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.