key: cord-0802498-fto3is56
authors: Cantarella, Giovanna; Nava, Nicolò; Pirondini, Cesare; Pignataro, Lorenzo
title: Misdirection of a nasopharyngeal SARS-CoV-2 swab: An unexpected complication
date: 2022-05-06
journal: Otolaryngol Case Rep
DOI: 10.1016/j.xocr.2022.100439
sha: 30bff32543655e39f9dd8f41ab80471472681a2c
doc_id: 802498
cord_uid: fto3is56

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.

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 [1] . Millions of nasopharyngeal swab tests are currently performed daily worldwide, since the global spread of COVID-19 pandemic [1] . Complications of the procedure are uncommon, but occasionally they can have dangerous consequences [2] [3] [4] [5] .

We describe a patient with orbital cellulitis that developed after a nasopharyngeal swab test for SARS-CoV-2. To our knowledge this is the first case report concerning this complication.

A 79-year-old male presented with a 2-day history of worsening right palpebral edema, conjunctival chemosis, proptosis and limitations in eye movements, originated after a nasopharyngeal swab test for SARS-CoV-2, obtained after a close contact with a relative affected This report highlights the importance of providing adequate instruction about nasal anatomy to health care professionals collecting the nasopharyngeal swab samples to avoid swab misdirections leading to potentially dangerous complications and, at the same time, to obtain an J o u r n a l P r e -p r o o f adequate specimen to reduce false negative results. The direction of the swab should always be along the nasal floor, and excessive force should never be applied [5] . Overall, the reported rate of complications is low worldwide, being as low as 1.24 per 100.000 performed tests [5] . Nose bleeds, foreign body retentions due to broken swabs and cerebrospinal fluid leakage deriving from cranial misdirection causing lesion of the cribriform plate have been described [2] [3] [4] [5] . In the reported case, misdirection was both cranial and lateral as the swab entered the ethmoidal cavity and was forced into the orbit.

Although nasopharyngeal swabs are generally safe procedures to diagnose COVID-19, the risk of complications should be considered, especially in patients with a history of sinonasal surgery, as modified anatomical conditions might predispose to potentially life-threatening complications.

J o u r n a l P r e -p r o o f

Pathophysiology, Transmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A Review

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

Cerebrospinal Fluid Leak After Nasal Swab Testing for Coronavirus Disease

Cribriform Plate Injury After Nasal Swab Testing for COVID-19

Complications of COVID-19 Nasopharyngeal Swab Test