Impact of coronavirus (COVID‐19) on otolaryngologic surgery: Brief commentary

3.1. Airway management and tracheotomy

Patients presenting with acute airway obstruction should be managed as if they are COVID‐19 positive because diagnostic testing is not feasible in an emergent clinical situation. All clinical personnel should wear enhanced PPE. The use of high‐flow nasal cannula is contraindicated in patients with unknown, suspected, or positive COVID‐19 status due to high risk of virus aerosolization.24, 25 Extreme caution should be utilized when performing awake fiberoptic intubation due to instrumentation of the nasopharynx and the potential for aerosol generation, however intubation via any means is preferable to emergent tracheotomy. For mask ventilation, a high‐efficiency hydrophobic filter should be placed between the face mask and breathing circuit or reservoir bag, the patient should be pre‐oxygenated while breathing spontaneously whenever possible, and rapid sequence intubation techniques should be used to minimize viral particle aerosolization. ²⁵ When available, video laryngoscopes should be used to maximize intubation success rate and disposable laryngoscopes to minimize infectious spread.24, 25

To minimize intubation time and exposure to the oropharynx, the 2015 Difficult Airway Society Guidelines ²⁶ should be followed with the exception that intubation should be performed only by the most senior practitioner available using enhanced PPE. Second‐generation laryngeal mask airways should be used, if indicated, as these provide an improved seal compared to first‐generation devices. ²⁵ If a “can't intubate, can't oxygenate scenario” is declared, emergent extracorporeal membrane oxygenation (ECMO) may be preferred over emergent surgical airway to reduce the risk of virus aerosolization, though this may not be readily available. Indications for primary emergent tracheotomy include obstructive laryngeal lesions, severe trismus precluding the ability to perform direct laryngoscopy, massive oropharyngeal bleeding, other conditions precluding intubation, and other emergent conditions anticipated to require long‐term means to secure the airway where ECMO would not be appropriate.

When caring for a patient with unknown, suspected, or positive COVID‐19 status, clinical staff should be limited to essential personnel (ie, senior attending anesthesiologist, experienced attending surgeon, senior surgical resident/clinical fellow, surgical technologist, and registered nurse) fully equipped with enhanced PPE in a negative pressure operating room with HEPA filtration. ²⁴ Technical pearls to consider when performing tracheotomy in a patient with unknown, suspected, or positive COVID‐19 status include avoiding electrocautery usage to minimize aerosolization of viral particles, advancing the endotracheal tube prior to incising the anterior tracheal wall to prevent cuff rupture and maintain a closed circuit, and holding ventilation until a non‐fenestrated tracheotomy tube has been placed within the tracheal lumen and the cuff has been inflated. Further details regarding safe tracheotomy have been outlined by Wei et al and Harrison et al.27, 28

Postoperatively, the tracheotomy tube should not be changed or manipulated until the COVID‐19 status of the patient has been determined. Routine tracheotomy tube care as delineated by ENT‐UK should include maintenance of a closed circuit, exclusively in‐line suctioning, frequent cuff leak checks, and avoiding humidification. ²⁸ At this time elective tracheotomy is contraindicated for patients with unknown COVID‐19 status and should only be performed once COVID‐19 status has been determined with appropriate quarantine and the merits of tracheotomy are discussed as it is a high‐risk, aerosol‐generating procedure. ²⁹ Likewise, percutaneous dilation tracheotomy is contraindicated in patients with unknown, suspected, or positive COVID‐19 status. This contraindication is due to the need for simultaneous bronchoscopy (itself a high‐risk procedure), and longer period of exposure to an open tracheostomy site during serial dilation resulting in increased risk of virus aerosolization.

There is limited information regarding management of patients with tracheotomy no longer requiring ventilator support in the setting of COVID‐19. The use of filters over the open tracheotomy, such as humidification‐moisture exchangers (HMEs), preferably with an integrated antimicrobial filter, may be beneficial and reduce aerosolization. Alternatively, Chan et al describe using a closed circuit system identical to that used for a mechanical ventilator for all patients with tracheotomy, including those not requiring ventilator support. ⁴ Ultimately, the choice of device may be dependent on the COVID‐19 status of the individual patient and the ability to provide appropriate isolation to minimize the spread of aerosols.

3.2. Endonasal surgery

At this time, several national and regional otolaryngology organizations have released statements regarding endonasal and nasopharyngeal surgery (functional endoscopic sinus surgery, endonasal skull base surgery, adenoidectomy, etc.) and the risk of COVID‐19 spread.30, 31 In a preliminary study of 17 symptomatic patients with COVID‐19, high viral loads were detected soon after symptom onset, with higher viral loads in the nasopharynx compared to the oropharynx. ²² Increasing reports of hyposmia and anosmia as cardinal symptoms of COVID‐19 further suggest that the virus is highly active in the nasal cavity. ¹¹ Aerosolized viral particles are viable for up to 3 hours and may be disseminated by sinus instrumentation such as balloons, drills, microdebriders, and suction electrocautery.7, 32 Due to the high risk of occupational COVID‐19 exposure during endonasal surgery, elective sinonasal cases should be postponed until the COVID‐19 pandemic has been controlled. Urgent endonasal surgery cases mandate preoperative COVID‐19 testing 48 hours prior to the procedure with the patient remaining in strict quarantine until the day of surgery. When possible, rapid COVID‐19 testing should be repeated on the day of surgery. For patients found to be negative for COVID‐19, appropriate PPE should be used by all operating room staff. However, consideration may be given to the use of enhanced PPE given the high risk for occupational exposure during endonasal procedures and the possibility of false‐negative test results. Consideration should be given to postponing surgery for patients with COVID‐19‐positive. Finally, emergent sinonasal cases require enhanced PPE, with a strong preference for the use of PAPR, for all operating room staff until further information is available. ³²

3.3. Craniomaxillofacial trauma and urgent otolaryngologic conditions

As emergency departments across the United States continue to serve patients with urgent medical needs, individuals who present with facial trauma, uncontrolled epistaxis, abscesses, and other conditions will require urgent management by otolaryngologists, including bedside procedures or operative intervention. Given our current understanding of COVID‐19, the nasopharynx and nasal cavity harbor the highest viral load and protective precautions must be enforced with addressing injuries or urgent conditions in this location. We recommend the use of enhanced PPE for providers performing bedside procedures on patients with unknown, suspected, or positive COVID‐19 status including repair of facial lacerations, management of animal bite wounds, control of epistaxis, peritonsillar abscess drainage, or any other condition requiring invasive examination or instrumentation of the oral cavity, oropharynx, nasal cavity, or nasopharynx. Enhanced PPE is indicated due to the increased risk aerosolization of saliva and nasal secretions in this setting. Patients presenting with operative facial fractures (eg, orbital, mandibular, nasal, Le Fort pattern fractures, etc.), should undergo preoperative COVID‐19 diagnostic testing 48 hours prior to proceeding with elective surgical intervention with the patient kept in strict quarantine until the day of surgery. When possible, rapid COVID‐19 testing should be repeated on the day of surgery. In scenarios warranting emergent surgical intervention (eg, rectus muscle entrapment, retrobulbar hemorrhage, flail mandible fractures, etc.) all operating room staff should utilize enhanced PPE as the COVID‐19 status for these patients is unknown and should be presumed positive.

3.4. Head and neck oncology

At tertiary referral centers, many patients with head and neck cancer have traditionally traveled far distances for oncologic care. In the setting of the COVID‐19 pandemic, concerns exist for exposing patients to the disease in the hospital setting. Retroactive to January 27, 2020, the federal government expanded telemedicine services under Medicare and Medicaid with HIPAA flexibilities. ³³ This provides the ability to discuss pathology results and radiographic imaging findings with patients without direct contact, as well as continue important longitudinal cancer care. The more difficult decisions include delay of treatment for patients who are currently undergoing or starting chemoradiation. For patients with solid tumors, radiant adjuvant therapy with or without curative intent should proceed, despite the threat of COVID‐19 infection during treatment. ³⁴ As outlined in the CMS Adult Elective Surgery and Procedures Recommendations, cancer surgery is categorized as a tier 3a procedure and should not be postponed. ¹⁵ Although oncologic procedures may continue as scheduled with preoperative COVID‐19 diagnostic testing and quarantine, operative intervention requires prioritization; for example, definitive radiation therapy for a T1/T2 laryngeal carcinoma instead of a high‐risk microscopic laryngeal resection using CO₂/KTP laser may be appropriate for some patients during the COVID‐19 pandemic. Additional consideration may be given to patients undergoing resections requiring microvascular reconstruction due to anticipated postoperative hospitalization and use of hospital resources. Continued multidisciplinary discussions regarding all head and neck oncologic patients are essential. Similar to other otolaryngology procedures in patients with suspected or confirmed COVID‐19, enhanced PPE should be used at all times.

3.5. Nasal endoscopy and flexible fiberoptic laryngoscopy

The impact of COVID‐19 on clinical activity at an academic otolaryngology department is expected to be substantial. Over a 9‐week period during the SARS outbreak, weekly outpatient clinic visits at the Prince of Wales Hospital in Hong Kong declined by 59%, the number of operations performed dropped by 79%, the average hospital capacity rate reduced by 79%, and the daily admission rate diminished by 84%. ³⁵ Furthermore, as viral density has been shown to be the highest in the nasal cavity and nasopharynx, elective diagnostics such as flexible laryngoscopy and nasal endoscopy should not be routinely performed in the office or inpatient setting. If endoscopic evaluation is required in the urgent or emergent setting, this should be only be performed using appropriate PPE and disposable nasal pledgets for decongestion and local anesthesia. A clinical study of 1491 otolaryngology service consultations at Duke University from 2017 revealed 995 (66.7%) consultations resulted in a bedside procedure and 243 (16.3%) consultations required operative intervention. In comparison to the emergency department, inpatient services more frequently requested consultation for airway evaluation (362 [47.3%] vs 143 [19.7%]) and nasal evaluation (79 [10.3%] vs 18 [2.5%]). During these evaluations, flexible fiberoptic laryngoscopy (554 [55.7%]) and rigid nasal endoscopy (109 [11.0%]) were two of the most commonly performed bedside procedures. In the operating room, direct laryngoscopy (47 [11.3%]), bronchoscopy (47 [11.3%]), and tracheotomy (41 [9.9%]) were three of the most commonly performed operations. ³⁶ Continued demand for these critical services during the COVID‐19 pandemic must be carefully evaluated by otolaryngologists on a case by case basis in light of CMS and AAO‐HNS recommendations against elective endoscopy to mitigate risk of infectious spread and ensure patients who require such evaluations are carefully assessed using the proper precautions and appropriate PPE.