Review of practical recommendations for otolaryngologists and head and neck surgeons during the COVID-19 pandemic

A new telemedicine-based sleep service using WatchPAT® ONE for patients with suspected OSA: what does the patient experience?

PURPOSE

Obstructive Sleep Apnea is a widespread disease but is very underdiagnosed and undertreated. The aim of this study is to assess the effectiveness and patient satisfaction of using the WatchPAT® ONE, a disposable home sleep apnea test device, within a telemedicine-based management pathway.

METHODS

All patients who used the telemedicine services for OSA diagnosis using the WatchPAT® ONE were prospectively enrolled in the study. Patients receive the device at home and download its associated application to learn how to perform the test autonomously at night. Clinicians then review automated results transmitted by the cloud and conduct the follow-up visit via telemedicine, providing diagnostic and therapeutic guidance.

RESULTS

The study included 167 patients (78% male; mean age 55 ± 14 years; BMI: 27.5 ± 4.5 kg/cm²), with a mean distance of 147.29 ± 172.35 km from our hospital. The median time from test request to result delivery was 5 working days. The study cohort showed a median pAHI of 16.7 events/h, a median pODI was 7.9 events/h, and an pRDI of 20.7 events/h. 99% of respondents were satisfied with the remote management. Half of the subjects found both the application installation and the device operation extremely easy, and 60% of them were willing to recommend the use of WatchPAT® ONE.

CONCLUSION

The telemedicine pathway represents an efficient and patient-friendly method for diagnosing OSA. This approach improves diagnostic ease and accessibility while reducing time to diagnosis and societal and healthcare costs. Further large-scale studies are necessary to confirm these results.

A Pilot Study of 0.4% Povidone-Iodine Nasal Spray to Eradicate SARS-CoV-2 in the Nasopharynx

Purpose

This study aimed to evaluate the virucidal efficacy of 0.4% povidone-iodine (PVP-I) nasal spray against SARS-CoV-2 in the patients' nasopharynx at 3 minutes and 4 hours after PVP-I exposure.

Patients and Methods

The study was an open-label, before and after design, single-arm pilot study of adult patients with RT-PCR-confirmed COVID-19 within 24 hours. All patients received three puffs of 0.4% PVP-I nasal spray in each nostril. Nasopharyngeal (NP) swabs were collected before the PVP-I spray (baseline, left NP samples), and at 3 minutes (left and right NP samples) and 4 hours post-PVP-I spray (right NP samples). All swabs were coded to blind assessors and transported to diagnostic laboratory and tested by RT-PCR and cultured to measure the viable SARS-CoV-2 within 24 hours after collection.

Results

Fourteen patients were enrolled but viable SARS-CoV-2 was cultured from 12 patients (85.7%). The median viral titer at baseline was 3.5 log TCID₅₀/mL (IQR 2.8-4.0 log TCID₅₀/mL). At 3 minutes post-PVP-I spray via the left nostril, viral titers were reduced in 8 patients (66.7%). At 3 minutes post-PVP-I, the median viral titer was 3.4 log TCID₅₀/mL (IQR 1.8-4.4 log TCID₅₀/mL) (P=0.162). At 4 hours post-PVP-I spray via the right nostril, 6 of 11 patients (54.5%) had either the same or minimal change in viral titers. The median viral titer 3 minutes post-PVP-I spray was 2.7 log TCID₅₀/mL (IQR 2.0-3.9 log TCID₅₀/mL). Four hours post-PVP-I spray the median titer was 2.8 log TCID₅₀/mL (IQR 2.2-3.9 log TCID₅₀/mL) (P=0.704). No adverse effects of 0.4% PVP-I nasal spray were detected.

Conclusion

The 0.4% PVP-I nasal spray demonstrated minimal virucidal efficacy at 3 minutes post-exposure. At 4 hours post-exposure, the viral titer was considerably unchanged from baseline in 10 cases. The 0.4% PVP-I nasal spray showed poor virucidal activity and is unlikely to reduce transmission of SARS-CoV-2 in prophylaxis use.

Utility of telemedicine in tracheostomy-dependent children

Objectives

Telemedicine can improve access to pediatric otolaryngology care by decreasing travel time and cost, and lowering the risk of viral transmission during the SARS-CoV-2 (COVID-19) pandemic. This study aims to identify the clinical role and outcomes of telemedicine for tracheostomy-dependent children before and during the COVID-19 pandemic.

Methods

Retrospective chart review of 42 tracheostomy-dependent pediatric patients who utilized telemedicine between October 2013 and April 2020 (pre-COVID-19), and 111 patients who utilized telemedicine between May 2020 and July 2021 (during COVID-19) at a tertiary free-standing children's hospital outpatient clinic.

Results

The majority of pre-COVID-19 telecommunication solely addressed tracheostomy stomal concerns as compared with during COVID-19 (99% vs. 3%, p < .001), while telecommunication during COVID-19 was mainly used for routine follow-up as compared with pre-COVID-19 (99% vs. 0%, p < .001). Telemedicine visits during COVID-19 were significantly less likely to result in the need for in-person office visits as compared with those pre-COVID-19 (4% vs. 22%; p < .001). There was no significant difference in urgent emergency department (ED) evaluation following telemedicine pre- and during COVID-19 (16% vs. 11%). The most common reasons for ED presentation both pre- and during COVID-19 following telemedicine visit included respiratory distress, dislodged tracheostomy tube, and tracheostomy bleeding.

Conclusion

The clinical role of telemedicine has evolved from problem-based evaluation to routine follow-up during the COVID-19 pandemic. Although telemedicine can decrease the need for in-person office evaluation of routine tracheostomy concerns, respiratory complications and tracheostomy bleeding still require urgent in-person ED evaluation.

Level of evidence

Level 4.

Recommendations from the Italian Society of Otolaryngology for clinical management during the SARS-CoV-2 pandemic

The coronavirus disease (COVID-19) pandemic has deeply impacted health, and affects many different medical specialties. Head and neck surgeons, in particular, have been recognised as one of the professionals at the highest risk of infection through aerosol-generating procedures as part of their usual job. The aim of this document is to review the current literature on the topic, to provide useful recommendations to avoid both healthcare staff exposure to contagion and the delay in the diagnosis and treatment of Head and Neck diseases, in this new phase of COVID-19 pandemic.

Risk of SARS-CoV-2 contagion in otolaryngology specialists

COVID-19 has rapidly spread in the past two years with a profound impact on otolaryngological activities, which has undergone radical transformation to guarantee diagnostic and therapeutic procedures mainly in oncology and urgent patients, while ensuring protection for healthcare personnel and patients. During the initial phases of the pandemic, scheduled visits and elective surgeries were postponed leading to a delay in the diagnosis and treatment of several diseases, including head and neck cancer, with a shift toward more advanced cancer stages and more aggressive treatments. Aerosol and droplets are the main routes of transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), thus leading to a high risk of contagion during otolaryngology visits and surgery. Therefore, the correct use of personal protective equipment (PPE) and attention to procedure-specific risks and measures to avoid contagion are of utmost importance for healthcare professionals, and especially for those dealing with otolaryngology diseases. This narrative review highlights that otolaryngological activity implies a high risk of contagion during outpatient visit, surgery, or urgent conditions. The correct use of PPE, evaluation of procedure-specific risks and reduction of non-urgent procedures are considered the main strategies to limit contagion.

[The role of local antiseptics in the prevention of coronavirus infection during endonasal interventions on the lacrimal ducts]

In connection with the pandemic of coronavirus infection, it is urgent to develop measures to prevent the intraoperative spread of coronavirus particles and infection of the operating room staff.

OBJECTIVE

Generalization and analysis of available data concerning local antiseptic therapy for the prevention of coronavirus infection during endonasal interventions on the lacrimal tract.

MATERIAL AND METHODS

The search for literature sources was carried out using MEDLINE search engines and the Russian Science Citation Index for queries with the keywords "COVID-19", "coronavirus infection", "antiseptics", "protocol for otorhinolaryngological operations", "dacryosurgical operations" and similar in various combinations.

RESULTS

It has been shown that during endonasal operations on the lacrimal tract, the number of risk factors for infection increases, since these procedures are aerosol-generating, and contact occurs not only with the nasal mucosa, but also with the lacrimal fluid, in which the coronavirus is also replicated. The data on the effectiveness of various antiseptics are summarized, the analysis of the possibility of their use in preoperative preparation for endonasal interventions on the lacrimal tract from the point of view of efficacy and safety is carried out. Information is provided on the proprietary protocol for the use of antiseptics to prevent the spread of coronavirus infection during endonasal dacryocystorhinostomy. It is shown that the preventive use of local disinfectants reduces the number of viral particles on the nasal mucosa, which leads to a decrease in contamination of the surrounding space. Among the available and studied antiseptics, the most suitable is povidone-iodine, which can be used in concentrations up to 1.25% to irrigate the nasal mucosa before surgery with an exposure of 30-60 sec. When performing operations on the lacrimal pathways, it is also advisable to carry out antiseptic treatment of the conjunctival cavity with a 5% solution of povidone-iodine and rinse the lacrimal pathways before the operation with povidone-iodine in a concentration of 0.4%.

CONCLUSION

To date, information has been obtained that makes it advisable to use antiseptics before performing endonasal aerosol-generating interventions, in particular endonasal dacryocystorhinostomies and recanalization of the tear ducts.

Measurement of airborne particle emission during surgical and percutaneous dilatational tracheostomy COVID-19 adapted procedures in a swine model: Experimental report and review of literature

INTRODUCTION

Surgical tracheostomy (ST) and Percutaneous dilatational tracheostomy (PDT) are classified as high-risk aerosol-generating procedures and might lead to healthcare workers (HCW) infection. Albeit the COVID-19 strain slightly released since the vaccination era, preventing HCW from infection remains a major economical and medical concern. To date, there is no study monitoring particle emissions during ST and PDT in a clinical setting. The aim of this study was to monitor particle emissions during ST and PDT in a swine model.

METHODS

A randomized animal study on swine model with induced acute respiratory distress syndrome (ARDS) was conducted. A dedicated room with controlled airflow was used to standardize the measurements obtained using an airborne optical particle counter. 6 ST and 6 PDT were performed in 12 pigs. Airborne particles (diameter of 0.5 to 3 μm) were continuously measured; video and audio data were recorded. The emission of particles was considered as significant if the number of particles increased beyond the normal variations of baseline particle contamination determinations in the room. These significant emissions were interpreted in the light of video and audio recordings. Duration of procedures, number of expiratory pauses, technical errors and adverse events were also analyzed.

RESULTS

10 procedures (5 ST and 5 PDT) were fully analyzable. There was no systematic aerosolization during procedures. However, in 1/5 ST and 4/5 PDT, minor leaks and some adverse events (cuff perforation in 1 ST and 1 PDT) occurred. Human factors were responsible for 1 aerosolization during 1 PDT procedure. ST duration was significantly shorter than PDT (8.6 ± 1.3 vs 15.6 ± 1.9 minutes) and required less expiratory pauses (1 vs 6.8 ± 1.2).

CONCLUSIONS

COVID-19 adaptations allow preventing for major aerosol leaks for both ST and PDT, contributing to preserving healthcare workers during COVID-19 outbreak, but failed to achieve a perfectly airtight procedure. However, with COVID-19 adaptations, PDT required more expiratory pauses and more time than ST. Human factors and adverse events may lead to aerosolization and might be more frequent in PDT.

Difficult lung separation. An insight into the challenges faced during COVID-19 pandemic

Difficult lung isolation or separation in patients undergoing thoracic surgery using one-lung ventilation might be attributed to upper airway difficulty or abnormal anatomy of the lower airway. Additionally, adequate deflation of the surgical lung can impair surgical exposure. The coronavirus disease 2019 (COVID-19) has a harmful consequence for both patients and anesthesiologists. Management of patients with difficult lung isolation can be challenging during the COVID-19 pandemic. Careful planning and preparation, preoperative routine testing, protective personal equipment, standard safety measures, proper preoxygenation, and individualize the patients care are required for successful lung separation. A systematic approach for management of difficult lung separation is centered around securing the airway and providing adequate ventilation using either a blocker or double-lumen tube. Several measures are described to expedite lung collapse.

International Survey of Operative Practices for Otologists and Neurotologists During the COVID-19 Crisis

OBJECTIVE

To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally.

STUDY DESIGN

Cross-sectional survey.

METHODS

A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition.

RESULTS

Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p < 0.001). 71.5% of providers did not perform an elective otologic or neurotologic operative procedure during the initial crisis period. 49.8% reported modifying their surgical technique due to the COVID-19 pandemic. Use of powered air-purifying respirators and filtering facepiece 2 or 3 (FFP2/FFP3) respirators were in minimal supply for 66.9% and 62.3% of respondents, respectively.

CONCLUSION

The COVID-19 pandemic impacted the otology and neurotology community globally, resulting in significant changes in operative volume and case selection. Modification of surgical technique and shortages of personal protective equipment were frequently reported.

ENT Symptomology in Active COVID-19 Patients in our Tertiary Care Centre

The aim of this study is to obtain a clear picture of ENT related symptoms in active COVID-19 patients. This study also intends to determine the association of ENT symptoms with Olfactory and Gustatory dysfunction in these patients.

MATERIAL AND METHODS

This is a prospective study on 70 active COVID-19 patients who were admitted in the Tertiary Care Hospital. History of all symptoms including Olfactory and Gustatory function were enquired after obtaining Informed Consent.

RESULTS

Throat related symptoms was 77.78%, Nasal symptoms accounted for 63.49% and Ear related symptoms constituted 14.28%. It was seen that Rhinorrhoea and Sneezing was significantly more associated in the presence of Olfactory dysfunction. The most common ENT symptoms were Sore throat (49.21%), Rhinorrhoea (34.92%), Sneezing (33.33%), changes in Smell perception (36.51%), changes in Taste perception (47.62%) and Headache (30.16%). 17.14% of the patients in this study had both Olfactory and Gustatory dysfunction. Ear related symptoms were also observed where 11.11% had Aural fullness, 3.17% with Tinnitus and 6.35% of the patients complained of Hearing loss which was either noticed for the first time or had worsened on contracting the COVID-19 disease.

DISCUSSION

Knowledge of ENT symptomatology in COVID 19 patients will aid in early quarantine and hence limitation of viral transmission. The manifestation of Anosmia or Hyposmia, Ageusia and Aural Fullness in SARS-CoV-2 infected patients can also act as an important tool and help in early isolation and quicker initiation of COVID-19 therapy.

Evidence, not eminence, for surgical management during COVID-19: a multifaceted systematic review and a model for rapid clinical change

BACKGROUND

Coronavirus (COVID-19) forced surgical evolution worldwide. The extent to which national evidence-based recommendations, produced by the current authors early in 2020, remain valid, is unclear. To inform global surgical management and a model for rapid clinical change, this study aimed to characterize surgical evolution following COVID-19 through a multifaceted systematic review.

METHODS

Rapid reviews were conducted targeting intraoperative safety, personal protective equipment and triage, alongside a conventional systematic review identifying evidence-based guidance for surgical management. Targeted searches of PubMed and Embase from 31 December 2019 were repeated weekly until 7 August 2020, and systematic searches repeated monthly until 30 June 2020. Literature was stratified using Evans' hierarchy of evidence. Narrative data were analysed for consistency with earlier recommendations. The systematic review rated quality using the AGREE II and AMSTAR tools, was registered with PROSPERO, CRD42020205845. Meta-analysis was not conducted.

RESULTS

From 174 targeted searches and six systematic searches, 1256 studies were identified for the rapid reviews and 21 for the conventional systematic review. Of studies within the rapid reviews, 903 (71.9 per cent) had lower-quality design, with 402 (32.0 per cent) being opinion-based. Quality of studies in the systematic review ranged from low to moderate. Consistency with recommendations made previously by the present authors was observed despite 1017 relevant subsequent publications.

CONCLUSION

The evidence-based recommendations produced early in 2020 remained valid despite many subsequent publications. Weaker studies predominated and few guidelines were evidence-based. Extracted clinical solutions were globally implementable. An evidence-based model for rapid clinical change is provided that may benefit surgical management during this pandemic and future times of urgency.

Self-care and clinical management of persons with laryngectomy during COVID-19 pandemic: a narrative review

Objective

To summarize guidelines on self-care and clinical management of persons with laryngectomy during the COVID-19 pandemic.

Method

Articles published in electronic databases—PubMed, Scopus, Web of Science, and CINHAL with the compliant keywords—were scouted from December 2019 to November 2020. All original articles, letters to editors, reviews, and consensus statements were reviewed and included.

Results

In all, 20 articles that had information pertaining to self-care of persons with laryngectomy or guidelines for clinicians working with this population were identified. Four of the included studies were case reports of persons with laryngectomy who contracted the COVID-19 virus. One of the included articles was a cohort study that explored the use of telerehabilitation in persons with laryngectomy.

Conclusion

The hallmarks of preventative strategies for persons with laryngectomy during the COVID-19 pandemic are as follows: physical distancing, use of a three-ply mask or surgical mask to cover the mouth and nose, and use of Heat Moisture Exchange (HME) device over stoma in addition to covering it with a surgical mask or laryngectomy bib. Telerehabilitation, not a preference with this population prior to the pandemic, has gained popularity and acceptance during the COVID-19 situation. The reports of COVID-positive persons with laryngectomy have indicated contrary findings from the tracheal and nasal swabs, necessitating compulsory inclusion of both nasal and tracheal swabs.

The Impact of the COVID-19 Pandemic on Head and Neck Surgery Training: A Brazilian National Survey

Introduction  The COVID-19 pandemic has had a high impact on surgical training around the world due to required measures regarding the suspension of elective procedures and the dismissal of nonessential personnel.

Objectives  To understand the impact the pandemic had on head and neck surgery training in Brazil.

Methods  We conducted a 29-question online survey with head and neck surgery residents in Brazil, assessing the impact the pandemic had on their training.

Results  Forty-six residents responded to the survey, and 91.3% of them reported that their residency was affected by the pandemic, but most residents were not assigned to work directly with patients infected with the new coronavirus (71.4%). All residents reported decrease in clinic visits and in surgical procedures, mostly an important reduction of ∼ 75%. A total of 56.5% of the residents described that the pandemic has had a negative impact on their mental, health and only 4 (8.7%) do not have any symptoms of burnout. The majority (78.3%) of the residents reported that educational activities were successfully adapted to online platforms, and 37% were personally infected with the virus.

Conclusion  Most surgical residencies were greatly affected by the pandemic, and residents had an important decrease in surgical training. Educational activities were successfully adapted to online modalities, but the residency programs should search for ways of trying to compensate for the loss of practical activities.

Antiviral Essential Oil Components Against SARS-CoV-2 in Pre-procedural Mouth Rinses for Dental Settings During COVID-19: A Computational Study

COVID-19 mainly spreads through cough or sneeze droplets produced by an infected person. The viral particles are mostly present in the oral cavity. The risk of contracting COVID-19 is high in the dental profession due to the nature of procedures involved that produce aerosols. Along with other measures to limit the risk of infection, pre-procedural mouth rinses are beneficial in reducing the viral particles in the oral cavity. In this study, the antiviral efficacy of essential oil components has been determined specifically against SARS-CoV-2 by molecular docking and conceptual DFT approach. Based on the binding affinities of the components against the receptor binding domain of the S1 glycoprotein, cuminal, carvacrol, myrtanol, and pinocarveol were found to be highly active. The molecular descriptor values obtained through conceptual DFT also indicated the above-mentioned components to be active based on the correlation between the structure and the activity of the compounds. Therefore, pre-procedural mouth rinses with these components included may be specifically suitable for dental procedures during the COVID-19 period.

Coronavirus Disease-19: Challenges Associated with the Treatment of Head and Neck Oncology and Laryngology Patients in the Coronavirus Disease-19 Era

This review explores the changes to practice associated with COVID-19 for providers treating patients with head and neck cancer and laryngeal pathology. The aim of the review is to highlight some of the challenges and considerations associated with treating this patient population during the pandemic. Additionally, it seeks to discuss some of the areas of concern related to ramping up clinical volume.