This study has revealed significant reductions in the overall number of all visits in an ENT emergency department during the lockdown period. Available unpublished data of the Athens area show a reduction in ENT visits to other health care facilities as well, including public and private hospitals.
The total reduction in the number of ENT emergency visits by 73% during the COVID-19 pandemic have many explainations. The fact that not only true emergencies visit ENT emergency departments due to the length of waitlists to access outpatient care has been also reported by other authors with similar health care systems, such as Italy [3].
In our study the greatest reductions were seen in general ENT cases and infections that do not need hospitalization. This suggests that most of the general ENT cases that present to the ENT emergency department of a tertiary hospital due to the referral pattern in this country could/should be treated by a primary or secondary health care facility. Furthermore, an overall reduction of other upper respiratory infections should me attributed to the lockdown including school closure.
Telephone advice was used during the lockdown period by most primary care physicians as well as private office-based Otolaryngologists. Since a reduction of deep neck infections was also noted, this could imply that early advice and treatment strategies used by the community health care professionals including local pharmacists was in fact effective. It is established that self-medication by patients and antimicrobial consumption are high in Greece. Moreover, there is also a dispensing of antibiotics by pharmacies without prescription [4].
The second greater reduction was seen in otology cases, suggesting its cause to be similar to general ENT cases.
Patients with vertigo presumably remained at home waiting for their symptoms to recess.
In regard to trauma cases, it is safe to presume that the lockdown itself has led to a reduction of these cases. Reports reveal that there is a significant decrease in visits to emergency trauma departments [5]. Other authors have reported the lower volumes of trauma and injury cases caused by fight, vehicle, ladder accidents or incidents at work, school and sport [6].
We can assume that mild epistaxis incidents could be and were managed by the patients themselves. It is known that while the great majority of epistaxis are limited in severity and duration, only about 6% will seek medical attention. Interventions for nosebleeds range from self-treatment and home remedies to more intensive procedural interventions in medical offices, emergency departments, hospitals, and operating rooms. Epistaxis has been estimated to account for 0.5% of all emergency department visits and up to one-third of all otolaryngology-related emergency department encounters. Inpatient hospitalization for aggressive treatment of severe nosebleeds has been reported in 0.2% of patients with nosebleeds [7].
On the other hand, the least reduction occurred in foreign body cases; this does not come as a surprise since most foreign body ingestion incidents happen in the home and cannot be self-treated.
Surprisingly, there was also a reduction in oncology cases, including insecure airway and an increase in numbers of these cases or cases of inoperable or advanced stage cancer, may be expected in the near future. Oncologic and insecure airway cases, although found to have a statistically significant reduction in volume of visits, are traditionally considered real emergency cases and this reduction was not expected. However, a significant increase in the visitation numbers of these cases is expected in the period following the lift of the national lockdown, due to the large numbers of undiagnosed/untreated oncologic cases. It is mentioned that even oncology cases, although prioritized, are sometimes impacted to limit necessity of ICU or tracheostomy [8,9]. Patients had to balance the risk of diagnosis/treatment delay versus harm from COVID-19 disease. This resulted in a change of the patient’s perception as to what is considered an emergency and should seek treatment in an emergency department of a tertiary hospital. We should keep in mind, though, that many of the cases that did not present to the emergency department during the COVID-19 pandemic could very well present at a later stage with increased severity.
The impact of SARS-CoV-2 pandemic on otolaryngology diagnostic and surgical activities is still unknown, as well as the effects on future general health care strategy and hospital organization. The current situation has caused a drastic reduction of the routine activity of otolaryngology units, with a dramatic impact on the service offered to patients [10]. The reduction in admissions observed should raise serious concerns about the well-being and health outcomes of patients who are not receiving inpatient care for conditions that require emergency treatment [11].
One of the greatest enemies is the consequences of hospitalizations' reduction for conditions requiring timely treatment. One of the greatest friends is to find the way to earn the patients back.