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September 22/29, 2020

Otolaryngology–Head and Neck Surgery and COVID-19

Author Affiliations
  • 1Department of Otolaryngology–Head & Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
  • 2Editor, JAMA Otolaryngology–Head & Neck Surgery
JAMA. 2020;324(12):1145-1146. doi:10.1001/jama.2020.15779

The novel coronavirus disease 2019 (COVID-19) pandemic has had a particularly large influence on the specialty of otolaryngology–head and neck surgery. Molecular studies implicate nasal epithelial cells, specifically goblet and ciliated cells, as the entry site for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and a reservoir for dissemination within a given patient and from person to person. The development of acute loss of smell and taste was quickly recognized as one of the symptoms of COVID-19.1 Thus, otolaryngologists were placed in the front line of management and risk exposure for COVID-19. Now, reports of various acute and chronic neuropathies in patients with COVID-19 disease support the continued involvement by otolaryngologists.

As specialists of the upper airway, otolaryngologists are particularly vulnerable to transmission of SARS-CoV-2 through aerosol-generating procedures as part of their usual work in the ear, nose, and throat areas.2 Along with colleagues in emergency medicine, intensive care medicine, and anesthesiology, otolaryngologists experience high rates of exposure and complications, including death due to COVID-19.3 As a result, the practice of otolaryngology has changed substantially in response to COVID-19. The number of surgical procedures performed has decreased significantly. One of the first practice management changes in response to the pandemic was to recommend surgery only for patients deemed to have conditions for which surgery would lead to preservation of important function (ie, breathing, swallowing) or prevention of death. At an individual patient level, the determination of what set of conditions contribute to essential surgery became challenging. Some departments established strict criteria, while others convened a treatment decision-making board, much like a tumor board, to help adjudicate treatment recommendations in a fair and equitable way. New devices were developed to limit the spread of aerosols, such as a negative-pressure aerosol cover as an additional barrier to limit the spread of aerosols during tracheostomy, and a clear plastic barrier during mastoidectomy that keeps the operative team separated from aerosolized products.4,5

Outpatient practice, a large part of otolaryngology, was essentially stopped during the early months of the pandemic and has only recently resumed with major modifications in the number of patients seen, type of office-based procedures performed, utilization of personal protective equipment and mitigation of risk for staff, and conversion of many patient visits to telehealth. Many of these modifications were informed by the experience of clinicians and other health care personnel in Southeast Asia who faced similar challenges in the SARS epidemic of 2003.3 Because of concern about a high percentage of false-positive test results, otolaryngologists are often consulted at their institutions to help health care workers correctly place the nasal swab at the back of the nose to ensure adequate nasopharyngeal samples. The use of hypertonic nasal saline lavage (neti pot) with or without additives, such as corticosteroids and povidone-iodine, has been proposed to eliminate viral particles and reduce transmission of COVID-19.6

The 2 subspecialties in otolaryngology that have been most affected are rhinology and head and neck cancer.

Rhinologists spend their entire professional time examining and manipulating tissue within the nasal cavity, which is an area with known high viral load. As a result, rhinologists are at especially high risk of exposure to SARS-CoV-2. In fact, multiple reports from around the world describe high rates of transmission of virus, infection, and mortality among otolaryngologists performing endonasal endoscopic procedures in patients with COVID-19.7 Because of this concern, use of endoscopic sinus surgery and balloon sinuplasty for treatment of chronic rhinosinusitis will likely be limited to patients with the highest level of acuity or concern for complications of sinusitis. Nonsurgical treatments, such as use of topical steroids delivered via nasal lavage and biologic therapies for targeted approaches to inflammation, will likely become more common. In the outpatient setting, routine use of rigid nasal endoscopes now presents too large of a risk of viral transmission, and thus, rhinologists will rely more on history and noninvasive assessments to inform treatment decision-making.

For many patients, anosmia and dysgeusia are the presenting symptom of COVID-19. The reported frequency of taste and smell disturbance as a symptom of COVID-19 varies widely, with estimates of 65% or higher.8 Olfactory dysfunction has a tremendous adverse effect on health, safety, and quality of life. Fortunately, the sense of smell and taste seems to return within 7 to 10 days in approximately half of affected patients and by 3 months in as many as 90% of patients. Nevertheless, given the large and increasing number of patients who experienced anosmia and have recovered from COVID-19 infection, the anticipated number of people in the US with chronic taste and smell problems is unprecedented. COVID-19–associated olfactory dysfunction is on course to be an important public health problem.9 Treatment options for olfactory dysfunction are limited, and thus, there is a pressing need to identify effective treatments.

Surgical oncologists treating patients with head and neck cancer are faced with the tremendous challenges of operating in the upper respiratory and alimentary tracts and protecting themselves and other health care workers from exposure to the virus and infection. Adhering to strict safety precautions, including use of appropriate personal protective equipment, separate rooms for aerosol-generating procedures, limiting rigid and flexible endoscopic examinations, and coordination of care with the anesthesia and nursing teams, is mandatory to ensure as few health care workers are present as necessary for patient safety.10

Performing tracheotomy in a patient with COVID-19 poses unique challenges for surgeons and entire health care teams, as a large amount of aerosol-generating secretions occur during performance of the tracheotomy and during routine suctioning of the tracheostomy. When planning use of tracheostomy in a patient with COVID-19 who has prolonged ventilatory needs, there is a need to consider the timing, location, and type of tracheostomy. The timing of the tracheostomy is influenced by conflicting considerations: whether to delay the procedure to ensure that the patient will actually require prolonged respiratory support and to potentially decrease the volume of infectious aerosols as the acute phase of the infection wanes must be balanced against the benefit of earlier tracheotomy with earlier initiation of improved respiratory management. The location of performance of the tracheotomy, whether bedside in the intensive care unit or in the operating room, should be selected based on the counterbalancing effects of safety of transporting an acutely ill infectious patient from the intensive care unit to the operating room and back, presence of appropriate air filtration systems to minimize the spread of aerosolized viral particles, and other factors that will likely vary in each patient and health care institution. The type of tracheostomy (percutaneous vs open) is based on the preferences and experience of the surgical staff. There is concern that percutaneous procedures may generate more aerosolization than open procedures. A variety of modifications to standard surgical draping have been proposed to decease the spread of aerosols during intubation and performance of tracheotomy.5

Head and neck surgeons have been forced to triage patients based on urgency of their condition and likelihood of improved outcome with surgery. The pandemic has necessitated greater use of nonsurgical alternatives. In addition, there is greater utilization of watchful waiting for indolent neoplastic disease, such as well-differentiated thyroid cancer, nonsymptomatic hyperparathyroidisim, and, in older patients, parotid pleomorphic adenoma. The consequences of delays in diagnosis and treatment and use of alternative nonsurgical treatment options will be an active area of research in the future. Surveillance and survivorship clinics and management of treatment-related complications have transitioned to video-based telehealth visits. The use of virtual group visits may become more popular as a way of providing support to survivors of head and neck cancer.

The scope and practice of otolaryngology, a specialty of the upper airway, have been substantially affected by the COVID-19 pandemic. A major focus of the field has been the change in delivery of otolaryngology services in the surgical suite and outpatient setting to minimize disease transmission. Because of stringent restrictions in hospital utilization, otolaryngologists have had to triage or prioritize surgical care in new and at times uncomfortable ways. Outpatient practice has changed considerably, including reduced use of endoscopes for diagnosis and relatively minimally invasive procedures. As the pandemic resolves, it is likely that many COVID-related changes in otolaryngology–head and neck surgery may remain and that some aspects of the field will have changed permanently once the pandemic is over.

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Article Information

Corresponding Author: Jay F. Piccirillo, MD, Department of Otolaryngology–Head & Neck Surgery, Washington University School of Medicine in St Louis, 660 S Euclid Ave, St Louis, MO 63110 (piccirij@wustl.edu).

Conflict of Interest Disclosures: None reported.

References
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Chan  JYK, Wong  EWY, Lam  W.  Practical aspects of otolaryngologic clinical services during the 2019 novel coronavirus epidemic: an experience in Hong Kong.   JAMA Otolaryngol Head Neck Surg. 2020;146(6):519-520. doi:10.1001/jamaoto.2020.0488PubMedGoogle ScholarCrossref
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Carron  JD, Buck  LS, Harbarger  CF, Eby  TL.  A simple technique for droplet control during mastoid surgery.   JAMA Otolaryngol Head Neck Surg. 2020;146(7):671-672. doi:10.1001/jamaoto.2020.1064PubMedGoogle ScholarCrossref
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Bertroche  JT, Pipkorn  P, Zolkind  P, Buchman  CA, Zevallos  JP.  Negative-pressure aerosol cover for COVID-19 tracheostomy.   JAMA Otolaryngol Head Neck Surg. 2020;146(7):672-674. doi:10.1001/jamaoto.2020.1081PubMedGoogle ScholarCrossref
6.
Farrell  NF, Klatt-Cromwell  C, Schneider  JS.  Benefits and safety of nasal saline irrigations in a pandemic—washing COVID-19 away.   JAMA Otolaryngol Head Neck Surg. Published online July 23, 2020. doi:10.1001/jamaoto.2020.1622PubMedGoogle Scholar
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Patel  ZM, Fernandez-Miranda  J, Hwang  PH,  et al.  Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic.   Neurosurgery. 2020;87(1):E66-E67. doi:10.1093/neuros/nyaa125PubMedGoogle ScholarCrossref
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Spinato  G, Fabbris  C, Polesel  J,  et al.  Alterations in smell or taste in mildly symptomatic outpatients with SARS-CoV-2 infection.   JAMA. 2020;323(20):2089-2090. doi:10.1001/jama.2020.6771PubMedGoogle ScholarCrossref
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Levy  JM.  Treatment recommendations for persistent smell and taste dysfunction following COVID-19—the coming deluge.   JAMA Otolaryngol Head Neck Surg. Published online July 2, 2020. doi:10.1001/jamaoto.2020.1378PubMedGoogle Scholar
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Givi  B, Schiff  BA, Chinn  SB,  et al.  Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 pandemic.   JAMA Otolaryngol Head Neck Surg. 2020;146(6):579-584. doi:10.1001/jamaoto.2020.0780PubMedGoogle ScholarCrossref
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