Prevalence of otorhinolaryngological manifestations of COVID-19 infection during third wave and comparison from seasonal flu and allergic rhinitis in a tertiary care hospital :Aditya Singhal, Pooja Agrawal, Vijender Kumar Agrawal, Journal of Surgical Specialties and Rural Practice

ORIGINAL ARTICLE
Year : 2022 | Volume : 3 | Issue : 3 | Page : 53--58

Prevalence of otorhinolaryngological manifestations of COVID-19 infection during third wave and comparison from seasonal flu and allergic rhinitis in a tertiary care hospital

Aditya Singhal¹, Pooja Agrawal², Vijender Kumar Agrawal³,
¹ Department of ENT, Teerthankar Mahaveer Medical College and Research Centre, Moradabad, India
² Department of Pharmacology, Teerthankar Mahaveer Medical College and Research Centre, Moradabad, India
³ Department of Community Medicine, Rajshree Medical Research Institute, Bareilly, Uttar Pradesh, India

Correspondence Address:
Aditya Singhal
Department of ENT, Rajshree Medical Research Institute, Bareilly, Uttar Pradesh
India

Abstract

Background: Ever since the cluster of COVID-19 cases seen in Wuhan, China, the animal-origin virus has created havoc. These changes in clinical manifestations have been tracked in different waves, in different countries, also the virus behaving differently according to race and culture. To assess the prevalence of symptoms of COVID-19 infection during the third wave and compare it with seasonal flu and allergic rhinitis. Materials and Methods: A cross-sectional, comparative study was conducted at a tertiary hospital in Bareilly. A close-ended questionnaire was prepared to assess the otorhinolaryngological symptoms of COVID-19, seasonal flu, and allergic rhinitis. ENT findings were further confirmed by a suitable test. Results: A total of 145 tested positive for COVID-19 infection, 121 patients were diagnosed with seasonal flu, and 124 patients were diagnosed as cases of allergic rhinitis. Fever was the most common symptom in seasonal flu (100%) and COVID (93.8%) patients. Rhinorrhea (100%), lacrimation (100%), and sneezing (100%) were common symptoms in the allergic rhinitis group. A Chi-square test with Bonferroni correction showed a significant difference in the prevalence of symptoms in all three groups (P < 0.0001). Vaccination also contributed to less severity of COVID-19 disease. Conclusion: Involvement of otorhinolaryngology is considered a biomarker in all three groups with less frequent pulmonary features. It becomes necessary to correctly differentiate COVID-19 from the other two diseases for the proper treatment of patients.

How to cite this article:
Singhal A, Agrawal P, Agrawal VK. Prevalence of otorhinolaryngological manifestations of COVID-19 infection during third wave and comparison from seasonal flu and allergic rhinitis in a tertiary care hospital.J Surg Spec Rural Pract 2022;3:53-58

How to cite this URL:
Singhal A, Agrawal P, Agrawal VK. Prevalence of otorhinolaryngological manifestations of COVID-19 infection during third wave and comparison from seasonal flu and allergic rhinitis in a tertiary care hospital. J Surg Spec Rural Pract [serial online] 2022 [cited 2023 Mar 29 ];3:53-58
Available from: http://www.jssrp.org/text.asp?2022/3/3/53/364428

Full Text

Introduction

The COVID-19 SARS-CoV-2 infection that speeded rapidly throughout the world was declared a pandemic by World Health Organization (WHO) on March 11, 2020.[1],[2] Since December 2020–May 2021, COVID-19 SARS-CoV-2 had undergone many known mutations and antigenic drifts. The mutation and antigenic drifts and shifts are responsible for different symptoms and severity of infection over the period of time. The current variant of concern B.1.1.529, designated as the Omicron variant by the WHO was first identified in South Africa on November 23, 2021, after an upstroke in the number of cases of COVID-19.[3]

This new variant has undergone significant mutations in comparison to its previous variants. The Delta variant (B.1.617.2) had 8 mutations, whereas Omicron (B.1.1.529) has undergone 32 mutations of the spike protein. It is to be noted that with eight mutations, the Delta variant created havoc in India and other countries early this year in 2020.[4]

Clinical presentations of COVID-19 show a wide spectrum across different geographical borders. The symptoms varied from upper respiratory tract-related symptoms such as low-grade fever, dry cough, headache, rhinorrhea, and nasal obstruction to the involvement of the lower respiratory tract that includes dyspnea and chest pain to acute respiratory distress syndrome.[5] In addition, ear, nose, and throat (ENT) symptoms, including loss of sense of smell and/or loss of sense of taste, have also been reported in several patients.[6]

Many studies including systematic reviews and meta-analyses have been conducted for many COVID-19 symptoms including differentiation between flu and COVID-19.[2],[4] Besides the management of COVID-19 patients, an important aspect that goes unrecognized is the differentiation and timely diagnosis of patients with similar symptoms of allergic rhinitis and the common cold. A similar study was conducted in France and used a modified Delphi approach that enabled the differentiation of upper respiratory symptoms between COVID-19, the common cold, and allergic rhinitis.[7] Such studies have being conducted in the Chinese and Indian subcontinents, however, studies in the Indian subcontinent are lacking.

There was no demarcation of COVID waves, but after the second wave, there was a sudden increase in COVID cases during the time period, at which the present study was conducted. To analyze this changing paradigm of the novel coronavirus and its effect in the human body, this study was conducted to identify the different clinical manifestations in COVID-19 third wave in the Indian population. This study is also done to assess the severity of the symptoms in COVID-19 infection in comparison to seasonal flu virus infection and allergic rhinitis occurring in similar months of the year.

Materials and Methods

Participants

The observational, cross-sectional, comparative study was conducted by surveying the patients who visited ENT-OPD of a tertiary care hospital in Bareilly. The survey was conducted from January 1, 2022, to January 31, 2022, to record the demographic data, symptomatology, and vaccination status. Patients who came to the hospital with a positive COVID antigen test and reverse transcription–polymerase chain reaction (RT-PCR) were included in the COVID group. The patients with negative COVID reports were included in the seasonal flu group. Patients with allergic rhinitis were diagnosed according to Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines.[7]

Sample size calculation

The sample size is determined using the following formula: n = Z2 P (1 − P)/d2. Where: n = sample size P = estimate of proportion, 0.5, d = margin of sampling error tolerated, and 0.05 Z = the standard normal value at confidence interval of 95% = 1.96.

The sample size was = 384. Approximately 400 patients were taken to reduce the error.

Ethical approval and consent

Ethical approval was taken from the Institutional Ethical Committee of RMRI, Bareilly. Consent of participants was taken in Google Forms itself.

Sampling method

The current survey commenced in January 1, 2022, and was completed in January 31, 2022. Participants were asked to fill survey questionnaire form through the Google Forms link sent to their android phones. Patients who were having difficulty in assessing the Internet or who were not having android phones or Internet connectivity were given printed copies and data were uploaded later on.

Data collection

Data were collected through Google Forms. Form was prepared into two parts: the initial part registered demographic details and the second part was semi-structured questionnaire. The demographic details, age, gender, symptoms, and vaccination status were recorded. The type of symptom, duration form, and the onset of the symptoms were also calculated. For obtaining comorbid conditions, patients were given the list of comorbid conditions with the option of multiple selections. Otorhinolaryngologic symptoms were confirmed from the patients through telephonic interviews. All the answers were subjective or self-reported, and no documentary proof was asked from the participants.

Statistical methods and analysis

The data collected were analyzed statistically on SPSS version 21 software (IBM) using descriptive statistics, namely mean and standard deviation for quantitative variables, and nonparametric tests for qualitative variables. Wherever necessary, the results were depicted in the form of percentages and graphs. The data were checked for missing details, duplicate entries, and followed by questionnaire. Two groups were formed on the basis of a rapid antigen detection test or RT-PCR test.

Survey analysis

Survey was conducted among these patients who consented for the study. A detailed history was taken with regard to the presence of generalized COVID-related symptoms and different otorhinolaryngological symptoms in those patients. During the survey, it was also made sure that otorhinolaryngologic symptoms were new-onset and were not explained by any other underlying disease. They were also asked about the onset time of the symptoms to assess symptom duration. Patients were then examined for any positive findings in ENT were examined as per routine ENT examination guidelines in consideration with COVID-19.

Results

A total of 410 patients were participated in the study. One hundred forty-five patients were diagnosed as COVID-positive cases. One hundred thirty-one patients were diagnosed as cases of seasonal flu, as they were COVID-negative and there were no symptoms of anosmia and ageusia. One hundred twenty-four patients were diagnosed as a case of allergic rhinitis according to ARIA guidelines. Ten patients were excluded from the study as five patients had hearing loss due to other trauma in RTA. Three patients underwent septoplasty 1 month before the outbreak. Two had ageusia due to some psychiatric problem and were referred in psychiatry.

The demographic characteristics of patients are shown in [Table 1]. COVID and allergic rhinitis were common in the 20–39 years age group, whereas seasonal flu was common in the 40–60 year and <20 year age group. COVID and seasonal flu were more common in males, whereas allergic rhinitis is more common in females. Comorbidities were present in all three groups. The prevalence of hypertension and diabetes was more in the COVID group. Asthma was more common in allergic rhinitis patients. The most obvious symptom in all three groups was noted and frequency was analyzed [Table 2]. Fever was the most common symptom in COVID-19 (93.8) and seasonal flu (100). Rhinorrhea (100%), lacrimation (100%), and sneezing (100%) were the common symptoms in allergic rhinitis. Nasal obstruction (93.1%), ageusia (84.1%), and anosmia (37.9%) were the next most common finding in COVID patients. There were significant differences in symptomatology between the three groups. The mean and standard deviation of the duration of each ENT symptom were calculated and compared with graph [Figure 1] and [Table 3]. Hearing loss was seen in ten patients. It was sudden in onset and resolved within 7 ± 3.6 days. Vaccination status of groups was compared. The result was not significant [Table 4].{Figure 1}{Table 1}{Table 2}{Table 3}{Table 4}

ORL symptoms were examined in all the groups. ENT findings were confirmed by complete ENT examination. For ear examination, a tuning fork test at a frequency of 512 Hz, the Weber test was performed. It showed lateralization to the right in patients with left-sided hearing loss and to the left in those with right-sided hearing loss. Olfactory sensory loss was proved by the UPSIT test, and four basic taste modalities were tested using the appropriate solutions. [Table 5] denotes findings on ENT examination of patients. Pharyngitis (100% and 96.1%, respectively) was the most common symptom in COVID and seasonal flu patients. Swollen inferior turbinate and allergic crease were present in allergic rhinitis patients that confirmed our diagnosis.{Table 5}

Discussion

World Health Organization has denoted Delta and Omicron as variants of concern currently spreading in various parts of the world. Indian subcontinent faced cases of Delta surge in May 2021 and recently the Omicron surge in January 2022. The COVID-19 symptomatology is also evolving depending upon the nature of mutation occurring in the virus. The first wave of COVID-19 showed high morbidity in elderly and immunocompromised individuals. The second wave in 2021, mainly affected healthy and young adults along with debilitated individuals. This study compares between the symptomatology of COVID-positive patients during the third wave that affected in India in comparison to those who were COVID-negative and presented to the hospital during the same duration. This study also compared the symptomatology with the previous waves.

The mean age in this study is 37.914 years in the COVID group, whereas in a study by Huang et al. shows a mean age of 49 years,[5] 47 years by Guan et al.,[8] 55.5 years by Chen et al.,[9] and 57 years by Liu et al.[10] The mean age of patients was found to be 48.7 years by Gunjan et al.[11] and 58 years by Iftimie et al.[12]

The gender distribution in this study reveals that males are more affected with female patients in COVID and seasonal flu cases as males are more involved in outdoor activities.

In [Table 6], we have conducted a comparison of different ENT symptoms and compared from previous two waves. There was a significant difference in the percentage of different symptoms among the various studies.{Table 6}

In our study, ENT symptoms were nonspecific in nature and did not involve any emergencies [Table 2], [Table 3] and [Table 5].

There are minor differences in symptom logy among all the three groups. The triage of patients with newly developed symptoms remained a challenge during this pandemic.

The incidence of allergy has increased. The prevalence of allergic rhinitis is 10%–40%.[13] The patients of allergic rhinitis present with symptoms coinciding with COVID-19 and seasonal flu. Rhinitis is a symptomatic disorder of the nose. It causes nasal obstruction, secretion, and sneezing which are most commonly induced by allergen exposure. The allergen may be bacteria or virus which causes allergic rhinitis and the common cold.[14] The results in our study were consistent with Hagemann et al.,[7] where lacrimation, rhinorrhea, and sneezing were common in the allergic rhinitis group. Dysgeusia and anosmia were common in the COVID group. In a study conducted by Smith et al.,[15] the presence of only two symptoms taste and smell dysfunction can help physicians to triage COVID-19 patients from other diseases.

Seasonal flu and allergic rhinitis are the most common differential diagnosis in COVID-19 patients. They need to be identified correctly and treated accordingly.

Limitations

Our study was limited to a city. Only patients with the mild-to-moderate disease were included in the study. As seen in the demographic profile, the maximum representation is in the young age group, which may be the confounding factor in the study. The symptom was graded and asked on a subjective basis, no objective scales were used to confirm their presence. The study was solely based on self-reporting, thus increasing the chances of recall bias. The study was purely noninterventional, thus no radiological and other pathological test was performed to confirm the diagnosis. Due to the lack of clear definitions of the disease, there may be variation in clinical data collection, as the studies are rapidly being conducted.

Conclusion

As recently reported by WHO, COVID-19 has created a mortality burden of 60 lacs in the world. It becomes the moral responsibility of every human being to identify the new COVID-19 infection case and report them timely, get isolated in time to reduce the spread. This study reveals the clinical manifestations of the latest COVID-19 strain infection. There is a change in the virulence nature partly due to the host and due to the environment. The Indian subcontinent that recently went through the third upsurge in the number of COVID cases showed mild-to-moderate symptoms involving mainly the otorhinolaryngological part rather than the second wave upsurge which had involvement of lungs with early pulmonary complications.

All the participants in the study were vaccinated, which also contributed to less severity of infection from the host point of view. There seems to be a significant clinical overlap in the symptomatology of the seasonal flu viral strains that commonly affect northern India in the months of December to January. The key differentiating point between the groups depends upon the duration of the disease and examination findings.

This study serves as a platform for further research in the symptomatology accordingly to newer emerging strains of COVID-19.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1	Cucinotta D, Vanelli M. WHO declares COVID-19 a pandemic. Acta Biomed 2020;91:157-60.
2	Fu L, Wang B, Yuan T, Chen X, Ao Y, Fitzpatrick T, et al. Clinical characteristics of coronavirus disease 2019 (COVID-19) in China: A systematic review and meta-analysis. J Infect 2020;80:656-65.
3	Vaughan A. Omicron emerges. New Sci [Internet]. 2021;252:7. Available from: http://dx.doi.org/10.1016/S0262-4079(21)02140-0.
4	Kannan S, Shaik Syed Ali P, Sheeza A. Evolving biothreat of variant SARS-CoV-2 – Molecular properties, virulence and epidemiology. Eur Rev Med Pharmacol Sci 2021;25:4405-12.
5	Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497-506.
6	Avcı H, Karabulut B, Farasoglu A, Boldaz E, Evman M. Relationship between anosmia and hospitalisation in patients with coronavirus disease 2019: An otolaryngological perspective. J Laryngol Otol 2020;134:710-6.
7	Hagemann J, Onorato GL, Jutel M, Akdis CA, Agache I, Zuberbier T, et al. Differentiation of COVID-19 signs and symptoms from allergic rhinitis and common cold: An ARIA-EAACI-GA2LEN consensus. Allergy Eur J Allergy Clin Immunol 2021;76:2354-66. .
8	Guan WJ, Ni ZY, Hu Y, Liang WH, Ou CQ, He JX, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. Journal Article. Doi: 10.1056/NEJMoa2002032. PMID-32109013. New England Journal of Medicine April 30, 2020 382(18):1708.
9	Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
10	Liu K, Chen Y, Lin R, Han K. Clinical features of COVID-19 in elderly patients: A comparison with young and middle-aged patients. J Infect 2020;80:e14-8.
11	Kumar G, Mukherjee A, Sharma RK, Menon GR, Sahu D, Wig N, et al; National Clinical Registry for COVID-19 Team. Clinical profile of hospitalized COVID-19 patients in first & second wave of the pandemic: Insights from an Indian registry based observational study. Indian J Med Res 2021;153:619-28. doi: 10.4103/ijmr.ijmr_1628_21.
12	Iftimie S, Lopez-Azcona AF, Vallverdu I, Hernandez-Flix S, De Febrer G, Parra S, et al. First and second waves of coronavirus disease-19: A comparative study in hospitalized patients in Reus, Spain. PLoS One. 2021;16:1-13.
13	Klimek L, Bachert C, Pfaar O, Becker S, Bieber T, Brehler R, et al. ARIA guideline 2019: treatment of allergic rhinitis in the German health system. Allergo J Int. 2019;28:255-76.
14	Hellgren J, Cervin A, Nordling S, Bergman A, Cardell LO. Allergic rhinitis and the common cold - High cost to society. Allergy Eur J Allergy Clin Immunol 2010;65:776-83.
15	Smith PK, Lesslar O, Price DB. Correspondence to "Differentiation of COVID-19 signs and symptoms from allergic rhinitis and common cold: An ARIA-EAACI-GA2LEN consensus". Allergy 2022;77:2571-3.