Be aware of childhood anxiety disorders in the COVID-19 era

Dear Editor,

I read with great interest the article by Sulibhavi and Isaacson entitled “TikTok Tonsils,” which reported an association between increased tonsillolithiasis outpatient visits of pediatric patients and frequent viewing of tonsillolithiasis videos on the social media application TikTok. ¹ This paper made me think that otolaryngologists should be aware of childhood anxiety disorders in the COVID-19 era. Here, I have some thoughts to share with my otolaryngology colleagues.

The COVID-19 pandemic has severely affected our lives, and there have been changes in the illnesses of patients presenting to the hospital compared to the past. The otolaryngology department is also deeply involved in these changes. Due to frequent anosmia in patients with COVID-19, there has been an increase in the number of patients presenting to the otolaryngology department, a phenomenon that has also increased the risk of cross-infection among healthcare staff. ² A clinical cross-sectional study using the identification test found that 86.1% of children patients with COVID-19 had olfactory impairment. The severity of olfactory and gustatory loss in patients with COVID-19 has been associated with depression and anxiety. ³ Therefore, children who come to the otolaryngology clinic with COVID-19-induced anosmia may present symptoms of anxiety.

As of October 2021, there are 4.55 billion social media users worldwide, equivalent to 57.6% of the total global population. ⁴ If used properly, social media may serve as a helpful tool, providing patients, clinicians, and scientists with the opportunity to disseminate and receive relevant information. ⁵ However, the quality of videos on some social media platforms is a concern, and some even provide misleading information. ⁶ As Sulibhavi and Isaacson describe, this infant was overwhelmed and came to the hospital after watching a video about tonsillolithiasis on TikTok, which also shows the anxiety of this infant. Palatine tonsils consist of roughly 15 branched and interconnected tonsillar crypts, which are bilobular and separated by intra-tonsillar cleft within the tonsils. ⁷ Tonsillolithiasis can develop in any of these structures. Therefore, patients with tonsillolithiasis with severe halitosis cannot be cured at home by themselves as taught in the TikTok video—some patients need to go to the hospital for surgery. Moreover, school closures and home quarantine have led to a significant increase in children’s screen time and physical activity during the pandemic. However, studies have revealed that the longer the screen time, the worse the mental health of children. ⁸

Because of the limitations of our specialty, otolaryngologists often overlook anxiety symptoms in children patients in routine outpatient practice. For this reason, multidisciplinary knowledge, including psychiatry, should be strengthened to identify anxiety disorders in the COVID-19 era. If necessary, we may invite a psychiatrist to provide a consultation to assist the outpatient clinic.