Prevention of Transmission
Early reports from Wuhan, China noted that Otolaryngologist – Head and Neck Surgeons were at a disproportionately increased risk of infection. In the early stages, transmission during a single skull base case at a partner hospital in Wuhan resulted in widespread transmission amongst surgeons and healthcare workers, resulting in several deaths including some senior colleagues (personal communication). Recently, hospitals in British Columbia, Canada have also reported several Otolaryngologists being infected with COVID-19 after performing endoscopic sinus surgery before appropriate PPE guidelines were established (personal communication).
The SARS-CoV-2 viral particles have been reported to be highly concentrated within the nasal cavity, nasopharynx, and oropharynx12. Given the scope of Otolaryngology – Head and Neck Surgery, there is the concern for aerosolization of viral particles during procedures that include flexible nasopharyngolaryngoscopy, transoral examination, sinonasal surgery, airway surgery, and major head and neck surgery13.
The use of PPE is paramount given that head and neck procedures and examinations are performed on the upper aerodigestive tract, where high viral loads are encountered12. Stemming from the Wuhan experience in combating COVID-19, specific recommendations were made with regards to workflow and PPE for Otolaryngology – Head and Neck Surgery14. National and international societies are drawing attention to this issue with groups like the Australian Society for Otolaryngology – Head and Neck Surgery, and the British Association of Otorhinolaryngology recently releasing guideline statements15,16. Recently, guidelines on proper PPE usages were also released by the Canadian Society of Otolaryngology – Head and Neck Surgery17.
While we will not repeat all guideline recommendations here, clearly a high degree of caution should be exercised when performing procedures that enter the nasal cavity, oral cavity, larynx, or pharynx. Indications for endoscopy must be made clear, as to avoid any unnecessary procedures, and to minimize exposure to head and neck surgeons. In many clinical scenarios, endoscopy can be delayed or avoided in the pandemic setting with increased reliance on history, other physical examination maneuvers, and imaging. In Wuhan, airborne precautions were taken during all head and neck examinations. To protect healthcare providers, the Canadian Society of Otolaryngology – Head and Neck Surgery has stated that airborne precautions should be taken for all aerosolizing procedures including, but not limited to, the use of N95 respirators, face shields or goggles, gloves, gowns, disposable medical caps, and shoe covers17. In cases of limited PPE, avoidance or deferral of full physical examination may be warranted.
In the setting of increasing PPE demands and dwindling medical supplies, measures have been instituted to ensure provision of essential equipment to medical personnel. In Toronto, this has included repurposing research labs and equipment such as 3D printers in order to print and manufacture PPE, such as face-shields, along with nasopharyngeal swabs for viral testing.
In a further effort to conserve PPE and minimize exposure, the number of individuals inside operating rooms have been reduced to the bare minimum required for completion of cases and additional monitoring methods have been implemented. We have restricted access to the operating room to a single entry and exit point. A nurse observes all donning and doffing of PPE while providing support and instructions to ensure high quality and compliance. Moreover, there are no trainees in the room for portions of the procedure that may lead to aerosolized exposure. For instance, if a patient is undergoing an oral cavity resection and neck dissection, the neck dissection is performed first with involvement of trainees, while the oral cavity resection is performed separately with only staff physicians in the room. As an additional measure, within the University of Toronto hospitals, we are currently saving N95 masks. Efforts have been put towards developing a process for N95 mask re-sterilization utilizing equipment similar to other centres in the US, though this is not yet needed nor standardized across Ontario18,19.