10.14639/0392-100X-N1036
Introduction. The restrictive measures adopted by the Italian Government during the COVID-19 outbreak caused dramatic changes in routine public health care. Surprisingly, emergency activity also registered a reduction in frequency. Methods. This multicentre retrospective study aims to investigate eventual changes in ENT surgical emergencies in a highly populated area of southern Italy during the COVID-19 pandemic. Data concerning the period between the February 1 and the May 31, 2020 were collected from the main three hospitals in the district and compared with the same period of 2019. Results. A substantial reduction was found in the number of ENT emergency interventions in 2020 compared to the same period of 2019, particularly in the main lockdown phase and in the tertiary referral centre. Conclusions. The reduction in the absolute number of emergency ENT interventions can be only partially explained by social distancing and home confinement. We have reason to believe that some of these patients may have not sought medical support due to fear of nosocomial SARS-CoV2 infection. This study could represent a trigger for further implementation of health system responses to emergencies in a period of transition that is likely to last for a prolonged period of time.
application/xml
1827-675X
1036
6
en
Nicola Quaranta
https://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
surgery
ENT surgical emergencies during the COVID-19 outbreak
Text.Serial.Journal
https://www.actaitalica.it/
40
COVID-19
2020-11-24
2020-07-31
2021-01-21
2021-01-21
399-404
1
Nicola Quaranta
2020/11/24
10.14639/0392-100X-N1036
399
Otolaryngology Unit, Department of BMS, Neuroscience and Sensory Organs, Policlinico di Bari, University of Bari, Italy
1827-675X
6
surgery
404
ENT surgical emergencies during the COVID-19 outbreak
https://www.actaitalica.it/article/download/1036/459
40
ACTA OTORHINOLARYNGOLOGICA ITALICA 2020;40:399-404; doi: 10.14639/0392-100X-N1036




COVID-19


ENT surgical emergencies during the COVID-19
outbreak
Le urgenze chirurgiche otorinolaringoiatriche durante l’epidemia di COVID-19
Vito Pontillo1, Lucia Iannuzzi1, Paolo Petrone2, Pasqua Irene Sciancalepore1,2, Carlo D’Auria3, Massimo Rinaldi1,3,
Giusi Graziano4, Nicola Quaranta1
1
 Otolaryngology Unit, Department of BMS, Neuroscience and Sensory Organs, Policlinico di Bari, University of Bari, Italy;
2
 Otolaryngology Unit, Ospedale Di Venere, Bari, Italy; 3 Otolaryngology Unit, Ente Ecclesiastico Ospedale Miulli, Acquaviva delle
Fonti, Italy; 4 Biomedical Sciences and Human Oncology Department, University of Bari, Italy


SUMMARY
Introduction. The restrictive measures adopted by the Italian Government during the
COVID-19 outbreak caused dramatic changes in routine public health care. Surprisingly,
emergency activity also registered a reduction in frequency.
Methods. This multicentre retrospective study aims to investigate eventual changes in ENT
surgical emergencies in a highly populated area of southern Italy during the COVID-19
pandemic. Data concerning the period between the February 1 and the May 31, 2020 were
collected from the main three hospitals in the district and compared with the same period
of 2019.
Results. A substantial reduction was found in the number of ENT emergency interventions
in 2020 compared to the same period of 2019, particularly in the main lockdown phase and
                                                                                               Received: July 31, 2020
in the tertiary referral centre.
                                                                                               Accepted: August 18, 2020
Conclusions. The reduction in the absolute number of emergency ENT interventions can           Published online: November 24, 2020
be only partially explained by social distancing and home confinement. We have reason
to believe that some of these patients may have not sought medical support due to fear of
                                                                                               Correspondence
nosocomial SARS-CoV2 infection. This study could represent a trigger for further imple-        Vito Pontillo
mentation of health system responses to emergencies in a period of transition that is likely   Otorinolaringoiatria Universitaria Policlinico di
to last for a prolonged period of time.                                                        Bari, Università di Bari, piazza Giulio Cesare 11,
                                                                                               70124 Bari, Italy
KEY WORDS: COVID-19, outbreak, ENT, emergency, surgery
                                                                                               Tel. +39 080 5592299
                                                                                               E-mail: pontillovito@gmail.com
RIASSUNTO
Introduzione. Le misure restrittive adottate in Italia durante la pandemia di COVID-19         Funding
hanno determinato uno stravolgimento delle attività medico chirurgiche. Inaspettatamente,      None.
anche le prestazioni urgenti hanno registrato una riduzione.
Metodi. Abbiamo retrospettivamente confrontato le urgenze chirurgiche ORL eseguite nei         Conflict of interest
tre principali ospedali della Provincia di Bari nel periodo compreso tra il 1° febbraio e il   The Authors declare no conflict of interest.
31 maggio del 2020 con quelle dello stesso periodo del 2019.
Risultati. È stata riscontrata una importante riduzione nel numero di interventi nel 2020        How to cite this article: Pontillo V, Iannuzzi
rispetto all’anno precedente, in particolare nella fase del lockdown vero e proprio e nel        L, Petrone P, et al. ENT surgical emergencies
centro di riferimento terziario.                                                                 during the COVID-19 outbreak. Acta Otorhi-
Conclusioni. La riduzione del numero di urgenze chirurgiche ORL può essere solo par-             nolaryngol Ital 2020;40:399-404. https://doi.
zialmente spiegata dal distanziamento sociale e dal confinamento domiciliare imposti             org/10.14639/0392-100X-N1036
dalle misure restrittive. Abbiamo motivo di credere che alcuni pazienti potrebbero aver
evitato l’assistenza medica per paura di contrarre l’infezione nosocomiale da SARS-            © Società Italiana di Otorinolaringoiatria
CoV2. Questo primo studio potrebbe avviare un processo di implementazione del sistema          e Chirurgia Cervico-Facciale
di risposta alle urgenze ORL che sarebbe auspicabile in un periodo di transizione poten-
zialmente duraturo.                                                                                           OPEN ACCESS

                                                                                               This is an open access article distributed in accordance with
PAROLE CHIAVE: COVID-19, pandemia, ORL, urgenze, chirurgiche                                   the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                               Commercial-NoDerivatives 4.0 International) license. The
                                                                                               article can be used by giving appropriate credit and mentio-
                                                                                               ning the license, but only for non-commercial purposes and
                                                                                               only in the original version. For further information: https://
                                                                                               creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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Introduction                                                                 • Phase 2 (immediate post-lockdown period): starting
                                                                                with the first and partial relaxation of these measures
The COVID-19 pandemic rapidly spread in Europe in the
                                                                                (May 4, 2020);
first months of 2020. Italy was one of the first and most af-
                                                                             • Phase 3 (post-lockdown complete opening): between the
fected countries worldwide, with more than 240,000 cases                        18th (opening decree) and 31st of May 2020.
to date. The outbreak mainly struck the northern regions,                    The same sub-periods were set for 2019.
while the peak was delayed and weakened in middle and                        All procedures were in accordance with the ethical stand-
southern Italy.                                                              ards of the institutional research committee and with the
The province of Bari, with more than 1,200,000 inhabit-                      1964 Helsinki Declaration and its later amendments or
ants, is the most populated province in the Puglia region,                   comparable ethical standards. Our Ethics Committee was
the third in southern Italy and the seventh in Italy. Thanks                 informed of the retrospective data collection.
to the restrictive measures adopted by the Italian Govern-                   Surgical emergencies were divided according to the cause
ment, this district was relatively spared by the first COV-                  into respiratory, haemorrhagic, suppurative, traumatic and
ID-19 outbreak, despite presenting a consistent number of                    obstructive. Post-operative haemorrhagic complications of
infected people, 1493 at time of writing, almost one-third                   elective interventions were the only ‘internal emergencies’
of all Apulian cases. Nevertheless, the lockdown caused                      and were considered separately since this data is strongly
dramatic changes in routine public health care. Surpris-                     influenced by the impairment of scheduled surgery during
ingly, even emergency activity has registered a reduction                    the outbreak. All ‘external’ patients were assigned a yellow
in frequency.                                                                or red code at the Emergency Department. We retrospec-
The aim of this study is to investigate changes in ENT sur-                  tively reclassified priority codes based on our clinical and
gical emergencies in a highly populated area of southern                     radiological assessment.
Italy during the COVID-19 pandemic.
                                                                             Statistical analysis
Materials and methods                                                        The number of emergency interventions was expressed as
This multicentre retrospective study was conducted in the                    absolute number and percentage. Age was expressed as
three ENT Units covering all emergencies in the province                     mean ± sd. Chi-square or Fisher’s exact tests and Mann-
of Bari: ‘Policlinico’ (tertiary referral centre), ‘Di Venere’               Whitney test were used to compare categorical and contin-
and ‘Miulli’ Hospitals (secondary care centres). While ‘Di                   uous variables between the two considered periods, respec-
Venere’ Hospital remained COVID-free, ‘Policlinico’ and                      tively. The difference, in terms of surgical interventions,
‘Miulli’ were designated to host COVID-19 patients during                    between 2019 and 2020 was calculated as percent change.
the pandemic.                                                                A p-value < 0.05 was considered statistically significant.
We collected data about ENT surgical emergencies per-                        The software R (version 3.5.2) was used for statistical anal-
formed between the February 1 and the May 31 for 2020                        ysis.
and 2019. We divided this period into four phases, based on
the main restrictive decrees released by the Italian Govern-                 Results
ment (Fig. 1):                                                               Forty-five surgical emergencies were performed in the
• Phase 0 (pre-lockdown);                                                    study period of 2020, versus 65 interventions performed in
• Phase 1 (lockdown): starting with the beginning of the                     2019, for a reduction of 30.77% (Tab. I and Fig. 2).
   restrictive measures (March 9, 2020);                                     We found a significant reduction (p = 0.0275) in the rate
                                                                             of interventions performed in the tertiary referral centre
                                                                             (35.6% vs. 61.5% in 2019). On the other hand, the pro-
                                                                             portion of cases increased in the secondary clinics (51.1%
                                                                             and 13.3% vs. 30.8% and 7.69% in 2019 respectively),
                                                                             especially at ‘Di Venere’, the only COVID-free hospital
                                                                             (Tab. I).
                                                                             A higher percentage of emergencies was recorded for res-
                                                                             piratory (31.1% vs. 26.2% of 2019) and haemorrhagic con-
                                                                             ditions (11.1% vs. 6.15% of 2019), while traumatic (31.1%
Figure 1. Phases of the study based on the main restrictive and easing de-   vs. 35.4%) and infectious causes (22.2% vs. 24.6%) re-
crees by the Italian Government.                                             mained stable or slightly reduced (Tab. I). Thus, the pro-



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Table I. Emergency interventions in February-May 2019 and 2020.
                    Variable                                    2019                                 2020                           p-value
 N                                                                65                                  45
 Age (mean ± sd)                                              48.6 ± 23.3                         52.7 ± 25.6                       0.3856
 Gender n (%)
 F                                                             23 (35.4)                           18 (40.0)
                                                                                                                                    0.6226
 M                                                             42 (64.6)                           27 (60.0)
 Care centre N (%)
 Hospital 1 (Policlinico)                                      40 (61.5)                           16 (35.6)
 Hospital 2 (Di Venere)                                        20 (30.8)                           23 (51.1)                        0.0275
 Hospital 3 (Miulli)                                            5 (7.7)                            6 (13.3)
 Causes N (%)
 Respiratory                                                   17 (26.2)                           14 (31.1)
 Traumatic                                                     23 (35.4)                           14 (31.1)
 Haemorrhagic                                                   4 (6.2)                            5 (11.1)
                                                                                                                                    0.9015
 Post-operative bleeding                                        4 (6.2)                             2 (4.4)
 Infectious                                                    16 (24.6)                           10 (22.2)
 Foreign bodies                                                 1 (1.5)                             0 (0.0)
 Subperiods N (%)
 Phase 0                                                       17 (26.2)                           14 (31.1)
 Phase 1                                                       31 (47.7)                           19 (42.2)
                                                                                                                                    0.9381
 Phase 2                                                       10 (15.4)                           7 (15.6)
 Phase 3                                                       7 (10.8)                            5 (11.1)




Figure 2. Number of emergency interventions by subperiod in 2019 (blue) and 2020 (red).



                                                                                                                                                 401
V. Pontillo et al.




Table II. Emergency interventions in the different hospitals.
 Causes N (%)                                                     Policlinico                         Di Venere                    Miulli
                                                           2019                 2020         2019                 2020    2019               2020
 Respiratory                                              10 (25)          5 (31.25)         4 (20)           5 (21.74)   3 (60)            4 (66.67)
 Traumatic                                                18 45)           5 (31.25)         4 (20)           9 (39.13)   1 (20)               0 (0)
 Haemorrhagic                                              2 (5)            1 (6.25)         2 (10)           4 (17.39)   0 (0)                0 (0)
 Post-operative bleeding                                  3 (7.5)           1 (6.25)          1 (5)            1 (4.35)   0 (0)                0 (0)
 Infectious                                               7 (17.5)           4 (25)          9 (45)           4 (17.39)    0 (0)            2 (33.33)
 Foreign bodies                                             0 (0)             0 (0)           0 (0)              0 (0)    1 (20)               0 (0)



portion of code red life-threatening emergencies increased                         strictive measures by the Italian Government anticipated
from 44.62% of 2019 to 51.11% of 2020.                                             possible negative evolutions. These measures impacted
Table II shows the distribution by cause in the different                          both people’s lifestyle and public health care routine. In
hospitals.                                                                         particular, ENT elective activity was deeply affected by the
When considering the different subperiods, we observed                             outbreak and various national and international scientific
a substantial reduction in the number of emergencies in                            societies proposed best-practice recommendations in or-
Phase 1, the period of the lockdown (19 cases of 2020 vs.                          der to adapt elective clinical and surgical activity during
31 cases of 2019), while we found comparable values in the                         pandemic conditions 1-5. Italian societies have also recently
pre- (Phase 0) and post-lockdown (Phases 2 and 3) periods.                         published their strategic plan for management of surgical
The lack of statistical significance (p = 0.93) is probably                        patients in the current era 6,7.
related to the small sample size (Tab. I).                                         Gelardi et al. 8 reported an important decrease in emergen-
Specifically, a significant reduction (p = 0.0334) in the pro-                     cy ENT consultations (80.8%) in the Apulia region during
portion of interventions performed at ‘Policlinico’ (Hos-                          the COVID-19 pandemic. However, to our knowledge the
pital 1) was found in Phase 1 (26.3% vs. 58.1% of 2019),                           impact of the lockdown on ENT emergency surgical activ-
again related to a proportional increase at the COVID-free                         ity has not been previously analysed.
centre (52.63% vs. 38.71% of 2019) (Tab. III). Moreover,                           Our analysis showed a reduction in the number of ENT
the frequency of interventions for traumatic and infective                         surgical emergencies in the entire province in the months
causes halved in this subperiod (4 cases in Phase 1 2020 vs.                       of the outbreak (February-May). The major reduction reg-
9 cases in Phase 1 2019) (Tab. III).                                               istered in the tertiary referral centre, specifically during the
Surprisingly, a significant change (p = 0.0076) in the pro-                        main lockdown (Phase 1), is probably to put in relation to
portion of emergencies between hospitals was also demon-                           the fact that a large part of the workforce and spaces were
strated at the end of the lockdown, specifically in Phase 3                        dedicated to the care of COVID-19 patients and some of the
(Tab. III).                                                                        emergencies were rerouted to secondary centres. Surpris-
Finally, we investigated the eventual relation between the                         ingly, similar results were also found in the post-lockdown
rate of emergency ENT interventions and the number of                              period (Phase 3), when all hospitals were gradually return-
new COVID-19 cases per week in the same province. As                               ing to routine activity. We have reason to believe that this
represented in Figure 3, a fall in the number of interven-                         could be imputable to the patients’ preference to present to
tions was observed in the two weeks (23-29 March and 30                            COVID-free hospitals for fear of the virus.
March - 5 April) in which the highest number of new COV-                           It appears obvious that home confinement, traffic restric-
ID-19 patients was registered (287 and 272 respectively).                          tion and social distancing inevitably reduced the incidence
                                                                                   of traumas, common cold and other upper respiratory tract
                                                                                   viral or bacterial infections, together with their eventual
Discussion                                                                         evolutions. Additionally, the worry about the risk of noso-
The COVID-19 pandemic has rapidly spread in Italy, and is                          comial infection probably contributed to the reduction in
strongly influenced by socio-demographic characteristics.                          medical demand in hospitals.
The province of Bari is one of the most populated districts                        In fact, in our series the proportion of life-threatening res-
in Italy, and thus predictions in terms of pandemic spread                         piratory and haemorrhagic emergencies increased during
and strain on public health care were not promising. South-                        the pandemic, while interventions for traumatic and in-
ern Italy was partially spared by the outbreak since the re-                       fectious diseases remained unchanged with respect to the



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                                                                                How restrictive measures impacted ENT emergency care in the era of COVID-19




Figure 3. Graphical representation of the relationship between surgical emergencies and new COVID-19 cases per week in the Province of Bari.


Table III. Emergency interventions in the different subperiods categorised by hospital and cause.
 Variable                       Phase 0                             Phase 1                            Phase 2                          Phase 3
                        2019        2020      p-value     2019       2020         p-value     2019      2020      p-value    2019        2020     p-value
 N                        17         14                    31          19                      10         7                    7           5
 Care centre, N (%)
 Hospital 1            8 (47.06) 8 (57.14)                  18      5 (26.32)                8 (80)   3 (42.86)             6 (85.71)      0
 (Policlinico)                                           (58.06)
 Hospital 2            5 (29.41) 5 (35.71)    0.5593        12         10         0.0334     2 (20)   4 (57.14)   0.9825    1 (14.29)    4 (80)   0.0076
 (Di Venere)                                             (38.71)     (52.63)
 Hospital 3 (Miulli)   4 (23.53)   1 (7.14)              1 (3.23)   4 (21.05)                  0          0                    0         1 (20)
 Causes, N (%)
 Respiratory           4 (23.53) 3 (21.43)              9 (29.03) 8 (42.11)                  2 (20)   2 (28.57)             2 (28.57)    1 (20)
 Traumatic             5 (29.41) 5 (35.71)              9 (29.03) 4 (21.05)                  5 (50)   2 (28.57)             4 (57.14)    3 (60)
 Haemorrhagic          1 (5.88) 1 (7.14)                 2 (6.45) 2 (10.53)                  1 (10)   1 (14.29)                 0        1 (20)
 Post-operative        1 (5.88) 1 (7.14)        1        2 (6.45) 1 (5.26)        0.8536     1 (10)       0       0.8056        0          0         1
 bleeding
 Infectious            5 (29.41) 4 (28.57)              9 (29.03) 4 (21.05)                  1 (10)   2 (28.57)             1 (14.29)      0
 Foreign bodies        1 (5.88)      0                      0         0                        0          0                     0          0



same period of 2019. Most of our trauma patients were                              percentage of emergency intervention for infectious dis-
treated for nasal bone fracture, a non-life threatening and                        eases, especially in Phase 1 (4 cases vs. 9 cases of 2019)
optionable condition that certainly registered a decline dur-                      may be partially explained by home confinement and so-
ing the outbreak. On the other hand, the reduction in the                          cial distancing, at least for bacterial suppurations that are



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V. Pontillo et al.




secondary to upper respiratory tract infections. However,        hospitals for participating in elective and emergency activ-
the quota of odontogenic neck infections should have been        ity during the COVID-19 outbreak. We would also like to
unchanged since it does not depend on social and environ-        show our gratitude to the University of Bari for the support
mental exposition. Our theory is that a part of these sub-       and for providing all the scientific material for the research.
jects may have ignored the problem for fear of nosocomial        All data and material are available and can be provided if
SARS-COV2 contagion. No data are available about the             requested.
possible outcomes of these individuals, but a future focus
on the cause of deaths during this pandemic could help to        References
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