Current Otorhinolaryngology COVID-19 Literature Review

Otolaryngologic Procedures and COVID-19
As the COVID-19 pandemic caused by the novel coronavirus SARS-CoV-2 continues to escalate in the United States and elsewhere, we are faced with developing methods to provide care to our patients while also keeping them, our co-workers, and ourselves safe. Much of the information available to date is anecdotal and is evolving as the pandemic continues, however, it would be imprudent not to use what data is available and learn from the experiences of countries such as China and Italy where the virus has been spreading longer.

Healthcare workers are at increased risk of exposure to and infection by the virus, and there is mounting evidence that otolaryngologists are one of the highest risk categories among doctors and healthcare workers.1,2 SARS-CoV-2 can be detected on swabs from the throat and particularly the nose of both symptomatic and asymptomatic patients3, and researchers have shown stability of the virus on surfaces for up to 72 hours and remaining in the air for at least 3 hours if not longer.4 It has also been found in the lung and oropharynx.5 Procedures that involve instrumentation of the upper airway including the nose, oral cavity, pharynx, larynx, and trachea have the risk of aerosolizing particles.5 When aerosolized, the virus has been demonstrated to spread and contaminate multiple surfaces including that air exhaust vents that circulate air.6,7 In one case of endoscopic transnasal pituitary surgery in China, all 14 individuals who entered the operating room during the procedure later became infected, highlighting the potentially high infectivity associated with upper airway procedures, potentially owing to a higher viral load experienced in this type of exposure compared to a community exposure.1

If we compare the Covid-19 (SARS-CoV-2) nosocomial data to that of the SARS epidemic (SARS-CoV-1) of 2003, we saw that over 20% of those infected were medical personnel.8 For Covid-19, data from Lombardy (Italy) shows that 10% of all physicians and nurses tested positive in early March.9 In Wuhan, a case series of 138 patients at an academic hospital showed an infection rate of 29% of medical staff.10 Indeed, thousands of doctors have been infected in Wuhan and otolaryngologists have been reported to infected at higher rates than others.11

We do, however, still have an obligation to perform urgent and emergent cases in the interest of our patients for life-threatening situations or diseases, such as cancer, where failure to act will lead to high morbidity or eventual mortality. It is known that cancer patients are susceptible to infection – early data from China showed that among patients with Covid-19, there is a ~3 fold higher proportion with cancer than the incidence of cancer in the general population and that these patients did poorer in disease recovery.12 The CMS recently developed recommendations to assist with determining which cases should be deferred and which should not.13 We are struck, then, with finding a balance between providing essential treatment to our patients who need it while not placing ourselves and our hospital teams at unnecessary risk.

Although initial reports of asymptomatic carriers from Chinese data were low, it appears that up to 1/3 of patients who test positive may be asymptomatic.1,14,15 At this point, the majority of patients being tested in the US are symptomatic, meaning that there is likely a potentially large subset of sub-clinically infected individuals who may wind up on our operating room tables, placing our surgical teams at risk. Asymptomatic patients have been found to spread Covid-19 with high efficiency even when providers use conventional protection (face masks).1 There are reports of young healthy patients infected with Covid-19 being completely asymptomatic but still demonstrating visible ground-glass changes on radiography1,16 – suggesting that instrumenting the airway of an otherwise young, healthy and asymptomatic patient could aerosolize virus. In addition, while facemasks may protect non-respiratory mucosal surface, there is evidence that the virus can spread to health care workers through non-respiratory mucosal surfaces which was exemplified in the report of one worker exhibiting conjunctivitis before progressing to catarrhal symptoms and fever.1,17

Many centers have moved towards pre-operative screening of asymptomatic patients 48 hours prior to undergoing any aerosol generating procedure (airway procedures including laryngoscopy, nasal or sinus surgery, head and neck mucosal surgery, mastoid surgery) and even routine intubation – so all patients undergoing ay procedure under general anesthesia should be screened.6,18–20 Indeed, the American Academy of Otolaryngology – Head & Neck Surgery developed a statement in response to the CMS guidelines, stating “unless emergent, surgical procedures should only be undertaken after ascertaining the COVID-19 status and then performed using either

N95 respirator masks with either goggles or a faceshield or PAPR.”21 Likewise the CDC and WHO recommend that health care workers wear a gown, gloves, goggles and a medical mask that protects against droplet-based transmission, and that once supply chains are restored the CDC recommends N95 masks specifically.22,23 The Chinese Society of Anesthesiology, The National University Health System of Singapore and the Stanford University guidelines however recommend using PAPR hood when available for high risk procedures including intubations.24,25

Of note, respiratory viruses have been found to contaminate 10.2% of the outer surfaces of medical masks even in a non-outbreak context26, we can therefore imagine viable virus particles on the mask surface that could contaminate the user when reapplying the mask if it is removed to be reused later (especially given the known 3 day surface stability4). The Dutch National Institute for Public Health carried out a study showing that sterilization of marks can successfully be performed with aerosolized hydrogen peroxide without deforming the mask or affecting its fit,27 which could be a better method of mask reuse.

1. Chang D, Xu H, Rebaza A, Sharma L, Dela Cruz CS. Protecting health-care workers from subclinical coronavirus infection. Lancet Respir Med. 2020;8(3):e13. doi:10.1016/S2213-2600(20)30066-7

2. 2. RT. Why Surgeons Don’t Want to Operate Right Now. Bloomberg News. Published March 24, 2020.

3. 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(12):1177-1179. doi:10.1056/NEJMc2001737

4. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. March 2020. doi:10.1056/NEJMc2004973

5. Lu D, Wang H, Yu R, Yang H, Zhao Y. Integrated infection control strategy to minimize nosocomial infection of coronavirus disease 2019 among ENT healthcare workers. J Hosp Infect. February 2020. doi:10.1016/j.jhin.2020.02.018

6. Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist – preliminary evidence-based review. Laryngoscope. March 2020. doi:10.1002/lary.28672

7. Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. March 2020. doi:10.1001/jama.2020.3227

8. Ho P-L, Tang X-P, Seto W-H. SARS: hospital infection control and admission strategies. Respirology. 2003;8 Suppl:S41-45. doi:10.1046/j.1440-1843.2003.00523.x

9. Thomas-Rüddel D, Winning J, Dickmann P, et al. Coronavirus disease 2019 (COVID-19): update for anesthesiologists and intensivists March 2020. Anaesthesist. March 2020. doi:10.1007/s00101-020-00760-3

10. Wang D, Hu B, Hu C, et al. Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. February 2020. doi:10.1001/jama.2020.1585

11. Europe’s Doctors Repeat Errors Made in Wuhan, China Medics Say. Bloomberg News. March 17, 2020.

12. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020;21(3):335-337. doi:10.1016/S1470-2045(20)30096-6

13. CMS Adult Elective Surgery and Procedures Recommendations. Published March 18, 2020.

14. Nishiura H, Kobayashi T, Suzuki A, et al. Estimation of the asymptomatic ratio of novel coronavirus infections (COVID-19). Int J Infect Dis. March 2020. doi:10.1016/j.ijid.2020.03.020

15. 7. MJ Lew L, Jeong-ho L. A third of coronavirus cases may be ‘silent carriers,’ classified Chinese data suggests. South China Morning Post. Published March 22, 2020.

16. Chan JF-W, Yuan S, Kok K-H, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet. 2020;395(10223):514-523. doi:10.1016/S0140-6736(20)30154-9

17. Alice Yan. Chinese expert who came down with Wuhan coronavirus after saying it was controllable thinks he was infected through his eyes. South China Morning Post. Published January 23, 2020.

18. Guidance for Health Care Workers Performing Aerosol Generating Medical Procedures during the COVID-19 Pandemic. CSO-HNS Executive Committee. March 26, 2020.

19. Guidance for ENT surgeons during the COVID-19 pandemic. Australian Society of Otolaryngology. March 20, 2020.

20. Otolaryngologists May Contract COVID-19 During Surgery. ENT Today: Triologic Society. Published March 20, 2020.

21. AAO-HNS Responds to CMS Statement on Adult Elective Surgery and Procedures Recommendations. American Academy of Otolaryngology – Head & Neck Surgery. Published March 26, 2020.

22. Rational Use of Personal Protective Equipment for Coronavirus Disease 2019 (COVID-19). World Health Organization. 2020.1-eng.pdf. Published 2020.

23. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Centers for Disease Control. 2020. recommendations.html.

24. Zuo M, Huang Y, Ma W, et al. Expert Recommendations for Tracheal Intubation in Critically ill Patients with Noval Coronavirus Disease 2019. cmsj. 2020;0(0):0. doi:10.24920/003724

25. Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anesth/J Can Anesth. March 2020. doi:10.1007/s12630-020-01617-4

26. Chughtai AA, Stelzer-Braid S, Rawlinson W, et al. Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers. BMC Infect Dis. 2019;19(1):491. doi:10.1186/s12879-019-4109-x

27. Reuse of FFP2 masks. Dutch National Institute for Public Health and the Environment. Published March 18, 2020.

979 thoughts

  1. Pingback: Vratar
  2. Pingback: Cherkassy 2020
  3. Pingback: moskva-psiholog
  4. Pingback:
  5. Pingback: 323
  6. Pingback: 525
  7. Pingback: dom2-ru
  8. Pingback: Tenet Online
  9. Pingback: psy psy psy psy
  10. Pingback:
  11. Pingback: Viagra 50 mg usa
  12. Pingback: Cialis 40 mg uk
  13. Pingback:
  14. Pingback: Cialis 20 mg price
  15. Pingback: Cialis 10mg usa
  16. Pingback: propecia 1mg cheap
  17. Pingback: buy lexapro 5 mg
  18. Pingback: cheap actos 15mg
  19. Pingback: CFOSPUK
  20. Pingback: MAMprEj
  21. Pingback: fgu0ygW
  22. Pingback: amaryl 2mg online
  23. Pingback: arava 10 mg coupon
  24. Pingback:
  25. Pingback: aricept 10mg uk
  26. Pingback: akmeologiya
  27. Pingback: dizain cheloveka
  28. Pingback: human-design-hd
  29. Pingback: cardizem nz
  30. Pingback: ceftin pills
  31. Pingback: celebrex cost
  32. Pingback: best casino online
  33. Pingback: casino world
  34. Pingback: slot machines
  35. Pingback: slots real money
  36. Pingback: best online casino
  37. Pingback: slot machine games
  38. Pingback: generic cialis
  39. Pingback: cialis 20mg pills
  40. Pingback: cialis online
  41. Pingback: cialis 20mg pills
  42. Pingback: safe car insurance
  43. Pingback: quick loans loans
  44. Pingback: tsoy
  45. Pingback: 5mg cialis
  46. Pingback: cbd oil florida
  47. Pingback: 44548
  48. Pingback: 44549
  49. Pingback: hod-korolevy-2020
  50. Pingback: buying essays
  51. Pingback: HD
  52. Pingback: assignments help
  53. Pingback: 158444
  54. Pingback: clozaril 50 mg usa
  55. Pingback: compazine 5mg cost
  56. Pingback: 38QvPmk
  57. Pingback: matrica-film
  58. Pingback: usa cialis online
  59. Pingback: cozaar cheap
  60. Pingback: order crestor 5mg
  61. Pingback: buy viagra dubai
  62. Pingback: order dapsone caps
  63. Pingback: Human design
  64. Pingback: ddavp otc
  65. Pingback: diamox purchase
  66. Pingback: differin usa
  67. Pingback: diltiazem 30mg uk
  68. Pingback: buy dramamine 50mg
  69. Pingback: 1444
  70. Pingback: etodolac 400mg otc
  71. Pingback: hyzaar 12,5 mg nz
  72. Pingback: imdur cost
  73. Pingback: cialis 20mg
  74. Pingback: cialis for sale
  75. Pingback: daily cialis
  76. Pingback: imitrex 25 mg nz
  77. Pingback: cialis cost
  78. Pingback: imodium 2mg prices
  79. Pingback: go to my blog
  80. Pingback: canadian viagra
  81. Pingback: lopid nz
  82. Pingback: lopressor pharmacy
  83. Pingback: micardis cheap
  84. Pingback: pharmacy express
  85. Pingback:
  86. Pingback: 232dfsad
  87. Pingback: pharmacy intern
  88. Pingback: viagra
  89. Pingback: prevacid generic
  90. Pingback: buy provigil 200mg
  91. Pingback: order pulmicort
  92. Pingback: pyridium usa
  93. Pingback: reglan purchase
  94. Pingback: join vk
  95. Pingback: vk login
  96. Pingback: revatio uk
  97. Pingback: rogaine 5% tablet
  98. Pingback: tricor tablet
  99. Pingback: voltaren price
  100. Pingback: wellbutrin uk
  101. Pingback: zanaflex tablet
  102. Pingback: helpful hints
  103. Pingback: buy zovirax 400mg
  104. Pingback: zyprexa cost
  105. Pingback: zyvox price
  106. Pingback: sildenafil price
  107. Pingback: tadalafil 20mg uk
  108. Pingback: svaty—7—sezon
  109. Pingback: svaty 7 sezon
  110. Pingback: svaty 7
  111. Pingback: order glimepiride
  112. Pingback: donepezil canada
  113. Pingback: buspirone coupon
  114. Pingback: clonidine cheap
  115. Pingback: clindamycin cost
  116. Pingback: warfarin cheap
  117. Pingback: trazodone online
  118. Pingback: tolterodine cheap
  119. Pingback: safe viagra online
  120. Pingback: phenytoin pharmacy
  121. Pingback: oxybutyninmg uk
  122. Pingback: permethrin cheap
  123. Pingback: tik tok
  124. Pingback: zzdkqfwm
  125. Pingback: glipizide pills
  126. Pingback: køb cialis dk
  127. Pingback: loperamide canada
  128. Pingback: cialis walmart
  129. Pingback: buy female viagra
  130. Pingback: cialis soft tablet
  131. Pingback: buy propranolol
  132. Pingback: buy cialis toronto
  133. Pingback: essay on the help
  134. Pingback: clubhouse invite
  135. Pingback: clotrimazole price
  136. Pingback: img
  137. Pingback: img1
  138. Pingback: doxycycline staph
  139. Pingback: clomid round 2
  140. Pingback: priligy game
  141. Pingback: dosing synthroid
  142. Pingback: sat essay help
  143. Pingback: thesis statistics
  144. Pingback: 666
  145. Pingback: splitting cialis
  146. Pingback: neurontin warning
  147. Pingback: generic paxil cr
  148. Pingback: plaquenil lyme
  149. Pingback: The Revenant
  150. Pingback: tadalafil wiki
  151. Pingback:
  152. Pingback: 2021
  153. Pingback: celebrex vs motrin
  154. Pingback: cymbalta ssri
  155. Pingback: vardenafil 75 mg
  156. Pingback: viagra gel price
  157. Pingback: riley reid viagra
  158. Pingback: D4
  159. Pingback: viagra 100mg uk
  160. Pingback: cialis otc months
  161. Pingback: tadalafil otc usa
  162. Pingback: 777
  163. Pingback: cialis otc us
  164. Pingback: acheter viagra 200
  165. Pingback: cialis prn mexico
  166. Pingback: best ed pills
  167. Pingback: link
  168. Pingback: buy cialis now
  169. Pingback: Zakhar Berkut
  170. Pingback: 4569987
  171. Pingback: cialis sale 20mg
  172. Pingback: buy toronto
  173. Pingback: news news news
  174. Pingback: psy
  175. Pingback: psy2022
  176. Pingback: projectio-freid
  177. Pingback: kerja viagra
  178. Pingback: Tinderentrar.Com
  179. Pingback:
  180. Pingback: topvideos
  181. Pingback: video
  182. Pingback: zestoretic generic
  183. Pingback: Ukrainskie-serialy
  184. Pingback: site
  185. Pingback: sa free dating
  186. Pingback: lexapro and cialis
  187. Pingback: cialis timing
  188. Pingback: top
  189. Pingback: pharmacy orlando
  190. Pingback: med rx pharmacy
  191. Pingback: cialis 5mg tablet
  192. Pingback: virectin vs viagra
  193. Pingback: generic ed pills
  194. Pingback: ed pills
  195. Pingback: natural viagra gnc
  196. Pingback: viagra cost
  197. Pingback: viagra discount
  198. Pingback: cialis daily pill
  199. Pingback: cialis cheap
  200. Pingback:
  201. Pingback: chelovek-iz-90-h
  202. Pingback:
  203. Pingback: meloxicam 15mg
  204. Pingback: cialis 60mg
  205. Pingback: prednisone 20mg
  206. Pingback: amitriptyline 25mg
  207. Pingback: generic cymbalta
  208. Pingback: buspar withdrawal
  209. Pingback: citalopram 10 mg
  210. Pingback: tizanidine hcl 4mg
  211. Pingback: bupropion price
  212. Pingback: clonidine generic
  213. Pingback: ed meds online
  214. Pingback: bender na4alo 2021
  215. Pingback: blogery_i_dorogi
  216. Pingback: cialis 800mg black
  217. Pingback: cialis capsule
  218. Pingback: levitra soft tabs
  219. Pingback: cause of ed
  220. Pingback: acyclovir cream
  221. Pingback: keflex generic
  222. Pingback: cialis 100mg uk
  223. Pingback: tadalafil 40 mg
  224. Pingback: viagra price
  225. Pingback: chernaya vodova
  226. Pingback: 66181
  227. Pingback: fucking on viagra
  228. Pingback: viagra 100mg
  229. Pingback: levitra discounts
  230. Pingback: Porno
  231. Pingback: vechernyy urgant
  232. Pingback: ukraine
  233. Pingback: doxycycline cost
  234. Pingback: lasix for dogs
  235. Pingback: xenical pills uk
  236. Pingback: proscar medication
  237. Pingback: bimatoprost 3ml
  238. Pingback: cialis 20mg usa
  239. Pingback: A3ixW7AS
  240. Pingback: domperidone men
  241. Pingback: nolvadex prolactin
  242. Pingback: canadianmed cialis
  243. Pingback: walmart cialis
  244. Pingback: cvs cialis cost
  245. Pingback: tadalafil 10 mg
  246. Pingback: women on viagra
  247. Pingback: canada viagra cost
  248. Pingback: KremlinTeam
  249. Pingback:
  250. Pingback:
  251. Pingback:
  252. Pingback:
  253. Pingback: Suicide Squad 2
  254. Pingback: psiholog
  255. Pingback: care rx pharmacy
  256. Pingback: viagra for men
  257. Pingback:
  258. Pingback: ivermectin 9 mg
  259. Pingback: ed pills cheap
  260. Pingback: cialis canadian
  261. Pingback: norvasc benazepril
  262. Pingback: walmart stromectol
  263. Pingback: prilosec 40 mg otc
  264. Pingback: effexor vs lexapro
  265. Pingback: cymbalta overdose
  266. Pingback: lipitor action
  267. Pingback: best pills for ed
  268. Pingback: cialis generic
  269. Pingback: buy cialis tablets
  270. Pingback: ivermectin liquid
  271. Pingback: Duna 2021
  272. Pingback: 1
  273. Pingback: amoxiclav tablet
  274. Pingback: clomid pills
  275. Pingback: propecia proscar
  276. Pingback: prednisone on line
  277. Pingback: chewing cialis
  278. Pingback: review of cialis
  279. Pingback: treating ed
  280. Pingback: dapoxetine fake
  281. Pingback: tamoxifenworld
  282. Pingback: clomid 50mg
  283. Pingback: prednisone 20
  284. Pingback: buy ivermectin nz
  285. Pingback: azithromycin otc
  286. Pingback: ivermectin tablet
  287. Pingback: canada ed drugs
  288. Pingback: ivermectin oral
  289. Pingback: generic amoxil
  290. Pingback: buy lasix on line
  291. Pingback: cheap viagra
  292. Pingback: neurontin 204
  293. Pingback: cost of priligy
  294. Pingback: ivermectin 15 mg
  295. Pingback:
  296. Pingback: azithromycin pills
  297. Pingback: viagra dosage
  298. Pingback: ivermectin 1
  299. Pingback: deltasone 10 mg
  300. Pingback: albuterol 4mg
  301. Pingback: cialis 200mg pills
  302. Pingback: sildenafil uses
  303. Pingback: stromectol uk
  304. Pingback: buy ivermectin uk
  305. Pingback: cialis pills uk
  306. Pingback:
  307. Pingback: ne-smotrite-naverx
  308. Pingback: best otc ed pills
  309. Pingback: arrogant
  310. Pingback: Dead-Inside
  311. Pingback: tadalafil alcohol
  312. Pingback: ivermectin 2ml
  313. Pingback: sildenafil 25 mg
  314. Pingback: ivermectin 2mg
  315. Pingback: pain relief
  316. Pingback: viagra connect cvs
  317. Pingback: buy ivermectin
  318. Pingback: ivermectin oral
  319. Pingback: ivermectin human
  320. Pingback: stromectol tablete
  321. Pingback: Betapace
  322. Pingback: website
  323. Pingback: flccc ivermectin
  324. Pingback: lumigan
  325. Pingback: baricitinib tablet
  326. Pingback: how to buy clomid
  327. Pingback: latisse for sale
  328. Pingback: buy clomid pills
  329. Pingback: aralen generic
  330. Pingback: Anonymous
  331. Pingback: stromectol xr
  332. Pingback: Malegra DXT
  333. Pingback: Anonymous
  334. Pingback: stromectol oral
  335. Pingback: ivermectin cost
  336. Pingback: ivermectin cost
  337. Pingback: 3rpUI4X
  338. Pingback: uliocx
  339. Pingback: 34tfA26
  340. Pingback: 3J6w3bD
  341. Pingback: 3GrvxDp
  342. Pingback: 3rrZhf7
  343. Pingback: 3L1poB8
  344. Pingback: my-vse-mertvy-2022
  345. Pingback: stromectol nz
  346. Pingback: cialis price
  347. Pingback: viagra men
  348. Pingback: tadalafil powder
  349. Pingback: sildenafil citrate
  350. Pingback: stromectol sales
  351. Pingback: cheap cialis india
  352. Pingback: tadalafil prix
  353. Pingback: cialis goodrx
  354. Pingback: covid antiviral
  355. Pingback: cialis pour femme
  356. Pingback: molnupiravir
  357. Pingback: prednisone
  358. Pingback: viagra online shop
  359. Pingback: cialis online
  360. Pingback: online casinos usa
  361. Pingback: cialis best price
  362. Pingback: cefdinir food
  363. Pingback: keflex frequency
  364. Pingback: sumycin
  365. Pingback:
  366. Pingback: 3esplanade
  367. Pingback: ivermectin 2ml
  368. Pingback: drugstore online
  369. Pingback:
  370. Pingback:
  371. Pingback:

Comments are closed.