The functionality of our unit changed markedly especially during the initial phases of the lockdown, which was particularly stringent. There were 2160 visits scheduled in the pre-lockdown period, of which 1911 were completed (88.5%). During the equivalent post-lockdown time period i.e. 85 days there were 1220 scheduled visits and 937 patients attended (76.8%). The data comparisons between the pre- and post-lockdown periods revealed significant decreases in both the number of patients booked (p=0.01) and the attendance rates (p=0.0001) at our specialist out-patient clinics. The greatest impact was seen in the general ENT (p=0.009) and Head and Neck clinics (p=0.017). A possible factor in the decrease in number of scheduled visits was the number of public holidays during the post-lockdown period but even accounting for this the number of scheduled visits was meaningfully decreased. [5]
Our out-patient clinic attendance rate post-lockdown decreased (76.8%) but paled in comparison to published data [1]. Kasle et al (2020) conducted a retrospective review within the Division of Otolaryngology at the Yale School of Medicine to examine the quantitative changes in patient visits, modality of their care and subspecialty practice patterns during a selected period in the COVID-19 pandemic and compared it to the same period in 2019. Of the 5044 scheduled appointments, only 649 (12.9%) were completed in the 2020 period with the majority rescheduled or cancelled due to COVID-19. In addition, the majority (55.8%) of their completed visits were via telehealth, an impractical option in our setting. This discrepancy between our clinic non-attendance rates and that of Kasle et al is consistent with previous suggestions of North American healthcare culture and possibly linked to our service being a government sponsored healthcare system. [6]
It was noted during the analysis of the data that the monthly patient attendance at the outpatient clinics were fairly consistent in the pre-lockdown phase up to 25th March 2020 (31-35), in terms of patients seen/day. During the immediate period after lockdown which included 4 clinic days in March and the following month of April, the patient attendance reduced drastically (10/ day). At this stage, South Africa was at level 5 lockdown, which entailed a severe curtailment of all activities. The months of May and June, saw a steady increase in the number of patients attending the outpatient clinics (15-21/day), with the lockdown levels becoming more relaxed. The attendance numbers however remain lower than pre-lockdown levels. The rapid initial decline in patient visits mirrors that of Kasle et al. Their subsequent documented increase in completed visits was mainly attributed to telehealth visits, unfeasible in our clinics. [1]
We observed a decrease in attendance at all our clinics with the general ENT and Head and Neck clinics having the most significant declines in their attendance. This finding is consistent with that of Kasle et al. They observed that during the 2020 period, appointment completion rates dropped for all specialities and was highest for head and neck oncology (25.5%). [1] This decline could be due to a fear of accessing the hospital which is rightly considered a risky environment.
As previously mentioned, all purely elective cases were postponed from 24rd March 2020, however, oncology and emergency cases were still prioritised. This postponement led to a one third decline in the ward admission rate during the post-lockdown period. The postponement is in line with measures adopted by comparable departments in Italy, a country which adopted a similar severe lockdown. [5,6] The decrease in the number of surgical procedures performed during the post-lockdown period was deemed insignificant (p=0.67). A study by Ralli et al documented a 50.8% decrease in the number of ENT procedures done. [6] Their drastic reduction could possibly be explained by the timing of their study which included the period during which Italy experienced their highest proportion of COVID-19 infections. Our post-lockdown period included only the initial phase of the very high numbers of infections documented to date in South Africa. [7]
There were variations noted in the proportion of the different procedures performed with the most significant changes noted in the numbers of tonsillectomies and sinus surgical procedures. This is readily explained by the departmental policy to cancel scheduled cases. Upper airway endoscopy consisting predominantly of direct laryngoscopy and surgical drainage of deep neck space infections remained the most common procedures performed in both periods. Both procedures were performed more frequently in the post-lockdown period. In the study by Ralli et al a drastic reduction in the number of head and neck infections were noted. [6] It is possible that data from the peak of our pandemic may reflect similar changes.
In this study the surgical procedures performed for the diagnosis and treatment of head and neck oncology did not vary considerably between the 2 periods (p=0.38), a finding consistent with that of Ralli et al. [8]
The Covid19 pandemic has resulted in disruption of ENT and head and neck services throughout the world. The head and neck region has one of the highest concentrations of virus particles and thus there has been a trend to postpone all elective surgery and reschedule out-patient clinics where possible.[9] Though at our instuition we saw a reduction in the number of booked patients at the outpatient clinics there was still a need for the provision of urgent ENT services throughout the lockdown period with increased numbers in certain areas such as head and neck endoscopy and tracheostomy.
The study illustrates the despite a lockdown period there is still an ongoing need for specialist medical and surgical services and health care systems need to be tailored to manage all patients such that care is not shifted away from vulnerable groups and solely focused on Covid19 patients. Unfortunately clinic non-attendance and rescheduling of elective procedures in a system under constraint as ours is could have long lasting repercussions on patient health which may be difficult to recover from timeously. A possible long-term solution would be the adoption of telehealth, a trend which would require significant commitment both financial and patient and healthcare education.