Infection Control Precautions
In the setting of the current COVID-19 pandemic, routine head and neck examinations and head and neck procedures present a significant occupational hazard for physicians in the field of Otolaryngology. Instrumentation of the upper airway including the oral cavity, nose, naso/oro/hypopharynx, and larynx should be treated as high-risk procedures for transmission. Given this risk, otolaryngologic procedures should be deferred unless deemed medically necessary or until preoperative COVID-19 diagnostic testing is performed, particularly for Tier 1 and 2 patients, as defined by the American College of Surgeons.14,15 However, due to the acuity in workup and treatment of airway compromise, craniomaxillofacial trauma, and head and neck malignancy, examination and intervention will remain absolutely necessary in many patients during this time, without having COVID-19 testing in advance. Therefore, it is of utmost importance during diagnostic and therapeutic procedures that Otolaryngologists, as well as all other staff in the room, practice effective use of personal protective equipment. Perhaps the most easily implemented and effective method for limiting transmission is reducing redundant patient interaction overall, and minimizing the number of practitioners in the room at any time to perform examinations and procedures.
We define “appropriate PPE” as the use of standard-of-care procedure-specific PPE for patients who are confirmed to be negative for COVID-19 with appropriate pre-operative testing and quarantine and consideration for use of enhanced PPE in the appropriate setting. “Enhanced PPE” is defined as use of either an N95 respirator plus face shield or PAPR (preferred), disposable surgical cap, disposable gown, and gloves. This should be used for any patient with unknown, suspected, or positive COVID-19 status requiring invasive examination or instrumentation of the oral cavity, oropharynx, nasal cavity, or nasopharynx. The appropriate sequence of donning and removing PPE is also of importance (https://www.cdc.gov/hai/pdfs/ppe/PPE-Sequence.pdf).16
There is conflicting data regarding mask protection for healthcare workers in the setting of pandemic airborne infections. Large meta-analyses have either demonstrated a lack of sufficient data to suggest superiority or no decreased risk with the use of N95 respirators compared to surgical masks in regard to laboratory-confirmed influenza.17,18 Regardless, N95 respirators are preferred in clinical settings when the risk of transmission is high given its superior filtration. However, the use of N95 respirators should be limited to healthcare workers who have been trained and properly mask fit tested. In general, face shields and surgical masks are mandatory during close patient encounters and may be used to cover the N95 respiratory masks if necessary. If the patient wears a mask for the entire encounter and the provider remains 3-6 feet away from the patient, a surgical mask may be sufficient, however this is not feasible for many otolaryngology clinical encounters. A suspected or known COVID-19 patient encounter requiring examination within 3 feet should proceed only with N95 respirator use, elastomeric respirator, or PAPR.19
With the current widespread shortage in supply of N95 respirators, the CDC has suggested using these respirators past their shelf life. Components of the respirators degrade over time; however, US stockpiles have been found to perform in accordance with the National Institute of Occupational Safety and Health (NIOSH) performance standards.19 Extended use may be preferable to limited reuse to decrease touching of the respirator, but both strategies are viable options. An exception to this is following an aerosol-generating procedure (i.e. tracheotomy, sinus surgery, oropharyngeal surgery, etc.), where it is recommended to discard the N95 respirator. Given the high viral load seen in the upper airway of COVID-19 infected patients, the use of a PAPR instead of an N95 respirator has been advocated.20-22 In a patient with unknown COVID-19 status requiring an upper airway procedure in the acute setting, enhanced PPE should be used even in the absence of suspicion for COVID-19 by history alone given that patients may be asymptomatic carriers or may be contagious prior to the development of symptoms.12,13 Consideration for excluding otolaryngologists who are of older age or have chronic medical conditions from interacting with COVID-19 patients should be made. During severe resource limitations when respirators are unavailable, convalescent doctors may be designated, although immunity following infection has not yet been confirmed and there is at least one report of disease recurrence in a convalescent patient.19,23