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 BetadineĀ® (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 . CMS) Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I American College of Surgeons. Local Resumption of Elective Surgery Guidance Ambulatory pediatric otolaryngologic procedures in the United States: characteristics and perioperative safety. The Laryngoscope SARS-CoV-2 viral load in upper respiratory specimens of infected patients Pediatric otolaryngology divisional and institutional preparatory response at Seattle Children's Hospital after COVID-19 regional exposure. Otolaryngology-Head and Neck Surgery Antiseptics and disinfectants: activity, action, and resistance. Clinical microbiology reviews Increased bactericidal activity of dilute preparations of povidone-iodine solutions Chemical and microbiologic characteristics and toxicity of povidone-iodine solutions. The American journal of surgery Coronavirus disease 19 (COVID-19): implications for clinical dental care Consideration of povidoneiodine as a public health intervention for COVID-19: Utilization as "Personal Protective Equipment" for frontline providers exposed in high-risk head and neck and skull base oncology care Topical preparations to reduce SARS-CoV-2 aerosolization in head and neck mucosal surgery Topical antimicrobial therapy in the prevention of early childhood caries Effect of povidone-iodine on Streptococcus mutans in children with extensive dental caries. Pediatric dentistry Antibacterial treatment needed for severe early childhood caries Efficacy of preoperative decontamination of the oral cavity. Plastic and reconstructive surgery Interstitial pneumonitis after betadine aspiration Aspiration Pneumonia caused by Povidoneiodine (Betadine) in Cleft Palate Patient. Archives of Craniofacial Surgery Chemical disinfection of virus-contaminated surfaces Iodine revisited. International wound journal Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. The Lancet Inactivation of SARS coronavirus by means of povidone In vitro bactericidal and virucidal efficacy of Povidone-Iodine gargle/mouthwash against respiratory and oral tract pathogens. Infectious diseases and therapy Genome composition and divergence of the novel coronavirus (2019-nCoV) originating in China. Cell host & microbe Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 Evaluation of the bactericidal activity of povidone-iodine and commercially available gargle preparations Povidone-iodine: use in hand disinfection, skin preparation and antiseptic irrigation Practical use of povidoneiodine antiseptic in the maintenance of oral health and in the prevention and treatment of common oropharyngeal infections. International journal of clinical practice New aspects of mechanism of action of povidone-iodine A comparison of the irritant and allergenic properties of antiseptics Allergic contact dermatitis from povidone-iodine: a re-evaluation study. Contact Dermatitis A randomized trial comparing povidone-iodine to a chlorhexidine gluconate-impregnated dressing for prevention of central venous catheter infections in neonates Anaphylaxis to povidone in a child. Pediatric allergy and immunology Comparative Effects of Chlorhexidine Gluconate and Povidone Iodine Mouthwashes to Chemotherapy-Induced Oral Mucositis in Children with Acute Lymphoblastic Leukemia Disinfection with 10% povidone-iodine versus 0.5% chlorhexidine gluconate in 70% isopropanol in the neonatal intensive care unit Wolff-Chaikoff effect in a newborn: is it an overlooked problem A systematic review of thyroid dysfunction in preterm neonates exposed to topical iodine. Archives of Disease in Childhood-Fetal and Neonatal Edition Betadine has a ciliotoxic effect on ciliated human respiratory cells A clinical study on the tolerability of a liposomal povidone-iodine nasal spray: implications for further development The efficacy of diluted topical povidone-iodine rinses in the management of recalcitrant chronic rhinosinusitis: a prospective cohort study Topical Povidone-Iodine as an Adjunctive Treatment for Recalcitrant Chronic Rhinosinusitis Van Furth R. Interaction of povidone-iodine compounds, phagocytic cells, and microorganisms. Antimicrobial agents and chemotherapy Comparative toxicity of antimicrobial agents on transformed human keratinocytes