A 5-year Clinical Analysis of Pattern of Ear, Nose, and Throat Procedures in Pre-COVID-19, COVID-19 Waves, and Post-COVID-19 Period

DISCUSSION

In the published literature, there is a paucity of subsite data for patterns of ENT diseases in pre-COVID-19, COVID-19 waves, and post-COVID-19 time periods.

This study documents the variety of otorhinolaryngology surgeries and procedures performed by the department of ENT in a tertiary care teaching hospital in Central India for a period from January 2018 to December 2022 and to analyze the change in the pattern of procedures in pre-COVID-19, COVID-19, and post-COVID-19 time period.

The initial COVID-19 wave resulted in a decrease in the number of patients presenting in our OPD, a trend also similarly established in other countries across the globe.⁷ Thus, the least number of OPD procedures performed (1,896) was during 2020, while a maximum of 4,249 procedures were done in the post-COVID-19 period of 2022 (Table 1). Similarly, 2020 had a minimum number of OT cases (328), while 2022 had a maximum of OT cases (784) (Fig. 1). While travel restrictions caused disparity in the yearly total patient inflow, it would not cause a bias of the subsite representation. In every year from 2018 to 2020, as well as in 2022, the most common subsite for surgery was the ear, followed by the nose, transoral and oral cavity, and neck. However, in 2021, nasal surgeries predominated (290/740 total cases), followed by transoral and ear surgeries. This indirectly documented the substantial number of sinonasal mucormycosis occurring in the second COVID-19 wave (Fig. 1).

In our clinical analysis of 5 years, we performed 15,592 OPD clinic procedures (Table 1). In totality, DNE was the common OPD procedure performed, followed by VLS, EUM, clinical vertigo evaluation with particle repositioning maneuver, and VNG. In the yearly analysis, VLS was common in the years 2018 and 2019, EUM was common in the year 2020, and DNE was common in the years 2021 and 2022. COVID-19 spreads mainly through aerosol. During the first wave of COVID-19, the lack of DNE and VLS reflected concern for operator safety in the examination of the nose and throat (Table 1). In 2021, there was an unprecedented number (1,760) of nasal endoscopies compared to previous years. Similarly, in 2022, a high number (1,405) of nasal endoscopies were done in OPD. This documented that during the second wave, there was a profusion of post-COVID-19 mucor. Mucor requires nasal endoscopy for diagnosis as well as postoperative cleaning and follow-up endoscopic screening for residual disease.

Endoscopies are a diagnostic tool that aids in documentation and teaching purposes. It helps in patient counseling regarding the etiology and provides a baseline for the follow-up.⁸ Nasal endoscopy is better than computer tomography of paranasal sinuses as a diagnostic technique to detect various anatomical variations, thus initiating early management of rhinogenic headaches.⁹ VLS is the gold standard for visualizing the larynx in patients complaining of change in voice. Glottic closure and mucosal waves are the main parameters that are evaluated to assess the cause of voice change.¹⁰

Allergy testing is done to diagnose the offending food allergens. Their avoidance reduces patient morbidity and the need for pharmaceutical agents.¹¹

Chronic ear diseases need EUM, which helps in the proper diagnosis and management of ear diseases. It allows detailed visualization of the structures after the removal of debris to confirm the otoscopic findings.

Benign paroxysmal positional vertigo (BPPV) is one of the common causes of peripheral vertigo. Vertigo evaluation is done using various clinical maneuvers, and in the case of BPPV, appropriate repositioning techniques are implemented. VNG can supplement clinical vertigo evaluation in specific cases. It not only helps us to detect the weakest of nystagmus but also correctly diagnose the involvement of canals in BPPV.¹²

Fibreoptic laryngoscopy (FOL) is more easily performed and well tolerated by the patients than indirect laryngoscopy and traditional direct laryngoscopy.¹³

From 2018 to 2022, the most common individual surgical procedure was tympanoplasty (255) (Table 2). This was followed by biopsy from the oral cavity and oropharynx or hypopharynx (245) (Table 4), FESS (241) (Table 3), mastoidectomy (194) (Table 2), and intratympanic medication (175) (Table 2).

Tonsillectomy is one of the most common surgical procedures in the United States, with >530,000 procedures performed annually in children younger than 15 years.¹⁴ In a 1-year surgical audit done in Mayo Hospital, Lahore, Pakistan, from March 2014 to February 2015, tonsillectomy (23.25%) was the most common surgery performed, followed by septoplasty (15.6%).¹⁵ Similarly, in Rangaraya Medical College, Andhra Pradesh, India, a retrospective analysis of the pattern of surgeries conducted in the years 2015–2016 showed tonsillectomy (with or without adenoidectomy) was the most common surgery performed (25.03%). Their septoplasty for deviated nasal septum was found to be the second most common surgery (15.01%). In our center, the number of tonsillectomy cases was limited as the incidence of chronic tonsillitis and the need for surgeries has fallen in recent times due to better antibiotics.¹⁶ Also, this routine surgery is rarely referred to our tertiary care center.

Among ear surgeries, the most common procedures were tympanoplasty, mastoidectomy, intratympanic injection, myringotomy, and cochlear implant in descending order (Table 2). This matches with a study conducted in Rangaraya Medical College, Andhra Pradesh, India (2015–2016), where among the ear surgeries, the common surgery was tympanoplasty in 47.5% and tympanoplasty with mastoidectomy in 25.4%. Chronic suppurative otitis media (CSOM) is a major cause of surgically treatable hearing loss. Tympanoplasty to restore hearing was the most common otological surgical procedure performed in the case of safe CSOM. This was followed by mastoid exploration with tympanoplasty for unsafe CSOM (Table 2).

Among nasal surgeries, the most common were FESS, septoplasty, endoscopic surgery for beyond sinus disease, FESS with septoplasty, and endoscopic cautery of nasal bleed (Table 3). In a similar study in Rangaraya Medical College, Andhra Pradesh, India (2015–2016), the common surgery was septoplasty, done in 49.2% for deviated nasal septum. FESS was done in 15.6% for antrochoanal and ethmoidal polyposis, followed by FESS for sinusitis in 12.4%.

During the second wave of COVID-19 (2021), surgeries such as FESS, endoscopic surgery for beyond sinus disease, and external approach to sinuses were done in significant numbers. The mutilating surgery of orbital exenteration had to be undertaken in nine patients due to eye involvement. These surgeries denote the overwhelming number of sinonasal mucormycosis presenting at that time.

Among transoral and oral cavity surgeries, the most common procedures done in our institute in descending order were biopsy from the oral cavity, MLS, direct laryngoscopy with biopsy, removal of oral dysplastic lesions by laser, and tonsillo-adenoid resection (Table 4). In a similar study at Rangaraya Medical College, Andhra Pradesh, India, common oral cavity and oropharyngeal procedures were tonsillectomy at 82.3%, followed by palate biopsies at 7.2% and esophagoscopy at 5.2%, followed by MLS and direct laryngoscopy.

The World Health Organization has named precancerous lesions as an oral potentially malignant disorder (OPMD), a condition that may exhibit epithelial dysplasia upon histopathologic evaluation.¹⁷ Leukoplakia is among the most common OPMDs, with a malignant conversion rate of approximately 1.36%.¹⁸ Biopsies are required for definitive diagnosis and management of suspected malignancies. In our center, the maximum transoral procedure was a biopsy of the oral cavity.

In our center, the second and third most common transoral procedures were MLS and direct laryngoscopy with biopsy, respectively. With the increasing demand for voice quality, the advantages of carbon dioxide (CO₂) laser in phonosurgery are well accepted. We use CO₂ laser with AcuSpot and AcuBlade technology for MLS.

We successfully treated 54 children with foreign bodies in bronchus in the last 5 years (Table 4). For pediatric foreign body (FB) aspiration, rigid bronchoscopy along with optical instruments is the procedure of choice as it allows excellent visualization with good ventilation and airway control.¹⁹

Among head and neck surgeries, the common procedures in descending order were excision of neck nodes, WLE with ND, tracheostomy, thyroidectomy, and incision and drainage of head and neck abscesses (Table 4). In contrast, tracheostomy (58.18%) was the most common head and neck surgery performed in another study conducted at Rangaraya Medical College, Andhra Pradesh, India.

In children and young adults, lymphadenopathy is generally due to infections, whereas malignant disorders form the major cause of lymphadenopathy in those aged above 50 years.²⁰ Excision of neck nodes for definitive diagnosis was our common head and neck procedure.

In India, around 77,000 new cases of oral cancer and 52,000 deaths are reported annually, which is approximately one-fourth of global incidences.²¹ WLE of the lesion, along with ND, was the second most common head and neck procedure done in our institution.