Pediatric Otolaryngology Divisional and Institutional Preparatory Response at Seattle Children's Hospital after COVID-19 Regional Exposure

Lessons Learnt from the COVID-19 Pandemic in Pediatric Otolaryngology

Purpose of Review

The current COVID-19 pandemic has challenged the international paediatric otolaryngology community: we review its impact in clinical, resource, and human settings.

Recent Findings

The SARS-CoV-2 virus, while generally mild in paediatric populations, has caused an increased incidence in severe croup, invasive fungal sinus disease, and multi system inflammatory syndrome (MIS-C). The incidence of other common otolaryngology presentations such as otitis media and tonsillitis has decreased due to quarantine measures. The pandemic has also changed the way in which we work: guidelines for aerosol-generating procedures (AGPs) have changed, digital technology and videoconferencing platforms have flourished, and new pathways of providing healthcare have been developed to minimise footfall and avoid overcrowded waiting rooms. Finally, the importance of personal protective equipment (PPE) to protect healthcare workers and patients cannot be understated, although the mental and physical toll is considerable.

Summary

There has been a tectonic shift in paediatric otolaryngology and healthcare globally. Continued adaptability and resilience are required to face these challenges in the coming months. With lessons learnt from managing SARS-CoV-2, we are hopefully well equipped to combat any future pandemics.

Pediatric otolaryngology in the coronavirus disease 2019 pandemic: what have we learned?

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19) has changed the face of healthcare. The current review is to discuss the major aspects that have changed in pediatric otolaryngology, from surgical operations management, to clinic workflow, to procedural precautions.

RECENT FINDINGS

There have been many studies over the past year describing different ways to improve the safety of healthcare delivery in pediatric otolaryngology amidst a global pandemic, as well as ways to improve clinic and surgical logistics along with guidelines for telehealth of a surgical specialty.

SUMMARY

COVID-19 has forever altered how healthcare is viewed and practiced, and pediatric otolaryngology was not exempt. With an increased focus on provider safety, as well as novel ways of utilizing changes in methods of communication, the practice of pediatric otolaryngology has evolved with the rest of healthcare to take on the new challenges brought on by this global pandemic.

Immunopathological similarities between COVID-19 and influenza: Investigating the consequences of Co-infection

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been a global public health emergency since December 2019, and so far, more than 980,000 people (until September 24, 2020) around the world have died. SARS-CoV-2 mimics the influenza virus regarding methods and modes of transmission, clinical features, related immune responses, and seasonal coincidence. Accordingly, co-infection by these viruses is imaginable because some studies have reported several cases with SARS-CoV-2 and influenza virus co-infection. Given the importance of the mentioned co-infection and the coming influenza season, it is essential to recognize the similarities and differences between the symptoms, immunopathogenesis and treatment of SARS-CoV-2 and influenza virus. Therefore, we reviewed the virology, clinical features, and immunopathogenesis of both influenza virus and SARS-CoV-2 and evaluated outcomes in cases with SARS-CoV-2 and influenza virus co-infection.

A cross-sectional survey of anxiety levels of oral and maxillofacial surgery residents during the early COVID-19 pandemic

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has increased anxiety among the general population. The purpose of this project was to investigate attitudes and anxiety among oral and maxillofacial surgery (OMS) residents during the early COVID-19 pandemic.

MATERIALS AND METHODS

This was a cross-sectional study. OMS residents were sent electronic invitations to answer a survey. The survey was sent in April and May 2020. Residents enrolled in OMS residency programs accredited by the Commission on Dental Accreditation were included. Predictor variable was attitudes of OMS residents toward the pandemic. The outcome variable was anxiety levels of OMS residents due to the pandemic according to the Hospital Anxiety and Depression Scale-A. Other variables were demographic characteristics, general knowledge regarding the pandemic, and attitudes of OMS residents toward the pandemic. Statistical analysis was performed using Fisher's exact test, Wilcoxon rank sum test, and univariate and multivariate logistic regression (P < .05).

RESULTS

We received 275 responses. The majority of respondents were males (74.5%) aged 26 to 30 (52.7%). Residents reported different levels of anxiety (i.e., mild 58.2%, severe 41.8%). Based on multivariate analysis, moderate or severe anxiety was associated with being female (P = .048) and a senior resident (P = .049). Factors such as potential deployment to other services, availability of personal protective equipment, and unclear disease status of patients contributed to anxiety.

CONCLUSION

Our study found that during the early COVID-19 pandemic, all residents experienced some anxiety. Senior OMS residents and female OMS residents experience higher anxiety levels than other residents.

Pediatric E.N.T. emergencies during COVID-19 pandemic: our experience

Our aim is to analyze effect of covid-19 pandemic in management of pediatric emergencies in E.N.T. and to provide recommendations for management of pediatric emergencies in E.N.T. during pandemic. In this retrospective study we included emergency pediatric cases required early intervention during covid-19 pandemic. Pre operative radiological investigation x-ray was done in all aero digestive foreign body patients. Pre operative HRCT neck and chest with virtual bronchoscopy in foreign body inhalation & compromised airway patients was done only in cases where patient’s clinical condition was stable. Similarly RT PCR for covid-19 screening done only in cases where patient’s clinical condition was stable. Adequate personal protective equipment was used during all the procedures. Total 29 Pediatric patients age ranging from 1 day to 13 years underwent procedures due to history of foreign body inhalation; ingestion, insertion and compromised airway in form of immediate endotracheal intubation were included. Comprehensively we recommend intervention only in emergency procedures during pandemic, use of personal protective equipment during all procedures, preoperative investigations for diagnosis and modifications in operation theatre, anesthesia and surgical techniques to reduce aerosols generation will minimize risk of infection transmission to health care workers.

YO-IFOS Guidelines for Pediatric ENT Surgery during COVID-19: An Overview of Recommendations

OBJECTIVE/HYPOTHESIS

To review the literature on pediatric ENT COVID-19 guidelines worldwide, in particular, surgical practice during the pandemic, and to establish a comprehensive set of recommendations.

STUDY DESIGN

Review.

METHODS

A comprehensive literature review through an independent electronic search of the COVID-19 pandemic in PubMed, Medline, Google, and Google Scholar was performed on April 26-30, 2020. Resources identified comprised of published papers, national and international pediatric ENT society guidelines.

RESULTS

Fourteen guidelines fit the inclusion criteria. Key statements were formulated and graded: 1) Strong recommendation (reported by 9 or more/14); 2) Fair recommendation (7-8/14); 3) Weak recommendation (5-6/14); and 4) Expert opinion (2-4/14). Any single source suggestion was included as a comment. Highly scored recommendations included definition of urgent/emergent cases that required surgery; surgery for acute airway obstruction; prompt diagnosis of suspected cancer; and surgical intervention for sepsis following initial first-line medical management. Other well scored recommendations included senior faculty to perform the surgery; the use of open approaches rather than endoscopic ones; and avoidance of powered instruments that would aerosolize virus-loaded tissue. A tracheostomy should be performed on a case by case basis where key technical modifications become necessary.

CONCLUSIONS

The COVID-19 pandemic will have a profound short and long-term impact on pediatric ENT practice. During this rapidly evolving climate, guidelines have been based on local practice and expert opinion. Until evidence-based practice in the COVID era is established, a comprehensive set of recommendations for pediatric ENT surgical practice based on a review of currently available literature and guidelines, is therefore, appropriate. Laryngoscope, 131:1876-1883, 2021.

Considerations for povidone-iodine antisepsis in pediatric nasal and pharyngeal surgery during the COVID-19 pandemic

PURPOSE

Surgeons resuming elective procedures during the COVID-19 pandemic should consider strategies to mitigate risk of exposure. For otolaryngologists performing surgery on children, unique vulnerability to SARS-CoV-2 results from a regular interface with the upper respiratory tract mucosa. A growing interest in perioperative application of povidone‑iodine (PVP-I) to the nasopharynx and oropharynx has emerged. The purpose of this review is to provide an evidence-based assessment of PVP-I in pediatric oral, nasal and pharyngeal surgery.

METHODS

A contemporary literature review with algorithmic approach to the potential use of PVP-I in pediatric mucosal surgery.

RESULTS

Several formulations of PVP-I have shown rapid in vitro virucidal activity against SARS-CoV-2. Antisepsis using 1.0% PVP-I mouthwash and 0.45% PVP-I throat spray can occur after 30 seconds of contact time. To date, in vivo effectiveness of PVP-I against SARS-CoV-2 has yet to be established and possible risks of its direct use on upper aerodigestive mucosa of children must be weighed.

CONCLUSION

Further research is required prior to strongly recommending PVP-I use in preparation for nasal, oral or pharyngeal surgery in children.

Head and Neck Practice in the COVID-19 Pandemics Today: A Rapid Systematic Review

Introduction  Head and neck specialists and otorhinolaryngologists are greatly exposed to coronavirus disease 2019 (COVID-19) transmission in their everyday praxis. Many articles are being published regarding medical staff protection and patient management during the pandemic. Objective  To provide an easy access to and a trustful review of the main aspects that have changed in the head and neck surgery and otorhinolaryngology practice due to the COVID-19 pandemic. Data Synthesis  The search terms used were: ( head and neck or otorhinolaryngology or ORL or thyroid ) AND ( severe acute respiratory syndrome coronavirus 2 [ SARS-COV-2] or COVID-19 or CORONAVIRUS ). The results were limited to the year of 2020. Articles were read in English, Portuguese, French, German, and Spanish or translated from Chinese. All included articles were read by at least two authors. Thirty-five articles were included. Most articles suggest postponing elective surgeries, with exception to cancer surgeries, which should be evaluated separately. Twenty-five articles recommended some kind of screening prior to surgery, using polymerase chain reaction (PCR) tests and epidemiological data. Extra precautions, such as use of personal protective equipment (PPE), are suggested for both tracheostomies and endoscopies. Fifteen articles give recommendation on how to use telemedicine. Conclusion  The use of PPE (N95 or powered air-purifying respirator [PAPR]) during procedures should be mandatory. Patients should be evaluated about their COVID-19 status before hospital admission. Cancer should be treated. Tracheostomy tube cuff should be inflated inside the tracheal incision. All COVID-19 precautions should be kept until there is a validated antiviral treatment or an available vaccine.

Otolaryngology in the Time of Corona: Assessing Operative Impact and Risk During the COVID-19 Crisis

OBJECTIVE

Limited research exists on the coronavirus disease 2019 (COVID-19) pandemic pertaining to otolaryngology-head and neck surgery (OHNS). The present study seeks to understand the response of OHNS workflows in the context of policy changes and to contribute to developing preparatory guidelines for perioperative management in OHNS.

STUDY DESIGN

Retrospective cohort study.

SETTING

Pediatric and general adult academic medical centers and a Comprehensive Cancer Center (CCC).

SUBJECTS AND METHODS

OHNS cases from March 18 to April 8, 2020-the 3 weeks immediately following the Ohio state-mandated suspension of all elective surgery on March 18, 2020-were compared with a 2019 control data set.

RESULTS

During this time, OHNS at the general adult and pediatric medical centers and CCC experienced 87.8%, 77.1%, and 32% decreases in surgical procedures as compared with 2019, respectively. Aerosol-generating procedures accounted for 86.8% of general adult cases, 92.4% of pediatric cases, and 62.0% of CCC cases. Preoperative COVID-19 testing occurred in 7.1% of general adult, 9% of pediatric, and 6.9% of CCC cases. The majority of procedures were tiers 3a and 3b per the Centers for Medicare & Medicaid Services. Aerosol-protective personal protective equipment (PPE) was worn in 28.6% of general adult, 90% of pediatric, and 15.5% of CCC cases.

CONCLUSION

For OHNS, the majority of essential surgical cases remained high-risk aerosol-generating procedures. Preoperative COVID-19 testing and intraoperative PPE usage were initially inconsistent; systemwide guidelines were developed rapidly but lagged behind recommendations of the OHNS department and its academy. OHNS best practice standards are needed for preoperative COVID-19 status screening and PPE usage as we begin national reopening.

Literature-guided recommendations for otolaryngologists during the COVID-19 pandemic: A contemporary review

OBJECTIVE

The objective of this study was to review the current literature and guidelines on management of the novel coronavirus 2019 (COVID-19 or 2019nCoV) with respect to the field of Otolaryngology.

DESIGN

Contemporary literature review.

METHODS

Systematic literature review of global medical literature databases and communications were queried to find all available literature recommendations, research, and guidelines applicable to otolaryngologists in the COVID-19 pandemic.

RESULTS

Guidance on personal protective equipment, office visits, and surgical scheduling, as well as recommendations for safe airway management and tracheotomy performance during the COVID-19 pandemic were compiled and interpreted.

CONCLUSIONS

Little guidance exists for otolaryngologists who are among the highest risk groups during the rapidly evolving COVID-19 pandemic. This synthesis and compilation of global resources serve as a building block for further guidance during the epidemic.

LEVEL OF EVIDENCE

NA.

Outpatient Otolaryngology in the Era of COVID-19: A Data-Driven Analysis of Practice Patterns

Introduction

Coronavirus disease 2019 (COVID-19) has induced a prioritization of acute care and telehealth, affecting the quantity of patients seen and the modality of their care.

Study Design

Retrospective review.

Setting

Single-institution study conducted within the Division of Otolaryngology at the Yale School of Medicine.

Subjects and Methods

Data on all outpatient appointments within the Division of Otolaryngology were obtained from administrative records of billing and scheduling from March 16 to April 10, 2020. For comparison, a corresponding period from 2019 was also utilized.

Results

Of 5913 scheduled visits, 3665 (62.0%) were seen between March 18 and April 12, 2019, in comparison with 649 of 5044 (12.9%) during the corresponding COVID-19–affected period. The majority of completed visits performed in weeks 1 and 2 were in person, while the majority in weeks 3 and 4 were via telehealth. Among subspecialties, a larger proportion of completed visits in 2020 were performed by pediatric and head and neck oncology otolaryngologists as compared with general/specialty otolaryngologists (P < .001). Older adults (≥65 years) were less likely to have telehealth visits than younger adults (18-64 years; 45.6% vs 59.6%, P = .003).

Conclusions

A major decrease in the completion rates of scheduled visits was seen in the COVID-19–affected period, though this was not proportional among subspecialties. An associated increase in telehealth visits was observed. After COVID-19–related hospital policy changes, approximately 2 weeks passed before telehealth visits surpassed in-person visits, though this was not true among older adults.

Defining Essential Services for Deaf and Hard of Hearing Children during the COVID-19 Pandemic

COVID-19 is a rapidly growing global pandemic caused by a novel coronavirus. With no vaccine or definitive treatment, public health authorities have recommended a strategy of "social distancing," reducing individual interaction, canceling elective procedures, and limiting nonessential services. Health care providers must determine what procedures are considered "elective," balancing risk of treatment delays with that of coronavirus exposure to patient, family, and providers. Given critical periods for language development and the long-term impact of auditory deprivation, some audiologic and otologic services should be considered essential. In this article, we describe the experience of a quaternary referral pediatric hospital in Seattle, the epicenter of COVID-19 in the United States, and share strategies for risk minimization employed by Seattle Children's Hospital. We hope that this work can be a reference for other centers continuing care for children who are deaf and hard of hearing during the COVID-19 and future resource-limiting crises.