Is oro/nasopharyngeal swab for SARS-CoV-2 detection a safe procedure? Complications observed among a case series of 4876 consecutive swabs

Our Experience With Intractable Epistaxis After COVID-19 Nasopharyngeal Swab

INTRODUCTION

Although a COVID-19 nasopharyngeal swab is a safe procedure routinely performed by healthcare providers, it can lead to complications that can be life-threatening. We present seven cases of intractable epistaxis following a nasopharyngeal swab that required sphenopalatine artery ligation. We aim to shed light on this life-threatening condition, emphasizing the importance of recognizing and mitigating such complications.

MATERIALS AND METHODS

This retrospective chart review involved cases of intractable epistaxis following a COVID-19 swab from January 2020 to June 2022. The patient's charts were reviewed for the location of the epistaxis and different intranasal and extranasal factors that could have led to it.

RESULTS

Seven cases had intractable epistaxis following a nasopharyngeal COVID-19 swab. Six of the seven cases had a deviated nasal septum, and one case had an enlarged inferior turbinate. All patients had bleeding from the ipsilateral nasal structural abnormality. All patients underwent successful sphenopalatine artery ligation.

CONCLUSION

Our study highlights the significance of recognizing the potential risk of intractable epistaxis post-COVID-19 swabs and emphasizes the importance of comprehensive training programs to ensure the safe and effective execution of nasopharyngeal swab procedures.

Evaluation of SARS-CoV-2 quantification from oropharyngeal swabs, nasopharyngeal swabs, and naso-oropharyngeal swabs: A cross-sectional study

The current naso-oropharyngeal swab for SARS-CoV-2 detection faces several problems, such as waste issues and its use for quantitative studies. This study aimed to evaluate the total RNA and viral loads from different upper respiratory tract swabs types and whether SARS-CoV-2 quantification can use the current internal control for normalization. This cross-sectional study collected positive specimens with single oropharyngeal or nasopharyngeal swabs and naso-oropharyngeal swabs. The samples were extracted, tested with qualitative RT‒PCR, and then tested with quantitative RT‒PCR. The RNA eluate was measured for the total RNA concentration. The total RNA concentration, viral load, and RNaseP Ct values were collected and analysed statistically. The positive results came from 41 oropharyngeal swabs, 34 nasopharyngeal swabs, and 36 naso-oropharyngeal swabs. The total RNA increased significantly from oropharyngeal swabs to nasopharyngeal swabs to naso-oropharyngeal swabs. Significant differences in RNaseP Ct values between groups and their correlations with total RNA were found. In addition, the increase in the total RNA and the RNaseP Ct values were unrelated to the viral load. The physical features in the naso-oropharyngeal area and the swabbing procedures could affect the total RNA but not the viral load. However, since the virus particles could present inside and outside human cells, the increase in collected human cells may not always be followed by the viral load increase. Normalization using the RNaseP Ct value became unnecessary due to the factors mentioned above. Therefore, a careful approach is needed in viral load studies of swab specimens.

The swab site of the upper airways influences the diagnostic sensitivity for the omicron variant of SARS-CoV-2

The cycle-threshold-value (CT -value) is a quantitative value of the polymerase chain reaction (PCR), which represents the gold standard for the detection of severe acute respiratory syndrome coronavirus 2 (SARS CoV 2). The CT -value can be used to indicate the viral load in swabs of the airways. The collection of a specimen is the only part of the testing process, which is performed manually and carries, therefore, a high potential for increasing measurement variability. The comparison of different PCR results is often difficult since the exact swabbing technique of each test and how do swabs relate in a direct comparison is unknown. For these reasons, the infection course in a patient can be hard infer even after multiple swabs. As the Omicron variant spread from 06/2022 to 08/2022, all common modalities of the upper airway swabs (nasopharyngeal, oropharyngeal, combined naso-oropharyngeal, nasal orifice swabs as well as swabs of the buccal mucosa), which were performed on patients with a suspected infection with SARS CoV 2. RT-PCR was used for SARS CoV 2 RNA detection and the sample comparison was based on the CT -values obtained. Viral loads can vary significantly depending on the swab sites of the upper airways. For the maximum clinical sensitivity, a combined naso-oropharyngeal swab should be considered. In case a single point and single sample measurement is the norm, a nasopharyngeal swab can deliver the highest viral load at the presumed beginning of the infection. Furthermore, the findings of this study can be valuable to correctly interpret results of different PCR with different sampling techniques.

Brain abscess as a complication of nasopharyngeal COVID-19 swab testing: Two case reports and a literature review

INTRODUCTION AND IMPORTANCE

The nasopharyngeal swab, which has experienced a marked increase in utilization during the COVID-19 pandemic and is considered the gold standard for COVID-19 testing due to its high diagnostic accuracy and sensitivity, The procedure is generally safe and well-tolerated, with pain, discomfort, and the urge to cough or sneeze being the most common complications. Though it is occasionally associated with serious complications.

CASE PRESENTATION

we report two cases of brain abscess as a complication of nasopharyngeal COVID-19 testing. The first case was of a 47-year-old male diabetic patient with a positive medical history for immune thrombocytopenic purpura (ITP) who developed a frontal brain abscess one week after the swabbing procedure and was treated with systemic antibiotics followed by a successful functional endoscopic sinus surgery. The second case involved a hypertensive female patient in her 40s who also developed a frontal brain abscess on the same side as painful nasal COVID-19 testing. Systemic antibiotics were used to treat the patient.

CLINICAL DISCUSSION

Serious adverse events from nasopharyngeal COVID-19 testing were reported to occur rarely, with incidences ranging from 0.0012 to 0.026 %. Retained swabs, epistaxis, and CSF leakage were commonly reported complications, which were frequently associated with high-risk factors such as septal deviations, pre-existing basal skull defects, and sinus surgeries. However, brain abscess complications are considered one of the extremely rare complications, with only a few cases reported in the literature.

CONCLUSION

Appropriate approaches that depend on adequate anatomical knowledge are necessary for practitioners to perform nasopharyngeal COVID-19 testing.

Orbital cellulitis complicated with subperiosteal abscess following post-nasopharyngeal swab for COVID-19: A case report

Key Clinical Message

The nasopharyngeal swab for COVID-19 is associated with low risks of severe complications, but it is important to consider the patient's medical history and anatomy of the nasal cavity to ensure safety and accuracy of the test. Orbital complications can occur up to 85% secondary to acute sinusitis, and prompt treatments are crucial, particularly in the pediatric group. A conservative approach is effective for subperiosteal abscess if certain criteria are met, and it is not an absolute indication for immediate surgical intervention. However, timely management of orbital cellulitis is essential for better outcomes.

Abstract

Pre-septal and orbital cellulitis are more commonly seen in children than in adults. The incidence of pediatric orbital cellulitis is 1.6 in 100,000. The impact of COVID-19 has led to the increasing practice of nasopharyngeal swab surveillance. We presented a case of rare pediatric orbital cellulitis complicated with subperiosteal abscess secondary to severe acute sinusitis following a nasopharyngeal swab. A 4-year-old boy was brought in by his mother with increasing painful left eye swelling and redness. Three days prior, the patient developed a fever and mild rhinitis with loss of appetite which raised concerns about COVID-19. He had a nasopharyngeal swab on that same day and tested negative. Clinically, there was marked erythematous and tender periorbital and facial oedema involving the left nasal bridge, maxilla extended to the left upper lip with a deviation of the left nasal tip contralaterally. Computed tomography confirmed left orbital cellulitis with left eye proptosis, fullness of left maxillary and ethmoidal sinuses and left subperiosteal abscess. The patient received empirical antibiotics and surgical intervention promptly and recovered well with improvements in ocular symptoms. The nasal swabbing techniques may vary among practitioners, and it is associated with extremely low risks of severe complications from 0.001% to 0.16%. Whether the swab had aggravated the underlying rhinitis or traumatized the turbinates leading to sinus drainage obstruction; a nasal swab may impose the risk of severe orbital infection in a susceptible pediatric patient. Any health practitioner conducting the nasal swab should be vigilant about this potential complication.

Paroxysmal Atrial Fibrillation with Rapid Ventricular Response Following COVID-19 Nasopharyngeal Swab: A Case Report

Nasopharyngeal (NP) swab sampling is a simple procedure that has become extremely popular in the coronavirus disease 2019 (COVID-19) era, with hundreds of million specimens collected every day. However, rare but serious complications have been reported following NP swab acquisition. Here we present a case of paroxysmal atrial fibrillation associated with NP specimen collection in a healthy healthcare provider undergoing COVID-19 testing during departmental screening. This response may have been caused by an exaggerated vagal tone triggered by the trigeminocardiac reflex. Less invasive collection methods, such as saliva testing, may be warranted in predisposed individuals.

An Unusual Retained Choanal Foreign Body: A Possible Complication of COVID-19 Testing With Nasopharyngeal Swab

Testing for coronavirus disease 2019 is critical in controlling the pandemic all over the world. Diagnosis of severe acute respiratory syndrome coronavirus-2 infection is based on real-time polymerase chain reaction performed on nasopharyngeal swab. If not adequately performed, the viral specimen collection can be painful and lead to complications. We present a complication occurred during a nasopharyngeal swab collection performed in a noncooperative patient where the plastic shaft of the swab fractured during the procedure, resulting in swab tip retention deep into the nasal cavity. The foreign body was found endoscopically, stuck between the nasal septum and the superior turbinate tail at the upper level of the left choana and removed under general anesthesia in a negative pressure operating room with the health care personnel wearing personal protective equipment. Unpleasant complications like the one described can happen when the swab is collected without the necessary knowledge of nasal anatomy or conducted inappropriately, especially in noncooperative patients. Moreover, the design of currently used viral swabs may expose to accidental rupture, with risk of foreign body retention in the nasal cavities. In such cases, diagnosis and treatment are endoscopy-guided procedures performed in an adequate setting to minimize the risk of spreading of the pandemic.

Hypertensive Urgency and Anterior Epistaxis Caused by Antihypertensive Medication Noncompliance: A Case Report

Background and Aims

A sudden increase in blood pressure without serious, life-threatening symptoms or indications of immediate target organ damage is referred to as "hypertensive urgency." This case study revealed the rare direct cause of epistaxis and the direct cause of hypertensive urgency in an elderly man due to antihypertensive medication noncompliance.

Case Presentation

A black male farmer, age 63, was brought to the emergency room on June 1st, 2022, with chief complaints of breathing difficulties, epistaxis, and disorientation. The patient was hospitalized after exhibiting symptoms of breathlessness, malaise, nausea, and vomiting. Magnetic resonance imaging, an echocardiogram, and a computed tomography scan of the brain are all clear. For the treatment of epistaxis, he received 1g of tranexamic acid intravenously three times a day for two days. He received intravenous labetalol, which was effective in treating his hypertensive urgency and rebound hypertension, utilizing repeated dosages of 5-20 mg. The patient's intravenous labetalol and previous enalapril were switched to captopril 25 mg orally three times a day for one month after starting drugs per os.

Discussion

The patient's hypertensive urgency is directly caused by forgetting to take his blood pressure medication and by not adhering to his previous antihypertensive drugs as prescribed. In this study, the patient's hypertension had been uncontrolled for the previous six months despite his treatment plan. Unaware that he had missed two doses of his antihypertensive medication, he was admitted to the emergency room with progressive anterior nose bleeding that persisted for four hours. The patient's elevated arterial blood pressure is what's causing the patient's nose to bleed.

Providing Evidence for Dogma: Risk of Epistaxis After COVID-19 Nasal-Screening Swab

OBJECTIVE

There is anecdotal evidence SARS-CoV-2 (COVID) RT-PCR screening nasal swabs confer an elevated epistaxis risk. We aimed to assess the association between epistaxis and exposure to a COVID nasal swab.

STUDY DESIGN

A matched pairs design was used.

SETTING

The study was performed in a single, integrated healthcare system.

METHODS

All patients who received a single COVID nasal swab at our institution between April 2020 and March 2021 were included. McNemar's test was used to compare rates of epistaxis between the 7 days following the index COVID swab (hazard period), and the 7 days preceding the index COVID swab (control period). Conditional logistic regression was used to evaluate sociodemographic and clinical risk factors for epistaxis.

RESULTS

A total of 827,987 participants were included, with 1047 epistaxis encounters. The prevalence of epistaxis during the hazard and control periods were 0.08% and 0.04%, respectively. Swab exposure was associated with 1.92-fold odds of epistaxis during the hazard period (95% confidence interval [1.73, 2.12]). Older age, Asian/Pacific Islander (PI) (compared to white), male sex, hypertension, prior facial trauma, and warfarin or direct-acting oral anticoagulant use were also associated with significantly increased odds of epistaxis (p ≦ 0.01).

CONCLUSION

COVID nasal swabs are associated with increased odds of epistaxis. Physicians should counsel patients, particularly those at the highest risk, including a history of prior facial trauma, anticoagulants/antiplatelets, or hypertension.

Nasal Septal Abscess as a Complication of COVID-19 Nasal Swab Test: A Case Report

Nasal swab tests are widely used to screen for coronavirus disease 2019 (COVID-19). Pain, discomfort, and the urge to sneeze are the most common complications of this screening method. We report a case of a 55-year-old female patient with beta-thalassemia major suffering from a nasal septal abscess (NSA) as a complication of a COVID-19 nasal swab test. Following the test, the patient only had mild nasal congestion. However, three days later, her clinical condition deteriorated, and she developed fever, and her level of consciousness decreased to lethargy and drowsiness. Physical examinations revealed a bilateral nasal abscess. She underwent surgical intervention, and the abscess was removed. For the first time in Iran, a case of NSA after a COVID-19 nasal swab test is reported. It is strongly recommended to exercise caution while performing nasal swab tests, especially in the elderly and patients at risk of bleeding or hemoglobinopathy.

Sinonasal Lobular Capillary Hemangioma After Continuous Self-tests for COVID-19: A Case Report and Review of the Literature

Sinonasal lobular capillary hemangiomas (LCH) are rare benign vascular lesions commonly arising from the nasal septum. Nasopharyngeal, nasal mid-turbinate, and anterior nasal swabbing is the preferred method of screening for coronavirus disease-2019 (COVID-19). Herein, we present a case of a sinonasal LCH in a child after continuous self-tests for COVID-19, with an anterior nasal swab. The child presented with a well-defined red mass in the anterior part of the nasal septum, which was removed endoscopically. Histopathology revealed a LCH. This is the first report of a complication other than epistaxis with the use of an anterior nasal swab. Our literature review identified 32 studies reporting complications of COVID-19 screening. Cerebrospinal fluid leaks and foreign body retention are the most common ones. A proper specimen collection technique and a quick patient history with an emphasis on risk factors are the best practices to prevent complications from COVID-19 screening.

Unusual Causes of Nasal Septal Abscess Including a COVID-19 Swab Test After Nasal Surgery

A nasal septal abscess is a rare lesion that usually results from a nasal septal hematoma after nasal trauma or surgery, although it can occur unexpectedly. Nasal septal abscesses should be prevented and treated immediately. The authors describe 2 unusual cases: 1 caused by sudden loosening of the quilting suture of the nasal septum and the other by a nasopharyngeal swab test for coronavirus disease-2019. The authors also provide an intraoperative video and a literature review.

Misdirection of a nasopharyngeal SARS-CoV-2 swab: An unexpected complication

Background

The diagnosis of coronavirus disease (COVID-19) is based on detecting viral RNA of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasal cavities and the nasopharynx. Millions of nasopharyngeal swab tests are currently performed daily worldwide; complications of the procedure are uncommon, but occasionally they occur.

Case report

We describe the case of a 79-year-old man who developed right orbital cellulitis after a nasopharyngeal swab test for SARS-CoV-2. He underwent two surgeries for nasal polyposis 20 and 15 years prior, that probably caused an easy pathway to the medial wall of the orbit. At hospital admission he presented right visual loss, proptosis, palpebral edema, conjunctival chemosis, and limitations in eye movements. Computed tomography showed violation of the lamina papyracea, which appeared related to misdirection of the nasopharyngeal swab. He received intensive antibiotic treatment and achieved complete resolution of the orbital infection. To our knowledge this is the first case report concerning this dangerous complication.

Conclusion

Orbital cellulitis is a serious condition that requires prompt diagnosis and treatment, as it may result in permanent visual loss or life-threatening complications, such as intracranial abscess and cavernous sinus thrombosis, if inadequately treated. This case highlights the importance of providing adequate instruction about nasal anatomy to health care professionals performing nasopharyngeal swab tests to avoid misdirections leading to potentially dangerous complications.

Pandemic driven innovation: A pilot evaluation of an alternative respiratory pathogen collection device

Background

Methods

Results

Conclusion

Performance study of the anterior nasal AMP SARS-CoV-2 rapid antigen test in comparison with nasopharyngeal rRT-PCR

Introduction.

The gold standard for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection is real-time reverse transcription PCR (rRT-PCR), which is expensive, has a long turnaround time and requires special equipment and trained personnel. Nasopharyngeal swabs are uncomfortable, not suitable for certain patient groups and do not allow self-testing. Convenient, well-tolerated rapid antigen tests (RATs) for SARS-CoV-2 detection are called for.

Gap statement.

More real-life performance data on anterior nasal RATs are required.

Aim.

We set out to evaluate the anterior nasal AMP RAT in comparison with rRT-PCR in a hospital cohort.

Methodology.

The study included 175 patients, either hospitalized in a coronavirus disease 2019 (COVID-19) ward or screened in a preadmittance outpatient clinic. Two swabs were collected per patient: an anterior nasal one for the RAT and a combined naso-/oropharyngeal one for the rRT-PCR. Sixty-five patients (37%) were rRT-PCR-positive [cycle threshold (C_t) <40].

Results.

The anterior nasal AMP RAT showed an overall sensitivity and specificity of 29.2 % (18.6–41.8, 95 % CI) and 100.0 % (96.7–100.0, 95 % CI) respectively. In patients with a C_t value <25, <30 and <33, higher sensitivities were observed. Time since symptom onset was significantly higher in patients with a false-negative RAT (P=0.02).

Conclusion.

The anterior nasal AMP RAT showed low sensitivities in this cohort, especially in patients with a longer time since symptom onset. Further knowledge concerning the viral load and antigen expression over time and in different swabbing locations is needed to outline the usage time frame for SARS-CoV-2 RAT.

Effect of RNA quality to SARS-CoV-2 RT-qPCR detection from saliva

Saliva is an alternative sample material to nasopharyngeal swab in SARS-CoV-2 diagnostics. We investigated possible aspects to improve the reliability of SARS-CoV-2 detection from saliva. Saliva was collected from asymptomatic healthy subjects (n=133) and COVID-19 patients (n=9). SARS-CoV-2 detection was performed with quantitative reverse-transcriptase PCR (RT-qPCR) with two viral and one host target serving as an internal control. The use of internal control revealed that in the first RT-qPCR run 25-30 % of assays failed. The failure is associated with poor RNA quality. When the amount of RNA was cut down to half from the original amount, the performance of RT-qPCR was greatly enhanced (95 % of the assays succeeded). The quality of RNA was not affected by the use of different nucleic acid stabilizing buffers. Our study showed that saliva is suitable material for RT-qPCR based SARS-CoV-2 diagnostics, but the use of internal control is essential to distinguish the true negative samples from failed assays.

ENT symptoms in acute COVID-19: a narrative review

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterised by a wide spectrum of disease severity ranging from asymptomatic or oligosymptomatic cases to severe and life-threatening forms. As this new coronavirus is a respiratory virus, it is not surprising that many symptoms caused by SARS-CoV-2 infection are related to the involvement of the upper respiratory tract. In addition the most pathognomonic of symptoms, i.e. the alteration of smell, nasal obstruction, sore throat and cough have been consistently described as early symptoms of the disease. However, for other ENT symptoms, such as oral lesions and audio-vestibular changes, a causal relation is far from proven. The rapid and extensive spread of COVID-19 makes it difficult to demonstrate a causative link between several ENT symptoms and SARS-CoV-2 infection and it is reasonable to assume that at least in some cases this link is actually coincidental in some cases. Moreover, following the phenomenon of the race to publish, there has been an uncontrolled release of poor-quality articles showing the most disparate associations mainly based on a temporal association between SARS-CoV-2 infection and symptoms of various types including those of the ENT area. In this narrative review of the literature, we will critically describe the ENT symptoms of COVID-19.

Complications of Nasopharyngeal Swabs and Safe Procedures for COVID-19 Testing Based on Anatomical Knowledge

Nasopharyngeal swabs have been widely to prevent the spread of coronavirus disease 2019 (COVID-19). Nasopharyngeal COVID-19 testing is a generally safe and well-tolerated procedure, but numerous complications have been reported in the media. Therefore, the present study aimed to review and document adverse events and suggest procedural references to minimize preventable but often underestimated risks. A total of 27 articles were selected for the review of 842 related documents in PubMed, Embase, and KoreaMed. The complications related to nasopharyngeal COVID-19 testing were reported to be rarely happened, ranging from 0.0012 to 0.026%. Frequently documented adverse events were retained swabs, epistaxis, and cerebrospinal fluid leakage, often associated with high-risk factors, including severe septal deviations, pre-existing skull base defects, and previous sinus or transsphenoidal pituitary surgery. Appropriate techniques based on sufficient anatomical knowledge are mandatory for clinicians to perform nasopharyngeal COVID-19 testing. The nasal floor can be predicted by the line between the nostril and external ear canal. For safe testing, the angle of swab insertion in the nasal passage should remain within 30° of the nasal floor. The swab was gently inserted along the nasal septum just above the nasal floor to the nasopharynx and remained on the nasopharynx for several seconds before removal. Forceful insertion should be attempted, and alternative examinations should be considered, especially in vulnerable patients. In conclusion, patients and clinicians should be aware of rare but possible complications and associated high-risk factors. The suggested procedural pearls enable more comfortable and safe nasopharyngeal COVID-19 testing for both clinicians and patients.

Complications Associated With Nasopharyngeal COVID-19 Testing: An Analysis of the MAUDE Database and Literature Review

BACKGROUND

Nasopharyngeal swab testing, which has greatly increased in utilization due to the COVID-19 pandemic, is generally safe and well-tolerated, although it may be rarely associated with adverse events.

METHODS

Publicly reported adverse events associated with nasopharyngeal COVID-19 testing within the Manufacturer and User Facility Device Experience (MAUDE) database and the published literature were queried.

RESULTS

A total of 129 adverse events were reported, including 66 from the MAUDE database and 63 from literature review. The most common complications were swab fracture resulting in retained foreign body (47%), followed by epistaxis (17%), and headache (11%). Seven (12%) of the reported retained foreign body cases required removal under general anesthesia, while 1 (5%) of the epistaxis cases required surgical intervention. The most serious adverse event was meningitis following cerebrospinal fluid leak.

CONCLUSIONS

Patients and healthcare providers should be aware of the potential risks associated with testing, with attention to ensuring proper technique, and be prepared to recognize and manage adverse events.

Diagnostic techniques for COVID-19: A mini-review

COVID-19, a new respiratory infectious disease, was first reported at the end of 2019, in Wuhan, China. Now, COVID-19 is still causing major loss of human life and economic productivity in almost all countries around the world. Early detection, early isolation, and early diagnosis of COVID-19 patients and asymptomatic carriers are essential to blocking the spread of the pandemic. This paper briefly reviewed COVID-19 diagnostic assays for clinical application, including nucleic acid tests, immunological methods, and Computed Tomography (CT) imaging. Nucleic acid tests (NAT) target the virus genome and indicates the existence of the SARS-CoV-2 virus. Currently, real-time quantitative PCR (qPCR) is the most widely used NAT and, basically, is the most used diagnostic assay for COVID-19. Besides qPCR, many novel rapid and sensitive NAT assays were also developed. Serological testing (detection of serum antibodies specific to SARS-CoV-2), which belongs to the immunological methods, is also used in the diagnosis of COVID-19. The positive results of serological testing indicate the presence of antibodies specific to SARS-CoV-2 resulting from being infected with the virus. Viral antigen detection assays are also important immunological methods used mainly for rapid virus detection. However, only a few of these assays had been reported. CT imaging is still an important auxiliary diagnosis tool for COVID-19 patients, especially for symptomatic patients in the early stage, whose viral load is low and different to be identified by NAT. These diagnostic techniques are all good in some way and applying a combination of them will greatly improve the accuracy of COVID-19 diagnostics.

Role of the otolaryngologist in nasopharyngeal swab training: A case report and review of the literature

Nasopharyngeal swabs are commonly done in the medical field for a multitude of reasons, and they recently have been an essential component of widespread testing to control the spread of COVID-19. Although rare, improper technique when performing nasopharyngeal swabs has the potential to lead to injury or misleading test results. We present a case of uncontrolled epistaxis requiring hospitalization following a routine nasopharyngeal swab in a healthy patient. Both the complexity and variability of the anatomy of the nasopharynx can contribute to poor swabbing technique. Otolaryngologists should be encouraged to educate and support other healthcare workers to improve the yield and reduce the risk of harm due to nasopharyngeal swabs. Increased comfort levels with performing nasopharyngeal swabs will also improve the sensitivity of screening tests for common respiratory viruses such as influenza, Epstein-Barr virus (EBV), or bacteria such as Staphylococcus aureus.

The Effect of Isotonic Saline Nasal Lavages in Improving Symptoms in SARS-CoV-2 Infection: A Case-Control Study

Background: Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) mainly colonizes nasopharynx. In upper airways acute infections, e.g., the common cold, saline nasal irrigations have a significant efficacy in reducing symptoms. The present study aimed to test the efficacy of nasal lavages in upper airways symptoms of Coronavirus Disease 2019 (COVID-19).

Methods: A series of consecutive adult subjects who tested positive for SARS-CoV-2 from December 2020 to February 2021 performed daily nasal lavages with saline solution (Lavonase®—Purling, Lugo di Romagna, Italy) for 12 days, starting on the day after the SARS-CoV-2 positive swab. A control group included a historical series of patients who were infected in February-March 2020 and who did not perform lavages. An ad hoc questionnaire regarding symptoms was administered to each subjects at base-line and 10 days after diagnosis (i.e., on the same day of the control swab) in both cases and controls.

Results: A total of 140 subjects were enrolled. 68 participants in the treatment group and 72 in the control group were included. 90% of respondents declared the lavages were simple to use and 70% declared they were satisfied. Symptoms of blocked nose, runny nose, or sneezing decreased by an average of 24.7% after the treatment. Blocked nose and sneezing increased in the same period of time in the control group. Ears and eyes symptoms, anosmia/ageusia symptoms, and infection duration (10.53 days in the treatment group and 10.48 days in the control group) didn't vary significantly among the two groups.

Conclusion: Nasal lavages resulted to significantly decrease nasal symptoms in newly diagnosed SARS-CoV-2 patients. These devices proved to be well-tolerated and easy to be used. Further studies on a larger number of subjects are needed in order to possibly confirm these preliminary results.

Discrepancies of SARS-CoV-2 testing results among patients with total laryngectomy

PURPOSE

Prevention of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is obtained with nasopharyngeal swabs. By the way, there is no consensus regarding sampling in totally laryngectomized subjects (who thus breathe directly by the tracheostomy and, theoretically, may be infected in the trachea). The aim of this study is to evaluate possible differences between swab results in the trachea and in the nasopharynx of this category of patients.

METHODS

A retrospective chart review was performed in April 2021 among patients who previously had been operated on for total laryngectomy and who underwent swabs for SARS-CoV-2 research in 3 health-care centers in Northern-Eastern Italy. Data regarding the site of swabbing (trachea or nasopharynx) were analyzed. A comprehensive review of the literature regarding the same topic was then performed.

RESULTS

A total of 25 totally laryngectomized subjects underwent swabs. Among them, 5 tested positive in the trachea (1) and in the nasopharynx (4). According to the literature review, 4 more subjects tested positive in the trachea (1) and in the nasopharynx (3). Data were overall divergent and no statistically significant correlations emerged between results of the tests performed in the two sites.

CONCLUSION

Due to these discrepancies, both tracheal and nasopharyngeal swabs are recommended in these kinds of patients, to obtain a reliable test and to avoid false negatives.

COVID-Q: Validation of the first COVID-19 questionnaire based on patient-rated symptom gravity

OBJECTIVES

The aim of the present study was to develop and validate the CoronaVirus-Disease-2019 (COVID-19) Questionnaire (COVID-Q), a novel symptom questionnaire specific for COVID-19 patients, to provide a comprehensive evaluation that may be helpful for physicians, and evaluate the questionnaire's performance in identifying subjects at higher risk of testing positive.

MATERIALS AND METHODS

Consecutive non-hospitalised adults who underwent nasopharyngeal-throat swab for severe-acute-respiratory-syndrome-coronavirus-2 (SARS-CoV-2) detection at Treviso Hospital in March 2020, were enrolled. Subjects were divided into positive (cases) and negative (controls). All subjects answered the COVID-Q. Patients not able to answer COVID-Q because of clinical conditions were excluded. Parallel Analysis and Principal Component Analysis identified items measuring the same dimension. The Item Response Theory (IRT)-based analyses evaluated the functioning of item categories, the presence of clusters of local dependence among items, item fit within the model and model fit to the data.

RESULTS

Answers obtained from 230 cases (113 males; mean age 55 years, range 20-99) and 230 controls (61 males; mean age 46 years, range 21-89) were analysed. Six components were extracted with parallel analysis: asthenia, influenza-like symptoms, ear and nose symptoms, breathing issues, throat symptoms, and anosmia/ageusia. The final IRT models retained 27 items as significant for symptom assessment. The total questionnaire's score was significantly associated with positivity to the molecular test: subjects with multiple symptoms were more likely to be affected (P < .001). Older age, male gender presence of breathing issues and anosmia/ageusia were significantly related to positivity (P < .001). Comorbidities had not a significant association with the COVID-19 diagnosis.

CONCLUSION

COVID-Q could be validated since the evaluated aspects were overall significantly related to infection. The application of the questionnaire to clinical practice may help to identify subjects who are likely to be affected by COVID-19 and address them to a nasopharyngeal swab in order to achieve an early diagnosis.

Ethmoidal silent sinus syndrome after nasal swab test

This study reported the case of a healthy male in his 40s who presented with a 3-month history of frontal headache and post-nasal drip, which did not improve with oral antibiotics. One month prior to the onset of the symptoms, he underwent a nasopharyngeal swab testing for SARS-CoV-2 (which yielded a negative result) for a history of malaise and cough. The patient claimed that the swab insertion into the nasal cavity was particularly painful on the left side. Sinus computed tomography (CT) scan showed deformity of the left middle nasal turbinate with occlusion of the osteomeatal complex, resulting in ethmoid silent sinus syndrome. This study makes a significant contribution to the literature because nasopharyngeal, midturbinate and anterior nasal swabs have been recommended as initial diagnostic specimen collection methods by the US Centers for Disease Control and Prevention (CDC) for the coronavirus disease 2019. These methods require introducing an instrument into the nasal cavity, potentially leading to adverse effects due to the delicate and complex nasal anatomy. However, complications related to swab testing for respiratory pathogens have not yet been fully discussed in the literature.

Iatrogene Liquorfistel als Folge eines SARS-CoV-2-Nasopharyngealabstrichs

In Österreich wurden seit Beginn der COVID-19(„coronavirus disease 2019“)-Pandemie über 16 Mio. Abstriche durchgeführt, wobei hier bevorzugt Nasen-Rachen-Abstriche zum Einsatz kommen. Neben Blutungen und lokalen Abszessen gibt es wenige Daten hinsichtlich möglicher schwerwiegenderer Komplikationen. Anhand von 4 Kasuistiken wird eine iatrogene Liquorfistel als mögliche Folge eines Nasen-Rachen-Abstriches aufgezeigt. Bei entsprechenden Symptomen sollte an diese seltene, jedoch potenziell lebensgefährliche Komplikation gedacht werden.

Nasopharyngeal versus nasal swabs for detection of SARS-CoV-2: a systematic review

Nasopharyngeal swabbing (NPS) coupled with RT-PCR is the current gold standard for detecting SARS-CoV-2 infections. However, numerous studies have recently demonstrated the advantages of alternative nasal specimen collection approaches over NPS specifically for COVID-19 diagnosis. The present review was conducted according to PRISMA guidelines and summarises the current literature to give a clear overview of nasal specimen collection methods for SARS-CoV-2 detection. Publications investigating NPS and at least one other form of nasal specimen collection in combination with RT-PCR for viral detection in the context of COVID-19 were assessed. We identified 425 articles and ultimately included 18 studies in this systematic review. The suitable publications evaluated different forms of nasal specimen collection, with anterior nasal swabbing (ANS) and midturbinate swabbing (MTS) being the most frequently examined techniques. The analysed studies report sensitivity and specificity results (67.5-96.2% and 97.9-100.0%, respectively) similar to those achieved via NPS, especially in the early stages of disease or when paired with an oropharyngeal swab. Results from these studies suggest that ANS and MTS are suitable alternatives to NPS for COVID-19 testing. Due to their ease of collection, ANS and MTS collection techniques may facilitate broader testing strategies and allow for economization of medical staff.

Development of an alternative saliva test for diagnosis of SARS-CoV-2 using TRIzol: Adapting to countries with lower incomes looking for a large-scale detection program

The use of saliva for the diagnosis of SARS-CoV-2 has shown to be a good alternative to nasopharyngeal swabs (NPS), since it permits self-collection, avoids the exposure of healthy persons to infected patients, reduces waiting times, eliminates the need of personal protective equipment and is non-invasive. Yet current saliva testing is still expensive due to the need of specialized tubes containing buffers to stabilize the RNA of SARS-CoV-2 and inactivate the virus. These tubes are expensive and not always accessible in sufficient quantities. We now developed an alternative saliva testing method, using TRIzol for extraction, viral inactivation, and storage of SARS-CoV-2 RNA, combined with RT-qPCR, which was comparable in its performance to NPS. Paired saliva samples and NPS were taken from 15 asymptomatic healthcare workers and one patient with SARS-CoV-2. Further 13 patients with SARS-CoV-2 were only saliva-tested. All the tests were performed according to CDC 2019-Novel Coronavirus (2019-nCoV) Real-Time RT-PCR Diagnostic Panel. Saliva (4 mL) was taken in sterile 50 mL tubes, 1.5 mL TRIzol were added and mixed. Our results show that 5 μL of saliva RNA extracted with TRIzol allow for an adequate detection of the virus in patients positive for SARS-CoV-2 and was equally sensitive to NPS in TRIzol. We conclude that saliva testing using TRIzol is a recommendable method for diagnosis of SARS-CoV-2 since it has several advantages over currently used saliva tests: it can be done with normal sterile tubes, does not need cold-chain handling, is stable at room temperature, is non-invasive and less costly, making it more accessible for low-income countries. Cheaper saliva testing using TRIzol is especially relevant for low-income countries to optimize diagnosis and help define quarantine durations for families, healthcare workers, schools, and other public workplaces, thus decreasing infections and mortality caused by SARS-CoV-2.

Complications of nasal SARS-CoV-2 testing: a review

Transnasal swab testing for the detection of SARS-CoV-2 is well established. The Centers for Disease Control and Prevention advocates swabbing either of the anterior nares, middle turbinate, or nasopharynx for specimen collection depending on available local resources. The purpose of this review is to investigate complications related to transnasal SARS-CoV-2 testing with specific attention to specimen collection site and swab approach. The literature demonstrates that while nasopharyngeal swabbing is associated with an increased risk of complications, it should remain the gold-standard test due to greater diagnostic accuracy relative to anterior nasal and middle turbinate swabs.

The role of mouthwash sampling in SARS-CoV-2 diagnosis

BACKGROUND

The current practice of COVID-19 diagnosis worldwide is the use of oro-nasopharyngeal (ONP) swabs. Our study aim was to explore mouthwash (MW) as an alternative diagnostic method, in light of the disadvantages of ONP swabs.

METHODS

COVID-19 outpatients molecular-confirmed by ONP swab were repeatedly examined with ONP swab and MW with normal saline (0.9%). Other types of fluids were compared to normal saline. The Cq values obtained with each method were compared.

RESULTS

Among 137 pairs of ONP swabs and MW samples, 84.6% (116/137) of ONP swabs were positive by at least one of the genes (N, E, R). However MW detected 70.8% (97/137) of samples as positive, which means 83.6% (97/116) out of positive ONP swabs, missing mainly Cq value > 30. In both methods, the N gene was the most sensitive one. Therefore, MW samples targeting N gene, which was positive in 95/137 (69.3%), are comparable to ONP swabs targeting E and R genes which gave equal results-95/137 (69.3%) and 90/137 (65.7%), respectively. Comparing saline MW to distilled water gave equal results, while commercial mouth-rinsing solutions were less sensitive.

CONCLUSIONS

MW with normal saline, especially when tested by N gene, can effectively detect COVID-19 patients. Furthermore, this method was not inferior when compared to R and E genes of ONP swabs, which are common targets in many laboratories around the world.

A Severe Acute Respiratory Syndrome Coronavirus 2 detection method based on nasal and nasopharyngeal lavage fluid: A pilot feasibility study

OBJECTIVE

Nose and nasopharyngeal swab is the preferred and worldwide-accepted method to detect the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) within the nose and nasopharynx. This method may be linked with possible difficulties, such as patient's discomfort or complications. This article shows a pilot study of SARS-CoV-2 detection with nasal and nasopharyngeal lavage fluids (level of evidence: 3).

METHODS

Nasal lavage fluid was collected from patients who were submitted to SARS-CoV-2 screening test, due to a preceding positive rapid antigen test. A control group was enrolled among health care professionals whose nasopharyngeal swab tested negative. Nasal lavages were performed using isotonic saline solution injected through a nasal fossa. Both lavage fluid and traditional nasopharyngeal swab were analyzed by real-time (RT) PCR and antigenic test.

RESULTS

A total of 49 positive subjects were enrolled in the study. Results of the analysis on lavages and nasopharyngeal swabs were concordant for 48 cases, regardless of the antigenic and molecular test performed. RT-PCR resulted weakly positive at swab in one case and negative at lavage fluid. Among the control group (44 subjects), nasopharyngeal swab and lavage fluid analyses returned a negative result. Sensitivity of the molecular test based on nasal lavage fluid, compared to traditional nasal swab, was 97.7%, specificity was 100%, and accuracy was 98.9%, with high agreement (Cohen's κ, 0.978).

CONCLUSION

Nasal and nasopharyngeal lavages resulted to be highly reliable and well tolerated. A larger series is needed to confirm these results. This approach may potentially represent a valid alternative to the traditional swab method in selected cases.

LEVEL OF EVIDENCE

3.

Correct Execution of the Nasopharyngeal Swab: A Fundamental Method to Improve Diagnosis of SARS-CoV-2 Infection

BACKGROUND

Severe acute respiratory infection Coronavirus 2 (SARS-CoV-2) infection has spread all over the world since December 2019. Treatment of the syndrome represents an important challenge for all physicians. Spread prevention relies on a correct diagnosis which is performed with nasopharyngeal swabs.

OBJECTIVE

To describe the proper execution of the swab with a few simple steps.

METHODS

Figures and video recording.

RESULTS

A few simple steps are presented within this paper in order to perform easily nasopharyngeal swab for SARS-Cov-2 diagnosis and for other possible infectious diseases of the airways tract.

CONCLUSIONS AND IMPLICATION FOR NURSING

Nasopharyngeal swab may be performed in an easier way than usually thought. This method may also be used for any other microorganism detection. By following simple steps, a correct diagnosis can easily be obtained.

The importance of early detection of ENT symptoms in mild-to-moderate COVID-19

Objectives

Patients with coronavirus disease-19 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may present with a wide range of symptoms. In this paper, a detailed characterisation of mild-to-moderate ear, nose nd throat (ENT) symptoms is presented with the aim of recognising the disease early to help reduce further spread and progression.

Methods

A total of 230 cases testing positive for SARS-CoV-2 and 134 negative controls were recruited for a case-control analysis. Symptoms were analysed using the Acute Respiratory Tract Infections Questionnaire, while other symptoms were investigated by ad hoc questions.

Results

Among the study samples (n = 364), 149 were males and 215 were females with age ranging from 20 to 89 years (mean 52.3). Four main groups of symptoms were obtained: influenza-like symptoms, ENT-symptoms, breathing issues and asthenia-related symptoms, representing 72%, 69%, 64% and 53% of overall referred clinical manifestations, respectively. ENT symptoms, breathing issues and influenza-like symptoms were associated with positivity to SARS-CoV-2, whereas asthenia-related symptoms did not show a significant association with SARS-CoV-2 infection after controlling for other symptoms, comorbidities and demographic characteristics.

Conclusions

ENT symptoms are equally represented with influenza-like ones as presenting symptoms of COVID-19. Patients with ENT symptoms should be investigated for early identification and prevention of SARS-CoV-2 spread.

Asystole During Nasopharyngeal Swab: Is COVID-19 to Blame?

The use of nasopharyngeal (NP) swab sampling for the detection of various respiratory pathogens has been a standard procedure in medicine for many years. While this is a fairly common procedure, there has been a significant increase in utilization recently due to the SARS-CoV-2 pandemic. We describe a case of a 40-year-old SARS-CoV-2 positive patient with no prior cardiac history who developed asystole while an NP swab was being used to obtain a sample for a SARS-CoV-2 assay. Return of normal sinus rhythm was achieved with chest compressions alone. The incident was deemed to have been an exaggerated vagal response to intranasal stimulation; better known as the trigeminocardiac reflex. This is the first reported case describing asystole during use of an NP swab. This case occurred in a patient with no known cardiac disease and highlights the potential importance of the arrhythmogenic nature of COVID-19 that could potentiate the vagal response in susceptible individuals undergoing NP sampling.

A Novel Just-In-Time-Online-Training for Nasopharyngeal Swab Specimen Collection During the COVID-19 Pandemic

INTRODUCTION

 The spread of coronavirus disease 2019 (COVID-19) is controlled by timely detection of infected patients using a nasopharyngeal (NP) swab test, followed by isolation and treatment. One challenge encountered with NP swab collection was to train healthcare providers (HCPs) with different training backgrounds and experience for collecting NP swab specimens across Nebraska, including a sizeable rural area. In-person training for NP swab collection skills was challenging due to social distancing. We developed a Just-In-Time-Online Training (JITOT) and delivered it using Facebook Live (TM) to meet our HCPs' training needs.

METHODS

 Online training was held on April 21, 2020, and attended by 453 HCPs. A quasi-experimental study based on a survey and a multiple choice questionnaire (MCQ) was conducted to evaluate its effectiveness in improving the participants' knowledge and attitudes.

RESULTS

 Group mean knowledge score increased from a pre-test score of 57%-95% in the post-test showing a large effect size (Hedges' g = 0.976877). On a five-point Likert scale, the majority (86.21%) of the survey respondents agreed/strongly agreed that this training increased their overall comfort for nasal swab specimen collection as compared to their pre-training comfort (37.93%) with this procedure. The majority of respondents (96.55%) in the post-training evaluation agreed/strongly agreed that "the delivery method was appropriate."

CONCLUSION

 A JITOT session is helpful to teach, demonstrate, clarify doubts, and improve the knowledge and comfort of the participants. It can be quickly delivered using a free social media platform for broader outreach during public health emergencies.

Safety Precautions for Self-Performed Severe Acute Respiratory Syndrome Coronavirus 2 Tests: A Case of a Swallowed Swab

Oropharyngeal and nasopharyngeal specimens collected by swabbing are the pillars of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diagnostics. Commercially available rapid antigen tests and self-sampling polymerase chain reaction services have made specimen collection available anytime and anywhere in nonmedical settings. In this study, we report the case of a 45-year-old man who accidentally ingested a swab during self-performed SARS-CoV-2 rapid antigen testing. Imaging studies revealed an elongated foreign body in the stomach. Urgent gastroscopy confirmed the presence of the swabbing applicator in the gastric lumen, which was retrieved using a loop without any complications. Millions of SARS-CoV-2 tests are performed daily, of which an increasing proportion are performed by laypeople. Foreign bodies account for a particular set of complications, which can be avoided by cautious sampling and using the correct technique. Radiopaque labeling of instruments would be useful. Otherwise, rare serious events can occur that may require immediate medical interventions.