key: cord-0881686-0d8yu9fa authors: Pitak-Arnnop, Poramate; Tangmanee, Chatpong; Meningaud, Jean-Paul; Neff, Andreas title: Prolonged viral shedding identified from external splints and intranasal packings in immediately cured COVID-19 patients with nasal fractures: A retrospective study date: 2022-04-09 journal: J Stomatol Oral Maxillofac Surg DOI: 10.1016/j.jormas.2022.04.003 sha: c47e74c94f726d3a06e760b53b3854d3a3f2ccc7 doc_id: 881686 cord_uid: 0d8yu9fa BACKGROUND: Our aim was to measure and compare prolonged viral shedding (PVS) identified from external splints (ES) and intranasal packings (IP) for isolated nasal fracture (INF) repair in immediately cured asymptomatic vs. mildly symptomatic COVID-19 patients (AS-COVID vs. MS-COVID). METHODS: We designed a retrospective cohort study and enroled a sample of post-AS-COVID and post-MS-COVID patients, whose INF were treated at a German level 1 trauma centre. The primary predictor variable was COVID severity presurgery (AS-COVD vs. MS-COVID). The main outcome variable was PVS detected in ES/IP. Other study variables were separated into demographic, clinical, and operative. Descriptive, bi- and multivariate statistics were computed, and statistical significance was set at P≤ 0.05. RESULTS: The study sample comprised 15 INF patients (53.3% females; 46.7% post-AS-COVID) with a mean age of 42.2 ± 22.7 years (range, 18–85). 13.3% ES and 53.3% IP were contaminated with SARS-CoV-2. However, only IP-contamination between the two cohorts reached statistical significance (P= 0.01; odds ratio, 0.02; 95% confidence interval, 0 to 0.47; Pearson's r= 0.73; post hoc power = 87.4%). Multiple linear regression models refuted the associations between PVS and the other parameters (i.e. age, gender, time to treatment, length of hospital stay, lengths of ES/IP placement). CONCLUSIONS: Despite a relative low sample size, our findings suggest PVS via endonasal materials removed from cured COVID-19 patients, especially those healed from MS-COVID. This PVS may trigger re-infection and surgical site infections and/or transmission to other humans, and thereby, requires further investigations. Our recent meta-narrative review and prospective study documented that the nasal and oral cavities and ocular surfaces are reservoirs of the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) [1] [2] . Despite decreased craniomaxillofacial trauma (CMFT) cases during the coronavirus disease 2019 (COVID-19) pandemic (e.g. due to lockdowns), many COVID-19 patients with CMFT required immediate treatments, such as those with retrobulbar haematoma or polytrauma [2] . Conversely, treatments for isolated nasal bone fractures (INBF) may be postponed until posttraumatic swelling subsides and the COVID-19 heals, especially in asymptomatic/mildly symptomatic COVID-19 (AS/MS-COVID) patients [2] . Prolonged viral shedding (PVS) in INBF patients post-symptom has never been studied before. The purpose of this study was to answer the following clinical question: "Among immediately COVID groups?". The investigators' null hypothesis was that there would be no different PVS following the COVID-19 course between these two patient groups. Our specific aims were to 1) measure PVS in immediately cured AS/MS-COVID subjects apt to CR-INBF, 2) compare PVS between the two groups, and 3) discuss PVS and its possible relevance. At the end of this study, we supposed to reach the Oxford Centre for Evidence-Based Medicine's Level of Evidence 2c. The study was approved by the institutional review board, and followed the Helsinki Declaration and the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement. All patients gave written consent for their anonymous data usage. A retrospective double cohort study was designed and implemented enrolling two patient samples derived from the immediately cured AS/MS-COVID patient populations who had undergone CR-INBF at a German level 1 trauma centre of a regional hospital group comprising seven hospitals in six "hot-spot" locations (over 65,000 confirmed cases during the study period) during a 12-month interval. Subjects eligible for study were age ≥ 18 years, immediately cured from AS/MS-COVID (i.e. 2) asymptomatic, and 3) tested negative twice for the virus by a rapid antigen test (RAT) and a nucleic acid amplification test (NAAT) using real-time reverse transcription polymerase chain reaction (RT-PCR) [2] . The total amount of intravenous dexamethasone 16 mg was provided for both cohorts when parenteral anaesthetic induction was begun and before the surgery ended (i.e. 8 mg twice). Subjects were excluded if they did not satisfy the inclusion criteria, or had other procedures for treating INBF, or had an underlying disease that affects wound healing and/or microbial accumulation, such as diabetes mellitus, chronic rhinosinusitis. The primary predictor variable was COVID-19 symptoms before surgery ( Table 1 ) [3] , which were recorded as binary (AS-COVID vs. MS-COVID). The main outcome variable was PVS detected in ES/IP (i.e. the inner side of ES in contact with the nasal alar skin, and both sides of IP) removed from the patients (Figure 1 ), using an NAAT/RT-PCR. This variable was categorical (positive vs. negative on ES/IP). Viral RNA was extracted from the swabs using our previously described method [2] . The primary author (P.P.) performed every surgery (including fracture repair, IP insertion, and ES application), which conformed to suggestions by the AO CMF After collecting data from the hospital database, de-identified data were exported to Microsoft 15 patients were included. In general, CR-INBF patients require a one-night hospital stay in order to observe postoperative bleeding, which is a common cause of readmission among "ambulatory" CR-INBF patients [4] . However, the patients in this cohort underwent delayed treatment and a longer antibiotic prophylaxis, i.e. 5 days, (none had penicillin allergy). The purpose of the present study was to measure PVS on ES/IP in immediately cured AS/MS- [5] [6] [7] . We prescribed a course of antibiotics for our patients because of delayed treatment with re-fracturing, subsequent mucosal breakdown, and nasal packing for 24-72 hours, in agreement with other authors [5] [6] [7] . However, routine systemic antibiotic prophylaxis is "not" recommended (because of adverse drug reactions, e.g. emergence of resistant bacterial strains, anaphylaxis, or gastrointestinal disturbances), cost-effective, and evidence-based [5] [6] [7] [8] . Merocel ® porosity could increase biofilm formation [6, 7] , and antibiotic impregnation does not reduce microbial growth [5] . The strengths of this study include a relatively generalisable sample with demographics (e.g. a wide age range in both genders), and the absence of confounding factors related to different practice patterns, clinical skill levels, and triaging protocols, as limited to one surgeon. Weaknesses of our study were the retrospective design (i.e. data might have been missed, lost, or inaccurate), a small sample size (despite high power), and the probability that our findings were false-negative cases (whose IgM titre chemiluminescent immunoassay showed a superior diagnostic value over the dual RAT and RT-PCR  The nasal and oral cavities and ocular surfaces are reservoirs of SARS-CoV-2.  Craniomaxillofacial trauma patients with COVID-19 may be treated after the COVID-19 heals.  Prolonged viral RNA shedding (PVS) on intranasal packings could be found in "immediately cured" (i.e. 1) being isolated/quarantined for ≥ 14 days, 2) no clinical symptoms, and 3) two negative test results), asymptomatic or mildly symptomatic COVID-19 patients with isolated nasal bone fractures.  PVS appears to be high, if the patient was COVID-19-symptomatic.  The abovementioned criteria in confirming the COVID-19 cure might be inappropriate and require a revision.  IP/ES removal during this COVID-19 pandemic requires strict protective measures, regardless of the presence of SARS-CoV-2 infection (i.e. "universal precaution"). Deidentified individual participant data are not available. The datasets generated and analysed during this study are available from the first author (P.P.) upon reasonable request. [3] , and metaanalytic data with respect to viral shedding [8] . Note: 95% CI -95% confidence interval. A German AWMF's S2e/realist synthesis and meta-narrative snapshot of craniomaxillofacial manifestations in COVID-19 patients: Rapid living update on 1 Inanimate surface contamination of SARS-CoV-2 during midfacial fracture repair in asymptomatic COVID-19 patients COVID-19-Krankheitslast in Deutschland im Jahr 2020 -Durch Tod und Krankheit verlorene Lebensjahre im Verlauf der Pandemie Local versus general anesthesia for the management of nasal bone fractures: a systematic review and meta-analysis Study of microorganism growth pattern in nasal pack of patients visiting the Department of ENT, Head and Neck Surgery Intranasal septal splints: Prophylactic antibiotics and nasal microbiology Is the tradition of nasal packing just an illusion of permanence or a necessary evil? An evidence-based approach to antibiotic prophylaxis for oral, craniomaxillofacial plastic/head and neck surgical procedures Characteristics of viral shedding time in SARS-CoV-2 infections: A systematic review and meta-analysis The authors received no financial support for the research, authorship, and/or publication of this article. Conception and study design: P.P., C.T., J-P.M., A.N.Acquisition of (blinded) data: P.P., C.T. Overall Note: ORodds ratio; 95% CI-95% confidence interval; N/Anot applicable; NANundefined. Continuous data are listed as mean ± SD (range); §median. † "Time to treatment" means the duration between the COVID-19 cure (which were justified using 3 indications: 1) isolated for ≥ 14 days since the first laboratory diagnosis of SARS-CoV-2 infection, 2) no symptom, and 3) tested negative twice for the virus by an RAT and an NAAT/RT-PCR) and surgical repair of the nasal bone. * In general, patients with closed nasal reduction require a one-night hospital stay; however, the patients in this cohort underwent delayed treatment and a longer antibiotic prophylaxis. Categorical data are presented as number (percentage). Statistically significant P-values are indicated in bold typeface.