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