10.14639/0392-100X-N2452
Objective. The COVID-19 pandemic profoundly modified the work routine in healthcare; however, its impact on the field of paediatric otorhinolaryngology (ORL) has been rarely investigated. The aim of this study was to assess the impact of COVID-19 on paediatric ORL. Methods. A questionnaire was developed by the Young Otolaryngologists of the Italian Society of ORL-Head and Neck Surgery. The questionnaire consisted of 26 questions related to workplace and personal paediatric ORL activities. The link was advertised on the official social media platforms and sent by e-mail to 469 Italian otolaryngologists. Results. The questionnaire was completed by 118 responders. During the pandemic, the main reduction was observed for surgical activity (78.8%), followed by outpatient service (16.9%). The conditions that were mostly impacted by a delayed diagnosis were respiratory infections in 45.8% of cases and sensorineural hearing loss in 37.3% of cases. Conclusions. Paediatric ORL was highly impacted by the COVID-19 pandemic, with a significant reduction of surgical and outpatient activities and a delay in time-sensitive diagnosis. Therefore, the implementation of new strategies, such as telemedicine, is recommended.
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Task Force of the Young Otolaryngologists of the Italian Society of Otolaryngology-Head and Neck Surgery
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tonsillectomy
Impact of the COVID-19 pandemic on paediatric otolaryngology: a nationwide study
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COVID-19
2023-07-28
2022-12-29
2023-09-29
2023-10-02
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Task Force of the Young Otolaryngologists of the Italian Society of Otolaryngology-Head and Neck Surgery
2023/07/28
10.14639/0392-100X-N2452
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Marco Bonali, Pasquale Capasso, Carlo Cavaliere, Cristoforo Fabbris, Matteo Fermi, Pierre Guarino, Valeria Iannini, Niccolò Mevio, Davide Topazio.
1827-675X
tonsillectomy
en
359
Impact of the COVID-19 pandemic on paediatric otolaryngology: a nationwide study
https://www.actaitalica.it/article/download/2452/1028
43
ACTA OTORHINOLARYNGOLOGICA ITALICA 2023;43:352-359; doi: 10.14639/0392-100X-N2452




COVID-19


Impact of the COVID-19 pandemic on paediatric
otolaryngology: a nationwide study
Impatto della pandemia COVID-19 sull’otorinolaringoiatria pediatrica
Eleonora M.C. Trecca1-4, Michele Gaffuri1,5,6, Giulia Molinari1,7,8, Francesca Yoshie Russo1,9, Mario Turri-Zanoni1,10,
Andrea Albera1,11, Antonella Miriam di Lullo1,12, Gennaro Russo2,13, Giuditta Mannelli2,14, Massimo Ralli1,9
Task Force of the Young Otolaryngologists of the Italian Society of Otolaryngology-Head and Neck Surgery
1
  Research group of Pediatric Otorhinolaryngology of the Task Force of the Young Otolaryngologists of the Italian Society
of Otolaryngology-Head and Neck Surgery; 2 Task Force of the Young Otolaryngologists of the Italian Society
of Otolaryngology-Head and Neck Surgery; 3 Department of Maxillofacial Surgery and Otolaryngology, IRCCS Research Hospital
Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy; 4 Department of Otolaryngology, University Hospital of Foggia,
Foggia, Italy; 5 Department of Otolaryngology and Head and Neck Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milan, Italy; 6 Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy; 7 Department
of Otolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy; 8 Department
of Experimental Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy; 9 Department of Sense Organs, ENT
Department, Sapienza University of Rome, Rome, Italy; 10 Division of Otorhinolaryngology, Department of Biotechnology and Life
Sciences, University of Insubria, Varese, Italy; 11 Department of Surgical Sciences, University of Turin, Turin, Italy; 12 ENT
Unit- Department of Neuroscience, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples,
Italy; 13 Otolaryngology Unit, AORN dei Colli, V. Monaldi Hospital, Napoli, Italy; 14 Department of Experimental and Clinical Medicine,
University of Florence, Florence, Italy


SUMMARY
Objective. The COVID-19 pandemic profoundly modified the work routine in healthcare;
however, its impact on the field of paediatric otorhinolaryngology (ORL) has been rarely in-
vestigated. The aim of this study was to assess the impact of COVID-19 on paediatric ORL.
Methods. A questionnaire was developed by the Young Otolaryngologists of the Italian So-
ciety of ORL-Head and Neck Surgery. The questionnaire consisted of 26 questions related             Received: December 29, 2022
to workplace and personal paediatric ORL activities. The link was advertised on the official        Accepted: April 10, 2023
social media platforms and sent by e-mail to 469 Italian otolaryngologists.                         Published online: July 28, 2023
Results. The questionnaire was completed by 118 responders. During the pandemic, the
main reduction was observed for surgical activity (78.8%), followed by outpatient service           Correspondence
(16.9%). The conditions that were mostly impacted by a delayed diagnosis were respiratory           Eleonora Maria Consiglia Trecca
                                                                                                    IRCCS Casa Sollievo della Sofferenza, Department
infections in 45.8% of cases and sensorineural hearing loss in 37.3% of cases.
                                                                                                    of Maxillofacial Surgery and Otolaryngology,
Conclusions. Paediatric ORL was highly impacted by the COVID-19 pandemic, with a sig-               viale Cappuccini 1, 71013 San Giovanni Rotondo
nificant reduction of surgical and outpatient activities and a delay in time-sensitive diagnosis.   (FG), Italy
Therefore, the implementation of new strategies, such as telemedicine, is recommended.              E-mail: e.trecca@operapadrepio.it
KEY WORDS: children, paediatric otolaryngology, COVID-19, adenoidectomy,
tonsillectomy                                                                                         How to cite this article: Trecca EMC, Gaffuri M,
                                                                                                      Molinari G, et al. Impact of the COVID-19 pan-
                                                                                                      demic on paediatric otolaryngology: a nationwide
RIASSUNTO                                                                                             study. Acta Otorhinolaryngol Ital 2023;43:352-
Obiettivo. L’impatto della pandemia COVID-19 sul settore dell’otorinolaringoiatria (ORL)              359. https://doi.org/10.14639/0392-100X-N2452
pediatrica è stato poco studiato. Lo scopo di questa ricerca è stato, pertanto, quello di va-
lutare l’impatto del COVID-19 sull’ORL pediatrica, concentrandosi sulle differenze con il           © Società Italiana di Otorinolaringoiatria
periodo precedente la pandemia.                                                                     e Chirurgia Cervico-Facciale
Metodi. Un questionario composto da 26 domande relative alle attività lavorative è stato
sviluppato dal Gruppo Giovani della Società Italiana di ORL e Chirurgia Cervico-facciale.                          OPEN ACCESS
Il link è stato diffuso sui social media della società e inviato via e-mail a 469 otorinolarin-     This is an open access article distributed in accordance with
goiatri.                                                                                            the CC-BY-NC-ND (Creative Commons Attribution-Non-
Risultati. Il questionario è stato compilato da 118 otorinolaringoiatri. Durante la pande-          Commercial-NoDerivatives 4.0 International) license. The
                                                                                                    article can be used by giving appropriate credit and mentio-
mia, la principale riduzione è stata osservata per l’attività chirurgica (78,8%), seguita dal       ning the license, but only for non-commercial purposes and
servizio ambulatoriale (16,9%). Le condizioni maggiormente colpite da una diagnosi ritar-           only in the original version. For further information: https://
data sono state le infezioni respiratorie nel 45,8% e l’ipoacusia neurosensoriale nel 37,3%.        creativecommons.org/licenses/by-nc-nd/4.0/deed.en




352
                                                                                                        COVID-19 and paediatric otolaryngology




Conclusioni. L’ORL pediatrica è stata influenzata dalla pandemia COVID-19 con una riduzione statisticamente significativa delle attività
chirurgiche e ambulatoriali. Molte diagnosi che necessitano di un trattamento tempestivo sono state differite. Pertanto, si raccomanda di im-
plementare nuove strategie, come la telemedicina.
PAROLE CHIAVE: bambino, otorinolaringoiatria pediatrica, COVID-19, adenoidectomia, tonsillectomia



Introduction                                                            was compliant with the Checklist for Reporting Results of
                                                                        Internet E-Surveys (CHERRIES) 7. The Task Force of the
The COVID-19 outbreak profoundly impacted work routines
                                                                        GOS proposed this study, which was approved by the Insti-
in healthcare. The main changes in otorhinolaryngology
                                                                        tutional Review Board of the Italian Society of ORL-Head
(ORL) practice included unit rearrangement, personnel real-
                                                                        and Neck Surgery. The questionnaire was developed in Ital-
location, changes in clinical and surgical activity, and SARS-
                                                                        ian and uploaded to Google Drive.
CoV-2 contagion among ORL physicians and patients 1. In
the first study conducted by the Task Force of the Young Oto-
                                                                        Development of the questionnaire
laryngologists of the Italian Society of ORL-Head and Neck
                                                                        A scientific committee of paediatric otolaryngologists, well
Surgery (GOS) in April 2020, a drastic reduction in sinona-
                                                                        acquainted with the topic involved, proposed a group of
sal procedures (98.5%), paediatric ORL surgery (97.6%) and
                                                                        questions concerning the main issues related to COVID-19
ear surgery (94.9%) was reported, while all elective proce-
                                                                        and paediatric ORL. A preliminary version of the question-
dures (100%) were homogeneously suspended across the
                                                                        naire including all the suggestions was developed by the
country 2. In addition, ORL emergencies presented a drastic
                                                                        first and last authors (E.M.C.T., M.R.). Finally, the expert
reduction ranging from 70% to 100% during the first wave of
                                                                        group developed a consensus version of the questionnaire.
pandemic, as reported by two main Italian referral centres 3.
                                                                        As a last step, the tool was pre-tested on a pilot group of eight
While the impact of these aspects has been investigated in
                                                                        otolaryngologists who fulfilled the inclusion criteria men-
the adult population, the field of paediatric ORL has been
                                                                        tioned in the previous section to check for comprehensibility,
less explored. The cancellation and/or the delay in treating
                                                                        redundancy, and consistency of the items, including technical
paediatric ORL surgical cases show the need to reconsider
                                                                        usability and functionality of the electronic platform.
algorithms for the diagnosis and treatment of these condi-
                                                                        The Google form consisted of three screens presenting the fol-
tions in children. In fact, lockdown measures such as the
mandatory use of masks, school closure and remote learn-                lowing sections on paediatric patients (0-16 years):
ing paradoxically led to a reduction in the transmission of             • a section for collecting demographic data of responders
upper respiratory tract infections (URTI) among children 4.                (i.e., name/surname, e-mail, age, sex, nationality, geo-
According to the scientific literature, social distancing and              graphic area, working position, workplace) and acquir-
other restrictive policies had a positive impact on the gener-             ing informed consent to participate in the study;
al symptoms (i.e., nasal obstruction, mouth breathing, rhi-             • workplace activities: 20 questions on the number and
norrhoea, snoring, apnoea, and behavioural changes) and                    types of outpatient visits, surgeries, and paediatric emer-
associated comorbidities such as otitis media with effusion                gencies at the responder’s workplace;
(OME) in children suffering from adenoid or adenotonsil-                • personal activity: 6 questions on outpatient care, day
lar hypertrophy 5,6.                                                       surgery and elective surgery of the responder.
The aim of this study was to assess the impact of the SARS-             The statements of the second and third parts referred to pre-
CoV-2 infection on paediatric ORL in Italy, highlighting                COVID-19 time (two-year period February 2018 - Febru-
the differences with a two-year period preceding the pan-               ary 2020) and to COVID-19 time (two-year period March
demic. The main outcomes were the volume of outpatient                  2020 - March 2022). The questionnaire included multiple-
visits, day surgeries and elective procedures, but also the             choice questions and responders could select only one
changes in the diagnosis, patients and parents’ behaviours,             statement among the proposed alternatives.
protocols and access to emergency departments. This is the
first nationwide article analysing the changes occurred af-             Administration of the questionnaire
ter the COVID-19 outbreak on the subspecialty of paediat-               Informed consent was obtained from all participants and in-
ric ORL with quantitative data.                                         structions and purpose of the research explained in the intro-
                                                                        duction. The link was advertised on social media platforms
                                                                        of the Italian Society of ORL-Head and Neck Surgery (i.e.,
Materials and methods                                                   Facebook, Instagram) and sent by e-mail to a sample of 469
The study was conducted between May and July 2022 and                   Italian otolaryngologists. The cohort included the members



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E.M.C. Trecca et al.




of the Italian Society of ORL-Head and Neck Surgery, com-         Of the responders, 80 (67.8%) were males, 38 (32.2%)
prising a variety of otolaryngologists working in hospital and    were females, 73 (61.9%) were hospital staff, 25 (21.2%)
academic settings, as well as private practice. University stu-   were university professors, 14 (11.9%) worked in private
dents and international/exchange visitors were not included       practice and 6 (0.5%) were PhD students or research fel-
according to the criteria mentioned above.                        lows. When sorting by geographic area, 52 (44.1%) worked
Before submitting the questionnaire, a mandatory com-             in Northern Italy, 24 (20.3%) in Central Italy, 42 (35.6%) in
pleteness check highlighted the missing response items.           Southern Italy and islands. When sorting by organisation-
Answers were automatically captured and stored in an elec-        al structure, 112 (94.9%) worked in a clinic treating both
tronic spreadsheet (Excel, Microsoft©, version 16.66.1). To       adults and paediatric patients, 4 (3.4%) in centres treating
prevent multiple entries from the same individual, users          only paediatric patients and 2 (1.7%) in centres treating
were required to register first. The username was stored          only adult patients, but sporadically visiting children. The
together with the survey results and later eliminated. The        average age of the responders was 43.7 years, while the
spreadsheet was stored and protected by unique passwords          median was 39 (range: 27-76 years).
and kept on a secure, restricted network drive. The data
were processed in anonymous and aggregate form in ac-             Workplace activities
cordance with the General Data Protection Regulation              The questionnaire was composed of 20 questions that inves-
(GDPR) of the European Community. Only the first and              tigated the number and types of outpatient visits, surgeries,
last Authors (E.M.C.T., M.R.) had access to the files.            and paediatric emergencies at the responder’s workplace.
No incentives were offered to complete the survey.                A comparison of the number of outpatient procedures per-
                                                                  formed during pre-COVID-19 (February 2018 - February
Reproducibility of the questionnaire                              2020) and during COVID-19 time (March 2020 - March
The reproducibility of the questionnaire was evaluated us-        2022) is shown in Figure 1. A significant reduction of total
ing internal consistency and test-retest reliability. Internal    procedures was found during the pandemic compared to
consistency was considered acceptable in case of Cron-            the pre-pandemic period (p = 0.0002, t = 3.720, p = 0.234).
bach’s alpha values between 0.7 and 0.9. Additionally,            A comparison of the number of surgical procedures per-
the pilot group of eight otolaryngologists was selected           formed during pre-COVID-19 and during COVID-19 time
for assessment of test-retest reliability. In this cohort, the    is shown in Figure 2. A significant reduction of total pro-
questionnaire was administered twice, after an interval of        cedures was found during the pandemic compared to the
one month, without any possibility for participants to look       pre-pandemic period (p < 0.0001, t = 4.493, p = 234).
at the answers given the first time. Test-retest reliability
was assessed through Intraclass Correlation Coefficients
(ICC2k) and considered acceptable with a minimum test-
retest correlation coefficient of 0.7.

Statistical analysis
Descriptive analysis was used to define the main clinical and
demographic characteristics based on the responses to the
questionnaire. Qualitative data were summarised as percent-
ages. Unpaired t-test was used to evaluate differences for nu-
meric values. A p-value ≤ 0.05 was considered the cut-off for
statistical significance. Prism Software version 9.4.1 (Graph-
Pad Software LLC) was used to perform statistical analysis.

Results
Demographics
Overall, 118 otolaryngologists answered the questionnaire
with a response rate of 25.2%. Calculation of Cronbach’s
alpha showed good internal reliability (a = 0.88). Test-re-
                                                                  Figure 1. Number of outpatient procedures performed during pre-COVID-19
test evaluation was also satisfactory for all the subscales,      and during COVID-19 time. A significant reduction of total procedures was
with an overall ICC2k = 0.85 (CI 0.8-0.9).                        found during pandemic compared to the pre-pandemic period (p = 0.0002).



354
                                                                                                        COVID-19 and paediatric otolaryngology




                                                                            cases they were urgent procedures (61.9%). Elective surgery
                                                                            was performed only for high priority cases (45.8%), followed
                                                                            by medium priority (21.2%). In 21.1% of cases no elective
                                                                            surgeries were performed during pandemic. Most treated con-
                                                                            ditions were obstructive sleep apnoea syndrome (69.5%), re-
                                                                            curring tonsillitis (13.6%), transmissive hearing loss (10.2%),
                                                                            adenoid hypertrophy (6.8%). Despite this, when investigating
                                                                            the number of surgeries that were mostly reduced during the
                                                                            COVID-19 pandemic, 42.4% were surgeries for obstructive
                                                                            sleep apnoea syndrome and ear surgery (32.2%), followed by
                                                                            sinonasal surgery (16.9%) and laryngeal surgery (8.5%).
                                                                            Emergency surgical procedures were performed on pae-
                                                                            diatric patients positive for COVID-19 in 41.5% of cases;
                                                                            these procedures were performed in a COVID-19 dedicated
                                                                            operating room provided by the hospital in 46.6% of cases,
                                                                            while 53.4% of hospitals did not provide a dedicated room
                                                                            and surgeries were performed in ordinary operating rooms.
Figure 2. Number of surgical procedures performed during pre-COVID-19       The percentage of elective surgical procedures delayed for
and during COVID-19 time. A significant reduction of total procedures was   COVID-19 positivity (child/parent) was < 25% in 39.8% of
found during pandemic compared to the pre-pandemic period (p < 0.0001).     cases, 25%-50% in 37.3% of cases, > 50% in 0.02%.
                                                                            When investigating the changes in waiting lists for surgical
                                                                            procedures due to the pandemic, 66.9% of responders re-
During the pandemic, the main reduction was observed for                    ported an increase of the number of procedures in the wait-
surgical activity (78.8%), followed by outpatient service                   ing list, 22% reported no significant changes while only
(16.9%) and emergency procedures (4.2%).                                    11% reported a decrease.
A preliminary evaluation of potential COVID-19 symp-
toms for outpatient visits was performed at admission by                    Personal activities
67.8% of responders’ workplaces, while in 13.6% of cases                    The questionnaire investigated 6 questions about outpatient
the evaluation was performed 24 hours before the visit via                  care, day surgery and elective surgery of the responder.
phone call. Nearly 20% of participants’ institutions (18.6%)                Figure 3 shows the number of outpatient procedures re-
did not perform any preliminary screening of COVID-19                       quiring fibreoptic evaluation performed individually by
symptoms. Upper airway endoscopy procedures during                          responders during pre-COVID-19 and during COVID-19
outpatient visits – when required – were performed only in                  time. A significant reduction of total procedures was found
selected cases for 55.1% of responders, always for 38.1%                    during pandemic compared to the pre-pandemic period
and not performed in 6.8% of cases.                                         (p = 0.0003, t = 3.664, p = 0.234).
When investigating the number of conditions that were                       Figure 4 shows the number of surgical procedures (day sur-
mostly impacted by a delayed diagnosis during outpatient                    gery) performed individually by responders during pre-COV-
visits during the COVID-19 pandemic, 45.8% reported                         ID-19 and during COVID-19 time. A significant reduction of
URTI, 37.3% sensorineural hearing loss (SNHL), 9.3%                         total procedures was found during the pandemic compared to
otitis media and 7.6% epistaxis. Delayed diagnosis was                      the pre-pandemic period (p < 0.0001, t = 4.402, p = 0.234).
also impacted by a reduction of the number of outpatient                    Figure 5 shows the number of surgical procedures (elec-
visits during pandemic, that – except for lockdown meas-                    tive surgery) performed individually by responders during
ures – was mainly due to the fear of parents of going to                    pre-COVID-19 and during COVID-19 time. A significant
healthcare facilities (44.1%), social distancing (30.5%),                   reduction of total procedures was found during pandemic
use of face masks (16.9%) and telemedicine (8.4%).                          compared to the pre-pandemic period (p = 0.0016, t = 3.189,
According to the responders, the main conditions treated in                 p = 0.234).
emergency settings during the pandemic were traumas (35.6%),
foreign bodies in the upper airways (22.9%), and acute mas-
toiditis (0.8%). All other cases, accounting for 40.7% of re-
                                                                            Discussion
sponses, were classified as “other conditions”.When analysing               Study results
surgical procedures performed during the pandemic, in most                  According to these results, both surgical and outpatient pro-



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E.M.C. Trecca et al.




Figure 3. Number of outpatient procedures requiring fibreoptic evaluation
performed individually by responders during pre-COVID-19) and during COV-
ID-19 time. A significant reduction of total procedures was found during pan-   Figure 5. Number of surgical procedures (ordinary surgery) performed in-
demic compared to the pre-pandemic period (p = 0.0003).                         dividually by responders during pre-COVID-19 and during COVID-19 time. A
                                                                                significant reduction of total procedures was found during pandemic compared
                                                                                to the pre-pandemic period (p = 0.0016).


                                                                                en the importance of a time-sensitive management of these
                                                                                conditions. Regarding hospital organisation, nearly 20% of
                                                                                cases did not undergo preliminary screening for COVID-19
                                                                                symptoms. Emergency surgical procedures were performed
                                                                                on paediatric patients positive for COVID-19 in 41.5% of
                                                                                cases, but more than half of hospitals (53.4%) did not pro-
                                                                                vide a dedicated room for their completion.
                                                                                Although the data show a tendency to return to normality,
                                                                                it is evident that the Italian national healthcare system was
                                                                                not prepared to deal with the unique context of the pan-
                                                                                demic. Additionally, the difficulties encountered in the hos-
                                                                                pital administration were amplified in cases of paediatric
                                                                                patients which routinely necessitate different protocols of
                                                                                diagnosis and treatment and that are mostly asymptomatic
                                                                                or mildly symptomatic with an underestimation of COV-
                                                                                ID-19 disease 8.
Figure 4. Number of surgical procedures (day surgery) performed individu-
ally by responders during pre-COVID-19 and during COVID-19 time. A signifi-
cant reduction of total procedures was found during pandemic compared to
                                                                                Management of adenotonsillar disease
the pre-pandemic period (p < 0.0001).                                           Even though the current risk of contagion is significantly
                                                                                decreased thanks to vaccination and protective measures,
                                                                                an increased number of procedures in the waiting list ac-
cedures presented a significant reduction (p ≤ 0.05) during                     counting for 66.9%, as reported by our data, is worrying
the pandemic compared to pre-COVID-19 time. Precise-                            and could keep growing without the application of an in-
ly, the main reduction was observed for surgical activity                       tegrated strategy. In fact, even a common diagnosis of ad-
(78.8%), which was mostly made up of urgent procedures in                       enotonsillar disease can lead to several comorbidities, such
61.9% and high priority cases in 45.8%. Conversely, emer-                       as cardiopulmonary complications, deficit of attention and
gency procedures underwent only a mild reduction. The two                       dental malocclusions 9-11.
most delayed diagnoses were URTI in 45.8% of cases and                          Medical management of severe obstructive sleep apnoea
SNHL in 37.3% of cases; this is particularly alarming giv-                      during the COVID-19 pandemic, including continuous



356
                                                                                                 COVID-19 and paediatric otolaryngology




positive airway pressure therapy in severe cases, showed            ditions requiring access to the emergency department during
that this kind of treatment is poorly tolerated, and that sur-      the pandemic accounted for 40.7% of responses. Even if the
gery remains the gold standard 12. Normally, stratification         number of ORL conditions requiring prompt evaluation is
of patients according to the endoscopic classification of           consistent, these data could suggest a trend in the Italian pop-
adenoid hypertrophy is the method of choice to indicate             ulation to seek emergency consultation even for non-critical
medical or surgical therapy 13. However, considering that           clinical situations 3. This may have further contributed to a
otolaryngologists are at high risk of contagion because of          reduction in the capacity of the ORL departments to provide
the proximity to superior airways during physical examina-          pre-pandemic levels of healthcare, in terms of timing and
tion and of the aerosolisation of many common procedures            consistency with surgical lists priorities.
including nasopharyngeal fibre-endoscopy 14, according to
our responders, the number of outpatient procedures re-             Lessons learnt from the COVID-19 pandemic
quiring fibreoptic evaluation significantly decreased during        Although some national and international societies devel-
the COVID-19 period. To reduce the rate of transmission             oped guidelines and recommendations focused on paediat-
of COVID-19 to healthcare workers, review of hospital re-           ric ORL during the first year of pandemic 20,21, they may be
cords and telemedicine via phone consultation as well the           subject to change considering the constant evolution of the
presence of risk factors (i.e., syndromic diseases, persistent      situation 22, and an update is surely warranted. As reported
OME, associated hearing impairment and/or language de-              by this study, although the reduction of outpatients and sur-
velopment delay) can be a good strategy to prioritise more          gical procedures was significant and the pathway toward
urgent cases in the exceptional contest of the COVID-19             pre-pandemic normality is still long, data from a long-term
pandemic 15.                                                        perspective are more encouraging than those published
Moreover, the delay in diagnosis of SNHL highlighted the            at the beginning of 2020 1,2. According to the several les-
shortage of audiological professionals 16, and the enhanced         sons learnt from the challenging context of COVID-19,
difficulties experienced by deaf individuals during the hos-        the building of a better post-pandemic healthcare system
pital visits and accessing specialised services in the COV-         should be based on new strategies and resources such as
ID-19 pandemic 17.                                                  telehealth consultations, videoconferencing platforms, un-
In some categories of adult and paediatric patients, such as        limited availability of personal protective equipment, and
cochlear implant users which necessitate lifelong post-op-          new solutions for aerosol generating procedures 23.
erative care, telemedicine has provided effective solutions         This management may also be fruitful to create a more
to limit in-person controls to urgent needs, while leaving          child-centred health-care system, in which paediatric oto-
ordinary maintenance and stable patients to remote/asyn-            laryngologists work and improve the quality and timing of
chronous check 18. Sadly, the application of telemedicine           care of paediatric patients.
systems was reported only by 8% of responders, showing
that although the COVID-19 pandemic accelerated tech-               Limitations
nology implementation, its diffusion in routine practices is        Limitations of this study include the possible subjective bi-
still limited in Italian ORL departments.                           ases described in other survey articles 24. Considering the
                                                                    responses that were received, it is not possible to stratify
The impact of lockdown measures                                     results according to the paediatric age. The low response
In accordance with previous literature 3,5,6,19, possible spec-     rate (25.2%; n = 118) could represent a major limitation of
ulations for the reduction of paediatric symptoms as well           this study; however, this value is consistent with a previ-
as paediatric emergencies and traumas can be due to lock-           ous survey about the impact of the COVID-19 pandemic on
down restrictions (30.5%), which forced children to have            ORL practice conducted by the Task Force of GOS where
distance learning with less interaction with their peers and        154 responses were collected 8. Moreover, the low response
minimal exposure to pathogens, but also to the fear of par-         rate may be explained by the fact that paediatric ORL is
ents (44.1%) to go to hospital and possibly contract nosoco-        even a more specialistic topic and not all otolaryngologists
mial infections or simply maintain the appointments espe-           treat paediatric patients.
cially if coming from suburbs or rural areas. This last data
is fundamental if we consider that children are dependent
on adults and cannot receive adequate medical care without
                                                                    Conclusions
family support.                                                     The field of paediatric ORL seemed to be highly impacted
It is interesting to note that besides traumas, foreign bodies in   by the COVID-19 pandemic with a significant reduction
the airways and acute mastoiditis, other miscellaneous con-         of surgical activities followed by outpatient services and



                                                                                                                                  357
E.M.C. Trecca et al.




emergency procedures. Also, the diagnosis of a wide range       ki. Informed consent was obtained from each participant
of conditions, which necessitate time sensitive manage-         for study participation and data publication.
ment, including SNHL, was delayed during these excep-
tional times. Given the importance of a timely treatment of     Task Force of the Young Otolaryngologists of the Italian
the ORL diseases in the paediatric age, the implementation      Society of Otolaryngology-Head and Neck Surgery:
of new strategies, such as teletherapy 25, it is recommended    Marco Bonali, Pasquale Capasso, Carlo Cavaliere, Cristo-
to avoid potential consequences on growth and develop-          foro Fabbris, Matteo Fermi, Pierre Guarino, Valeria Ian-
ment in children and adolescents.                               nini, Niccolò Mevio, Davide Topazio.

Acknowledgements
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