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REVIEW ARTICLE
Year : 2020  |  Volume : 47  |  Issue : 2  |  Page : 63-68

Otorhinolaryngological manifestations in COVID-19 infections: An early indicator for isolating the positive cases


Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Date of Submission17-Jun-2020
Date of Acceptance10-Jul-2020
Date of Web Publication11-Sep-2020

Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jss.JSS_57_20

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  Abstract 


COVID-19 is an infectious respiratory disease caused by a novel virus severe acute respiratory syndrome corona virus 2. Clinical manifestations of COVID-19 range from asymptomatic or flue such as symptoms to severe dyspnea or breathlessness. The combination of the symptoms such as anosmia, persistent cough, fever, fatigue, diarrhea, abdominal pain, and lack of appetite are commonly found in CVOID-19 patients. The symptomatology due to otorhinolaryngological manifestations is often by respiratory tract infections and predominantly found for consultation at otorhinolaryngology clinic. Otorhinolaryngological manifestations are usually associated with aerosol producing symptoms and so highly contagious in very short period. It is need to identify the patient with symptoms and rightly pinpoint to infect individuals. This review article focuses on the otorhinolaryngological manifestations and its implications in early transmission of the COVID-19 along with the preventions. This article will surely increase awareness among the frontliner clinicians and help them to protect themselves along with early suspicion of cases before spreading the diseases to community.

Keywords: Cough, COVID-19, hyposmia, otorhinolaryngological manifestations


How to cite this article:
Swain SK, Acharya S, Sahajan N. Otorhinolaryngological manifestations in COVID-19 infections: An early indicator for isolating the positive cases. J Sci Soc 2020;47:63-8

How to cite this URL:
Swain SK, Acharya S, Sahajan N. Otorhinolaryngological manifestations in COVID-19 infections: An early indicator for isolating the positive cases. J Sci Soc [serial online] 2020 [cited 2020 Nov 27];47:63-8. Available from: https://www.jscisociety.com/text.asp?2020/47/2/63/294804




  Introduction Top


The infection by novel coronavirus, severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) (Covid-19) was emerged as an outbreak from Wuhan city of China and subsequently spreaded rapidly to more than 200 countries of the world. Presently China, Italy, Spain, Germany, and the United States of America are counties with the highest number of cases.[1] The World Health Organization (WHO) declared COVID-19 as a global pandemic on March 11, 2020.[2] Clinicians specifically otolaryngologists have an important role as a health-care providers for seeing the patients with otolaryngological manifestations. The otorhinolaryngological manifestations include pharyngitis, nasal congestions, hyposmia, dysgeusia, rhinitis, epistaxis, otitis extern, dizziness, and tinnitus.[3] The otolaryngological manifestations have significantly higher risk of infections spread to others due to frequent touching sites of the hand particularly to nose and mouth. This review article will discuss regarding different otorhinolaryngological manifestations which should be known to otolaryngologists so that they can recommend early protective measures to the patients and also surrounding peoples. The otolaryngologists should use protective measures during examining this aerosol producing symptoms. The clinicians should use personal protective equipment (PPE) or N95 mask during the evaluation of the otolaryngological manifestations of the COVID-19 patients because of the contagious nature with rapid spread to others.


  Methods of Literature Search Top


The current research articles regarding COVID-19 infections were searched through a multiple systemic approach. First, we conducted an online search of the Scopus, PubMed, and Medline database with the COVID-19, otorhinolaryngological manifestations, and clinical manifestations of COVID-19. The abstracts of the published articles were identified by this search method and other articles identified manually from citations. This manuscript reviews the details of otorhinolaryngological manifestations along with its epidemiology and preventions. This review article presents a baseline from where further prospective trials for otorhinolaryngological manifestations and other clinical presentations could be designed and helps as a spur for further epidemiological, clinical, and basic research in the COVID-19 and so protect from such fatal pandemic from the world.


  Epidemiology Top


COVID-19 is highly contagious infections of the respiratory system due to novel virus SARS-CoV-2. The first case was reported in Wuhan, China, in late December 2019, where the outbreak of the novel corona virus now called as SARS-CoV-2 spreaded worldwide. The death percentage among 2684 positive cases of COVID-19 was around 2.84% as of January 25, 2020, and the median age of the patients those died was 75 (age range of 48–89 years).[4] By February 27, 2020, more than 82,000 COVID-19-positive cases and more than 2800 deaths have been documented of which around 95% of the cases and 97% of deaths were in China.[5] By the March 26,2020, there were 462684 cases of the COVID-19 reported in 199 countries.[6]


  Covid-19 Virus Top


Corona viruses causing COVID-19 are large, encapsulated, or enveloped positive strand RNA virus [Figure 1] which can be classified into four genera such as alpha, beta, delta, and gamma. Out of these four types alpha and beta are known to infect human beings.[7] The corona virus is ranging from 60 nm to 140 nm with spike like projection from the surface as a crown like appearance under electron microscope, so the name corona virus.[8] The spikes over surface of the virus is made up of glycoprotein which act as critical for binding to the host cell receptors and play a vital role in severity of the infections of the host.[7] The majority of the human receptors for glycoprotein of this virus, human angiotensin converting enzyme 2 is seen mainly in the lower respiratory tract rather than upper respiratory tract. Hence, scarcity of the receptors in the upper respiratory tract, the clinical symptoms related to upper airway is less. The incubation period of COVID-19 ranges from 1 to 14 days with a median of 5–6 days. Although recent study document that the incubation period may extend to 24 days.[9] A longer incubation has implication in quarantine policies and prevention of the spread of the disease. This virus primarily transmitted through droplets but also it is seen in blood and stool, so raising question regarding mode of transmission.[10]
Figure 1: Structure of the COVID-19 virus (Black arrow is spike protein over lipid membrane, Green arrow indicates RNA)

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  Symptomatology in Perspective to Otorhinolaryngological Manifestations Top


The COVID-19 infections are new to the human being. The causative virus is most likely associated with mutations and the different clinical patterns remain more questions than answers. The spectrum of clinical manifestations in COVID-19 includes mere flu-like symptoms to severe life-threatening condition. The studies from the hospitalized patients, mostly at Wuhan, China document that majority of the patients with median age of 50 years with slight predominance in male.[11] Approximately 25% of these patients have severe symptoms need intensive care whereas 10% of then require mechanical ventilation.[11] The clinical presentations include fever in approximately 83%–98% of the patients, dry cough in 76%–82%, and maylgia and fatigue in 11%–44%.[11] Other symptoms include headache, sore throat, pain abdomen, and diarrhea. The clinical presentation of COVID-19 ranges asymptomatic carriers to severe viral pneumonia. In comparison to nonsevere patients, severe symptomatic patients are older and more associated with comorbidities. The asymptomatic persons of COVID-19 are those who carries the virus but do not show symptoms but able to transmits the infections in the similar degree as symptomatic carriers. Common clinical presentations of SARS are fever, cough, dyspnea, and occasional diarrhea. Out of all patients, 20%–30% require mechanical ventilations and 10% died.[12] A study from china presented with otolaryngological manifestations among COVID-19 patients are rhinitis, hyposmia, loss of taste sensation, otitis externa, and tinnitus.[3] As the diseases of the olfactory tract often have a significant impact on the taste, hypogeusia is documented in the case of Covid-19.[13] One study was documenting most common neurological symptom was dizziness (16.8%) and headache (13.1%).[14] The most common upper respiratory tract manifestations were hypogeusia (5.6%) and hyposmia (5.1%).[14] The generalized symptoms are dry cough, maylgia, lack of appetite, fever, diarrhea, headache, and asthenia are found in 45% of the cases. The otolaryngological manifestations are most often related to the infections [Table 1]. Approximately 2%–3% of the patients present with olfactory manifestations such as hyposmia or anosmia in general populations and most common etiologies are flue and common cold.[15] Postviral olfactory diseases often found after upper respiratory tract infections in association with common cold or influenza.[15] Females are more commonly affected than male and postupper respiratory tract infections are usually seen between the fourth and eighth decades of life.[16] The clinical cases and media reports from pandemic affected countries such as China, Italy, France, South Korea, Germany, and the United Kingdom indicate that a major number of cases with proven COVID-19 have presented with anosmia or loss of smell and mechanism of actions for these symptoms by SARS-CoV-2 viral infection has been same as the flu virus.[17] The severity of COVID-19 may go to acute respiratory distress syndrome to multiple organ failure.[18] One recent study showing the otorhinolaryngological manifestations by COVID-19 infections [Table 1] where each of the symptom is presented in percentage in terms of their relationship with COVID-19 infections (the scale used: 0–4, 0 = not related, 4 = highly related).[19]
Table 1: Otorhinolaryngological manifestations in COVID-19 infection (Scale: 0-4, where 0=not related, 2-3=Somewhat related,4-Highly related)[19]

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Olfactory dysfunction

In one recent study, out of 357 patients of COVID-19, 85.6% had olfactory dysfunction. Among the patients with olfactory dysfunction, 79.6% were anosmic and 20.4% were hyposmic.[19] Parosmia and phantosmia were seen in 32.4% and 12.6% during the disease process, respectively.[19] The symptoms of the olfactory dysfunctions (11.8%) found before the appearance of general or otorhinolaryngological symptoms (22.8%) whereas the symptoms of the olfactory dysfunctions seen after (65.4%) or at the time of appearance of general or otorhinolaryngological symptoms (22.8%).[19] In last few weeks, some European otolaryngologists found that several patients infected with SARS-CoV-2 showing sever olfactory and gustatory problems without any nasal discharge or nasal obstruction. Hence, in these patients, no COVID-19 was suspected because they had no cough, fever, or any systemic complaints. The female patients were more affected with hyposmia or anosmia in comparison to the males.[19] The sudden onset of anosmia or ageusia required to be recognized by the international scientific forum as an important symptom of the COVID-19 infection.

Epistaxis

In one study from Wuhan, China, 30% of the hospitalized COVID-19 patients presented with epistaxis.[3] The nasal bleeding often seen from one or both nostrils. In intensive care unit, those patients under noninvasive-assisted ventilation or high flow oxygen by nasal cannula are prone for nasal bleeding. The patients those under anticoagulants at the intensive care units also sometimes presents with epistaxis. The mucosal inflammations of the nasal cavity and nasopharynx also lead to nasal bleeding by slight trauma.

Laryngotracheal manifestations

Laryngotracheal area is an important part for the generation of aerosol and spread infections rapidly. Patients of COVID-19 present with laryngotracheobronchitis and so need laryngeal examinations or intubations which is often challenging to clinicians. There are generalized inflammations and edema in the laryngotracheal area and patient present with cough, fever, and breathing difficulty. Patients of COVID-19 are at high risk for presenting severe symptoms of worsening cough, dyspnea, and hypoxia with deterioration.[20] The current literatures suggest new onset of dry cough and fever are the most common presenting symptoms in COVID-19. Tracheostomy patients are always at high risk for the transmission of aerosols from tracheostomy opening. In the intensive care unit, COVID-19 patients those are very sick go to coma where tracheostomy is required for prolonged ventilation. The droplet transmission from the tracheostomy opening can be prevented by covering with tracheal collar. If tracheostomy is required for COVID-19 patients, this surgery should be done by minimizing aerosol production by doing complete paralysis for avoiding coughing. Ventilator is connected with cuff inflation and stops ventilation before entering into the air way, avoid suctioning, and minimal use of cautery during tracheostomy. Personal protective measures should worn by all operation room staff.

Otological manifestations

The otological manifestations may be found in COVID-19 patients. Due to infections at the nose and nasopharynx, the  Eustachian tube More Details may be blocked and lead to eustachian tube dysfunction. The eustachian tube dysfunction leads to fullness of the ear and otalgia. The eustachian tube dysfunction further leads to acute suppurative otitis media which manifests as severe ear pain and fever. It sometimes present with hearing loss due to eustachian tube dysfunctions.[3]

Oral cavity oropharyngeal manifestations

COVID-19 patients often present with throat pain due to severe inflammations at the tonsils and other oropharyngeal area. They often have pharyngitis and tonsillitis with generalized inflammation over the mucosal membrane.[21] The tonsillitis may be follicular or membranous type of tonsillitis [Figure 2]. The infections at these areas are aerosol producing and high chance of the transmission of droplet to otolaryngologists or nearby persons. Due to infections at oral activity and oropharynx, patients may present with odynophagia and complain sore throat. Due to infections at the pharynx, the patient may complain referred ear pain. On examination, throat appears red and congested.[22]
Figure 2: A COVID-19 patient showing membranous tonsillitis

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Elderly and comorbid patients

The clinical presentations are more severe among elderly patients and patients with comorbid conditions such diabetes mellitus and hypertension. Elderly male have more severe manifestations. The fatality is more in elderly patients. The overall case fatality rate in Italy was 7.2% which is much higher than the China (2.3%).[23] When the data were compared with age group, the case fatality rate in China and Italy appear similar in the age group of 0–69 years.[23] However, the case fatality rates are higher in Italy in the persons aged 70 years or more and specifically among those more than 80 years or more.[23] This difference is often difficult to explain.

Pediatric patients

Pediatric patients have relatively milder otorhinolaryngological symptoms as compared to the adults and them often asymptomatic.[24] One hospital based study from Wuhan, China, showed 15% of the COVID-19-positive pediatric patients were asymptomatic.[25] These data may underscore the potential role of the children in community transmission. This is why otolaryngologists should be aware about the risk of the transmission from pediatric patients to health-care workers and also care givers or nearby persons.[21]


  Screening and Confirmation of the Covid-19 Top


The WHO and Center for Disease Control and Prevention recommended screening of the patients on the basis of travel history to China or close contact with diagnosed cases or under investigations for SARS-CoV-2 in first 14 days with cough and fever.[26] However, due to increasing number of cases in different countries, without travel history but known contact with positive cases can be under screening. The lack of adequate preventive measures and awareness with poor infection control plan during early stage of the pandemic, many patients were affected. So, second and third level protections are required. The second level protective measures are wearing protective medical masks equivalent to N95 respirators, protection to the eye by goggles and face shields, work cloths, disposable gowns, shoe covers, gloves, and also hair covers. The third level protection will add extra powered supply filter respirator (PAPR) such as positive pressure headgear or a comprehensive protective respiratory device as per expert consensus in China.[26] The level of protection can be adjusted as per specific need of working area and type of encounter.

Polymerase chain reaction (PCR)-based diagnostic reagents on the basis of rapidly developed available viral genome sequences are helpful for screening of the COVID-19. Nasal and nasopharyngeal samples are utilized for real time reverse transcriptase PCR (RT-PCR) for confirmation of the virus. Nasopharyngeal samples are usually collected in universal viral transport media and RNA extraction is carried out with the NucliSENS easy MAG system (bioMérieux, Marcy l'Etoile, France). Then, with the use of A*STAR Fortitude kit (Accelerate Technologies Pvt. Ltd., Singapore, Republic of Singapore), 55 ml of elute are used for performing the RT-PCR analysis as per the manufacturer's instruction.[10] Tears can be utilized for sample where Schirmer test may be helpful.


  Diagnosis Top


Chest X-ray shows bilateral patchy infiltrates and the computed tomography scan of the chest demonstrates ground glass infiltrates. RT-PCR test for COVID-19 nucleic acid are performed using nasopharyngeal swab. The specimen for RT-PCR is usually nasopharyngeal swab.[10] The ideal sample is lower respiratory tract sample such as induced sputum or bronchoalveolar lavage. Serum samples can be sent for antibody testing. Viral cultures are not a recommended test.


  Prevention Top


Currently, there is no vaccine available for SARS-CoV-2 infections. There are high chances of transmission of infections among health-care workers, so CDC recommended the use of PPE including eye protection. Health-care workers such as frontliners wear gowns, gloves, and N95 mask with face shield and or goggles. Separating the patients should be done at the shared waiting areas of the clinic and also ensure the thorough cleaning of the surfaces will reduce the spread of the infections. During nasal endoscopy or examination of the oral cavity oropharynx, the nasal cavity and pharynx mucosal layer should be well anaesthetized before procedure for reducing cough reflexes and sneeze reflex. Gel type of local anesthesia rather than spray can be used to decrease the aerosol production. The smallest nasal or throat endoscopes are used for diagnostic purpose for minimizing the cough and sneezing.[27] As otorhinolaryngology patients are often associated with aerosol producing procedures at the time of the nursing care, so high risk for transmission to health care or nurses are present. Open type suctions should be replaced by closed suction in patient with tracheostomy. Suction should be used before tracheal nursing for reducing sputum production at the time of procedure. Aerosol inhalation can also be replaced by in-tube infusion or spray humidification for humidifying the tracheal. COVID-19 patients need urgent otolaryngologist consultations for several reasons. The otolaryngologists play a vital role in managing the COVID-19 patients. However, due to their high risk of exposure to aerosols, should use protective measures so that can prevent infections by COVID-19. Careful attention should be given for proper hand hygiene and avoid touch to the nose, mouth, and eye. The otolaryngology health-care persons should be quarantine in an isolation center for 14 days after the consultation of the positive cases and do nucleic acid tests two times spanning a 24 h duration.

However, there is a large gap in the understanding of the etiopathogenesis, epidemiology, clinical presentations, and human transmission of the disease. There should be a continuous monitoring and tracing of this COVID-19 is needed to ensure the detail understanding of this disease.


  Conclusion Top


The outbreak of COVID-19 leads to an acute respiratory illness by the infections of novel corona virus SARS-CoV-2. The global attention is now on the infected patients. Although a large group of patients often present with flu-like symptoms, the otorhinolaryngological symptoms sometimes unnoticed but definite picture help in early diagnosis. The otorhinolaryngological manifestations of COVID-19 range from minor flu-like symptoms to severe respiratory symptom such as life-threatening dyspnea. The clinicians should give close attention to any nose, nasopharyngeal and throat infections along with symptoms of the respiratory airway. One of the important rhinological manifestations is anosmia which can be used as screening tool for identification of potential in mild cases and also instructed to self-isolate.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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