Facial Trauma During the COVID-19 Pandemic
1
Department of Otolaryngology, SUNY Upstate, 750 E Adams St, Syracuse, NY 13210-2306, USA
2
Department of Otolaryngology, Emory University, Atlanta, GA, USA
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2022, 15(4), 318-324; https://doi.org/10.1177/19433875211053760
Submission received: 1 November 2020
/
Revised: 1 December 2020
/
Accepted: 1 January 2021
/
Published: 27 December 2021
Abstract
:Study Design: Retrospective cohort study. Objective: The purpose of this study is to evaluate the impact of the COVID-19 global pandemic on the regional trends in facial trauma at a tertiary care, level 1 trauma center in Central New York. Methods: The study sample was derived from the population of patients who presented with facial trauma to the emergency department at the Downtown and/or Community Campuses of SUNY Upstate University Hospital between March 1, 2020, and May 15, 2020, and compared to two historical controls in 2018 and 2019. Descriptive and bivariate statistics were calculated for study variables in each cohort. Poisson regression was used to compare incident rate ratios (IRR) with 95% confidence intervals with significance set at P < .05. Results: Sixty five patients presented during the COVID-19 pandemic, while 83 presented in 2019 and 95 in 2018. For the study period, the most common mechanism was assault in 47.7%. IRR was significantly lower than in 2018 (IRR = 1.46, P = .018), but not significantly different from 2019 (IRR = 1.28, P = .14). During lockdown, IRR was significantly decreased compared to 2019 (IRR = 1.84, P = .0029) and 2018 (IRR = 2.16, P < .001). Conclusions: The volume of facial trauma seen in Central New York appears undeterred in the absence of “shelter in place” orders. Analysis of pandemic and regional trauma variations can offer valuable insight for improved resource allocation to better prepare for potentially high-risk procedures.
Introduction
Each year, there exists a seasonal relationship between trauma and crime in the Northern hemisphere. Indeed, it has been well established that long days and warmer temperatures result in increased alcohol consumption and higher rates of interpersonal violence.[1,2] In patients with facial trauma, this translates into increased midface and mandible fractures and, consequently, a higher likelihood of operative intervention.[3] As a result, emergency rooms (ER) and hospitals often experience a surge in trauma volume that is characteristic of the summer months.[4] However, little is known about the effects of a modern pandemic on facial trauma.
The global pandemic of COVID-19 due to the SARS-CoV-2 coronavirus has disrupted modern healthcare as we know it.[5] Implementation of social distancing and “shelter in place” guidelines have facilitated “flattening the curve” by slowing viral spread and allowing hospitals to increase capacity without becoming overburdened. As a result, ER visits and hospital admissions have drastically declined despite the relatively constant nature of everyday maladies. Moreover, hospitals have experienced an unexpected change in the pattern of non-COVID-19–related admissions. For example, admissions due to acute coronary syndrome have dropped as much as 30% in recent months.[6] Yet, some cities have experienced a surge in gun-related trauma despite statewide “shelter in place” orders.[7]
Some authors suspect that socioeconomic disparities resulting in an inability to comply with social distancing orders have heightened the stress of a global pandemic, thereby triggering higher rates of interpersonal violence.[7] Whether this represents a sustained increase or a simple coincidence remains unclear. Nevertheless, recognizing variations in facial trauma patterns is critical in the setting of an ongoing global pandemic that is plagued by limited resources and fear of iatrogenic aerosolization of nasopharyngeal viral particles.[8,9,10]
The purpose of this study is to understand the impact of the COVID-19 pandemic on the epidemiology of maxillofacial injuries at a level 1 trauma center in Central New York. Our hypothesis is that the incidence of facial trauma has remained constant throughout the COVID-19 pandemic, despite decreased crime rates and non-COVID-19– related hospital admissions.[6,11]
Methods
Patient Selection and Data Collection
A retrospective chart review was designed to evaluate facial trauma volume at a tertiary care, level 1 trauma center in Central New York (CNY) during the COVID-19 pandemic. Following institutional board review, the medical records of patients presenting with a diagnosis of “fracture of face bones” to the emergency department at the Downtown and/ or Community Campuses of SUNY Upstate University hospital were reviewed.
Patient variables included age, gender, and whether there was a prior history of facial trauma. Presentation-specific variables included associated drug or alcohol use, transfer from outside hospital (OSH), and the mechanism of facial trauma. Mechanism was recorded as assault, fall, motor vehicle/other traffic-related accident (MVA), sports-related, or other (including unspecified or unusual mechanisms). Because all facial trauma is exclusively managed by the otolaryngology (OHNS) service at the study institutions, whether consultation and/or procedural intervention (bedside and/or operating room) by OHNS was recorded. Due to reports of increased domestic assault during the lockdown period, this was additionally recorded.[12]
Study Period and Endpoints
The study period began on the date of the first confirmed case of COVID-19 in New York State (March 1, 2020) and ended on May 15, 2020. Incidence rates for the study period were subsequently compared to two historic controls, the corresponding intervals for the two preceding years (March 1 to May 15, 2019 (historical cohort 1) and March 1 to May 15, 2018 (historical cohort 2)). The primary outcome was the incidence rate of facial trauma. Incidence rates were equivalent to the number of presentations for each time period. Secondary outcomes included etiologic comparisons of maxillofacial injuries and incident rate comparisons between lockdown (March 22 to May 15, 2020) and prelockdown (March 1 to March 21, 2020) periods.
Statistical Analysis
Statistical analysis was performed using R Statistical Software (2017 Foundation for Statistical Computing; Vienna, Austria). Univariate analysis was performed using the chi-square test. Numerical variables are reported as sample size (N), mean, and standard deviation (SD). Categorical variables are given as N and percent (%).
Poisson regression was used to calculate incident rate ratios (IRR) between the study group and each historical control. Two additional analyses were performed to compare IR ratios during statewide lockdown orders (March 22 to May 15, 2020) and pre-lockdown orders (March 1 to March 21, 2020). The adjusted IRR for the lockdown and pre-lockdown periods were each compared for the study period and corresponding historical controls for 2018 and 2019. Results are reported as incidence rate ratios (IRR) with 95% confidence intervals (CI) and P-values. A P-value < .05 was considered statistically significant.
Results
A total of 65 patients presented with facial trauma between March 1, 2020, to May 15, 2020 (Figure 1). Of these patients, mean age was 40.2 years and 69.2% (45 of 65) were male. The most common mechanism was due to assault in 47.7% (31 of 65), followed by falls in 33.8% (22 of 65). Nearly 71% (46 of 65) of patients had specialist consultation by OHNS and 43% (28 of 65) underwent procedural intervention. 40% (26 of 65) of patients were transferred from an OSH. When compared to 2019 and 2018, there was no significant difference in age, gender, mechanism, domestic assault, alcohol or drug use, need for OHNS consultation, or procedural intervention, prior history of facial trauma or OSH transfer (Table 1).
The incidence of facial trauma presentations during the study period was significantly lower than that observed in 2018 (IRR = 1.46 (95% CI: 1.07–2.00), P = .018), but not statistically significant when compared to 2019 (IRR = 1.28 (95% CI: .923–1.77), P = .14).
After initiation of the “New York State on PAUSE” executive order on March 22, 2020, the incidence of facial trauma was statistically significant when compared to both 2019 (IRR = 1.84 (95% CI: 1.23–2.74), P = .0029) and 2018 (IRR = 2.16 (95% CI: 1.46–3.19), P < .001). Prior to the lockdown, IRR for the study period was increased when compared to 2019 (IRR = .536 (95% CI: .286–1.00), P = .051) and 2018 (IRR = .536 (95% CI: .286–1.00), P = .051). Complete results from univariate analysis during the lockdown period are reported in Table 2.
Discussion
New York State was the early epicenter of the COVID-19 pandemic during its North American outbreak, with nearly 350,000 cases and 30,000 deaths by May 2020.[13] Strict social distancing guidelines helped facilitate “flattening the curve,” but also led to additional unexpected fortuitous outcomes. For example, media agencies across the United States reported plummeting crime rates, while hospitals and ERs encountered a significant reduction in overall patient volume.[11] The purpose of this study is to understand the impact of the COVID-19 pandemic on the epidemiology of maxillofacial injuries at a level 1 trauma center in Central New York, with the hypothesis that the incidence of facial trauma injuries has remained consistent.
COVID-19 and Incidence of Facial Trauma
Despite decreased crime rates and non-COVID-19–related hospital admissions during the early COVID-19 pandemic, this study suggests that the incidence of maxillofacial injuries remained relatively constant.[6,11] Though the current study period indicates a significant decline in facial trauma when compared to 2018, this was not reproducible with 2019 data. However, after the implementation of statewide social distancing orders, there was a statistically significant decrease in the incidence of facial trauma when compared to the previous 2 years (Figure 2). Whether this is due to mandated social distancing or a decision to forgo medical treatment in fear of contracting SARS-CoV-2 coronavirus remains unclear. This suggests that the observed reduction in facial trauma was predominantly driven by “shelter-in-place” orders rather than patient fear of the ongoing pandemic.
In addition, we suspect the current study period may be confounded by an initial surge in facial trauma volume immediately prior to implementation of “NY State on PAUSE.” In fact, nearly two-thirds of the patients who presented in March 2020 did so during the first 3 weeks of the pandemic, prior to statewide executive mandates. When compared to corresponding dates for the previous two years, this initial increase approached significance and is similar to a recent study on gun violence in Philadelphia, which recorded its highest number of shootings in 5 years this past March (Figure 2).[7]
Socioeconomic factors such loss of work, lack of social support, lack of education, or fear of the unknown often result in heightened panic and stress, with a resultant increase in interpersonal violence.[7,14] This association is similar to what has previously been reported in the days following a natural disaster.[14,15]
In contrast to a recent report demonstrating reduced hospitalization due to cardiac disease throughout the pandemic, our results suggest this was only true after implementation of the lockdown period.[6] For facial trauma surgeons, this is particularly important as a significant proportion of operative facial trauma requires the use of surgical drills and temporary nasotracheal intubation. While the true aerosolization potential of SARS-CoV-2 remains uncertain,[16] the combination of increased oropharyngeal viral load and aerosol-generating procedures emphasizes the importance of appropriate PPE and pre-operative viral testing.[10,17,18,19,20]
Variations in Facial Trauma Patterns
When compared to previous years, there was no significant difference in alcoholor drug-related injuries, those requiring specialist consultation or procedural intervention, or domestic assault. Although not statistically significant, there was an unexpected increase in transfers from OSH during the study period. While this may reflect increased injury severity necessitating higher level of care, our results were not indicative of increased specialist consultation or a higher rate of procedural intervention. In CNY, the primary study institution is the only facial trauma referral center for 16 surrounding counties. Therefore, the increased rate of transfers may be a result of resource-limited, rural hospitals who are unable to arrange timely follow-up and/or have concerns with maintaining open beds, adequate staff, and PPE. Nevertheless, this finding reiterates the importance of communication with local hospitals and ER staff to minimize transfers for non-urgent trauma.
Study Limitations
This study has several limitations. First, this study represents a single institution, single-specialty experience, which may render generalization difficult. Additionally, its retrospective nature predisposes it to potential underreporting if there was a failure to include “facial trauma” or “facial fractures” as the chief complaint for ER presentation. Underreporting may have additionally occurred if patients did not present to the study institutions, which may have been more likely during the lockdown period as people were ordered to stay inside.
Because this study presents real-time data, it is limited by the relatively small sample size and ongoing evolution of facial trauma trends during the pandemic. Therefore, future studies are needed to evaluate the long-term impact of COVID-19 on patterns of facial trauma and the potential risks of transmission in facial trauma surgery.
Conclusion
The COVID-19 outbreak has presented critical challenges to modern healthcare. While some medical admissions have appeared to decrease throughout the pandemic,[6] facial trauma appears undeterred in the absence of “shelter in place” orders. For facial trauma surgeons operating amidst an ongoing pandemic, these patterns are essential to recognize because reduction techniques may be aerosol-generating and there is potential exposure to increased viral loads in patients with unknown or COVID-19–positive status.[10] Moreover, analysis of pandemic and regional trauma variations can offer valuable insight for improved resource allocation and facilitate communication between physician colleagues and hospital administration to better prepare for potentially high-risk procedures.
Funding
This research received no external funding.
Conflicts of Interest
The authors declare no conflict of interest.
Ethical approval
All research was conducted in a manner adherent to our institution. This manuscript is not currently being considered for publication in any other journal at this time. All contributing authors have seen and approved the manuscript.
References
- McLean, I. Climatic effects on incidence of sexual assault. J Forensic Leg Med. 2007, 14, 16–19. [Google Scholar] [PubMed]
- Thomas, J.; Lynham, A.; Borgna, S.; Jones, L.; Vasani, S. Climatic effects on the incidence of interpersonal maxillofacial trauma. Int J Publ Health Sci. 2017, 2, 124. [Google Scholar]
- Lee, K.H.; Qiu, M.; Sun, J. Temporal distribution of alcohol related facial fractures. Oral Surg Oral Med Oral Pathol Oral Radiol. 2017, 124, 450–455. [Google Scholar] [PubMed]
- Olson, R.A.; Fonseca, R.J.; Zeitler, D.L.; Osbon, D.B. Fractures of the mandible: a review of 580 cases. J Oral Maxillofac Surg. 1982, 40, 23–28. [Google Scholar] [CrossRef] [PubMed]
- Wu, Y.; Ho, W.; Huang, Y.; et al. SARS-CoV-2 is an appropriate name for the new coronavirus. Lancet. 2020, 395, 949–950. [Google Scholar] [PubMed]
- De Filippo, O.; D’Ascenzo, F.; Angelini, F.; et al. Reduced rate of hospital admissions for ACS during Covid-19 outbreak in Northern Italy. N Engl J Med. 2020, 383, 88–89. [Google Scholar] [CrossRef] [PubMed]
- Hatchimonji, J.S.; Swendiman, R.A.; Seamon, M.J.; Nance, M.L. Trauma does not quarantine: violence during the COVID-19 pandemic. Ann Surg. 2020, 272, e53–e54. [Google Scholar] [CrossRef] [PubMed]
- Mick, P.; Murphy, R. Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review. J Otolaryngol Head Neck Surg. 2020, 49, 29. [Google Scholar] [PubMed]
- Thamboo, A.; Lea, J.; Sommer, D.D.; et al. Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology—head and neck surgery during the COVID-19 pandemic. J Otolaryngol Head Neck Surg. 2020, 49, 28. [Google Scholar] [PubMed]
- Zou, L.; Ruan, F.; Huang, M.; et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020, 382, 1177–1179. [Google Scholar] [PubMed]
- Libonati, C. Arrests plummet accross central New York during coronavirus pandemic. 13 April 2020. Available online: https://www.syracuse.com/crime/2020/04/arrests-plummet-across-central-new-york-duringcoronavirus-pandemic.html (accessed on 13 April 2020).
- Boserup, B.; McKenney, M.; Elkbuli, A. Alarming trends in US domestic violence during the COVID-19 pandemic. Am J Emerg Med. 2020, 38, 2753–2755. [Google Scholar] [PubMed]
- CDC COVID Data Tracker. Center for disease control and prevention (CDC). United States COVID-19 cases and deaths by state web site. 15 May 2020. Available online: https://covid.cdc.gov/covid-data-tracker/#trends_totaldeaths (accessed on 16 May 2020).
- Rezaeian, M. The association between natural disasters and violence: A systematic review of the literature and a call for more epidemiological studies. J Res Med Sci. 2013, 18, 1103–1107. [Google Scholar] [PubMed]
- World Health Organization. Interpersonal Violence and Disasters; 2008; Available online: https://www.who.int/violence_injury_prevention/publications/violence/violence_disasters.pdf (accessed on 14 May 2020).
- Zhu, W.; Huang, X.; Zhao, H.; Jiang, X. A COVID-19 patient who underwent endonasal endoscopic pituitary adenoma resection: A case report. Neurosurgery. 2020, 87, E140–E146. [Google Scholar] [PubMed]
- Ishihama, K.; Sumioka, S.; Sakurada, K.; Kogo, M. Floating aerial blood mists in the operating room. J Hazard Mater 2010, 181, 1179–1181. [Google Scholar] [PubMed]
- Ishihama, K.; Koizumi, H.; Wada, T.; et al. Evidence of aerosolised floating blood mist during oral surgery. J Hosp Infect. 2009, 71, 359–364. [Google Scholar]
- Hallier, C.; Williams, D.W.; Potts, A.J.; Lewis, M.A. A pilot study of bioaerosol reduction using an air cleaning system during dental procedures. Br Dent J. 2010, 209, E14. [Google Scholar]
- Urban, M.; Patel, T.; Raad, R.; et al. Implementation of preoperative screening protocols in otolaryngology during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020, 163, 265–270. [Google Scholar] [CrossRef]
Figure 1.
Flowchart diagram illustrating selection of study population and historical comparison cohorts.
Figure 1.
Flowchart diagram illustrating selection of study population and historical comparison cohorts.
Figure 2.
Facial trauma incidence for the study period, lockdown period, and pre-lockdown period for 2018–2020. *indicates IRR was significant on Poisson regression.
Figure 2.
Facial trauma incidence for the study period, lockdown period, and pre-lockdown period for 2018–2020. *indicates IRR was significant on Poisson regression.
Table 1.
Comparison of Facial Trauma in CNY During the COVID-19 Pandemic and Two Historical Controls.a.
Table 1.
Comparison of Facial Trauma in CNY During the COVID-19 Pandemic and Two Historical Controls.a.
| Study Period No. (%) | Control Periods No. (%) | |||
|---|---|---|---|---|
| 2020 (n = 65) | 2019 (n = 83) | 2018 (n = 95) | P-value | |
| Age | 40.2 | 42.4 | 36.9 | .178 |
| Gender | ||||
| Male | 45 (69.2) | 51 (61.4) | 70 (73.7) | .212 |
| Female | 20 (30.8) | 32 (38.6) | 25 (26.3) | |
| Mechanism | ||||
| Assault | 31 (47.7) | 33 (39.8) | 50 (52.6) | .214 |
| Fall | 22 (33.8) | 29 (34.9) | 28 (29.5) | |
| MVA | 6 (9.2) | 10 (12.0) | 9 (9.5) | |
| Sports | 1 (1.5) | 8 (9.6) | 7 (7.4) | |
| Other | 5 (7.7) | 3 (3.6) | 1 (1.1) | |
| Domestic assault | ||||
| Yes | 3 (4.6) | 7 (8.4) | 7 (7.4) | .65 |
| No | 62 (95.4) | 76 (91.6) | 88 (92.6) | |
| EtOH or drug use | ||||
| Yes | 16 (24.6) | 19 (22.9) | 27 (28.4) | .687 |
| No | 49 (75.4) | 64 (77.1) | 68 (71.6) | |
| OHNS consult | ||||
| Yes | 46 (70.8) | 61 (73.5) | 76 (80.0) | .369 |
| No | 19 (29.2) | 22 (26.5) | 19 (20.0) | |
| Procedural intervention | ||||
| Yes | 28 (43.1) | 27 (32.5) | 41 (43.2) | .277 |
| No | 37 (56.9) | 56 (67.5) | 54 (56.8) | |
| OSH transfer | ||||
| Yes | 26 (40.0) | 21 (25.3) | 35 (36.8) | .123 |
| No | 39 (60.0) | 62 (74.7) | 60 (63.2) | |
| Prior facial trauma | ||||
| Yes | 8 (12.3) | 7 (8.4) | 6 (6.3) | .414 |
| No | 57 (87.7) | 76 (91.6) | 89 (93.7) | |
aThe study period was March 1, 2020–May 15, 2020. The two historical control periods were the corresponding dates for 2019 (March 1, 2019–May 15, 2019) and 2018 (March 1, 2018–May 15, 2020). Abbreviations. No., number; MVA, motor vehicle accident; EtOH, alcohol; OHNS, otolaryngology; OSH, outside hospital. Significant values are indicated with * and bold type font.
Table 2.
Comparison of Facial Trauma in CNY During Statewide Lockdown and Two Historical Controlsa.
| Study Group No. (%) | Historical Controls No. (%) | |||
|---|---|---|---|---|
| 2020 (n = 37) | 2019 (n = 68) | 2018 (n = 80) | P-value | |
| Age | 40.6 | 43.6 | 36.9 | .136 |
| Gender | ||||
| Male | 26 (70.3) | 41 (60.3) | 60 (75.0) | .153 |
| Female | 11 (29.7) | 27 (39.7) | 20 (25.0) | |
| Mechanism | ||||
| Assault | 19 (51.4) | 28 (41.2) | 42 (52.5) | .0617 |
| Fall | 11 (29.7) | 27 (39.7) | 24 (30.0) | |
| MVA | 3 (8.1) | 5 (7.4) | 8 (10.0) | |
| Sports | 0 (.0) | 6 (8.8) | 6 (7.5) | |
| Other | 4 (10.8) | 2 (2.9) | 0 (.0) | |
| Domestic assault | ||||
| Yes | 3 (8.1) | 4 (5.9) | 6 (7.5) | .891 |
| No | 34 (91.9) | 64 (94.1) | 74 (92.5) | |
| Procedural intervention | ||||
| Yes | 15 (40.5) | 21 (30.9) | 35 (43.8) | .264 |
| No | 22 (59.5) | 47 (69.1) | 45 (56.3) | |
| EtOH or drug use | ||||
| Yes | 13 (35.1) | 16 (23.5) | 23 (28.8) | .444 |
| No | 24 (64.9) | 52 (76.5) | 57 (71.2) | |
| OHNS consult | ||||
| Yes | 28 (75.7) | 51 (75.0) | 64 (80.0) | .743 |
| No | 9 (24.3) | 17 (25.0) | 16 (20.0) | |
| OSH transfer | ||||
| Yes | 16 (43.2) | 18 (26.5) | 27 (33.7) | .213 |
| No | 21 (56.8) | 50 (73.5) | 53 (66.3) | |
| Prior facial trauma | ||||
| Yes | 1 (2.7) | 7 (10.3) | 5 (6.3) | .326 |
| No | 36 (97.3) | 61 (89.7) | 75 (93.7) | |
aThe study period was March 22, 2020–May 15, 2020. The two historical control periods were the corresponding dates for 2019 (March 22, 2019–May 15, 2019) and 2018 (March 22, 2018–May 15, 2020). Abbreviations. No., number; MVA, motor vehicle accident; EtOH, alcohol; OHNS, otolaryngology; OSH, outside hospital. Significant values are indicated with * and bold type font.
© 2021 by the author. The Author(s) 2021.
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MDPI and ACS Style
Tipirneni, K.E.; Gemmiti, A.; Arnold, M.A.; Suryadevara, A. Facial Trauma During the COVID-19 Pandemic. Craniomaxillofac. Trauma Reconstr. 2022, 15, 318-324. https://doi.org/10.1177/19433875211053760
AMA Style
Tipirneni KE, Gemmiti A, Arnold MA, Suryadevara A. Facial Trauma During the COVID-19 Pandemic. Craniomaxillofacial Trauma & Reconstruction. 2022; 15(4):318-324. https://doi.org/10.1177/19433875211053760
Chicago/Turabian StyleTipirneni, Kiranya E., Amanda Gemmiti, Mark A. Arnold, and Amar Suryadevara. 2022. "Facial Trauma During the COVID-19 Pandemic" Craniomaxillofacial Trauma & Reconstruction 15, no. 4: 318-324. https://doi.org/10.1177/19433875211053760
APA StyleTipirneni, K. E., Gemmiti, A., Arnold, M. A., & Suryadevara, A. (2022). Facial Trauma During the COVID-19 Pandemic. Craniomaxillofacial Trauma & Reconstruction, 15(4), 318-324. https://doi.org/10.1177/19433875211053760
