Skip to main content

Main menu

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

User menu

  • Log in
  • Subscribe
  • Contact Us
  • My Cart

Search

  • Advanced search
  • ERS Publications
    • European Respiratory Journal
    • ERJ Open Research
    • European Respiratory Review
    • Breathe
    • ERS Books
    • ERS publications home

Login

European Respiratory Society

Advanced Search

  • Home
  • Current issue
  • ERJ Early View
  • Past issues
  • Authors/reviewers
    • Instructions for authors
    • Submit a manuscript
    • Open access
    • COVID-19 submission information
    • Peer reviewer login
  • Alerts
  • Podcasts
  • Subscriptions

Complications of nasal and pharyngeal swabs: a relevant challenge of the COVID-19 pandemic?

Bandik Föh, Max Borsche, Alexander Balck, Stefan Taube, Jan Rupp, Christine Klein, Alexander Katalinic
European Respiratory Journal 2021 57: 2004004; DOI: 10.1183/13993003.04004-2020
Bandik Föh
1Institute of Nutritional Medicine, University of Lübeck, Lübeck, Germany
6Shared first authorship, equal contributions
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Bandik Föh
Max Borsche
2Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
6Shared first authorship, equal contributions
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alexander Balck
2Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Stefan Taube
3Institute of Virology and Cell Biology, University of Lübeck, Lübeck, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jan Rupp
4Dept of Infectious Diseases and Microbiology, University of Lübeck, Lübeck, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Christine Klein
2Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alexander Katalinic
5Institute of Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • ORCID record for Alexander Katalinic
  • Article
  • Figures & Data
  • Info & Metrics
  • PDF
Loading

Abstract

Although swab procedures during SARS-CoV-2 testing are generally safe (3 adverse events in 11 476 swab procedures; 0.026%), increased awareness of complications is necessary, considering approximately 5.1 million tests conducted worldwide daily. https://bit.ly/2J5sd96

To the Editor:

The coronavirus disease 2019 (COVID-19) pandemic comprises approximately 50 million confirmed cases and over 1.2 million deaths as of 10 November, 2020 [1], affecting healthcare systems worldwide in an unprecedented way. In the absence of effective treatments or preventive measures, all attempts to control the pandemic are based on reliable diagnostic procedures, particularly RT-PCR of upper respiratory specimens, which is considered the diagnostic gold standard [2]. A previously unimaginable number of these diagnostic procedures has been performed since the beginning of the pandemic and there is a clear trend towards further expanding the number of tests [3]. Although specimens are frequently obtained by semi-skilled temporary staff, the collection is generally considered safe. However, possible adverse events of the procedure have largely escaped systematic recording and reporting to date. A Pubmed search, performed on 10 October, 2020, using every possible combination of the search terms “complications”, “adverse events”, “adverse effects” and “nasal swab”, “oral swab”, “nasopharyngeal swab”, “oropharyngeal swab”, revealed only three publications relevant for the question of adverse events caused by pharyngeal swab procedures. The first one represents a case report describing the break of a nasal swab by triggering the swab's breakpoint mechanism during the examination of an uncooperative patient [4]. The second publication compared commercially available swabs with three-dimensional printed nasopharyngeal swabs, reporting different mild complications in several individuals, and one individual with severe epistaxis needing medical help [5]. Lastly, one case of cerebrospinal fluid leak requiring endoscopic surgical repair was reported after a nasal COVID-19 test [6]. Of note, even the second study investigated adverse events in only 176 individuals [5].

Here, we evaluated complications caused by deep nasal and oropharyngeal swabs requiring immediate medical attention in a large, representative cohort from Northern Germany and estimated the number of tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) involving swab procedures during the pandemic worldwide.

Within our population-based SARS-CoV-2 monitoring study (ELISA cohort), 11 476 deep nasal and oropharyngeal swabs were taken in 3083 individuals from May to August 2020. Swab collection followed a clinically approved protocol as performed at the University Hospital Schleswig-Holstein, Campus Lübeck, Germany, and consisted of combined deep nasal (mid-turbinate) and oropharyngeal swabs in each participant. The deep nasal swab was performed by inserting the swab 2–3 cm into one nostril (until resistance was felt at the turbinates), while gently rotating. The same swab was then inserted through the mouth and rubbed between the tonsillar pillars over the posterior oropharynx avoiding the tongue, teeth, and gums. CE-marked PROBACT Transport Swabs (Technical Service Consultants Ltd., UK) and CITOSWAB Transport Swabs (Citotest Scientific, China) were used throughout the study. Specially trained medical students performed the swabs under the on-site supervision of a medical doctor.

Adverse events were documented in a standardised manner and classified as situations requiring immediate medical diagnosis or treatment, whereas severe adverse events were considered study-related complications causing permanent damage.

We observed a total of three adverse events (0.026%, 95% CI 0.007–0.077%). In two individuals, a 53-year-old and a 55-year-old male, the swab's tip broke off. In both cases, the swab tip was not visible by inspection. While the first person had a foreign body sensation, the second person did not report any similar complaints. Both individuals were immediately transferred to an otorhinolaryngology clinic, where the swab tip was retrieved without complications by nasal endoscopy in the first individual. The swab tip was no longer detectable in the second person despite a thorough examination by an otorhinolaryngologist, suggesting that the tip had been swallowed without further complications. Third, a 29-year-old female developed a spontaneous anterior dislocation of the left temporomandibular joint when opening her mouth for the oropharyngeal swab. Exhibiting relevant pain, she was admitted to a hospital by ambulance for external jaw repositioning. Notably, no individual developed epistaxis that would have required medical care, nor were there any severe adverse events.

According to World Health Organization data, at least 645 million tests involving swab procedures have been performed since the beginning of the pandemic until 13 November, 2020. In the first half of November 2020, the total number of daily tests amounted to 5.1 million (table 1). Of note, the observed occurrence of adverse events in 0.026% of swab procedures is possibly still an underestimate, as we performed a combination of deep nasal and oropharyngeal swabs that yield comparable virus detection rates [7], but are less invasive than nasopharyngeal swabs.

View this table:
  • View inline
  • View popup
TABLE 1

Number of swab procedures for detection of severe acute respiratory syndrome coronavirus 2 until 13 November, 2020

Our results from a well-monitored, large cohort demonstrate that the combination of deep nasal and oropharyngeal swabs is generally safe. Adverse events are very rare, severe adverse events are unlikely, but they cannot be entirely ruled out. However, given the exceptionally high number of SARS-CoV-2 tests performed worldwide that involve an increasing number of healthy, asymptomatic individuals with very low a priori probabilities for acute infections [8, 9], adverse events of the diagnostic procedure require appropriate attention, as is common practice in SARS-CoV-2 drug and vaccine development.

In conclusion, we would like to encourage: 1) increased awareness for adverse events during the standard medical procedure for SARS-CoV-2 testing; 2) the provision of appropriate diagnostic and therapeutic measures in case of adverse events; and 3) further research addressing adverse events, including the need to implement appropriate informed consent in clinical as well as in research settings.

Shareable PDF

Supplementary Material

This one-page PDF can be shared freely online.

Shareable PDF ERJ-04004-2020.Shareable

Footnotes

  • Author contributions: All authors contributed to the study concept and design. B. Föh, M. Borsche, A. Balck and S. Taube contributed to the acquisition of data. B. Föh, M. Borsche, C. Klein and A. Katalinic contributed to the analysis and interpretation of data. B. Föh and M. Borsche contributed to drafting the manuscript. S. Taube, C. Klein and A. Katalinic contributed to critically revising the manuscript for important intellectual content. B. Föh and M. Borsche contributed equally. All authors read and approved the final manuscript.

  • Conflict of interest: B. Föh has nothing to disclose.

  • Conflict of interest: M. Borsche has nothing to disclose.

  • Conflict of interest: A. Balck has nothing to disclose.

  • Conflict of interest: S. Taube has nothing to disclose.

  • Conflict of interest: J. Rupp has nothing to disclose.

  • Conflict of interest: C. Klein reports personal fees from Centogene GmbH, outside the submitted work.

  • Conflict of interest: A. Katalinic reports grants from State of Schleswig-Holstein, Germany and the Federal Ministry of Education and Research, Germany, during the conduct of the study.

  • Support statement: The main study was financially supported by the State of Schleswig-Holstein, the Federal Ministry of Education and Research (BMBF), and additional crowdfunding by the University of Lübeck. B. Föh's position was supported by the German Research Foundation (IRTG 1911). Funding information for this article has been deposited with the Crossref Funder Registry.

  • Received October 29, 2020.
  • Accepted November 18, 2020.
  • Copyright ©ERS 2021.
http://creativecommons.org/licenses/by-nc/4.0/

This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0.

References

  1. ↵
    World Health Organization. Coronavirus Disease (COVID-19) Weekly Epidemiological Update November 10, 2020. www.who.int/docs/default-source/coronaviruse/situation-reports/20201110-weekly-epi-update-13.pdf?sfvrsn=24435477_15&download=true Date last updated: 10 Nov 2020. Date last accessed: 11 Nov 2020.
  2. ↵
    1. Wiersinga WJ,
    2. Rhodes A,
    3. Cheng AC, et al.
    Pathophysiology, transmission, diagnosis, and treatment of coronavirus disease 2019 (COVID-19): a review. JAMA 2020; 324: 782–793. doi:10.1001/jama.2020.12839
    OpenUrlCrossRefPubMed
  3. ↵
    Our World in Data. Coronavirus Pandemic (COVID-19) – Statistics and Research. https://ourworldindata.org/coronavirus?utm_campaign=Optimizando&utm_medium=email&utm_source=Revuenewsletter Date last updated: 20 Oct 2020. Date last accessed: 20 Oct 2020.
  4. ↵
    1. Mughal Z,
    2. Luff E,
    3. Okonkwo O, et al.
    Test, test, test – a complication of testing for coronavirus disease 2019 with nasal swabs. J Laryngol Otol 2020; 134: 646–649.
    OpenUrlCrossRefPubMed
  5. ↵
    1. Callahan CJ,
    2. Lee R,
    3. Zulauf KE, et al.
    Open development and clinical validation of multiple 3d-printed nasopharyngeal collection swabs: rapid resolution of a critical covid-19 testing bottleneck. J Clin Microbiol 2020; 58: e00876-20. doi:10.1128/JCM.00876-20
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Sullivan CB,
    2. Schwalje AT,
    3. Jensen M, et al.
    Cerebrospinal fluid leak after nasal swab testing for coronavirus disease 2019. JAMA Otolaryngol Neck Surg 2020; 146: 1179–1181.
    OpenUrl
  7. ↵
    1. LeBlanc JJ,
    2. Heinstein C,
    3. MacDonald J, et al.
    A combined oropharyngeal/nares swab is a suitable alternative to nasopharyngeal swabs for the detection of SARS-CoV-2. J Clin Virol 2020; 128: 104442. doi:10.1016/j.jcv.2020.104442
    OpenUrlCrossRefPubMed
  8. ↵
    1. Gandhi M,
    2. Yokoe DS,
    3. Havlir DV
    . Asymptomatic transmission, the Achilles’ heel of current strategies to control Covid-19. N Engl J Med 2020; 382: 2158–2160. doi:10.1056/NEJMe2009758
    OpenUrlPubMed
  9. ↵
    1. Treibel TA,
    2. Manisty C,
    3. Burton M, et al.
    COVID-19: PCR screening of asymptomatic health-care workers at London hospital. Lancet 2020; 395: 1608–1610. doi:10.1016/S0140-6736(20)31100-4
    OpenUrlCrossRefPubMed
PreviousNext
Back to top
View this article with LENS
Vol 57 Issue 4 Table of Contents
European Respiratory Journal: 57 (4)
  • Table of Contents
  • Index by author
Email

Thank you for your interest in spreading the word on European Respiratory Society .

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Complications of nasal and pharyngeal swabs: a relevant challenge of the COVID-19 pandemic?
(Your Name) has sent you a message from European Respiratory Society
(Your Name) thought you would like to see the European Respiratory Society web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Print
Citation Tools
Complications of nasal and pharyngeal swabs: a relevant challenge of the COVID-19 pandemic?
Bandik Föh, Max Borsche, Alexander Balck, Stefan Taube, Jan Rupp, Christine Klein, Alexander Katalinic
European Respiratory Journal Apr 2021, 57 (4) 2004004; DOI: 10.1183/13993003.04004-2020

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero

Share
Complications of nasal and pharyngeal swabs: a relevant challenge of the COVID-19 pandemic?
Bandik Föh, Max Borsche, Alexander Balck, Stefan Taube, Jan Rupp, Christine Klein, Alexander Katalinic
European Respiratory Journal Apr 2021, 57 (4) 2004004; DOI: 10.1183/13993003.04004-2020
del.icio.us logo Digg logo Reddit logo Technorati logo Twitter logo CiteULike logo Connotea logo Facebook logo Google logo Mendeley logo
Full Text (PDF)

Jump To

  • Article
    • Abstract
    • Shareable PDF
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • PDF
  • Tweet Widget
  • Facebook Like
  • Google Plus One

More in this TOC Section

Agora

  • D-dimer cut-offs and machine learning for ruling out pulmonary embolism
  • Sputum cell counts in COPD patients who use electronic cigarettes
  • Extracorporeal life support allows lung transplant in rapidly progressive ILD
Show more Agora

Research letters

  • D-dimer cut-offs and machine learning for ruling out pulmonary embolism
  • Sputum cell counts in COPD patients who use electronic cigarettes
  • Extracorporeal life support allows lung transplant in rapidly progressive ILD
Show more Research letters

Related Articles

Navigate

  • Home
  • Current issue
  • Archive

About the ERJ

  • Journal information
  • Editorial board
  • Reviewers
  • Press
  • Permissions and reprints
  • Advertising

The European Respiratory Society

  • Society home
  • myERS
  • Privacy policy
  • Accessibility

ERS publications

  • European Respiratory Journal
  • ERJ Open Research
  • European Respiratory Review
  • Breathe
  • ERS books online
  • ERS Bookshop

Help

  • Feedback

For authors

  • Instructions for authors
  • Publication ethics and malpractice
  • Submit a manuscript

For readers

  • Alerts
  • Subjects
  • Podcasts
  • RSS

Subscriptions

  • Accessing the ERS publications

Contact us

European Respiratory Society
442 Glossop Road
Sheffield S10 2PX
United Kingdom
Tel: +44 114 2672860
Email: journals@ersnet.org

ISSN

Print ISSN:  0903-1936
Online ISSN: 1399-3003

Copyright © 2022 by the European Respiratory Society