key: cord-0780378-o1bkegpe
authors: Haapanen, Marjut; Renko, Marjo; Artama, Miia; Manninen, Iida‐Kaisa; Mattila, Ville M.; Uimonen, Mikko; Ponkilainen, Ville; Kuitunen, Ilari
title: Tympanostomies and tonsillar surgery in children during the COVID‐19 pandemic in Finland
date: 2021-07-15
journal: Laryngoscope Investig Otolaryngol
DOI: 10.1002/lio2.622
sha: 9df7501479ce3d184ad03d6402c91560fc975132
doc_id: 780378
cord_uid: o1bkegpe

OBJECTIVE: To assess the impact of social restrictions due to COVID‐19 on the number of tympanostomies and tonsillar surgeries in children. METHODS: Incidences were calculated per 100 000 children for tonsillar surgery and tympanostomies in 2020 and compared to the mean incidence of referral years 2017 to 2019 by incidence rate ratios (IRR) with 95% confidence intervals (CIs). Median waiting times were also compared. RESULTS: Before the lockdown, tonsillar surgery incidence was 33.4/100000 (IRR 1.14, CI 0.76‐1.71) in February 2020. After the lockdown began, the incidence of tonsillar surgery was 1.4/100000 (IRR 0.04, CI 0.01‐0.15) in April. In June, tonsillar operation incidence started to increase (20.4 per 100 000). The incidence of tympanostomies was 81% lower (IRR 0.19, CI 0.09‐0.39) in April 2020 and 61% lower (IRR 0.39, CI 0.22‐0.69) in August 2020 than in 2017‐2019. These incidence rates remained lower all year (December 2020 IRR 0.13, CI 0.05‐0.33). Median waiting time for tonsillar surgery was 3.3 months in 2020 and 1.6 months in 2017 to 2019; P <.001, and for tympanostomies 1.3 months in 2020 and 1.0 months in 2017 to 2019, P <.001. The referral rate to otorhinolaryngology during the severest restrictions was 35% lower in April and May 2020 compared with the reference years. CONCLUSION: This study suggests that the restrictions against COVID‐19 reduced the incidence rates of tonsil surgery and tympanostomies in children. Also, the lockdown and cancellations of elective operations in spring 2020 led to increased waiting times. These findings may help in preparing for future pandemics. Level of evidence: Level 3.

In 2020, the global coronavirus pandemic (COVID-19) caused considerable changes in people's daily lives due to restrictions and recommendations to prevent the spread of the disease. Social distancing and lockdowns were the most commonly implemented strategies during the first wave of COVID-19. During the second wave, the restrictions were regional and based on COVID-19 infection rates in Finland. 1, 2 The restrictions of the first wave decreased the number of pediatric respiratory infections and emergency room visits. [3] [4] [5] [6] Similarly, hospitalizations decreased. 7, 8 Recurrent throat infections and obstructive disorders are indications for tonsillar surgery, while indications for tympanostomy are recurrent middle ear infections and persistent effusion. 9, 10 In a survey of the tonsillectomy waiting list in the pediatric population, tonsillitis episodes diminished during the 2 months of social distancing in the UK. 11 Nevertheless, all patients from the waiting list were operated on electively either during or after the lockdown. Several studies have demonstrated a decrease in the number of acute otitis media in children during the lockdown, 3, 4, 12, 13 also in recurrent cases. 14 However, further research is needed on the impact of the first and second coronavirus waves on the number of tonsillar surgeries and tympanostomies.

The aim of this study was to evaluate the influence of social restrictions on the trends of tonsillar surgery and tympanostomies in children in 2020 during the first and second waves of the COVID-19 pandemic.

Data for this retrospective register study were collected over the period of 2017 to 2020 from the hospital discharge records of three 

The year 2020 was divided into four periods concerning restrictions: Since September, regional restrictions have been imposed based on COVID-19 infection rates. The epidemiologic situation was divided into three stages: base level, acceleration level, and spreading level. 2 At the base level, the recommendations were mostly for distancing and good hygiene; at the acceleration level, the recommendations for gatherings were tightened; at the spreading level, group leisure activities were recommended to be discontinued, and public places and upper secondary schools were closed if necessary. 22 

We calculated monthly incidence with 95% confidence intervals (CIs)

for the operations per 100 000 children by using Poisson exact method. We then compared these figures with the mean incidence of corresponding periods in 2017 to 2019 by using incidence rate ratios 

The data included a total of 3718 operations, of which 2060 were tonsillar operations and 1658 tympanostomies, during the study period between 2017 and 2020. Of these, 356 (17.3%) of the tonsillar operations and 212 (12.8%) of the tympanostomies were performed in 2020.

The overall referral rate to otorhinolaryngology units decreased during the lockdown and returned to reference level in September, although it remained lower from October to December (Figure 1 ).

The most common surgery in 2020 was combined tonsillectomy and adenoidectomy and in 2017 to 2019, the most common surgery was adenoidectomy (Table 1) . Waiting times from referral to operation were longer in 2020 compared with the reference years (3.3 vs 1.6 months, P <.001; Table 1 ). The most common indications for tonsillar surgery in 2020 as well as in the reference years were infections and obstructive disorders.

Before the lockdown, in January 2020, the incidence of tonsillar surgery was 29% lower than in the previous years (IRR 0.71, CI 0.48-1.06; Figure 2 ). In February 2020, the incidence was 33.4 per 100 000 person-months, 14% higher than in the previous years (IRR 1.14, CI 0.76-1.71; Figure 2 ). During the lockdown, the incidence of tonsillar surgery was 66% lower than in the previous years (IRR 0.34, CI 0.25-0.46). The incidence was at its lowest in April at 1.4 per 100 000

person-months, which was 96% lower than in the corresponding years (IRR 0.04, CI 0.01-0.15; Figure 2 ). When the restrictions were loosened, the incidence was 41% lower than in the previous years (IRR 0.59, CI 0.43-0.80). In June 2020, tonsillar operation incidence started to increase (20.4 per 100 000 person-months; Figure 2 ). During the implementation of regional restrictions, the incidence was 20% lower than in the reference years (IRR 0.80, CI 0.65-1.00).

In 2020, the median waiting time from referral to operation was longer (1.3 vs 1.0 months, P <0.001; Table 2 ). The incidence of tympanostomies was 27% lower than in the corresponding years before the lockdown (IRR 0.73, CI 0.53-0.99; Figure 3 ). During the lockdown, the incidence was 49% lower (IRR 0.51, CI 0.39-0.69) than in the corresponding years, and, in April, the incidence of tympanostomies was 81% lower (IRR 0.19, CI 0.09-0.39) than in the previous years. In

May, the incidence of tympanostomies was 17.7/100 000, which was 35% lower than in previous years (IRR 0.65, CI 0.40-1.07; Figure 3 ).

When the restrictions were loosened, the incidence from June to August was 72% lower than in the reference years (IRR 0.28, CI 0.18-0.43). During the regional restrictions period (September-December), the incidence of tympanostomies remained 68% lower than in the corresponding years (IRR 0.32, CI 0.23-0.44; Figure 3 ).

The F I G U R E 2 Incidence of tonsillar surgery with 95% confidence intervals in children, 2020 compared to three previous years before the lockdown in 2020 than in the previous years. Lower number of operations in January 2020 may reflect the timing of Christmas holidays or just random variation.

In the spring of 2020, otolaryngologists were considered at high risk of COVID-19 infection due to close contact with the respiratory secretions of patients. Therefore, only urgent oto-, rhino-, and laryngology procedures were recommended, and many outpatient visits and oto-, rhino-, and laryngology operations were cancelled. 23 Operating room teams were retrained to work in intensive care units, and some operating rooms were closed. 24 Also, the number of operations was affected by a lack of personal protective equipment. 25 In Finland, over three million secondary and tertiary care level outpatient visits were cancelled, and medical treatment debt increased by approximately three billion euros in the spring. 26 Globally, during the first 12 weeks of the pandemic, over 30 million operations were cancelled, of which approximately 4 million were oto-, rhino-, and laryngology operations. 27 These cancellations added to the treatment backlog and might have cause decreased quality of life as the waiting times increased and treatments were delayed.

A broad population base including one-sixth of the Finnish pediatric population is clearly one of the strengths of this study. The tonsillar operation and tympanostomy rates in our data probably reflect the real incidence of these procedures, as the majority of these are per- F I G U R E 3 Incidence of tympanostomies with 95% confidence intervals in children, 2020 compared to three previous years that the change in the number of overall otorhinolaryngology referral data also reflects the trend of children's oto-, rhino-, and laryngology referral rates.

The restrictions enacted due to the COVID-19 pandemic had a major impact in decreasing the number of tonsillar surgeries and the number of tympanostomies, in children. Additionally, the lockdown and the cancelling of elective operations in spring 2020 led to increased waiting times for operations. These findings clarify the burden of infections as indications for surgery, and they may assist planning for future pandemics.

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Tympanostomies and tonsillar surgery in children during the COVID-19 pandemic in Finland

The authors have no conflict of interest to declare. 

https://orcid.org/0000-0003-3357-3756