Introduction
In December 2019, a pneumonia outbreak of unknown etiology was reported
in Wuhan, Hubei province, China.1 This disease was
subsequently named Coronavirus disease 2019 (COVID-2019) by the World
Health Organization (WHO) and has spread globally affecting over 350,000
people and resulting in >15,000 deaths as of March 23,
2020.2 The causative agent was determined to be a
novel Coronavirus (originally called 2019 novel Coronavirus or
2019-nCoV) closely related to Severe Acute Respiratory Syndrome (SARS)
and Middle Eastern Respiratory Syndrome (MERS) viruses and has been
named SARS-CoV-2.3 Although the full route of
transmission is not clear, increasing evidence suggests that
otolaryngologists are at increased risk of occupational SARS-CoV-2
exposure due to the high viral load in the upper aerodigestive tract and
frequent examination and instrumentation of the oral cavity, oropharynx,
nasal cavity, and nasopharynx. Indeed, the first physician deaths during
the COVID-19 and SARS outbreaks were
Otolaryngologists.4 In this commentary, we provide a
brief overview of COVID-19 and provide recommendations for steps that
Otolaryngologists should take to ensure the safety of themselves,
operative teams, and patients. A summary of the recommendations
discussed below is provided in Table 1. Given the rapidly evolving
situation, these recommendations are based on the best available data
and expert opinion, and may be subjected to change as the pandemic
continues to develop.
Like all Coronaviruses, SARS-CoV-2 is an enveloped, positive-sense,
single-stranded RNA virus. Sequence analysis has revealed 76.9%
homology to SARS Coronavirus (SARS-CoV) and 96.4% homology to the bat
Coronavirus BatCoVRaTG13 (RaTG13), indicating that SARS-CoV-2 is likely
the result of a zoonotic infection.1 The viralspike (S ) protein interacts with the same cellular
receptor, angiotensin-converting enzyme II (ACE2), as SARS-CoV, however,
the SARS-CoV-2 S protein has significant sequence divergence from
all other known Coronaviruses except RaTG13. Importantly, SARS-CoV-2
appears to be highly transmissible with an R0 of
2-3, meaning that each infected person is likely to infect 2-3
additional people in a naïve population.5 While
respiratory droplet is presumed to be the major mode of transmission,
evidence suggests that the virus may also be spread via the fecal-oral
route and through the conjunctiva.6 Importantly,
SARS-CoV-2 appears to be highly stable in the environment. Viable virus
has been recovered from aerosols for up to 3 hours, porous surfaces
(cardboard) for up to 24 hours, and non-porous surfaces (stainless
steel, plastic) for up to 72 hours.7 This
environmental stability increases the risk of nosocomial transmission
and “super spreader” events, where a single individual infects more
naïve individuals than expected byR0 .7,8
The most commonly reported presenting symptoms of COVID-19 include cough
(67.8%), fever (43.8%), fatigue (38.1%), increased sputum production
(33.7%), dyspnea (18.7%), myalgias (14.9%), sore throat (13.9%), and
chills (11.5%) 9. However, some recent analyses
indicate that hyposmia or anosmia and dysgeusia may be underrecognized
symptoms.10,11 Laboratory testing may demonstrate
leukopenia (33.7%) and lymphopenia (83.2%); elevated C-reactive
protein (60.7%), D-dimer (46.4%), and lactate dehydrogenase (41%)
levels; transaminitis (~20%); and decreased
procalcitonin (5.5%). Chest computed tomography (CT) demonstrates
abnormalities in 86.2% of cases including ground-glass opacities,
patchy shadowing, and interstitial changes.9SARS-CoV-2 appears to have a median incubation period of 5.1 days, with
95% of patients developing symptoms between 2.2 and 11.5 days after
exposure.12 However, it is extremely important to
recognize that asymptomatic patients may be highly
contagious,12,13 highlighting the need for the use of
personal protective equipment (PPE) for even routine patient evaluation.