set as April 22, 2020. Data were subsequently
COVID-19 in the town of Lodi, Lombardy, the number of
                                                                       collected and compiled anonymously in a unified dataset.
patients and related deaths in Italy progressively increased 2.
                                                                       Duplicates, when present, were removed.
In fact, despite attempts to limit the outbreak at the primary
                                                                       The questionnaire investigated three major aspects of
cluster of infections by quarantining citizens and isolating
                                                                       Italian Otolaryngology Units during the pandemic:
the area, similar cases were progressively diagnosed in other
                                                                       1. the geographic distribution of respondent units;
cities and neighboring regions, such as Veneto and Emilia-
                                                                       2. the main changes in workload management and
Romagna, without evidence of any epidemiologic correlation
to the first case. Since then, the COVID-19 infection spread              distribution in terms of outpatient and inpatient procedure
across the country despite the containment measures applied               volumes;
by the Italian government, making Italy one of the worst               3. COVID-19 screening procedures for patients and
hit countries with more than 214,457 confirmed cases and                  healthcare workers.
29,684 deaths reported as of May 7, 2020 3. On March 11,               According to the Italian Instituto Superiore di Sanità (ISS)
2020, the Director-General of the World Health Organization            data 9, Italian regions were divided into five zones based on
(WHO) declared COVID-19 a pandemic 4.                                  the total number of cases as follows: 1) > 20,000 (Lombardia,
In the last two months, the Italian National Healthcare                Emilia-Romagna); 2) 10,000-20,000 (Piemonte, Veneto);
System has undergone multiple changes to face the                      3) 3,000-10,000 (Toscana, Marche, Lazio, Provincia
pandemic, with closure or conversion of many units and                 Autonoma di Trento, Campania, Puglia, Liguria); 4) 1,000-
hospitals into units solely dedicated to the treatment of              3,000 (Abruzzo, Friuli Venezia Giulia, Umbria, Provincia
COVID-19 patients 5. Most elective outpatient clinical and             Autonoma di Bolzano, Sicilia, Valle D’Aosta, Sardegna);
surgical procedures were delayed or suspended, allowing                5) < 1,000 (Molise, Calabria, Basilicata).
the confluence of most of the resources towards Emergency
Departments, Infectious Diseases Units, Respiratory                    Statistical analysis
Disease Units and Intensive Care Units (ICUs) 6,7.                     Descriptive analysis was used to define the main clinical
In this setting, although Otolaryngology-Head and Neck                 and demographic characteristics based on the responses
surgeons were not in the frontline of action, they were asked to       to the questionnaire. Unpaired T test was used to evaluate
contribute in managing patients with upper airway impairment,          differences for numeric values. A p-value less than 0.05
provide basic assistance, perform screening procedures (i.e.           was considered the cutoff for statistical significance. Prism
upper airway swab) and perform temporary tracheotomies in              Software version 8.3.1 (GraphPad Software LLC) was used
ICUs. This new arrangement implied a significant change in             to perform statistical analysis.
otolaryngology activities across the country 8.
The aim of this nationwide study, in accordance with the
                                                                       Results
Italian Society of Otolaryngology Head and Neck Surgery
(SIOeChCF), was to provide a picture of the changes                    One-hundred fifty-four Otolaryngology Units (52%)
and contributions of otolaryngologist specialists during               completed the questionnaire; 134 (87%) units were public
the COVID-19 pandemic over the last 2 months through                   and 20 (13%) were private and/or affiliated health facilities.



326
                                                                                                 Geographic distribution and changes in the workload management




Geographic distribution of respondent Italian                                            (45.5%) were merged with other units, and 10.4% were
Otolaryngology Units                                                                     temporarily closed. Interestingly, no changes were reported
Lombardy represented the region with the highest number                                  by 10.4% of the units, while 11.6% were converted into
of Otolaryngology Units that replied to the questionnaire,                               COVID-19 wards. A significant reduction in hospital
while the lowest response rates were registered in Trentino                              beds was reported by the remaining units (22.1%). Table I
Alto Adige, Valle d’Aosta and Molise. Figure 1 reports the                               summarises the activity changes sorted by zone.
geographic distribution of respondent units. Figure 2 shows                              A reduction in the number of team members was reported,
the division of zones and the number of responses received                               and its percentage change during the pandemic was
from each zone. Thirty-eight responses were received from                                compared to the pre-COVID-19 setting. A decrease of
units in zone 1, 27 from units in zone 2, 60 from zone 3, 21                             6.07% was recorded in the total number of otolaryngology
from zone 4 and 8 from units in zone 5.                                                  specialists belonging to the 154 units, which declared
Based on the responses received, the majority of units                                   a pre-COVID staff number of 1,136 specialists which
                                                                                         was reduced to 1,067 during the state of emergency. The
                                                                                         difference was not statistically significant (p = 0.364). In
                                                                                         addition, the number of residents on duty was reduced
                                                                                         from 465 to 397 (percentage reduction: 14.6%; p = 0.054).
                                                                                         The reduction in each unit was proportional to work shift
                                                                                         changes applied by each zone (Tab. II).
                                                                                         Interestingly, nearly 70% (107/154) of the respondents
                                                                                         declared a reallocation of staff members to Internal
                                                                                         Medicine COVID-19 Units (52/107 - 48.6%), emergency
                                                                                         departments (20/107 - 18.7%), ICUs (9/107 - 8.4%),
                                                                                         respiratory disease units (7/107 – 6.5%), other services
                                                                                         (7/107 - 6.5%), Internal Medicine non-COVID-19 Units
                                                                                         (5/107 - 4.7%), infectious disease wards (5/107 - 4.7%) and
                                                                                         basic assistance services (2/107 - 1.9%) (Fig. 3).
                                                                                         The highest percentage of reallocated colleagues was present
                                                                                         in zone 1 (46.7%), and these showed a progressive reduction
                                                                                         passing from 20.5% in zone 2 and 23.4% in zone 3, to less than
Figure 1. Representation of the response rate to our questionnaire sorted by             10% in zones 4 and 5 (6.5% and 2.9%, respectively).
region. The total number of responses is reported on the abscissa axis, while
the ordinate axis indicates the 20 Italian regions.
                                                                                         In this setting, 48% and 50% of reallocation changes
                                                                                         to Internal Medicine COVID-19 Units and Emergency
                                                                                         Departments, respectively, occurred in zone 1, while units
                                                                                         in zone 2 reported the majority of reallocations to Internal
                                                                                         Medicine non-COVID-19 Units (Tab. III).

                                                                                         Main changes in workload management and distribution
                                                                                         in terms of outpatient and inpatient procedure volumes
                                                                                         The questionnaire results showed a significant decrease
                                                                                         in otolaryngology activities across the country during the
                                                                                         pandemic with no substantial differences among the five
                                                                                         zones. Outpatient visits showed a significant decrease in
                                                                                         number of procedures per week (80.54%; p < 0.0001),
                                                                                         passing from a pool of 26,035 evaluations usually performed
                                                                                         during the pre-COVID-19 period to 5,067 registered
                                                                                         outpatient procedures during the COVID-19 pandemic. A
                                                                                         similar reduction (89.91%; p < 0.0001) was recorded for
 A                                                                                B      outpatient surgical procedures (i.e. surgical procedures
                                                                                         under local anaesthesia) and for inpatient surgical
Figure 2. Graphical representation of (A) the distribution of COVID-19 positive
cases in Italian regions (ISS, April 16, 2020); and (B) the response rate to our ques-   procedures that decreased from 2,823/week to 472/week,
tionnaire sorted by the five zones identified according to the total number of cases.    a reduction of 83.28% (p < 0.0001). A detailed summary



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G. Mannelli et al.




Table I. Activity changes in Otolaryngology Units sorted by zone.
 Zone                                              Changes in clinical practice in the 154 units                                                       Total
               No change        Reduction in beds        Merged with other units Converted into COVID-wards             Temporarily closed
 1                  1                       5                       17                           10                               5                  38 (24.7%)
 2                  4                       9                        9                            4                               1                  27 (17.5%)
 3                  6                      16                       29                            3                               6                   60 (39%)
 4                  5                       3                       10                            1                               2                  21 (13.6%)
 5                  0                       1                        5                            0                               2                   8 (5.2%)
 Total         16 (10.4%)              34 (22.1%)               70 (45.5%)                   18 (11.6%)                      16 (10.4%)              154 (100%)

Table II. Number of staff members sorted by zone and work shift changes.
 Zone      Number of specialists and residents                                                   Work shifts during COVID-19
             Pre-           During          Difference      P           Not              Applied for              Applied for         Applied for          Total
            COVID           COVID               (%)                   applied       all of the members          specialists only    residents only
 1           419              378             9.79%       0.645          16                 21                        0                       1            38
 2           330              309             6.36%       0.096          10                 13                        2                       2            27
 3           587              540             8.01%       0.217          20                 28                        9                       3            60
 4           227              203            10.57%       0.984           6                 11                        2                       2            21
 5            38               34            10.53%       0.677           4                  3                        1                       0             8
 Total      1,601            1,464           8.55%        0.069      56 (36.4%)         76 (49.4%)                 14 (9%)                8 (5.2%)        100%

of procedures performed per week in each zone and the                               Among the different types of surgery, only a small percentage
corresponding percentage reduction is shown in Figure 4                             of respondent units declared a reduction in head and neck
and described by Table IV.                                                          and emergency surgical procedures (10.74% and 3.54%,
                                                                                    respectively). On the other hand, the vast majority declared
                                                                                    a drastic reduction in endoscopic sinonasal procedures
                                                                                    (98.53%), paediatric otolaryngology surgery (97.59%) and
                                                                                    ear surgery (94.90%). All elective surgical procedures (100%)
                                                                                    were suspended uniformly across the country (Tab. V).
                                                                                    In this setting, upper airway management and tracheostomy
                                                                                    procedures were performed by 42.86% of units, while the
                                                                                    remaining 57.14% declared that they were not involved in
                                                                                    airway management procedures for COVID-19 patients.
                                                                                    The vast majority of the units (70.94%) declared that the
                                                                                    percutaneous tracheostomy technique was predominant
                                                                                    over the surgical one in their hospitals. When asked about
Figure 3. Reallocation of otolaryngology team members to other depart-              the timing of tracheostomy procedures the majority of
ments during the pandemic.                                                          Otolaryngology Units performed this after more than 14 days
Table III. Reallocation of physicians sorted by zone.
 Zone                                                 Reallocation to different departments
          Internal        Internal           Emergency          Intensive      Infectious       Respiratory             Basic         Others             Total
          Medicine        Medicine           Department         Care Units   Disease Units     Disease Units          assistance
           COVID         non-COVID
 1           25                 0                10                 6                 3                  3                 1              2           50 (46.7%)
 2           10                 4                 2                 2                 0                  2                 1              1           22 (20.5%)
 3           11                 1                 6                 1                 1                  2                 0              3           25 (23.4%)
 4            5                 0                 0                 0                 1                  0                 0              1            7 (6.5%)
 5            1                 0                 2                 0                 0                  0                 0              0            3 (2.9%)
 Total   52 (48.6%)         5 (4.7%)         20 (18.7%)         9 (8.4%)          5 (4.7%)           7 (6.5%)          2 (1.8%)       7 (6.6%)        107 (100%)




328
                                                                                              Geographic distribution and changes in the workload management




Figure 4. The number of outpatient visits, outpatient surgical procedures, and inpatient surgical procedures comparing pre-COVID and during-COVID variation.

Table IV. Otolaryngology procedures before and during COVID-19 pandemic.
 Zone                                 Otolaryngology procedures (difference %)                                                   Total (difference %)
        Outpatient Outpatient        P       Outpatient    Outpatient       P       Inpatient    Inpatient      P       Procedures Procedures             P
          visits     visits                   surgery       surgery                  surgery      surgery                 before     during
         before     during                     before        during                   before       during                 COVID      COVID
          COVID      COVID                     COVID         COVID                    COVID        COVID
 1        7,702        1,341     < 0.0001       375        34 (90.9%) < 0.0001        841          123       < 0.0001     8,918         1,498       < 0.0001
                      (82.6%)                                                                    (85.4%)                               (83.2%)
 2        5,912        1,272     < 0.0001       303        31 (89.8%) < 0.0001        573          111       < 0.0001     6,788         1,414       < 0.0001
                      (78.5%)                                                                    (80.6%)                               (79.2%)
 3        8,470        1,734     < 0.0001       506        42 (91.7%) < 0.0001        1,011        164       < 0.0001     9,987         1,940       < 0.0001
                      (79.5%)                                                                    (83.8%)                               (80.6%)
 4        3,147         620      < 0.0001       192        33 (82.8%)     0.0013      317           69       < 0.0001     3,656          722            0.0002
                      (80.3%)                                                                    (78.2%)                               (80.2%)
 5         805          100        0.0006        61        5 (91.8%)      0.081        81           5         0.003        947           110            0.0203
                      (87.6%)                                                                    (93.8%)                               (88.4%)
Total    26,036        5,067     < 0.0001      1,437          145        < 0.0001     2,823        472       < 0.0001    30,296         5,684      < 0.0001
                      (80.5%)                               (89.9%)                              (83.3%)                               (81.2%)

Table V. Percentage of variation in different types of surgical procedures during the COVID-period in comparison to the pre-COVID period.
 Period         Head and neck oncology             Emergency           Sinonasal      Pediatric otolaryngology         Ear         Basic otolaryngology
                         surgery                   procedures           surgery                surgery               surgery              surgery
 Pre-COVID                  121                     113                   136                     83                    98                   141
 During COVID               108                     109                    2                       2                     5                    0
 Percentage               10.74%                   3.54%                98.53%                  97.59%                94.90%                100%
 reduction (%)

of endotracheal intubation (38.5%), followed by 11-14 days                         screening procedures were performed for both patients and
(27.7%), 7-10 days (26.1%) and 3-6 days (7.7%) (Fig. 5).                           healthcare workers, and all of the departments performed
                                                                                   screening procedures for inpatients scheduled for surgery.
COVID-19 screening procedures for patients                                         About 20% of otolaryngology specialists in the respondent
and healthcare workers                                                             units tested positive for COVID-19 screening tests; the
In total, 35.71% of the respondent units declared that a                           highest percentages of cases were recorded in zones 1 and
HUB hospital was identified in their region to treat non-                          2 (34.21% and 29.63%, respectively).
COVID-19 patients. In detail, 68.42% of HUBs were located
in zone 1, while zones 2, 3 and 4 declared significantly
                                                                                   Discussion
smaller percentages in their regions (22.22%, 33.33% and
4.76%, respectively). Interestingly, zone 5 recorded the                           Since the outbreak of the COVID-19 pandemic, the Italian
highest percentage of HUBs (75%), although this data may                           National Healthcare System abruptly reduced elective
be biased by the low number of respondents from this zone.                         services to redirect resources to the units most affected
The majority of the units (72.73%) declared that COVID-19                          by the pandemic. This has translated into a significant



                                                                                                                                                              329
G. Mannelli et al.




                          A                                                                                                  B

Figure 5. (A) surgical and percutaneous tracheostomies; and (B) timing of surgical tracheostomies (days after intubation).

reorganisation of the system which required immediate                             changes was recorded with a superimposable percentage
efforts by all workers throughout the country.                                    reduction in staff members. On the other hand, specialist
The results of this study confirm that clinical and surgical                      reallocations to other units were mainly recorded in zone 1,
activities radically changed in Otolaryngology Units                              demonstrating the greater reorganisation made in the
across the country. According to the responses to our                             Lombardy and Emilia-Romagna regions 15.
questionnaire, more than one-fifth (22%) of the units were                        COVID-19 cases are not distributed homogenously in Italy,
converted or temporary closed, with a progressive and                             therefore a different rate of activity change was expected in
significant reduction according to the zone passing from                          Otolaryngology Units across the country. Instead, we did
39.5% in zone 1, to 18.5% in zone 2, 15% in zone 3, 14%                           not notice relevant differences in reductions in outpatient
in zone 4 and 25% in zone 5.                                                      evaluations and surgical cases among units in different
The consequent marked reduction in outpatient and surgical                        regions. This shows a great sense of responsibility by the
services per week (81.24%) confirms that a significant                            Italian National Healthcare System, which stopped elective
response to the crisis was provided by Otolaryngology                             activities even in less affected areas.
Units; however, this also meant a reduction of nearly 80,000                      Tracheostomy is a common procedure for patients admitted
outpatient visits and almost 10,000 surgical procedures per                       to ICUs with acute respiratory distress and with difficult
month. This might have dangerous consequences for the                             weaning. During the pandemic, many countries published
health status of the population and a difficult-to-manage                         their own guidelines, including the Italian Society of
workload in the near future 10,11.                                                Otolaryngology and Head & Neck Surgery (SIOeChCF) 16.
The activities that were guaranteed during the pandemic                           Nonetheless, guidelines about timing and technical
were oncology and emergency procedures. In this scenario,                         procedures for tracheostomy are still lacking. Indications
it would be fair to assume an increase in overall numbers                         and experiences have been published by Italian groups 17,18,
of these procedures. Nonetheless, the results revealed that                       but many questions remain about which technique should be
even these procedures decreased by nearly 10% across                              preferred (surgical or percutaneous) and the correct timing
the country. The reduction of emergency procedures                                to perform tracheostomies in COVID-19 patients. Experience
may be explained by the total lockdown that kept the                              gained from previous severe acute respiratory syndrome
majority of people at home, thus reducing risk factors for                        coronaviruses (SARS-CoV and MERS-CoV) and from
otolaryngology emergencies (abscess, bleeding, nasal bone                         SARS-CoV-2 demonstrated that nurses and physicians who
fractures, laryngeal oedema). On the other hand, head and                         deal with infected patients are at high risk of infection; among
neck cancer cannot be influenced by the lockdown, and                             physicians, otolaryngologists have been identified as having
some recent articles suggest continuing treating cancer as                        the highest risk of contracting COVID-19 19. Tracheostomy
before but including some safety measures for healthcare                          has been demonstrated not to change the course of the
workers and patients 12-14. The reduction observed may                            disease and is among the most dangerous procedures
be due to the reduced number of beds and personnel in                             for surgeons. For these reasons, many authors suggest
Otolaryngology Units, and might result in more advanced-                          performing tracheostomy after a longer intubation time. So
stage oncology cases in the near future.                                          far, the surgical technique seems to be safer compared with
Despite the five zones identified according to the total                          the percutaneous approach since airway opening is short and
number of COVID-19 cases, a homogenous distribution of                            controlled with the cuffed tube placed caudally to the trachea



330
                                                                                        Geographic distribution and changes in the workload management




opening. Some modifications to the well-known percutaneous                  3
                                                                                 https://COVID19.who.int
techniques have been proposed to minimise the risk related to               4
                                                                                 WHO. Virtual press conference on COVID-19. March 11, 2020.
                                                                                 https://www.who.int/docs/default-source/coronaviruse/transcripts/
COVID-19 infection 20. These uncertainties are reflected in                      who-audio-emergencies-coronavirus-press-conference-full-and-fi-
Figure 5, where differences in terms of technique and post-                      nal-11mar2020.pdf?sfvrsn=cb432bb3_2
intubation day are revealed. Another consideration is related               5
                                                                                 Zangrillo A, Beretta L, Silvani P, et al. Fast reshaping of intensive care
to the high volume of patients admitted to ICUs in some                          unit facilities in a large metropolitan hospital in Milan, Italy: facing
                                                                                 the COVID-19 pandemic emergency. Crit Care Resusc 2020;22:91-4.
hospitals during the first month of pandemic spread; in this
                                                                            6
                                                                                 Grasselli G, Pesenti A, Cecconi M. Critical care utilization for the
setting, an elevated number of tracheostomies was motivated                      COVID-19 outbreak in Lombardy, Italy: early experience and fore-
by the necessity for rapid weaning and transfer of patients to                   cast during an emergency response. JAMA 2020;323:1545-6. https://
sub-intensive care units.                                                        doi.org/10.1001/jama.2020.4031
This Italian nationwide study showed that otolaryngologists                 7
                                                                                 Cascella M, Rajnik M, Cuomo A, et al. Features, evaluation and treat-
                                                                                 ment coronavirus (COVID-19). [Updated 2020 Aug 10]. In: StatPearls
have a high risk of contracting SARS-CoV-2. According to                         [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Avail-
our data, more than 20% of Otolaryngology Units have had                         able from: https://www.ncbi.nlm.nih.gov/books/NBK554776/?elqTrackI
physicians with positive nasal swabs; this percentage was                        d=acb127f200d54529bf1a65898f737ab7&elqaid=3961&elqat=2
as high as 34% in the more severely affected regions and                    8
                                                                                 Ralli M, Greco A, de Vincentiis M. The effects of the COVID-19/
                                                                                 SARS-CoV-2 Pandemic outbreak on otolaryngology activ-
some Italian otolaryngologists have died.                                        ity in Italy. Ear Nose Throat J 2020:145561320923893. https://doi.
                                                                                 org/10.1177/0145561320923893
Conclusions                                                                 9
                                                                                 https://www.epicentro.iss.it/coronavirus/bollettino/Bollettino-sorveg-
                                                                                 lianza-integrata-COVID-19_16-aprile-2020.pdf
Since the outbreak of COVID-19 in Lombardy and the                          10
                                                                                 http://www.governo.it/it/faq-fasedue
following WHO declaration of a global pandemic, the Italian                 11
                                                                                 Xu K, Lai XQ, Liu Z. Suggestions for prevention of 2019 novel coro-
National Healthcare System has struggled to cope with the                        navirus infection in otolaryngology head and neck surgery medical
                                                                                 staff. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2020;55:E001.
unpredictable load of affected patients. Otolaryngology                          https://doi.org/10.3760/cma.j.issn.1673-0860.2020.0001
Units have been involved in treating patients who need                      12
                                                                                 Chaves ALF, Castro AF, Marta GN, et al. Emergency changes in in-
tracheostomy and guaranteeing diagnosis and treatment for                        ternational guidelines on treatment for head and neck cancer patients
oncology and emergency patients. This nationwide study                           during the COVID-19 pandemic. Oral Oncol 2020;107:104734. htt-
                                                                                 ps://doi.org/10.1016/j.oraloncology.2020.104734
showed how prominently phase 1 of the pandemic changed                      13
                                                                                 Crosby DL, Sharma A. Evidence-Based Guidelines for management
the organisation and activity of Otolaryngology Units                            of head and neck mucosal malignancies during the COVID-19 pan-
across the country. Italy is now starting phase 2 with many                      demic. Otolaryngol Head Neck Surg 2020;163:16-24. https://doi.
questions on the strategies to adopt in the near future to                       org/10.1177/0194599820923623
treat patients and protect healthcare personnel 21.                         14
                                                                                 Ansarin M. Surgical management of head and neck tumours during
                                                                                 the SARS-CoV (Covid-19) pandemic. Acta Otorhinolaryngol Ital
                                                                                 2020;40:87-9. https://doi.org/10.14639/0392-100X-N0783
Acknowledgements                                                            15
                                                                                 Saibene AM, Allevi F, Biglioli F, et al. Role and management of a
                                                                                 Head and Neck Department during the COVID-19 outbreak in Lom-
We heartily thank all of the personnel of the Head and                           bardy. Otolaryngol Head Neck Surg 2020;194599820917914. https://
Neck and Otorhinolaryngology Units who have responded                            doi.org/10.1177/0194599820917914
to the survey promptly and generously, and we thank our                     16
                                                                                 SIOeCHF. La tracheostomia in pazienti affetti da COVID 19. https://
                                                                                 www.sioechcf.it/wp-content/uploads/2020/03/
colleagues across the country for their brave commitment                    17
                                                                                 Mattioli F, Fermi M, Ghirelli M, et al. Tracheostomy in the COVID-19
during this unexpected crisis.                                                   pandemic. Eur Arch Otorhinolaryngol 2020;277:2133-5. https://doi.
A special acknowledgement is due to Professor Mario                              org/10.1007/s00405-020-05982-0
Bussi, President of the Italian Society of Otolaryngology                   18
                                                                                 Pichi B, Mazzola F, Bonsembiante A, et al. CORONA-steps for
and Head & Neck Surgery (SIOeChCF), who gave us his                              tracheotomy in COVID-19 patients: a staff-safe method for airway
                                                                                 management. Oral Oncol 2020;105:104682. https://doi.org/10.1016/j.
trust and support, and helped to gain widespread consent                         oraloncology.2020.104682
and cooperation with this investigation.                                    19
                                                                                 Shiba T, Ghazizadeh S, Chhetri D, et al. Tracheostomy considerations dur-
                                                                                 ing the COVID-19 pandemic. OTO Open 2020;4:2473974X20922528.
                                                                                 https://doi.org/10.1177/2473974X20922528
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