Otolaryngology procedure protocols for limiting COVID-19 transmission

This paper discusses COVID-19 and transmission during otolaryngology procedures based on evidence from Wuhan and strategies deployed at Stanford University Hospital.

Study design

This paper provides a comprehensive evidence-based review of COVID-19 demographics, presentation and infection control as they stand. It primarily focuses on otolaryngologists who are at a higher risk due to their close contact with mucus membranes of the upper respiratory tract and are among the most affected healthcare workers in Wuhan. The authors provide preliminary guidance on avoiding nosocomial transmission of COVID-19 based on practices implemented in China and other countries, and practical strategies deployed at Stanford University.

Outcomes

The authors describe the many mechanisms for possible aerosolization of mucus and virus, including any interaction of the airway mucus layer with high-speed flow via powered instrumentation such as debriders and drills. Some of the practice recommendations include:

• The nasal cavity and pharynx mucosal should be well anesthetized to reduce the cough and sneeze reflexes
• Gel type topical anesthetics rather than sprays should be used to minimize aerosol production
• The smallest diameter scope to reduce the likelihood of coughing and sneezing.

 In addition, they offer other considerations for otolaryngologists (e.g., procedural considerations, intubation and airway manipulation, role of tracheostomy) and management of special patient populations such as children and people with existing tracheostomies.

Limitations

The data is a preliminary review of evidence gathered from society and university guidelines as well as early reports and anecdotal information. As more studies are done these preliminary guidelines and recommendations will evolve. However, this method of data gathering is useful to protect the otolaryngologist and ophthalmologist during the height of the COVID-19 crisis.

Clinical significance

This paper reviews information on COVID-19 management relevant to otolaryngologists, however this is pertinent to oculofacial plastic surgeons as there are many areas of overlap in our practices and procedures. Of particular interest are the procedural considerations and precautions for surgeries that pose a high risk of aerosolization of viral particles, including procedures where significant nasal or sinus mucosal manipulation is anticipated. Pertinent to the oculofacial plastic surgeon, this would include endoscopic or external DCR, endoscopic or external decompression, complex nasolacrimal surgery or other sino-orbital procedures. Additionally, this article provides support for PPE choice depending on whether COVID-19 PCR status is unknown or known. This preliminary evidence can support oculofacial plastic surgeons to implement changes within their hospital systems where appropriate.