key: cord-0822698-x6r096gh authors: Parisi, Giuseppe Fabio; Brindisi, Giulia; Indolfi, Cristiana; Diaferio, Lucia; Marchese, Giuseppe; Ghiglioni, Daniele G.; Zicari, Anna Maria; Miraglia del Giudice, Michele title: Upper airway involvement in pediatric COVID‐19 date: 2020-11-24 journal: Pediatr Allergy Immunol DOI: 10.1111/pai.13356 sha: 0a138a22f8663cf4179ad3808c2770753956ed5d doc_id: 822698 cord_uid: x6r096gh The clinical spectrum of SARS‐CoV‐2 infection is mixed. It ranges from asymptomatic cases, medium‐intensity forms with mild to moderate symptoms, to severe ones with bilateral lung involvement and respiratory distress, which can require transfer to ICUs and intubation. In most cases, the clinical picture is characterized by a persistent fever, cough, dyspnoea, expectoration, myalgias, arthralgias, headache, gastrointestinal symptoms, nasal congestion, and pharyngodynia. The spread of COVID‐19 in Europe has highlighted an atypical presentation of disease involving upper airways and, above all, dysfunction of olfactory and gustatory senses. There is ample evidence that COVID‐19 is significantly less severe in children than in adults. However, due to difficulties in assessing the disorder in children, especially among very young patients, the olfaction and gustatory dysfunctions remain open issues. This article sheds light on the upper airway involvement in pediatric COVID‐19 subjects. patients. These data are provided by the Italian National Institute of Health. 3 The clinical spectrum of SARS-CoV-2 infection is quite heterogeneous and ranges from asymptomatic forms to medium-intensity cases characterized by mild or moderate symptoms. 4 There are also severe clinical presentations with bilateral lung involvement and respiratory distress that can evolve into critical forms, which sometimes require patient intubation and ICU transfer. About clinical studies conducted in Asia, the clinical picture in many cases is characterized by persistent fever, cough, dyspnoea, expectoration, myalgias, arthralgias, headache, gastrointestinal symptoms, nasal congestion, and pharyngodynia. In Europe, the spread of COVID-19 has sometimes highlighted an atypical clinical presentation, characterized by the involvement of upper airways and, above all, by the onset of olfactory and gustatory dysfunctions. 5 There is sufficient evidence worldwide that this disease is much less severe in children than in adults. 4 Although very common in adults, olfactory and gustatory dysfunctions remain an open issue in children, probably due to the lack of valid methods to assess these disorders among the pediatric population. This article aims to provide a focus on the upper airway involvement in pediatric COVID-19. Nasal obstruction, rhinorrhea, sneezing, pharyngodynia, olfactory, and gustatory dysfunctions could be the early symptoms of SARS-CoV-2 infection. 4,5 CoVs are a family of viruses that can be associated with anosmia. As early as 2007, CoV could be detected in the nasal secretions of patients with olfactory dysfunction. This occurs because CoV can invade the olfactory bulb and, thus, the central nervous system (CNS). From a biomolecular point of view, many viruses could infect peripheral neurons using the cellular mechanism of active transport to access the CNS, through interactions with the human angiotensinconverting enzyme 2 (ACE-2) receptor. Similar to its predecessor, also SARS-CoV-2, reach the olfactory bulb, as well as some regions of the cortex, midbrain, and basal ganglia, less than 70 hours after the infection. Therefore, the neuroinvasive potential of SARS-CoV-2 seems to plays a key role in the respiratory failure of COVID-19 patients. 5 A recent study analyzed the frequency of neurological manifestations in 214 patients with COVID-19, identifying anosmia in 11 patients (5.1%) and ageusia in 12 patients (5.6%). 6 Indeed, it seems chewing gum, banana, cherry, rose, chocolate, smoke, peppermint, and cinnamon). 8 Many drugs have been proposed for the treatment of upper airway disease in COVID-19, including oral corticosteroids, topical corticosteroids, and zinc sulfate; however, a recent systematic review has failed to identify any high-level evidence to support these treatments. As for nasal corticosteroids, their use in the treatment of COVID-19 anosmia does not seem recommended; however, they must not be suspended in case of a concomitant allergic rhinitis, since the increase in sneezing could promote viral spread. 9,10 COVID-19 results as a disease that involves not only the lower airways, but also the upper airways, which are frequently affected by symptoms like pharyngodynia, nasal congestion, and although less frequently in pediatric population, anosmia and ageusia. However, these latter two ones should be investigated in any case in children with specific tests suitable for them. The authors have no conflicts of interest to declare. The peer review history for this article is available at https://publo ns.com/publo n/10.1111/pai.13356. https://orcid.org/0000-0003-4291-0195 Giulia Brindisi https://orcid.org/0000-0001-5059-6082 Anna Maria Zicari https://orcid.org/0000-0002-2476-1790 A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster World Health Organization Sorveglianza Integrata COVID-19 in Italia Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in children and adolescents: a systematic review Olfactory and gustatory dysfunctions as a clinical presentation of mild-to-moderate forms of the coronavirus disease (COVID-19): a multicenter European study Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China Presentation of new onset anosmia during the COVID-19 pandemic Olfactory perception in children Intranasal corticosteroids in allergic rhinitis in COVID-19 infected patients: An ARIA-EAACI statement Allergy and asthma in children and adolescents during the COVID outbreak: What we know and how we could prevent allergy and asthma flares Upper airway involvement in pediatric COVID-19