Beware of COVID-19 Swab Testing in Those With Past Sinus/Skull Base Surgery

A simple screening question could help pharmacists and other healthcare professionals avoid a safety issue associated with nasopharyngeal swab testing, the most common type of COVID-19 assay. Find out why asking about past sinus/skull base surgery is important and why patients who answer in the affirmative should be diverted to receive other types of testing.

SAN ANTONIO – Here’s a question pharmacists participating in COVID-19 swab testing might want to ask those seeking the service: Have you had major sinus surgery?

If the patient has had extensive sinus or skull base surgery, according to a new report in JAMA Otolaryngology-Head & Neck Surgery, pharmacists and other testers should suggest an alternate type of testing.

Real-time reverse transcription–polymerase chain reaction of nasopharyngeal swab (NPS) specimens is the preferred method of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. The problem is that blind nasopharyngeal swab testing is risky for patients with sinus pathology, according to the research letter. The reason is that sinus and skull-base surgery frequently removes bony partitions between the nasal cavity and skull base, which often exposes critical neurovascular structures. That means that, after surgery, patients are theoretically at higher risk of cerebrospinal fluid leak and neurovascular damage during NPS insertion.

The authors point out that recent reports have discussed the risk of cerebrospinal fluid leak caused by NPS insertion during SARS-CoV-2 testing. In the same journal, University of Iowa researchers reported a case of a woman in her 40s presented with unilateral rhinorrhea, metallic taste, headache, neck stiffness, and photophobia after nasal COVID-19 testing for an elective hernia repair. Shortly after, she developed unilateral rhinorrhea, headache, and vomiting; the authors note that she had idiopathic intracranial hypertension and removal of nasal polyps over 20 years before presentation.

Yet, according to the recent study, online information about COVID-19 nasopharyngeal swabs doesn’t warn those with prior extensive sinus or skull base surgery against having the testing. "Not one site of the 200 we searched online had information cautioning against blind nasopharyngeal swab testing in those with a history of sinus or skull base surgery," said senior author Philip G. Chen, MD, of The University of Texas Health Science Center at San Antonio.

Chen suggests the problem is exacerbated when swabbing is performed incorrectly, noting that, if the swab angle is too high, a puncture can occur.

“Patients at risk of injury from SARS-CoV-2 testing must be educated about potentially adverse testing outcomes,” according to the report. “Many clinicians make preoperative and postoperative instructions available online to educate patients. Indeed, people often seek medical information online. Thus, it is imperative for health care professionals to quickly update websites to educate high-risk patients (and their clinicians) about the risks of NPS.”

To assess online preoperative and post-operative patient information about the potential risks of SARS-CoV-2 NPS testing for those with a history of sinus or skull-base surgery, researchers used the Google search engine to identify the top 100 results for two separate searches: sinus surgery instructions and pituitary surgery instructions. ‘”None of the top 200 websites (53 academic, 93 private practice, and 54 other sites) we checked contained warnings for high-risk patients or any information related to SARS-CoV-2 NPS testing,” they write.

The authors emphasize the lack of online information regarding risks of SARS-CoV-2 testing for patients with sinus and/or pituitary surgery creates an opportunity for patient education that could maximize safety during the pandemic. They suggest that pharmacists and other healthcare professionals identify high-risk patients and counsel them, while also updating websites/handouts to educate patients about potential injury related to SARS-CoV-2 NPS testing, with recommendations for alternative testing.

“During the COVID-19 pandemic, otolaryngologists should inform at-risk patients about blind NPS testing and alternative diagnostic methods,” researchers conclude. “Health care professionals ordering or administering testing must prescreen patients with a history of sinus and skull-base surgery prior to NPS testing and use alternative testing. This multifaceted approach to SARS-CoV-2 testing for at-risk patients can enhance patient safety and avoid injury.”

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