10.14639/0392-100X-suppl.1-42-2022-11
The coronavirus disease (COVID-19) pandemic has deeply impacted health, and affects many different medical specialties. Head and neck surgeons, in particular, have been recog- nised 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 dis- eases, in this new phase of COVID-19 pandemic.
text/xml
1827-675X
2114
en
Giada Cavallaro
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
otolaryngology
Recommendations from the Italian Society of Otolaryngology for clinical management during the SARS-CoV-2 pandemic
Text.Serial.Journal
https://www.actaitalica.it/
42
Annual congress report
2022-04-26
2022-04-06
2022-04-28
2022-04-28
S94-S106
1
Giada Cavallaro
2022/04/26
10.14639/0392-100X-suppl.1-42-2022-11
S94
Otolaryngology Unit, Department of Basic Medical Sciences, Neuroscience, and Sense Organs, University of Bari “Aldo Moro”, Bari, Italy
1827-675X
otolaryngology
S106
Recommendations from the Italian Society of Otolaryngology for clinical management during the SARS-CoV-2 pandemic
https://www.actaitalica.it/article/download/2114/782
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42(SUPPL.1):S94-S106; doi: 10.14639/0392-100X-suppl.1-42-2022-11




Recommendations from the Italian Society
of Otolaryngology for clinical management
during the SARS-CoV-2 pandemic
Raccomandazioni della Società Italiana di Otorinolaringoiatria per la gestione
delle attività cliniche durante la pandemia da SARS CoV-2
Nicola Quaranta1, Alessandra Pantaleo1, Antonio Mincione2, Stefano Berrettini3, Domenico Cuda4, Gaetano Paludetti5,
Cesare Miani6, Paolo Petrone7, Claudio Vicini8, Giada Cavallaro1
1
 Otolaryngology Unit, Department of Basic Medical Sciences, Neuroscience, and Sense Organs, University of Bari “Aldo Moro”,
Bari, Italy; 2 Department of Otorhinolaryngology, ASST-OVEST Milanese, Magenta, Italy; 3 Otolaryngology, Audiology and Phoniatrics
Unit, University of Pisa, Pisa, Italy; 4 Department of Otorhinolaryngology, “Guglielmo da Saliceto” Hospital, Piacenza, Italy; 5 Head
& Neck Department, Università Cattolica del Sacro Cuore, Rome, Italy; Otorhinolaryngology and Head & Neck Surgery Unit,
Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Rome, Italy; 6 Department of Otorhinolaryngology, Hospital of Tolmezzo,
ASUFC Udine, Udine, Italy; 7 Directorate General, ASL BA, Bari, Italy; 8 Department of Head-Neck Surgery, Head-Neck and Oral
Surgery Unit, Morgagni Pierantoni Hospital, Forlì, Italy


SUMMARY
The coronavirus disease (COVID-19) pandemic has deeply impacted health, and affects
many different medical specialties. Head and neck surgeons, in particular, have been recog-
nised 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 dis-
eases, in this new phase of COVID-19 pandemic.
KEY WORDS: recommendations, COVID-19, PPE, surgery, head and neck, otolaryngology

RIASSUNTO                                                                                         Received: January 28, 2022
                                                                                                  Accepted: February 2, 2022
La pandemia di COVID-19 ha avuto un profondo impatto sulla salute delle persone, e
colpisce molte diverse specialità mediche. I chirurghi della testa e del collo, in particolare,
                                                                                                  Correspondence
sono stati riconosciuti come i professionisti a più alto rischio di infezione, attraverso le
                                                                                                  Nicola Quaranta
procedure diagnostico-terapeutiche generatrici di aerosol come parte del loro lavoro. Lo          Otolaryngology Unit, Department of Basic Medical
scopo di questo documento è quello di rivedere la letteratura attuale sull’argomento, per         Sciences, Neuroscience, and Sense Organs, Univer-
fornire raccomandazioni utili al fine di evitare sia l’esposizione al contagio dei sanitari che   sity of Bari “Aldo Moro”, 70125 Bari, Italy
il ritardo nella diagnosi e nel trattamento delle malattie della testa e del collo, in questa     E-mail: nicolaantonioadolfo.quaranta@uniba.it
nuova fase della pandemia COVID-19.
PAROLE CHIAVE: raccomandazioni, COVID-19, PPI, chirurgia, testa e collo,                            How to cite this article: Quaranta N, Pantaleo A,
otorinolaringoiatria                                                                                Mincione A, et al. Recommendations from the Italian
                                                                                                    Society of Otolaryngology for clinical management
                                                                                                    during the SARS-CoV-2 pandemic. Acta Otorhi-
Introduction                                                                                        nolaryngol Ital 2022;42(SUPPL.1):S94-S106.
                                                                                                    https://doi.org/10.14639/0392-100X-sup-
COVID-19 pandemic is an ongoing global pandemic caused by severe acute                              pl.1-42-2022-11
respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes a wide
                                                                                                  © Società Italiana di Otorinolaringoiatria
range from mild to severe symptoms and is mainly transmitted from person to                       e Chirurgia Cervico-Facciale
person via respiratory droplets 1.
During the early phase of the pandemic, considering the high risk of contagion                                   OPEN ACCESS
and the need to treat COVID-19 patients, in many hospitals elective surgical and                  This is an open access article distributed in accordance with
                                                                                                  the CC-BY-NC-ND (Creative Commons Attribution-Non-
non-urgent procedures had to be postponed to conserve resources and limit ex-                     Commercial-NoDerivatives 4.0 International) license. The
posure. As a consequence, the pandemic has deeply impacted people’s health, as                    article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
it has affected many different medical specialties. Head and neck surgeons, in                    only in the original version. For further information: https://
particular, have been recognised as one of the professionals at the highest risk                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                            SARS CoV-2 pandemic Italian Otolaryngology recommendations




of infection through aerosol-generating procedure as part                         Outpatient clinic
of their usual job. In this context, in the early phase of pan-
demic, clinical and surgical procedures were restricted to
procedures that could impact disease prognosis if delayed.                        Before patient visit
In the last year, instead, thanks to COVID-19 containment                         The waiting room and public areas must have measures
measures adopted by world governments and large-scale                             in place to implement social distancing and all the non-
deployment of vaccines, there has been a gradually return                         essential objects should be removed from them. In order
to the routine pre-COVID-19 era.                                                  to minimise the number of patients in the waiting room
The aim of this document is to provide useful recommen-                           and to maintain the strictest hygiene regime, appointments
dations in order to avoid delay in the diagnosis and treat-                       should be scheduled every 20-30 min. Patients must have
ment of head and neck diseases in this new phase of the                           and show their COVID-19 green certificate in order to ac-
COVID-19 pandemic.                                                                cess to the consultation room. With the last Italian regula-
                                                                                  tions, the COVID-19 green certificate is a free document in
                                                                                  digital and printable format which attests to one of the fol-
Standard precautions during patient care                                          lowing criteria: vaccination against COVID-19, a negative
To minimise the risk of infection transmission in clinical                        antigenic or molecular swab taken within the last 48 hours,
practice, healthcare workers and patients must follow hand                        or recovery from infection.
hygiene, physical distancing and wear personal protective                         In case of lack of the COVID-19 certification, patients are
equipment (PPE).                                                                  requested to fill out a COVID-19 self-declaration form and
                                                                                  will have to present a negative molecular swab performed
Hand hygiene 2                                                                    within 48 hours or rapid antigenic test within 24 h.
Hand hygiene should be performed at 5 specific moments:                           The waiting room must provide areas of 4 square me-
• before touching a patient;                                                      tres (2 m x 2 m) for each patient and any accompany-
• before a procedure;                                                             ing person, marked on the floor with stencils or stickers;
• after procedure or body fluid exposure risk;                                    there must be a minimum distance of 1 metre between
• after touching patient;                                                         each area. Physical distancing is to be maintained be-
• after touching a patient’s surroundings.                                        tween staff and patients and between staff and staff. Staff
                                                                                  and patients must remain at least 1.5 metres apart with
Personal protection equipment (PPE)                                               the exception of clinical examinations and procedures.
• Latex, nitrile or vinyl gloves are recommended during                           Unnecessary items must be removed from the clinic, in
  all medical procedures; double gloving is recommended                           order to facilitate transit, order and subsequent cleaning
  as a protective measure during surgical practice.                               and disinfection.
• Sanitary staff, to protect the mucus membrane of the                            Patients should come alone or bring only one accompany-
  eye, nose and mouth during procedure that may generate                          ing person if essential (e.g. children, pregnant woman, pa-
  splashes or sprays of blood, body fluids, excretions and                        tients with disabilities or in case of language barriers) who
  secretions should wear goggles and face shields. Per-                           must have and show a COVID-19 green certificate. In case
  sonal eyeglasses and contact lenses are not considered                          of lack of COVID-19 certification, each caregiver must fill
  adequate eye protection.                                                        out a COVID-19 self-declaration form (Tab. I) and undergo
• During all medical procedures healthcare workers must                           a molecular test by swab with negative result 48 hours prior
  wear facial mask (FFP2); during aerosol-generating pro-                         to entering to the hospital. Non-touch temperature check is
  cedures* FFP3 must be worn 3.                                                   mandatory for entry in the building. Both healthcare work-
• Medical scrubs or company uniforms are recommended;                             ers, patients and their relatives should wear adequate PPE.
  machine wash workwear immediately after daily use.
• It is recommended to avoid jewellery while working, as
  they can be virus reservoir 4.                                                  Table I. S-declaration form. Last 14 days.
                                                                                   Fever (> 37.4°)                             Yes           No
                                                                                   Cough or respiratory signs                  Yes           No
*
  Ear, Nose and Throat (ENT) procedures that generate aerosols are: intubation-    Dysgeusia, anosmia                          Yes           No
extubation, oropharyngoscopy and manoeuvres on the oral cavity/oropharynx,
nasal and laryngeal endoscopy, gastrointestinal endoscopy, drainage of peri-       Fatigue or malaise                          Yes           No
tonsillar abscess, nasal tamponade, removal of foreign bodies from the airways,    Diarrhoea or digestive discomfort           Yes           No
tracheostomy, change of cannula and management of the tracheostomy, use of
motorised instruments in head and neck surgery (bur, microdebrider, etc).          COVID-19 contact (suspected or confirmed)   Yes           No




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Frequent opening of doors or windows can increase venti-        Audiology testing
lation in indoor settings and reduce COVID-19 transmis-         As a closed space, the audiometry booth is considered
sion.                                                           to be high risk of accumulation of viral load, and dif-
It is recommended to clean all surfaces frequently and to       ficult to disinfect. For these reasons, different precau-
remove all unnecessary items from waiting rooms. This           tions should be taken during the audiometry tests. Pa-
includes toys, magazines, books and brochures etc.              tients must wear face masks during tests, sanitise their
                                                                hands before entering the booth and should sit in the
Patient visit                                                   chair without touching anything. It is advisable to use
Exam room consideration                                         a recording, and never a live voice, during vocal tests
Patients should be unaccompanied unless absolutely neces-       and to use protective individual earphone covers (sepa-
sary if they require a caregiver or translator. To minimise     rate covers for each earphone that must be replaced after
environmental contamination, we recommend decluttering          each test). Allow enough time between patients for full
the exam room space by removing hand-outs, models and           booth air exchange and to clean and disinfect the test
exposed equipment. All paper materials and unnecessary          booth equipment after each test 7.
items must be removed as much as possible. The micro-           In case of newborn hearing screening programme:
scope used during otologic examination should be routinely      • the newborn must be accompanied by only one parent;
covered with a sterile, clear drape and frequent sanitization   • the parent must be screened at triage and use both a
of the instrument is recommended. Ensure the exam room              mask and gloves;
doors are closed, and only essential staff should be in the     • the PC keyboard and cables must be covered with trans-
examination room. Whenever possible, disposable instru-             parent film or properly disinfected after each perfor-
ments must be used. Containers must be used for infected            mance;
and sharp disposable instruments. Single-use instruments        • it is preferable to use inserts and in the case of use of
should preferably be used and placed in special containers          headphones, these are coated with disposable material;
for disposal after use. We do not recommend the use of a        • it is necessary to cover the stroller with disposable mate-
mobile phone in the examination room, but should it for             rial;
any reason be carried inside, it is recommended to cover it     • it is necessary to place a disposable towel on the stroller;
with plastic protection. Adequate ventilation of the room is    • it is necessary to allow for a longer time to carry out the
also recommended.                                                   exam;
ENT examination                                                 • it is recommended to maintain traceability of chil-
                                                                    dren who have not been screened because of the
Airway endoscopies
                                                                    COVID-19 emergency and specify that they must be
During the pandemic, it is useful to assess in advance
                                                                    rescheduled.
whether endoscopic examination is necessary or whether
it can be delayed.                                              Patients with tracheostomy
As endoscopic procedures can easily aerosolise SARS-            Patients with tracheostomy with positive or unknown status
CoV-2, ENT specialists should be equipped with adequate         of COVID-19 should always be examined using enhanced
PPE (fluid-resistant FFP3/N95 mask, double-gloving, full        PPE. Cases with confirmed negativity for COVID-19 may
face shield, head and shoe covers). The patients should         be cautiously evaluated using standard PPE. If a patient
only partially lower their mask during the exam to mini-        requires an in-office visit, it is important that the trache-
mise droplet production and transmission, and endoscopy         ostomy is equipped with adhesive baseplates and a heat
should be carried out by video monitoring in order to in-       moisture exchanger that filters viral or bacterial particles.
crease physical distance from patient’s face 5; ensuring        The tracheostomy must additionally be covered by a surgi-
adequate local anaesthesia to reduce cough and sneezing         cal mask.
reflexes 6. High-level disinfection should be used for clean-   It is recommended to change the tracheostomy tube in an
ing rooms and instruments; if available use disposable na-      outpatient setting, if possible/available, and to use a con-
sopharyngoscopy equipment, including the nasoendoscope          verted room with negative pressure or with frequent air
itself or sterile covers.                                       changes. The foresight to cover the area of the stoma with
Microscope                                                      a cloth (preferably transparent) and perform the cannula
If possible, use disposable items for each patient. After ex-   change under a covered sky is demonstrated to be of practi-
amination, sanitise the areas close to or in contact with the   cal use. For this procedure, it is recommended to use en-
patient, the lens and the binocular area.                       hanced PPE.



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Post-visit                                                        screening is not available, the patient should be treated as
• Disposable instruments are placed in special containers         potentially positive and PPE (N95/FFP2 and N99/FFP3
  after use.                                                      masks, goggles, face-shields, full-body covering gowns)
• A thorough cleaning and disinfection of all surfaces            must be kept ready to use 9.
  and areas in contact with the patient should be carried
  out with a disposable cloth, leaving the product to act         Head and neck oncology management
  for at least 2 minutes. The usual cleaning and disinfec-        As mandated by the COVID-19 context, social contacts
  tion products are effective against coronavirus (0.1%           must be limited to minimise viral transmission. Therefore,
  sodium hypochlorite solution; 30 ml common bleach               the reorganisation of the management of oncologic patients
  per litre of water).                                            is needed.
• High-level disinfection procedures must be performed            The stage of the head and neck cancer defines the extent
  for equipment such as rigid and flexible endoscopes.            of the tumour and is also determined by complete physical
  Disinfection will follow the usual clinical routine with        examination of head and neck district.
  phenolic compounds, peracetic acid and 10% sodium               Our society recommends the use of telemedicine for tu-
  hypochlorite. Alternatively, protective sheaths may be          mour boards and for multidisciplinary oncological evalu-
  used.                                                           ation. Malignant tumours of any site, with clinical lymph
• Rooms must be ventilated.                                       node involvement, amenable to surgical treatment, have the
• It may be considered useful to cover the computer key-          highest priority 10.
  board with plastic wrap. The mouse needs to be sanitised        Malignant tumours of any site without clinical lymph node
  with particular care.                                           involvement and amenable to surgical treatment, have pri-
                                                                  ority proportional to the T value of the TNM 8th classifica-
Priority visit                                                    tion, considering the possible evolution of the disease to-
In relation to the need to prioritise patients at risk for head   wards unresectable.
and neck neoplasms, it may be useful to implement pro-            With the same T of the malignant lesion, tumours of the
grams such as the Head and Neck Cancer Risk calculator            oral cavity/oropharynx should be given priority, followed
(available at http://orlhealth.com/risk-calculator-2.html).       by cancers of the hypopharynx/larynx, salivary glands and
                                                                  paranasal sinuses. However, clinical (symptomatology)
Tele-health                                                       and histological (grading and malignancy of the histotype)
The implementation of Telehealth systems will help to re-         factors must be taken into consideration.
duce access to ENT visits for patients with deferable pa-         Thyroid carcinomas must have priority over those of other
thologies.                                                        districts only in case of locally advanced or symptomatic
                                                                  T4 lesions (tracheal compression).
Operating setting                                                 Computerised tomography (CT) scan of the chest is always
                                                                  recommended to assess lung metastases in clinical stag-
                                                                  ing of the tumour.
Elective surgical procedure: preoperative diagnostic
                                                                  Preoperative CT imaging should be also considered to
assessment
                                                                  identify suspected active SARS-CoV-2.
Before surgery, a nasopharyngeal swab for real-time Poly-
                                                                  Molecular tests and serological tests must always be per-
merase Chain Reaction (RT-PCR) testing should be per-
                                                                  formed even in asymptomatic patients 10.
formed 48 h prior to surgery; strict quarantine awaiting
test results is recommended. On the day of admission, the         Surgical oncology setting
patient needs to be screened to COVID-19 symptoms/signs           Our society recommends to establish COVID-19-dedicated
and must undergo a rapid antigen test or PCR test 8. If a         operating room(s) with independent ventilation and nega-
patient tests positive for SARS-CoV-2, non-emergency sur-         tive pressure systems separate from those of the other op-
gical procedures should be delayed until the patient is no        erating rooms.
longer infectious.                                                Twenty-five air changes per hour may be the minimum re-
                                                                  quired.
Urgent surgical procedure                                         Endotracheal intubation must be performed in order to
All surgical patients who are waiting for hospital admission      avoid cuff leaks: this is a fundamental point in laryngeal
and urgent surgery must undergo RT-PCR nasopharyngeal             surgery which often involves the use of small diameter
swab test at the emergency department. If the COVID-19            tubes to facilitate exposure of the surgical field.



                                                                                                                               S97
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It is important to limit the use of powered electrical instru-   Tracheostomy care
ments for shedding viral particles from blood and to use         Staff caring for patients should be properly educated on
as little as possible suction and electrocautery that are also   COVID-19 airway management (such as using closed
considered aerosol-generating instruments.                       suctioning, cannula care) as these are high-risk (to staff)
If the patient has negative COVID-19 status, we recom-           scenarios, because of the direct communication with the
mend the use of two surgical caps, two pairs of surgical         respiratory tract.
gloves, a surgical mask and eye protection.                      Bronchial tree toilets including suctioning must be per-
In case of suspected COVID-19 infection or positive              formed using enhanced PPE.
PCR, the surgical team must wear two surgical caps, two          It is important to educate the patient as early as possible
pairs of surgical gloves, a suit and surgical gown or two        to be autonomous in the management of the tracheostomy.
water-resistant surgical gowns, surgical shoes with dis-         ENT specialists should educate patients not to touch their
posable covers, FFP2/3 and surgical mask and eye pro-            tracheostomy, and to wash their hands every time they have
tection.                                                         contact with the stoma.
Postoperative period                                             Follow-up
                                                                 Telehealth consultations should play a central role also in
Communication between hospital staff and family mem-
                                                                 the follow-up of head and neck cancer patients.
bers should preferably be done electronically.
                                                                 In the outpatient clinic visit, the ENT staff must pay attention
After surgery, patients are transferred to the recovery room,
                                                                 to the management of the tracheostomy if still present and of
where anesthesiologist consultation is immediately avail-
                                                                 the related implanted devices (e.g., voice prostheses).
able 10.
                                                                 If not strictly necessary, it is advisable to postpone the start
It is recommended to adopt maximum safety measures up
                                                                 of the speech therapy (in hospital).
to the swab test result during wound dressings.
                                                                 In case of use of a heat moisture exchanger, we recommend
Patients with head and neck tumours are frequently affect-
                                                                 the use of a “hands-free” tracheostoma valve.
ed by various comorbidities, such as chronic obstructive
pulmonary disease (COPD), arterial hypertension, type 2          Otology and otoneurological surgery
diabetes, heart failure (NYHA class II-III), chronic renal       The exposure risk during otologic procedures is unclear,
failure and gastro-oesophageal reflux disease.                   but it stands to reason that virus aerosolisation can also oc-
In these cases, the postoperative course may lead to diffi-      cur during middle ear procedures because of the continuity
culties in the differential diagnosis between a complication     with the nasopharynx 8,11.
related to surgery and SARS-CoV-2 infection.                     Mastoidectomy with bone drilling can generate high vol-
A systematic postoperative management protocol is char-          umes of aerosolised particulate and is considered a high-
acterised by:                                                    risk procedure. Emergent and urgent ear surgeries are rela-
• time-temperature curve;                                        tively uncommon compared to many other otolaryngologic
• SpO2 monitoring in patients with active COPD, espe-            procedures 12.
    cially if undergoing tracheostomy;                           Given the risk of exposure to potentially infectious aero-
• markers of inflammation and tissue damage (C-reactive          sols with the use of high-speed drills in patients with COV-
    protein, procalcitonin, erythrocyte sedimentation rate,      ID-19, patients with unknown status of COVID-19 should
    lactate dehydrogenase, complete blood count, D-dimer,        always be approached using enhanced PPE.
    leukocyte count).                                            Cases with confirmed negativity for COVID-19 may be
In case of dyspnoea and desaturation, it is recommended          cautiously evaluated using standard PPE.
to contact an infectious disease specialist and evaluate the     To minimise the operating time, the team must consist of
need for an emergency chest CT. In case of suspected infec-      expert surgeons.
tion, after transfer to an area dedicated to COVID-19 pa-        Only essential staff should be in the operating room.
tients, it is recommended to perform nasal and oropharyn-        We recommend inducing controlled hypotension to de-
geal swabs, repeated at 24 hours.                                crease intraoperative blood loss and to improve operating
It is recommended to adopt maximum safety measures up            conditions.
to the swab test result during wound dressings.                  The operative microscope does not offer protection for the
In case of negative swab test, a pneumological evaluation        eyes in practice (we recommend the surgical team to use
                                                                 and maintain PPE correctly).
SpO2 and arterial blood gas (ABG) should be monitored
for 24 hours. This assessment must be repeated before dis-       Tracheotomy in COVID-19 patients
charge to assess the possible need for home oxygen therapy.      As an aerosol-generating procedure, tracheostomy is as-



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                                                                         SARS CoV-2 pandemic Italian Otolaryngology recommendations




sociated with high droplet and particle generation, placing     Surgical intervention steps
healthcare providers at increased risk for transmission of
respiratory viral infections.
                                                                Before tracheal incision
We have based our guidelines upon consensus from the
                                                                • Expose the trachea.
currently available literature to form a pragmatic and safe
                                                                • Inform the anaesthetist of readiness to open the trachea.
approach 13-16.
                                                                • Confirm paralysis.
Tracheostomy is a common procedure in critically-ill pa-        • Pre-oxygenate with PEEP then stop ventilation and turn
tients who require an extended period on mechanical ven-          off flows.
tilation.                                                       • Allow time for passive expiration.
The advantages in COVID-19 patients can include offering a      • Push the tube beyond the point of the tracheal incision.
closed system for respiratory support. This may be preferable   • Hyperinflate cuff and re-establish oxygenation with
to primary extubation with a high risk of failure, a require-     PEEP.
ment for high-flow oxygen or non-invasive ventilation.          • When adequately oxygenated, communicate clearly and
Tracheostomy also allows a lower requirement for sedation         stop ventilation prior to opening the trachea.
and facilitates less invasive nursing care.
We suggest creating an “airway management team” with            Tracheal incision
representation from anaesthesiologists and otolaryngolo-        • Create tracheal window taking care to avoid the endotra-
gists, which forms a cross-specialty working group to de-         cheal tube cuff.
sign the tracheostomy team using shared expertise.              • Prepare the tracheal window preferring Metzembaum
Early planning and staff training is essential and can ensure     scissors over surgical blade # 11.
adequate expertise minimising exposure risk for healthcare      • Ensure the window is of sufficient size to allow easy in-
personnel.                                                        sertion of the tracheostomy tube without breaking the
                                                                  cuff.
                                                                • Create the stoma with numerous detached stitches with
            Tracheotomy in COVID-19 patients                      braided thread, non-absorbable, and needle with a small
                                                                  curvature (to limit the risk of damaging the tube).
  PPE: We recommend full PPE for all aerosol-generating         • Stop flows, allow passive expiration, consider clamping
                procedures including:                             the endotracheal tube.
                          FFP3 mask;                            • Deflate the endotracheal tube cuff and drawback proxi-
                         eye protection;                          mal to the tracheal window under direct vision.
                     head and face shield;                      • Insert a cuffed, non-fenestrated tracheal tube.
 fluid-repellent disposable surgical gown with long sleeves;    • Immediately inflate the tracheostomy tube cuff.
                  two pairs of surgical gloves;                 • Replace the introducer with a non-fenestrated inner tube
            surgical shoes with disposable covers;                and heat moisture exchanger.
                       two surgical caps.                       • Fast attachment of circuit.
PLACE: operating theatre. If it is not possible, it should be   • Resume ventilation.
performed at bedside in the intensive care unit (with closed    • Confirm the position of the tube in a 30° head-up position.
              doors during the procedure).                      • Confirm position with end-tidal CO2 only (avoid con-
       PATIENT: the team must review indications for              tamination of stethoscope by auscultation).
      tracheostomy; specifically, timing and prognosis.         • Withdraw clamped endotracheal tube carefully.
 EQUIPMENT: pre-prepared tracheostomy sets (only use            • Secure tube with sutures and tracheostomy tapes and use
  cuffed, non-fenestrated tracheostomy tube) and ensure           appropriate dressing.
       there is an adequate supply in various sizes.            • Doffing of PPE in the appropriate area.
Establish a system to record what has been used and what
                     needs restocking.                          Post-procedure
    COVID Airway Team: designate staff to form a core
                  COVID-19 Airway Team.                         Nursing care
 The suggested team makes up of at least two ENTs and           • Use only in-line closed suction circuits at all times.
   one anaesthetist experienced in head & neck surgery.         • Periodically check cuff pressures (the cuff should not
    Run simulation training with all key staff on location.       be deflated without considering risks to the patient, staff
             WHEN: semi-elective procedure.                       and environment).



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• Do not change dressings unless there are signs of infec-      • using instrumentation that limits the risk of aerosolisa-
  tion.                                                            tion or vaporisation of micro-fragments of tissue con-
                                                                   taminated with the virus. Drilling and use of a microde-
First tube change
                                                                   brider should be avoided;
• Delay first tube change to 7-10 days.
                                                                • it is advisable to apply disinfectant solutions to the nasal
• Use full PPE.
                                                                   cavities and the oral cavity/oropharynx.
• Perform the same sequence of pause in ventilation with
                                                                For COVID-19 positive patients, procedures should be
  flows off before deflating the cuff and insert new tube
                                                                postponed until after swab test is negative, when feasible.
  with immediately re-inflation of cuff and reconnection
                                                                In urgent cases, recommendations in managing patients
  of circuit.
                                                                with positive COVID-19 status are to wear appropriate
Intensive care unit discharge                                   PPE, including:
• Ideally to a dedicated COVID-19 tracheostomy ward             • two surgical caps;
  with trained nursing staff.                                   • two pairs of surgical gloves;
• Cuffed non-fenestrated tube to be used until the patient      • surgical shoes with disposable covers;
  confirmed COVID-19 negative.                                  • FFP3 mask;
• Subsequent planned tube changes at 30 day intervals.          • eye protection;
Decannulation                                                   • fluid-repellent disposable surgical gown;
• If the patient is confirmed COVID-19 negative and is to       • helmet;
  be moved to a COVID-19 negative ward, consider trials         • goggles.
  of cuff deflation.                                            In case of unknown COVID-19 status, we recommend:
• Readiness for decannulation should be made after verify-      • two surgical caps;
  ing that the patient is able to return to normal breathing.   • two pairs of surgical gloves;
                                                                • surgical shoes with disposable covers;
                                                                • FFP2 or FFP3 mask + surgical mask;
Urgent tracheostomy                                             • eye protection;
If COVID-19 status cannot be determined, patients should        • fluid-repellent disposable surgical gown;
be considered as positive and the surgery should take place     • helmet;
in full COVID-19 precautions and in a dedicated operating       • goggles.
room.                                                           In case of negative COVID-19 status, we recommend:
Insufficient precaution in managing a false-negative COV-       • one surgical cap;
ID-19 patient could cause contagion to surgical staff and       • one pair of surgical gloves;
negative patients.                                              • surgical shoes with disposable covers;
                                                                • surgical mask;
Endoscopic sinonasal and skull base surgery                     • eye protection;
The sinonasal cavity has consistently reported high viral       • fluid-repellent disposable surgical gown.
loads.                                                          Adequate advice should be provided to COVID-19 negative
Endoscopic sinonasal and skull base surgery necessitates        patients who undergo surgery to adhere to proper hygiene-
extensive manipulations within the nose/paranasal sinuses.      behavioural rules during the post-operative period, such
Elective cases should be deferred and emergent/urgent           as wearing an FFP2 + surgical mask. We also recommend
cases should be treated as high risk for COVID-19 expo-         limiting postoperative endonasal dressings and prescribing
sure 17-19.                                                     therapy to reduce sneezing and aerosol generation.
Our society recommends:
• the execution of two nasopharyngeal swabs, distanced          Paediatric ENT clinical and surgical
   by at least 24 hours, to improve the sensitivity of the
   method;
                                                                management
• surgery to be performed in dedicated negative-pressure        ENT specialists caring for paediatric patients must adapt to
   operating theatre with high frequency (25/h) of air ex-      changes of the COVID-19 era and reconsider many routine
   changes;                                                     management strategies 20,21:
• minimise the number of staff in the operating room. The       • transmission: as in the adult population, the primary
   team should consist of expert surgeons. Observers must         mode of transmission of the infection appears to be via
   be excluded from operating sessions;                           respiratory droplets and aerosols, although faecal-oral



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                                                                        SARS CoV-2 pandemic Italian Otolaryngology recommendations




  transmission may also occur. It is important to effec-        Rhinosurgery
  tively sanitise surfaces that may have been exposed to        For semielective and semiurgent procedures (e.g., bilater-
  children;                                                     al choanal atresia repair) surgery must not be postponed.
• clinic: COVID-19 symptoms seem to be less severe in           As in adults, to minimise the dissemination of aerosolised
  children than in adults and include fever, dry cough,         viral particles in patients with unknown, suspected, or
  headache, myalgia, gastrointestinal disorders, anosmia        positive COVID-19 status, surgical indications should be
  and dysgeusia. Children often can be asymptomatic car-        limited.
  riers. Acute breathing difficulties are rare.
                                                                Otological surgery
• general considerations: telephonic triaging should be
                                                                Surgery is necessary in life-threating complications such as
  used to identify patients and their family members with
                                                                acute mastoiditis or sinusitis with complications.
  COVID-19 symptoms. Temperature screening must be
  carried out both on the patient and on the child’s car-       Cervical surgery
  egiver upon access to the clinic.                             Surgery of neoplastic neck masses and abscesses should
                                                                be ensured.
Outpatient clinic children management
As expected for adults, for all procedures the healthcare       Management of paediatric emergencies
worker must use personal protective equipment which in-
cludes: FFP2 or FFP3 mask and surgical mask, protective         In order to avoid overload of the healthcare system, emer-
goggles, gloves and disposable gown.                            gency management in children must be aimed at simultane-
Gloves must be changed after each visit/exam. It is impor-      ously minimising hospitalisation and the risk of complica-
tant to provide for the use of PPEt for the patient and for a   tions.
single caregiver who must still be present during the visit.    Emergency management is at a high risk of transmission of
                                                                the infection due to the close contact between patient and
Otolaryngological visit                                         operator and the agitation of the small patient. The PPE and
Treatment of the paediatric patient must be limited to ur-      assessment procedures for SARS-CoV-2 infection before
gent cases or with a pathology that requires short-term vis-    and during hospitalisation are comparable to those indicat-
its and indispensable postoperative care. The child must be     ed in the guidelines for adults.
examined in a dedicated space using disposable material as
much as possible, using PPE and with adequate ventilation       Foreign bodies
of the rooms and sterilisation of surfaces between visits.      Foreign bodies in the upper respiratory tract and ear must
                                                                be removed on an outpatient basis if clearly visible and
Nasal endoscopy                                                 easily accessible. In case of difficulty in removing it in
Upper respiratory tract endoscopy should be limited to re-      an outpatient clinic or in the emergency room, it is advis-
stricted indications because of a high risk of viral spread     able to hospitalise the patient to carry out the procedure
in the air. The precautions to be taken in case of endos-
                                                                under sedation or general anaesthesia. As for the inhala-
copy are the same as for adults. We recommend the use of
                                                                tion of foreign bodies, certain or suspected, it is one of
small calibre optics and the use of a monitor to avoid close
                                                                the urgent needs that cannot be deferred under general
contact with the small patient and, if possible, the use of
                                                                anaesthesia.
disposable sheaths for the fibrescope associated with lubri-
cating gel with an anaesthetic effect.                          Epistaxis
                                                                Epistaxis must be considered a condition with a high risk
Hospitalization                                                 of transmitting the infection. Epistaxis management must
Determining which surgical procedures are elective de-          be performed by anterior tamponade on an outpatient ba-
pends on many unique patient factors. Elective surgery,         sis or in the emergency room, minimising cases of hos-
typically non-emergency and scheduled in advance, should        pitalisation and invasive treatment. A different approach
be considered upon assessment of all available medical and      should be reserved for the patient with a haematological
logistical information.                                         pathology.
Tonsillectomy and adenoidectomy                                 Fracture of nasal bones
The residual indications for this intervention are major        In the absence of a nasal septal haematoma or aesthetic na-
adenoid-tonsillar hypertrophy with severe obstructive sleep     sal deformity, it is recommended to not perform reduction
apnoea syndrome (OSAS).                                         of nasal fracture.



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N. Quaranta et al.




Complicated acute rhinosinusitis with orbital                   it prudent to determine if endoscopic examination is nec-
or intracranial extension                                       essary or if it can be delayed 23-27. Powered application of
Prior to considering surgical therapy, children who require     aerosol anaesthetics and decongestants are discouraged
hospital admission for complicated acute rhinosinusitis         in favour of hand-held spray or lidocaine/decongestants
with orbital extension but without vision or globe compro-      pledget. Another option is to ask patients to prespray de-
mise should be trialed on a course of medical treatment.        congestants into the nasal cavity prior to visit.
Abscess                                                         Audiology assessment
Incision and drainage of the abscess have been suggested in     It is always recommended that staff adhere to patient
the case with no improvement or failure to respond to ap-       screening, hand hygiene, social distancing and mask wear-
propriate medical treatment. Tonsillar and parapharyngeal       ing precautions (audiologist and patient) 28.
abscesses require hospitalisation to initiate intravenous an-   Head and neck oncology/head and neck cancer
tibiotic therapy.                                               (HNC) surgery
Acute mastoiditis                                               First consultation for new referrals should be managed by
Initial medical/non-surgical management is suggested.           videoconference or telephone to assess the necessity of ur-
Acute mastoiditis with convalescence, complicated mas-          gency to evaluate the patients in person. All patients should
toiditis and complicated acute otitis media require prompt      have a phone screening to detect symptoms of COVID-19
surgical treatment within 24 to 48 hours.                       and for contact with positive cases prior to visiting.
                                                                New patients with high suspicion for malignancy require
Tracheostomy                                                    face-to-face visits, telemedicine consultation or appoint-
Elective tracheostomy should be postponed pending con-          ment deferral 29. According to the Irish Head and Neck So-
trol of the COVID-19 pandemic.                                  ciety 30, patients at risk of suffering from complications of
Tracheostomy that cannot be postponed must be performed         COVID-19 should be prioritised to minimise the time in
using cuffed tracheotomy tube in a dedicated environment.       hospital when phone consultation is not an option.
Tracheotomy tube changes must be limited to a minimum           Patients with aggressive cancers still need to be operated
and preferably carried out at home.                             on quickly despite the pandemic. It is our responsibility to
                                                                make sure that these patients are operated on within the
                                                                expected time. The results of research conducted on HNC
Discussion                                                      management in South Tyrol showed, in fact, a statistically
                                                                significant difference in the number of diagnoses before
General considerations                                          and after lockdown, accompanied by a worsening of clini-
General care of ENT patients                                    cal T-stage at diagnosis, with a significant delay in the di-
                                                                agnosis of early cT-staged HNCs 31.
During the COVID-19 pandemic, effective biosafety pre-
                                                                According to French consensus 32, the waiting time rec-
cautions have been implemented in all clinics and hospitals
                                                                ommended for oncological surgeries is divided into three
because most infected patients are not symptomatic and
                                                                groups:
may have been exanimated only with inadequate protec-
                                                                1. Patients requiring emergency surgeries, which typically
tion 1-4. Otolaryngologist examination can produce aero-
                                                                   include cancers with airway compromise or with haem-
sols. Even patients examined later in the same room are at
                                                                   orrhage.
elevated risk. Consequently, healthcare professionals are at
                                                                2. Surgeries that should not be rescheduled for more than
high risk of contamination. Structured telephone triaging
                                                                   4 to 6 weeks, such as high stage squamous cell can-
can be used to separate low-risk from high-risk patients,
                                                                   cers of the aerodigestive tract (oral cavity, oropharynx,
with the latter cohort being seen sooner. Such patients can
                                                                   larynx, hypopharynx and nasopharynx), cancers with
be reassessed at a later time when the acute pandemic as-
                                                                   impending airway compromise, high grade or progres-
sociated issues are resolved. This approach has been sup-
                                                                   sive salivary gland cancers, T3 or T4 melanoma, skin
ported by ENT-UK, the British Association of Otolaryngol-
                                                                   cancers with regional disease or with progression, thy-
ogy - Head and Neck Surgery 22.
                                                                   roid cancers with aerodigestive invasion or with locore-
                                                                   gional metastasis or with progression, anaplastic thy-
Outpatient exams
                                                                   roid cancers and recurrent or persistent cancers which
Nasopharyngolaryngoscopy/rigid nasal endoscopy                     require salvage surgery.
During the pandemic, all guidelines agree in considering        3. Surgeries that can be postponed for more than 6 weeks,



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                                                                         SARS CoV-2 pandemic Italian Otolaryngology recommendations




   such as low-grade squamous cell cancers of the upper         be done after 7-10 days and subsequent change can be de-
   aerodigestive tract, low-grade and non-progressive sali-     layed 30 days after 41.
   vary gland cancers, non-progressive and non-metastatic       Cuffed tracheostomy tubes are recommended for COV-
   skin cancers, well-differentiated thyroid cancers (pap-      ID-19 positive individuals 16.
   illary and follicular thyroid cancers), medullary thyroid    Otologic clinic and surgery
   cancers and superficial lesions of the vocal cord.           Otoscopy, binocular microscopy, cerumen debridement (re-
According to all the other guidelines we considered, the sur-   quiring examination within 3 feet) on suspected or known
gery must be performed in a designated operating room with      COVID-19 patient encounters should proceed only with
negative pressure and only essential staff should be inside.    enhanced PPE. It is recommended to use curettage instead
The level of PPE required depends on the patient’s COV-         of drilling to limit aerosolisation during mastoidectomy,
ID-19 status: our society recommends performing two             regardless of COVID-19 status. If drilling is required, it is
nasal swabs (using PCR-RT) at 4 days and 2 days prior           recommended to use a slow drilling speed, reduce irrigation
to admission and the use of antibody testing (IgM + IgG)        volume and use effective suction to reduce aerosolization 8.
if available. Other societies recommend a single test 24 h      All the guidelines considered agree that necessary otologic
prior to surgery.                                               procedures on positive, suspected, or unknown COVID-19
Although head and neck oncologic patients require chest         status patients should be performed using enhanced PPE
CT to complete cancer staging, the guidelines from France       including eye protection. It is also recommended to use
recommend chest CT 24 h before surgery 10.                      PAPR if high-speed drills are required 8,11-13.
According to the American Academy of Otolaryngology,            Myringotomy and ventilation tube placement for unilateral
cold dissection should be practiced 33.                         persistent effusion should be performed in a contained en-
Transoral robotic surgeries (TORS) are not recommended          vironment: it is considered purely elective and should be
in guidelines elaborated in Quebec, Canada even though          postponed 42. According to Saadi et al. 8, tympanostomy
they play a significant role in the management of head and      tube insertion should be performed with endotracheal intu-
neck cancers 34.                                                bation to decrease the risk of aerosolisation.
In order to limit transmission of the SARS-CoV-2 virus,         Bilateral otitis media with effusion and hearing loss should
the pandemic guidelines suggest that medical treatments         be prioritised for operative intervention, given the risk for
(radiotherapy, chemotherapy, etc.) should be favoured over      speech delay after 3 months. However, even cases of bilat-
surgical treatments when a patient’s outcome is not differ-     eral otitis media may be considered elective, and individual-
ent with either modality 10.                                    ised considerations should be taken based on the availabil-
Tracheostomy                                                    ity of PPE and COVID-19 testing. Ear canal foreign bodies
The American Academy of Otolaryngology-Head and Neck            may require emergent or urgent intervention in the setting
Surgery issued a position statement on March 27, 2020 (re-      of retained button batteries or obstructive otitis externa 43.
vised April 2) 35, recommending to perform a tracheostomy       Cochlear implant in children with hearing loss following
in positive COVID-19 patients no earlier than 2 weeks after     meningitis (high risk of cochlear ossification) is classified
intubation. Recommendations of the ENT-UK and British           as a semi-urgent procedure 21.
Laryngological Association suggest waiting for 14 days of       ENT-UK recommended against the use of high dose oral
intubation to allow prognostic information to become clear      steroids for Meniere’s disease or sudden sensorineural
and for viral load to potentially decrease 36. Other authors    hearing loss. Instead, therapy based on intratympanic ster-
have proposed a timing of 7 days 37,38. One of the first case   oid injection should be preferred in managing these dis-
series of 32 patients from Italy reported a mean intubation     eases 44.
period of 15 days (range, 9-21 days) before performing tra-     Rhinology clinic and surgery/skull base surgery
cheotomy 39.                                                    Nasal surgical interventions, including endoscopic or open
The selection of the appropriate tracheotomy technique          sinus and skull base surgery, carry an extremely high-risk
(percutaneous dilatational tracheotomy vs open surgical         COVID-19 infection for ENT specialists and should be
technique) should be established in a team including sur-       postponed in all non-acute cases 11.
geons and critical care professionals 40.                       COVID-19 virus has a natural affinity for nasopharyngeal
Both the AAO-HNS and ENT-UK recommend no change                 mucosa and the theoretical possibility of the risk that a vi-
of the tracheostomy tube until COVID-19 testing is nega-        ral load may be directly inserted into the central nervous
tive and review with an infectious disease specialist. Other    system during surgical manipulations has been hypoth-
authors recommend that the first tracheostomy change can        esized 18.



                                                                                                                            S103
N. Quaranta et al.




All the guidelines considered recommend for negative              ing agencies in the public, commercial, or not-for-profit
COVID-19 patients the use of appropriate PPE for aerosol          sectors.
exposure.
The use of anaesthetic sprays must be limited in the clinic       Authors’ contributions
and it is instead recommended to apply anaesthetic and de-        All authors contributed equally to the ideation, writing end
congestants via thin tampons for nasal endoscopy 45.              editing of the study.
Some suggest favouring alternatives to an endonasal ap-
proach when possible to avoid the use of a microdebrider:         Ethical consideration
external paracanthal approach, paralateronasal approach,          The research was conducted ethically, with all study pro-
sublabial approach 46.                                            cedures being performed in accordance with the require-
A position statement from European Academy of Allergy             ments of the World Medical Association’s Declaration of
and Clinical Immunology and Allergic Rhinitis and its im-         Helsinki.
pact on asthma recommended that COVID-19 positive pa-
tients with allergic rhinitis should continue therapy based
on intranasal corticosteroids (including sprays) at the previ-    References
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