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.