Awake Rhinology Surgery in Response to the COVID-19 Pandemic in Europe.

BACKGROUND: European health-care systems are faced with a backlog of surgical procedures following the suspension of routine surgery during the COVID-19 crisis. Routine rhinology surgery under general anaesthetic (GA) is now faced with significant challenges which include limited theatre capacity, the negative ramifications of surgical prioritization, reduced patient throughput in secondary care, and additional personal protective equipment requirements. Delayed surgery in rhinology, particularly with regards to chronic rhinosinusitis, has previously been shown to have poorer surgical outcomes, a detrimental effect on quality of life and long-term negative health socio-economic effects. Awake rhinology surgery under local anaesthetic (LA) provides an ideal alternative to GA. It provides a means of operating on patients in a setting alternative to currently oversubscribed main theatres, by utilizing satellite facilities, while ensuring identical surgical outcomes for patients who may otherwise have been forced to wait a long time for their procedure. It also confers additional benefits in terms of shorter recovery time and hospital stay for patients. OBJECTIVES: We have developed a set of recommendations that are intended to help support clinicians and managers to better adopt LA rhinology protocols and minimize the risk to the patient and health-care professionals involved. METHODOLOGY: International roundtable forums were conducted and supplemented by individual interviews. The international board consisted of 12 rhinologists experienced in awake rhinology surgery. Feedback was analysed and shared to develop a consensus of best practice. RECOMMENDATIONS: Local and national guidelines need to be adhered to with specific focus on patient and clinician safety. When performing awake rhinology procedures in the COVID-19 recovery process, consider implementing specific safety measures and workflow practices to safeguard patients and staff and minimize the risk of infection. CONCLUSION: Awake surgery potentially provides quicker access to routine rhinology surgery in the post-COVID-19 recovery phase, ensuring patients are treated in a timely matter, thereby avoiding higher downstream costs, and improving outcomes.

Angioedema: differential diagnosis and acute management.

A clinical vignette illustrates a typical presentation of a patient seeking help for acute angioedema. Despite the risks of SARS-CoV-2 (COVID-19) exposure, it is critical to evaluate patients with acute angioedema in person, because there is always the potential for angioedema to progress to the head, neck, or lungs, which can rapidly compromise the airways and require immediate intervention to avoid potential asphyxiation. There are three mediators of angioedema, histamine, leukotriene, or bradykinin, each requiring different management. This article provides clinicians essential information for differentiating between these types of angioedema, including an overview of the underlying pathogenies of angioedema, and the subjective and objective findings that are useful in differentiating between angioedema types. The article ends with the appropriate management for each type of acute angioedema, including the medications approved by the FDA for on-demand treatment of an HAE attack.

UK Head and neck cancer surgical capacity during the second wave of the COVID-19 pandemic: Have we learned the lessons? COVIDSurg collaborative.

OBJECTIVES: The aim of this study was to evaluate the differences in surgical capacity for head and neck cancer in the UK between the first wave (March-June 2020) and the current wave (Jan-Feb 2021) of the COVID-19 pandemic. DESIGN: REDcap online-based survey of hospital capacity. SETTING: UK secondary and tertiary hospitals providing head and neck cancer surgery. PARTICIPANTS: One representative per hospital was asked to report the capacity for head and neck cancer surgery in that institution. MAIN OUTCOME MEASURES: The principal measures of interests were new patient referrals, capacity in outpatients, theatres and critical care; therapeutic compromises constituting delay to surgery, de-escalated surgery and therapeutic migration to non-surgical primary modality. RESULTS: Data were returned from approximately 95% of UK hospitals with a head and neck cancer surgery specialist service. 50% of UK head and neck cancer patients requiring surgery have significantly compromised treatments during the second wave: 28% delayed, 10% have received radiotherapy-based treatment instead of surgery, and 12% have received de-escalated surgery. Surgical capacity has been more severely constrained in the second wave (58% of pre-pandemic level) compared with the first wave (62%) despite the time to prepare. CONCLUSIONS: Some hospitals are overwhelmed by COVID-19 and unable to offer essential cancer surgery, but all have neighbouring hospitals in their region retaining good (or even normal) capacity. It is noteworthy that very few patients have been appropriately redirected away from the hospitals most constrained by their burden of COVID-19. The paucity of an effective central or regional strategic response to this evident mismatch between demand and surgical capacity is to the detriment of our head and neck cancer patients.

Early presentation of post-intubation tracheoesophageal fistula with severe tracheal stenosis in COVID-19 patient.

The current global COVID-19 pandemic is caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Currently, acquired tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. We present a case of tracheoesophageal fistula with severe tracheal stenosis following tracheal intubation in a patient with SARS-CoV-2 infection.

Profiling severe acute respiratory syndrome coronavirus 2 and its relevance to otolaryngologic examinations during the coronavirus disease 2019 pandemic.

PURPOSE OF REVIEW: The WHO announced the coronavirus disease 2019 (COVID-19) outbreak as a pandemic in February 2020 with over 15 million confirmed cases of COVID-19 globally to date. Otolaryngologists are at a high risk of contracting COVID-19 during this pandemic if there is inadequate and improper personal protective equipment provision, as we are dealing with diseases of the upper-aerodigestive tract and routinely engaged in aerosol-generating procedures. RECENT FINDINGS: This article discusses the background and transmission route for severe acute respiratory syndrome coronavirus 2, its viral load and temporal profile as well as precaution guidelines in outpatient and operative setting in otorhinolaryngology. SUMMARY: As it is evident that COVID-19 can be transmitted at presymptomatic or asymptomatic period of infections, it is essential to practice ear, nose, and throat surgery with high vigilance in a safe and up-to-standard protection level during the pandemic. This article provides a summary for guidelines and recommendations in otorhinolaryngology.

Urgent safety considerations for dermatologic surgeons in the COVID-19 pandemic.

Dermatologic surgeons are at increased risk of contracting SARS-COV-2. At time of writing, there is no published standard for the role of pre-operative testing or the use of smoke evacuators, and personal protective equipment (PPE) in dermatologic surgery. Risks and safety measures in otolaryngology, plastic surgery, and ophthalmology are discussed. In Mohs surgery, cases involving nasal or oral mucosa are highest risk for SARS-COV-2 transmission; pre-operative testing and N95 masks should be urgently prioritized for these cases. Other key safety recommendations include strict control of patient droplets and expanded pre-clinic screening. Dermatologic surgeons are encouraged to advocate for appropriate pre-operative tests, smoke evacuators, and PPE. Future directions would include national consensus guidelines with continued refinement of safety protocols.

Minimizing Contagion Risks of COVID-19 During Transoral Robotic Surgery.

In this communication, we would like to share our experience in managing TORS patients during COVID-19 pandemic. Laryngoscope, 130:2593-2594, 2020.

Uniform infection screening allowed safe head and neck surgery during the coronavirus disease 2019 pandemic in Japan.

BACKGROUND: The purpose of this study was to determine whether a uniform infection screening protocol could be used to safely perform head and neck cancer surgery during the coronavirus disease 2019 pandemic and clarify how surgical treatment changed compared with the pre-pandemic period. MATERIALS AND METHODS: During the unprecedented coronavirus disease 2019 pandemic in Tokyo, we continued providing head and neck cancer care, guided by our own uniform screening protocol. In this study, medical records of 208 patients with head and neck malignancy, who underwent surgical treatment at our hospital during the first and second wave of pandemic for each 2-month period (first wave: 30 March 2020-30 May 2020, second wave: 14 July 2020-14 September 2020) and the 2-month pre-pandemic period (30 October 2019-30 December 2020), were analysed. RESULTS: A total of 133 patients were admitted for surgical treatment and all, except six patients with emergency tracheostomy, were screened according to the protocol. As a result, all 127 patients received surgical treatment as planned, and all 1247 medical staff members involved in the surgeries were uninfected by severe acute respiratory syndrome coronavirus 2. During the first wave of pandemic, 20% reduction of head and neck surgery was requited; however, restrictions of surgery were not necessary during the second wave. Surgical procedure, length of hospitalization, postoperative complications and number of medical staff were unchanged compared with pre-pandemic period. CONCLUSION: Our data indicate that continuation of head and neck anticancer surgical treatment in an epidemic area during the coronavirus disease 2019 pandemic were safe and feasible, if adequate and strict preventive measures are vigorously and successfully carried out.

Resumption of Otolaryngology Surgical Practice in the Setting of Regionally Receding COVID-19.

The practice of otolaryngology has been drastically altered as a consequence of the ongoing coronavirus disease 2019 (COVID-19) pandemic. Geographic heterogeneity in COVID-19 burden has meant different regions have experienced the pandemic at different stages. Regional dynamics of COVID-19 incidence has dictated the available resources for the provision of surgical care. As regions navigate their own COVID-19 dynamics, illustrative examples of areas affected early by the COVID-19 pandemic may provide anticipatory guidance. In this commentary, we discuss our experience with performed and canceled surgical procedures across the various otolaryngology specialties at our institution over the course of regionally rising and falling incident COVID-19 cases.

In vitro comparison of surgical techniques in times of the SARS-CoV-2 pandemic: electrocautery generates more droplets and aerosol than laser surgery or drilling.

INTRODUCTION: Based on current knowledge, the SARS-CoV-2 is transmitted via droplet, aerosols and smear infection. Due to a confirmed high virus load in the upper respiratory tract of COVID-19 patients, there is a potential risk of infection for health care professionals when performing surgical procedures in this area. The aim of this study was the semi-quantitative comparison of ENT-typical interventions in the head and neck area with regard to particle and aerosol generation. These data can potentially contribute to a better risk assessment of aerogenic SARS-CoV-2-transmission caused by medical procedures. MATERIALS AND METHODS: As a model, a test chamber was created to examine various typical surgical interventions on porcine soft and hard tissues. Simultaneously, particle and aerosol release were recorded and semi-quantitatively evaluated time-dependently. Five typical surgical intervention techniques (mechanical stress with a passive instrument with and without suction, CO2 laser treatment, drilling and bipolar electrocoagulation) were examined and compared regarding resulting particle release. RESULTS: Neither aerosols nor particles could be detected during mechanical manipulation with and without suction. The use of laser technique showed considerable formation of aerosol. During drilling, mainly solid tissue particles were scattered into the environment (18.2 ± 15.7 particles/cm2/min). The strongest particle release was determined during electrocoagulation (77.2 ± 30.4 particles/cm2/min). The difference in particle release between electrocoagulation and drilling was significant (p < 0.05), while particle diameter was comparable. In addition, relevant amounts of aerosol were released during electrocoagulation (79.6% of the maximum flue gas emission during laser treatment). DISCUSSION: Our results demonstrated clear differences comparing surgical model interventions. In contrast to sole mechanical stress with passive instruments, all active instruments (laser, drilling and electrocoagulation) released particles and aerosols. Assuming that particle and aerosol exposure is clinically correlated to the risk of SARS-CoV-2-transmission from the patient to the physician, a potential risk for health care professionals for infection cannot be excluded. Especially electrocautery is frequently used for emergency treatment, e.g., nose bleeding. The use of this technique may, therefore, be considered particularly critical in potentially infectious patients. Alternative methods may be given preference and personal protective equipment should be used consequently.

Reusable respirators as personal protective equipment during ENT surgery.

BACKGROUND: Robust personal protective equipment is essential in preventing the transmission of coronavirus disease 2019 to head and neck surgeons who are routinely involved in aerosol generating procedures. OBJECTIVE: This paper describes the collective experience, across 3 institutes, of using a reusable half-face respirator in 72 head and neck surgery cases. METHOD: Cost analysis was performed to demonstrate the financial implications of using a reusable respirator compared to single-use filtering facepiece code 3 masks. CONCLUSION: The reusable respirator is a cost-effective alternative to disposable filtering facepiece code 3 respirators. Supplying reusable respirators to individual staff members may increase the likelihood of them having appropriate personal protective equipment during their clinical duties.

Pediatric Otolaryngology in the COVID-19 Era.

Although the majority of attention to the health care impact of COVID-19 has focused on adult first responders and critical care providers, the pandemic has had a profound effect on the entire health care industry, including the pediatric otolaryngology community. This article highlights the unique ramifications of COVID-19 on pediatric otolaryngology, with a focus on the immediate and potential long-term shifts in practice. Specifically, the article is divided into 3 sections (care for the patient, care for the practitioner, and care for the practice) and details the unique effects of the pandemic on the pediatric otolaryngology specialty.

Novel Use of Vitamin B2 as a Fluorescent Tracer in Aerosol and Droplet Contamination Models in Otolaryngology.

OBJECTIVE: During the COVID-19 era, a reliable method for tracing aerosols and droplets generated during otolaryngology procedures is needed to accurately assess contamination risk and to develop mitigation measures. Prior studies have not investigated the reliability of different fluorescent tracers for the purpose of studying aerosols and small droplets. Objectives include (1) comparing vitamin B2, fluorescein, and a commercial fluorescent green dye in terms of particle dispersion pattern, suspension into aerosols and small droplets, and fluorescence in aerosolized form and (2) determining the utility of vitamin B2 as a fluorescent tracer coating the aerodigestive tract mucosa in otolaryngology contamination models. METHODS: Vitamin B2, fluorescein, and a commercial fluorescent dye were aerosolized using a nebulizer and passed through the nasal cavity from the trachea in a retrograde-intubated cadaveric head. In another scenario, vitamin B2 was irrigated to coat the nasal cavity and nasopharyngeal mucosa of a cadaveric head for assessment of aerosol and droplet generation from endonasal drilling. A cascade impactor was used to collect aerosols and small droplets ≤14.1 µm based on average aerodynamic diameter, and the collection chambers were visualized under UV light. RESULTS: When vitamin B2 was nebulized, aerosols ≤5.4 µm were generated and the collected particles were fluorescent. When fluorescein and the commercial water tracer dye were nebulized, aerosols ≤8.61 µm and ≤2.08 µm respectively were generated, but the collected aerosols did not appear visibly fluorescent. Endonasal drilling in the nasopharynx coated with vitamin B2 irrigation yielded aerosols ≤3.30 µm that were fluorescent under UV light. CONCLUSION: Vitamin B2's reliability as a fluorescent tracer when suspended in aerosols and small droplets ≤14.1 µm and known mucosal safety profile make it an ideal compound compared to fluorescein and commercial water-based fluorescent dyes for use as a safe fluorescent tracer in healthcare contamination models especially with human subjects.

Survey and analysis of knowledge, attitude and practice among otolaryngologists in a state in eastern India in relation to the coronavirus disease 2019 pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic has resulted in various changes in knowledge, attitude and practice among doctors. A survey was conducted of otolaryngologists in India regarding these aspects in relation to the coronavirus disease 2019 pandemic. METHOD: Otolaryngologists from West Bengal (India) were invited to participate in an online self-administered survey. Data were collected and analysed using appropriate methods. RESULTS: Responses from 133 participants, grouped into 4 groups by their career stage, were collected and analysed. Of the participants, 36.8 per cent were directly involved in treating a known or suspected coronavirus disease 2019 patient, although 66.2 per cent considered the personal protective equipment inadequate. Ninety-four per cent indicated that their willingness to perform procedures depended on personal protective equipment availability. Of the respondents, 83.5 per cent revealed additional mental stress due to the pandemic. Of the participants, 41.4 per cent took hydroxychloroquine as coronavirus disease 2019 prophylaxis. CONCLUSION: This study provides an insight into which issues may need attention, to help ENT surgeons tackle the coronavirus disease 2019 pandemic more effectively based on analysis of responses in the survey.

Adaptations of a Tertiary Otorhinolaryngology Head and Neck Surgery Department in Singapore during the COVID-19 Outbreak.

PURPOSE: The novel coronavirus 2019 (COVID-19) outbreak which was first reported in Wuhan, China has been declared a pandemic by the World Health Organization on March 11, 2020. Otorhinolaryngologists deal intimately with pathologies of the head and neck region and upper respiratory tract and have been reported as a vulnerable group of healthcare workers who may be more susceptible to COVID-19 nosocomial infection. METHODS: In this article, we provide a comprehensive overview of the adaptations of Singapore's largest tertiary Otorhinolaryngology department during the COVID-19 outbreak. This was undertaken via an evidence-based approach. The relevant medical literature and evidence underlying our adaptations are highlighted. RESULTS: A four-pronged strategy including (1) personnel segregation, (2) triaging and decantment, (3) use of personal protective equipment and (4) changes in clinical practice was employed. The strategy was bolstered by drawing upon a collective learnt experience from the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak. CONCLUSION: A rigorous framework which can preserve operationality while navigating the heightened risks during this outbreak is critical for every Otorhinolaryngology department. As the pandemic continues to evolve and more scientific reports of this disease are made available, approaches will need to be morphed.

Review of practical recommendations for otolaryngologists and head and neck surgeons during the COVID-19 pandemic.

INTRODUCTION: Otolaryngologists are at very high risk of COVID-19 infection while performing examination or surgery. Strict guidelines for these specialists have not already been provided, while currently available recommendations could presumably change in course of COVID-19 pandemic as the new data increases. OBJECTIVES: This study aimed to synthesize evidence concerning otolaryngology during COVID-19 pandemic. It presents a review of currently existing guidelines and recommendations concerning otolaryngological procedures and surgeries during COVID-19 pandemic, and provides a collective summary of all crucial information for otolaryngologists. It summarizes data concerning COVID-19 transmission, diagnosis, and clinical presentation highlighting the information significant for otolaryngologists. METHODS: The Medline and Web of Science databases were searched without time limit using terms ''COVID-19", "SARS-CoV-2" in conjunction with "head and neck surgery", "otorhinolaryngological manifestations". RESULTS: Patients in stable condition should be consulted using telemedicine options. Only emergency consultations and procedures should be performed during COVID-19 pandemic. Mucosa-involving otolaryngologic procedures are considered high risk procedures and should be performed using enhanced PPE (N95 respirator and full face shield or powered air-purifying respirator, disposable gloves, surgical cap, gown, shoe covers). Urgent surgeries for which there is not enough time for SARS-CoV-2 screening are also considered high risk procedures. These operations should be performed in a negative pressure operating room with high-efficiency particulate air filtration. Less urgent cases should be tested for COVID-19 twice, 48 h preoperatively in 24 h interval. CONCLUSIONS: This review serves as a collection of current recommendations for otolaryngologists for how to deal with their patients during COVID-19 pandemic.

Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review.

BACKGROUND: Adequate personal protective equipment is needed to reduce the rate of transmission of COVID-19 to health care workers. Otolaryngology groups are recommending a higher level of personal protective equipment for aerosol-generating procedures than public health agencies. The objective of the review was to provide evidence that a.) demonstrates which otolaryngology procedures are aerosol-generating, and that b.) clarifies whether the higher level of PPE advocated by otolaryngology groups is justified. MAIN BODY: Health care workers in China who performed tracheotomy during the SARS-CoV-1 epidemic had 4.15 times greater odds of contracting the virus than controls who did not perform tracheotomy (95% CI 2.75-7.54). No other studies provide direct epidemiological evidence of increased aerosolized transmission of viruses during otolaryngology procedures. Experimental evidence has shown that electrocautery, advanced energy devices, open suctioning, and drilling can create aerosolized biological particles. The viral load of COVID-19 is highest in the upper aerodigestive tract, increasing the likelihood that aerosols generated during procedures of the upper aerodigestive tract of infected patients would carry viral material. Cough and normal breathing create aerosols which may increase the risk of transmission during outpatient procedures. A significant proportion of individuals infected with COVID-19 may not have symptoms, raising the likelihood of transmission of the disease to inadequately protected health care workers from patients who do not have probable or confirmed infection. Powered air purifying respirators, if used properly, provide a greater level of filtration than N95 masks and thus may reduce the risk of transmission. CONCLUSION: Direct and indirect evidence suggests that a large number of otolaryngology-head and neck surgery procedures are aerosol generating. Otolaryngologists are likely at high risk of contracting COVID-19 during aerosol generating procedures because they are likely exposed to high viral loads in patients infected with the virus. Based on the precautionary principle, even though the evidence is not definitive, adopting enhanced personal protective equipment protocols is reasonable based on the evidence. Further research is needed to clarify the risk associated with performing various procedures during the COVID-19 pandemic, and the degree to which various personal protective equipment reduces the risk.