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20 March 2020

Guidance for ENT surgeons during the COVID-19 pandemic 
 
20 March 2020

 

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The information contained in this document is subject to change due to the rapidly changing environment. This guidance is intended to complement rather than replace existing advice. These are challenging times and we are concerned about the health and safety of members, trainees and patients.
 
Most importantly, protect yourself and prevent the spread through the practice of 

 

  • good hygiene (cover cough, wash hands, avoid touching your face)
  • stay at home if you are sick,
  • self-isolation, and
  • social distancing and avoid shaking hands

 

Risk to healthcare workers through transmission of COVID-19 is primarily through droplet spread. Otolaryngologists are exposed to a high reservoir of viral load as we are dealing with the nose and airway. 1, 2, 3  
 
There is reliable information coming from the US indicating that otolaryngology is a high-risk group from COVID-19 infection. There is anecdotal evidence that a single endoscopic case in China reportedly infected 14 people who were in the operating room. There is a presumed high risk in any procedures involving the airway. The current recommendation is to reconsider the need for non-urgent surgery in particular sinonasal, tonsils and oral cavity. 

 

Current US advice is that pre-operative COVID-19 status should be prioritised for all procedures involving the upper and lower respiratory tract, and eventually all patients requiring endo tracheal intubation. In COVID-19 positive patients, endoscopic sinus cases should be conducted only with PAPR (Powered air-purifying respirator). 
 
The Australian Society of Anaesthetists guidelines are supported and are very much aligned with procedures for ENT surgeons as they are experts in airway management. 4
 
National and local guidelines from the Department of Health and others should be adhered to. State and Territory guidelines as well as individual hospital advice will also be frequently updated. 5
 
RACS advice for all fellows, trainees and IMGs as at 18 March is available here: 
https://mailchi.mp/surgeons/racs-covid19-update-326446?e=6f1443f171
 
ENT may not seem to be in the frontline with COVID-19 but we do have a key role to play, and this must be planned. All the data from China, Iran, Italy and most recently the UK suggests that ENT surgeons are an extremely high-risk group therefore we need to be vigilant to protect ourselves.Hospitals need to ensure ENT surgeons are supplied with the necessary PPE in order to avoid fatalities.
 
In response to pressures on the health system, elective surgery will be curtailed. Non-elective patients will continue to need care. We should seek the best local solutions to continue the proper management of these patients whilst protecting ourselves through proper supply of protective equipment. We understand that resources are under pressure for the response to COVID-19, however the experience overseas highlights the necessity for PPE for ENTs. 
 
We will be involved in airway management. We may also need to work outside of our specific areas of training and expertise, in the exceptional circumstances we may face.
 
We need in particular to consider patients who are vulnerable to the consequences of catching COVID-19, including those with a tracheostomy or respiratory compromise and patients with immune suppression – such as patients with head and neck cancer – either during or soon after treatment. 
 
There are multiple resources of information and we will need to make decisions based on our own personal circumstances within our practices, depending on the size of the rooms, waiting areas, staffing, etc. Signs on the door of your room and messages confirming appointments should communicate to patients who are feeling unwell to stay home and not attend their appointment. Telehealth options are available through the MBS for vulnerable / isolated patients.
 
Important recommendations:

 

  • Avoid powered atomisation – use actuated pumps sprays or similar soaked pledgets for topical        anaesthesia
  • Elective airway surgery patients (sinonasal, nasopharyngeal, oropharyngeal, laryngeal and tracheal) should be tested for COVID-19, where and when available, and be shown to be negative before proceeding; for acute cases specific PPE should be utilised; patients should be advised to practice hand hygiene and social distancing prior to surgery
  • Limit intervention in the clinic/rooms as much as possible and wear appropriate protection
  • Postpone any COVID-19 positive cases, anyone with recent travel history, anyone with potential symptoms of COVID-19 or anyone with COVID-19 contacts
  • Advice should be given to all COVID-19 negative patients undergoing elective surgery to practice social distancing and hand hygiene between the time of testing until the time of surgery.

Personal Protective Equipment (PPE)
 
We also need to protect ourselves and the appropriate use of personal protective equipment (PPE).
 
Any clinician assessing patients suspected or confirmed to be infected with COVID-19 should wear appropriate PPE. Training on the use of PPE is important to reduce the risk of transmission of COVID-19. Most hospitals are conducting PPE sessions, please attend. 
 
The highest regime for PPE for negative COVID-19 tested patients would be a fluid resistant surgical mask, single-use impermeable disposable gown, gloves and eye protection if blood and or body fluid contamination to the eyes or face is anticipated. This applies to examinations including flexible and rigid nasendoscopy. 
 
P2/N95 masks are recommended for COVID-19 positive patients / suspected positive patients requiring aerosol generating procedures – this includes intubation, open suctioning, tracheostomy, high speed drilling and bronchoscopy. Please also refer to guidance from your Local Health District and consult with your local infectious diseases team if in any doubt and note that guidance on this may change.
We have attempted and are continuing to attempt to gain selective access to PPE, but this is proving to be very difficult. We will continue to assist our members as much as possible.
 
Sterilisation of equipment practices are unchanged from standard procedures.

 


The following table outlines levels of precaution for different scenarios in the hospital environment:

 
Table that outlines levels of precaution
 

References:


1. Consensus statement: Safe Airway Society principles of airway management and tracheal intubation specific to the COVID-19 adult patient group, Med J Aust 16 March 2020, David J Brewster, Nicholas C Chrimes, Thy BT Do, Kirstin Fraser, Chris J Groombridge, Andy Higgs, Matthew J Humar, Timothy J Leeuwenburg, Steven McGloughlin, Fiona G Newman, Chris P Nickson, Adam Rehak, David Vokes and Jonathan J Gatward
https://www.mja.com.au/journal/2020/212/10/consensus-statement-safe-airway-society-principles-airway-management-and

2. ENT UK
https://www.entuk.org/advice-ent-examination-reduce-chances-droplet-spread-and-viral-transmission

3. American Academy of Otolaryngology Head and Neck Surgery
https://www.entnet.org/content/academy-supports-cms-offers-specific-nasal-policy

4. Australian Society of Anaesthetists (ASA)
The ASA has developed guidelines based on current evidence and may be subject to change as more information becomes available. They are intended for anaesthetists in Australia. For the latest version, please visit https://asa.org.au/covid-19-updates/ 


5. Department of Health information 

Federal Government Department of Health 
https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert?utm_source=health.gov.au&utm_medium=redirect&utm_campaign=digital_transformation&utm_content=health-topics/novel-coronavirus-2019-ncov


ACT COVID-19 Advice
https://www.health.act.gov.au/health-professionals/chief-health-officer-alerts

NSW COVID-19 Advice
https://www.health.nsw.gov.au/Infectious/diseases/Pages/coronavirus.aspx

NT COVID-19 Advice
https://health.nt.gov.au/health-alerts/novel-coronavirus-covid-19

QLD COVID-19 Advice
https://www.health.qld.gov.au/clinical-practice/guidelines-procedures/novel-coronavirus-qld-clinicians

 

SA COVID-19 Advice
https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/clinical+topics/infectious+disease+control/novel+coronavirus+%282019-ncov%29+infection+for+health+professionals

TAS COVID-19 Advice
https://www.dhhs.tas.gov.au/publichealth/communicable_diseases_prevention_unit

VIC COVID-19 Advice
https://www.dhhs.vic.gov.au/health-services-and-general-practitioners-coronavirus-disease-covid-19

WA COVID-19 Advice
https://ww2.health.wa.gov.au/Articles/A_E/Coronavirus


Disclaimer

The Australian Society of Otolaryngology Head and Neck Surgery has developed this information as guidance for its members. This is based on information available at the time of writing and the Society recognises that the situation is evolving rapidly, so recommendations may change. The guidance included in this document does not replace regular standards of care, nor do they replace the application of clinical judgement to each individual presentation, nor variations due to jurisdiction or facility type.


The Australian Society of Otolaryngology Head and Neck Surgery Limited is not liable for the accuracy or completeness of the information in this document. The information in this document cannot replace professional advice.