key: cord-0940651-5r56zryp authors: Chorney, Stephen R.; Rizzi, Mark D.; Dedhia, Kavita title: Considerations for povidone-iodine antisepsis in pediatric nasal and pharyngeal surgery during the COVID-19 pandemic date: 2020-09-19 journal: Am J Otolaryngol DOI: 10.1016/j.amjoto.2020.102737 sha: 28dc0eac636ccdb14c69b2282239375f56177bfe doc_id: 940651 cord_uid: 5r56zryp PURPOSE: Surgeons resuming elective procedures during the COVID-19 pandemic should consider strategies to mitigate risk of exposure. Prioritizing the safety of patients, caregivers and medical staff remains paramount as surgical volume increases. Until there is an acceptable therapeutic or vaccination against SARS-CoV-2, surgeons must exercise caution when caring for patients with high or uncertain potential for transmission. For otolaryngologists performing surgery on children, unique vulnerability results from a regular interface with the upper respiratory tract mucosa. A growing interest in perioperative application of povidone‑iodine (PVP-I) to the nasopharynx and oropharynx has emerged. METHODS: A contemporary review of the literature with algorithmic approach to the potential use of PVP-I in pediatric mucosal surgery. RESULTS: To date, effectiveness of PVP-I against SARS-CoV-2 has yet to be established and possible risks of its direct use on upper aerodigestive mucosa of children must be weighed. In this contemporary review, an assessment of PVP-I in pediatric oral, nasal and pharyngeal surgery is provided along with clinical considerations and a practical algorithmic approach. CONCLUSION: Further research is required prior to strongly recommending its use in preparation for nasal, oral or pharyngeal surgery in children. The gradual return of elective surgery during the COVID-19 pandemic underscores the need for risk mitigation and safety improvement strategies. Organizations such as The Centers for Medicare & Medicaid Services (CMS) as well as The American College of Surgeons (ACS) have offered clinicians early guidance for this process 1, 2 . Until an acceptable therapeutic or vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerges, surgeons must exercise caution when caring for patients with high or uncertain potential for transmission. Pediatric otolaryngologists confront particular challenges in resuming care during this pandemic. Many of the 1.5 million ambulatory procedures performed annually on children involve the upper respiratory tract mucosa 3 . Viral load of SARS-CoV-2 is highest in the nose and pharynx in infected patients 4 . Aerosol generation or surgical manipulation of these regions carries increased risk of disease transmission to health care personnel. Algorithms for practice modification, particularly for bronchoscopic procedures have offered practical approaches to reduce these risks 5, 6 . Continued reflection and analysis of outcomes will be crucial to ensure that resumption of elective surgical procedures in pediatric otolaryngology is safe for patients, caregivers and fellow staff. CoV-2 transmission through the use of PVP-I preparations is now being considered in the dental community 10 and among otolaryngologists caring for adult endonasal skull base and oncologic patients 11, 12 . A similar appraisal for PVP-I as an added measure during COVID-19 has not been considered for pediatric nasal, oral and pharyngeal surgery. Previous literature has focused on its oral application in preventing childhood caries [13] [14] [15] and as preparation prior to oral cavity procedures 16 including pediatric cleft and craniofacial surgery 17, 18 . Nonetheless, preparing the upper aerodigestive mucosal surfaces before adenoidectomy, tonsillectomy, or endonasal procedures in children may be reasonable to consider in select situations during the COVID-19 pandemic. This review highlights the current understanding of PVP-I as it relates to its use in pediatric patients. The objective is to provide otolaryngologists with a comprehensive summary to help consider what role PVP-I may have in reducing operative risk for SARS-CoV-2 transmission. Further, a clinical algorithm and specific applicability for pediatric otolaryngology procedures is presented. The rapid antimicrobial effect of PVP-I can occur at low concentrations but the exact mechanism of action is unknown 7 . Iodine likely attacks surface proteins of enveloped viruses and also destabilizes membrane fatty acids by reacting with unsaturated carbon bonds 19 and feeling of PVP-I. Shiraishi and colleagues found that the mean absence rate from school for cold or influenza was significantly lower among children encouraged to use PVP-I mouthwash, during the 3 month period 27 . In this study, neither the frequency of daily use nor any quantitative measures on viral activity were recorded. J o u r n a l P r e -p r o o f Journal Pre-proof Betadine® (Aviro Health L.P., Stamford, CT) is the commonly recognized trade name for 10% PVP-I solution. This aqueous solution contains 90% water, 8.5% PVP and 1% available iodine and iodide with a free iodine concentration of 1 parts-per-million (ppm) 9 . Commercially available PVP-I preparations also include scrubs, foams, ointments along with an alcoholic solution (10% PVP-I) for quick-drying purposes and a dry powder spray (2.5% PVP-I) 9,28 . Furthermore, PVP-I is available in common strengths of 10%, 7.5% and 1% and formulations such as a gargle or mouthwash and a 0.45% throat spray depending on application 29 . 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