10.14639/0392-100X-suppl.1-42-2022-06
COVID-19 has rapidly spread in the past two years with a profound impact on otolaryn- gological activities, which has undergone radical transformation to guarantee diagnostic and therapeutic procedures mainly in oncology and urgent patients, while ensuring protection for healthcare personnel and patients. During the initial phases of the pandemic, scheduled visits and elective surgeries were postponed leading to a delay in the diagnosis and treatment of several diseases, including head and neck cancer, with a shift toward more advanced cancer stages and more aggressive treatments. Aerosol and droplets are the main routes of transmis- sion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), thus leading to a high risk of contagion during otolaryngology visits and surgery. Therefore, the correct use of personal protective equipment (PPE) and attention to procedure-specific risks and measures to avoid contagion are of utmost importance for healthcare professionals, and especially for those dealing with otolaryngology diseases. This narrative review highlights that otolaryn- gological activity implies a high risk of contagion during outpatient visit, surgery, or urgent conditions. The correct use of PPE, evaluation of procedure-specific risks and reduction of non-urgent procedures are considered the main strategies to limit contagion.
text/xml
1827-675X
2110
en
Pasquale Capasso
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
head and neck surgery
Risk of SARS-CoV-2 contagion in otolaryngology specialists
Text.Serial.Journal
https://www.actaitalica.it/
42
Annual congress report
2022-04-26
2022-04-06
2022-04-28
2022-04-28
S58-S67
1
Pasquale Capasso
2022/04/26
10.14639/0392-100X-suppl.1-42-2022-06
S58
Otolaryngology Unit, AORN dei Colli, V. Monaldi Hospital, Napoli, Italy
1827-675X
head and neck surgery
S67
Risk of SARS-CoV-2 contagion in otolaryngology specialists
https://www.actaitalica.it/article/download/2110/772
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42(SUPPL.1):S58-S67; doi: 10.14639/0392-100X-suppl.1-42-2022-06




Risk of SARS-CoV-2 contagion in otolaryngology
specialists
Il rischio di contagio da SARS-CoV-2 tra gli specialisti in otorinolaringoiatria
Massimo Ralli1, Andrea Colizza1, Vittorio D’Aguanno1, Alfonso Scarpa2, Gennaro Russo3, Paolo Petrone4,
Rosa Grassia3, Pierre Guarino5, Pasquale Capasso3
1
 Department of Sense Organs. Sapienza University of Rome, Rome, Italy; 2 Department of Medicine, Surgery and Dentistry.
University of Salerno, Salerno, Italy; 3 Otolaryngology Unit, AORN dei Colli, V. Monaldi Hospital, Napoli, Italy; 4 Directorate General,
ASL BA, Bari, Italy; 5 Otolaryngology Unit, Santo Spirito Hospital, Pescara, Italy


SUMMARY
COVID-19 has rapidly spread in the past two years with a profound impact on otolaryn-
gological activities, which has undergone radical transformation to guarantee diagnostic and
therapeutic procedures mainly in oncology and urgent patients, while ensuring protection for
healthcare personnel and patients. During the initial phases of the pandemic, scheduled visits
and elective surgeries were postponed leading to a delay in the diagnosis and treatment of
several diseases, including head and neck cancer, with a shift toward more advanced cancer
stages and more aggressive treatments. Aerosol and droplets are the main routes of transmis-
sion of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), thus leading to a
high risk of contagion during otolaryngology visits and surgery. Therefore, the correct use of
personal protective equipment (PPE) and attention to procedure-specific risks and measures
to avoid contagion are of utmost importance for healthcare professionals, and especially for
those dealing with otolaryngology diseases. This narrative review highlights that otolaryn-
gological activity implies a high risk of contagion during outpatient visit, surgery, or urgent
conditions. The correct use of PPE, evaluation of procedure-specific risks and reduction of
non-urgent procedures are considered the main strategies to limit contagion.
KEY WORDS: COVID-19, SARS-CoV-2, otolaryngology, infection control measures,
head and neck surgery
                                                                                                  Received: January 21, 2022
                                                                                                  Accepted: January 31, 2022
RIASSUNTO
La malattia da COVID-19 si è rapidamente diffusa negli ultimi due anni con un forte im-           Correspondence
patto sull’attività otorinolaringoiatrica, che ha subito una radicale trasformazione per ga-      Massimo Ralli
rantire assistenza principalmente a pazienti oncologici e urgenti, e assicurare protezione al     Department of Sense Organs, Sapienza University
personale sanitario e ai pazienti. Durante le fasi iniziali della pandemia, le visite program-    of Rome, viale del Policlinico 155, 00186 Rome,
mate e gli interventi chirurgici elettivi sono stati posticipati, spesso causando un ritardo      Italy
nella diagnosi e nel trattamento di diverse condizioni, anche oncologiche, con diagnosi in        Tel. +39 06 49976808
fasi di malattia avanzata e trattamenti più aggressivi. L’aerosol e le goccioline di saliva       E-mail: massimo.ralli@uniroma1.it
sono la principale via di trasmissione del virus SARS-CoV-2. Pertanto, l’uso corretto dei
dispositivi di protezione individuale (DPI) e l’attenzione ai rischi e alle misure di prote-        How to cite this article: Ralli M, Colizza A,
zione specifiche per ogni procedura otorinolaringoiatrica sono della massima importanza.            D’Aguanno V, et al. Risk of SARS-CoV-2 con-
In conclusione, questa review evidenzia che l’attività otorinolaringoiatrica implica un alto        tagion in otolaryngology specialists. Acta Otorhi-
rischio di contagio in occasione di visite, interventi chirurgici o trattamento di condizioni       nolaryngol Ital 2022;42(SUPPL.1):S58-S67.
urgenti. Il corretto utilizzo dei DPI, la valutazione dei rischi specifici di ogni procedura e      https://doi.org/10.14639/0392-100X-sup-
                                                                                                    pl.1-42-2022-06
la riduzione di visite e interventi non urgenti sono considerate le principali strategie per
limitare il contagio.
                                                                                                  © Società Italiana di Otorinolaringoiatria
PAROLE CHIAVE: COVID-19, SARS-CoV-2, otorinolaringoiatria, controllo dell’infezione,              e Chirurgia Cervico-Facciale
chirurgia testa-collo
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In January 2020, a novel coronavirus disease (COVID-19) was officially an-                        article can be used by giving appropriate credit and mentio-
                                                                                                  ning the license, but only for non-commercial purposes and
nounced by the World Health Organization (WHO), which rapidly developed                           only in the original version. For further information: https://
into a worldwide public health emergency 1,2.                                                     creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                           SARS-CoV-2 contagion in otolaryngology




COVID-19 is caused by the severe acute respiratory syn-        ID-19 positive patients may be an important source of viral
drome coronavirus 2 (SARS-CoV-2). The human corona-            transmission before developing symptomatic disease 9.
viruses (HCoVs) are members of the coronaviruses fam-          The most common symptoms are fever, dry cough, pharyn-
ily, and responsible for multiple respiratory conditions       geal pain, headache and myalgia. Some patients complain
including the common cold, bronchiolitis and pneumonia 3.      of fatigue, shortness of breath, muscle pain, confusion, sore
HCoVs periodically appear in different places around the       throat, headache, vomiting, diarrhoea, olfactory and gus-
world and have been linked with epidemic or pandemic hu-       tatory dysfunctions and, more rarely, ocular inflammation
man pneumonia since the beginning of the 21st century 4;       such as kerato-conjunctivitis 10,11 (Fig. 1).
they include the severe acute respiratory syndrome coro-       Patients with severe disease typically present with fever,
navirus (SARS-CoV), in November 2002, and the Middle           dry cough, dyspnoea, and interstitial pulmonary infiltrates
East respiratory syndrome coronavirus (MERS-CoV) in            on thorax imaging. Complications of COVID-19 include
June 2012 5.                                                   acute respiratory distress syndrome (ARDS), respiratory
                                                               failure, liver injury, acute myocardial injury, acute kidney
SARS-CoV-2 characteristics                                     injury, septic shock and even multiple organ failure. In the
Generally, HCoVs are composed of some viral proteins:          case of severe complications, patients require invasive me-
spike, membrane, envelope, nucleocapsid proteins and he-       chanical ventilation (IMV); the case-fatality rate varies be-
magglutinin. Spike, membrane and envelope proteins are         tween 36 and 52% 12.
inserted into the viral envelop, while nucleocapsid protein    The risk factors for disease progression are old age, male
protects the viral RNA genome located in core of virus 6. In   sex and presence of comorbidities like chronic obstructive
particular, the spike protein is a glycosylated protein con-   pulmonary disease, hypertension, diabetes, coronary ather-
taining the receptor binding domain, which mediates viral      osclerotic heart disease and hepatitis B or liver cirrhosis 13.
entry into host cells 7.                                       In the literature, several studies confirm that one or more
Clinical aspects (symptomatic and asymptomatic infection)      underlying diseases are correlated with worse prognosis 14.
Several studies have documented the clinical severity of       Many cases of COVID-19 are asymptomatic, with posi-
COVID-19. In most cases, the incubation period (initial in-    tive detection of nucleic acid of SARS-CoV-2, but with no
fection to symptoms) varies between 0 to 24 days after ex-     typical clinical symptoms or signs 15. In these cases, the key
posure, with an average of 5-7 days 8. Interestingly, COV-     point to control COVID-19 diffusion is the early recogni-




Figure 1. Main clinical symptoms of patients with COVID-19.



                                                                                                                            S59
M. Ralli et al.




tion of an infected person, but most persons with asympto-     Focusing on emergency department activity, in the litera-
matic infection do not seek medical assistance, thus con-      ture a significant reduction of the number of visits has been
tributing to the rapid spread of SARS-CoV-2 16.                described in comparison with the same period of previ-
                                                               ous years (62-68%) 23. However, the most dramatic data is
Routes of virus transmission                                   the reduction of the number of urgent services during the
The main routes of virus transmission include direct trans-    COVID-19 outbreak 24. The reasons for the reduction of
mission through cough, sneezing and contact with oral,         emergency otolaryngology interventions can be explained
nasal and eye mucous membranes 17. The transmission of         by various factors, including the fear of nosocomial SARS-
infection can occur through both aerosol and droplets. Air-    CoV-2 infection, social distancing and home confinement.
borne transmission occurs through small inspirable aero-       Head and neck cancer surgical activity during COVID-19
sols (< 5-10 um) even over long distances, while droplet       pandemic consisted mainly in oncology-related diagnostic
transmission occurs through passage of larger aerosols         biopsies (generally performed through microlaryngoscopy
(> 5-10 um) directly from the infected person to the new       or endoscopy), endoscopic or open head and neck proce-
host over short distances 18.                                  dures and otologic and otoneurologic treatment 21,23. Head
                                                               and neck oncology multidisciplinary consultation meetings
Impact of COVID-19 on otolaryngological                        have been performed in video or teleconference to avoid
                                                               delays in treating and exposing patients to the risk of infec-
activity                                                       tion.
Reorganization of otolaryngology services                      Telemedicine is another important tool that quickly de-
As a consequence of the outbreak of SARS-CoV-2, national       veloped during the pandemic to ensure medical examina-
health care systems around the world underwent profound        tions; in this way, access to the hospital was reserved only
changes. The activity of otolaryngological services has        to patients who needed medical or surgical treatment 25. In
undergone radical transformation to guarantee diagnostic       addition, telemedicine allowed medical examination for
and therapeutic procedures mainly to oncology and urgent       patients in follow-up after cancer treatment or remote eval-
patients.                                                      uation of exams prescribed in previous visits.
A survey from the COVID-19 Task Force of the Young
Otolaryngologists of the Italian Society of Otolaryngology     Effects on otolaryngology patients’ health
Head and Neck Surgery 19,20 reported dramatic changes in       The drastic reduction of the routine activity of otolaryngol-
ordinary clinical and surgical activity of otolaryngology      ogy units had a dramatic impact on the services offered to
units in Italy. Non-urgent outpatient procedures were tem-     patients during the pandemic. Scheduled visits and elective
porarily suspended to limit viral diffusion, and healthcare    surgeries were postponed; this situation, associated with
personnel were relocated to dedicated COVID-19 wards 21.       the patients’ fear to contract the infection inside the hospi-
Following international recommendations 22, before enter-      tal, led to a delay in the diagnosis and treatment of several
ing the hospital, patients were called and queried about the   diseases, including head and neck cancer, with a dangerous
onset of specific COVID-19-related symptoms in the pre-        shift toward more advanced cancer stages and potential up-
vious two weeks or direct exposure to SARS-CoV-2, and          staging of TNM classification 26,27.
body temperature was measured at admission; furthermore,       Some authors report a reduction of 10-20% in outpatient
normothermia with a negative nasopharyngeal swab for           and surgical services in otolaryngology units, especially
SARS- CoV-2 were required before entering the operating        during the initial phase of the pandemic. For example, an
room.                                                          increased interval between diagnosis and successive treat-
                                                               ment was noted 28. Delayed surgery and difficulties in guar-
Impact on otolaryngology procedures (elective, emergency,      anteeing adjuvant therapies also resulted in reduced over-
oncology)                                                      all survival for oncology patients 28, tumour upstaging and
Urgent otolaryngology conditions are mainly represented        need for more aggressive treatment, with extension of hos-
by respiratory distress, epistaxis, sudden sensorineural       pital stay, increased probability of postoperative complica-
hearing loss, peritonsillar and neck abscesses, haemorrhage    tions and further reduction of beds.
of upper aerodigestive tract, foreign bodies, complicated      Furthermore, scientific evidence has confirmed that head
otomastoiditis and traums. These are situations for which      and neck oncological patients are at high risk for COVID-
otolaryngology examination cannot be postponed and may         19-related pulmonary complications, probably due to im-
require an upper airway endoscopy and/or an auditory eval-     munosuppression, impaired respiratory and swallowing
uation.                                                        function, and increased aspiration risk 29.



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Risk of contagion in otolaryngology specialists                               PPE: role in otolaryngology procedures
                                                                              The protection of healthcare staff is fundamental to limit
Otolaryngology visits that favour SARS-CoV-2 transmission                     spread of infection. In the literature it is highly recom-
Aerosol and droplets are the main route of transmission of                    mended the correct use of PPE during aerosol or droplets
SARS-CoV-2, thus leading to a high risk of contagion dur-                     generating procedures. The most popular and widely used
ing otolaryngological visits and surgery. In fact, the viral                  PPE are FFP2 or N95 respirator and surgical masks, gog-
membrane fuses with the host cell through cell-receptor                       gles or face shield, glasses, caps, eye protection, fluid-re-
angiotensin-converting enzyme 2 (ACE-2) and the mucosa                        pellent disposable, surgical gown and gloves 31,33.
of upper airway tract is rich of this receptor.                               The Canadian Society of Otolaryngology Head and Neck
Medical and surgical procedures for head and neck pa-                         Surgery developed guidelines defining the level of protec-
thology may favour otolaryngologist, surgeon, nurse and                       tion for healthcare workers based on specific parameters.
anaesthesiologist contamination with patients’ upper air-                     These include Level 1 PPE: Surgical mask + gown + gloves
way aerosol and droplets 30-32. During outpatient visits, the                 + eye protection; Level 2 PPE: N95 respirator + fluid repel-
otolaryngology specialist examines the nasal cavity, the                      lent gown + head cover including neck protection + double
oral cavity, the pharynx (naso-, oro- and hypo-) and lar-                     gloves + eye protection; and Level 3 PPE: Negative pressure
ynx, requiring the patient to remove their face mask and                      room with minimum staff + N95 mask with second surgical
often inducing sneezing and coughing. Moreover, during                        mask + face shield or goggles + double fluid repellent gown
most otolaryngology urgent procedures, it is impossible to                    + head cover including neck protection + double gloves 34,35.
exclude COVID-19. For these reasons, the correct use of                       Figure 2 schematises the algorithms for aerosol generating
personal protection equipment (PPE) is of utmost impor-                       medical procedures (AGMP) following the guidelines for
tance for healthcare professionals and especially for those                   healthcare workers during AGMP proposed by the Cana-
dealing with otolaryngological diseases 31-33.                                dian Society of Otolaryngology Head and Neck Surgery.




Figure 2. Guidelines for Healthcare Workers during Aerosol Generating Medical Procedures (AGMP) proposed by the Canadian Society of Otolaryngology Head
and Neck Surgery.



                                                                                                                                                 S61
M. Ralli et al.




Procedure-specific risk                                                          in the last two weeks. When possible, patients should wear a
Each otolaryngological surgical procedure implies a dif-                         surgical mask minimally covering the mouth.
ferent risk of contagion. In this section, we describe the                       For proper management of epistaxis performed in the
procedure-specific risk of the most frequent otolaryngol-                        emergency department, it is important to distinguish pa-
ogy procedures and the strategy to minimise the possibility                      tients who need prompt treatment from those who do not 40.
of contagion.                                                                    Table I summarises the clinical signs and symptoms of pa-
Endoscopy                                                                        tients with epistaxis requiring immediate assistance.
Endoscopy of nasal, pharyngeal and laryngeal sites is rou-                       The first approach for epistaxis is non-invasive interven-
tinely used in diagnostic otolaryngological activities and                       tion, including compression of the alar cartilages for at least
represents a high-risk procedure for otolaryngologists be-                       15 minutes and administration of antifibrinolytic agents. If
cause it requires a short physical distance between patients                     these attempts fail, more invasive interventions should be
and physicians and can induce sneezing and coughing 36.                          initiated.
Consequently, potential virus transmission through aerosol                       Ideally, invasive treatment should be performed in a nega-
and direct contact can be generated, especially in cases of                      tive-pressure operating room. In fact, nasal packing with-
long exposure in closed environments 31.                                         out anaesthesia or sedation can expose personnel to conta-
National and international otolaryngology societies pub-                         gion because the patient is unable to control coughing and
lished several recommendations to limit contagion during                         sneezing. Another recommendation is to reduce the num-
endoscopy procedures. In general, the most frequent advice                       ber of personnel in the room, limiting to one otolaryngol-
is to perform endoscopy with a flexible instrument in urgent                     ogy specialist and a nurse.
cases and only if strictly necessary 36. Another suggestion                      The most common treatments, which include nasal pack-
is to use topical decongestant with local anaesthetic solu-                      ing or cautery, should be performed in case of failure of
tion during the examination 37. In addition, during all endo-                    non-invasive procedures or in case of a life-threatening
scopic procedures, it is fundamental to use PPE and avoid                        epistaxis 40.
direct contact with contaminated equipment and potentially                       Nasal endoscopy with sphenopalatine artery ligation, in
harmful chemicals during the sterilisation procedures 38.                        case of posterior massive epistaxis, should be delayed until
                                                                                 COVID-19 testing is performed if clinically possible 41.
Epistaxis management
                                                                                 The last recommendation is that the first approach to
Epistaxis is one of the most common conditions in the
                                                                                 epistaxis should be performed only by an expert physician,
general population and in some cases requires prompt
                                                                                 because errors in this phase can expose other healthcare
treatment in an emergency department setting. Tunkel et
                                                                                 specialists to the risk of accidental contact with contami-
al. 39 estimated that epistaxis accounts for about 0.5% of
                                                                                 nated medical devices.
all emergency department visits and up to one-third of all
otolaryngology procedures in the emergency department.                           Tracheostomy
As a general rule, all patients must be considered COVID-19                      The outbreak of SARS-CoV-2 caused a high-rate admis-
positive and appropriate precautions should be used. In ad-                      sion to hospitals and intensive care units (ICU). Tracheos-
dition, healthcare personnel should inquire about contacts at                    tomy was one of the most common procedures performed
risk for COVID-19 and the presence of common COVID-19                            in sedated ICU patients who required prolonged intubation.
symptoms like fever, cough or alterations in taste and smell                     The best timing to perform the tracheostomy in COVID-19


Table I. Risk factors and clinical signs and symptoms of epistaxis requiring prompt treatment.
 Personal risk factors                                                                            High blood pressure not on therapy
                                                                                                       Haematological disease
                                                                                                          Oncologic disease
                                                                                                          Relapsing epistaxis
                                                                                                 Anticoagulant/antithrombotic therapy
 Clinical signs and symptoms                                                                              Prolonged bleeding
                                                                                                 Bleeding from both sides of the nose
                                                                                                       Bleeding from the mouth
                                                                                                              Tachycardia
                                                                                                                Syncope
                                                                                                             Hypotension
                                                                                                  Hypovolaemic/haemorrhagic shock




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Table II. Factors to define tracheostomy time in ICU patients.
                       Factors for early tracheostomy                               Factors for delay tracheostomy
                   Laryngeal injury, trauma or dysfunction                            Requirement for prone ventilation
               Ventilator-associated respiratory muscle atrophy                               Multiorgan failure
                              Pulmonary hygiene                          Potential risks to healthcare workers, patients and family
                         Cumulative effects of sedation
                      Expedited in rehabilitation post ICU
                            Ability to communicate
                          Maintenance of ICU capacity



patients is still controversial, but systematic reviews sug-      way isolation. Post-operative management of tracheostomy
gest executing it from 7 to 10 days after orotracheal intuba-     patients includes safe suction of secretions, regular cuff-
tion to reduce the duration of invasive ventilation, mortality    pressure check and correctly planned cannula changes.
rate and length of stay in ICU 42. However, it should be
                                                                  Endoscopic sinonasal and skull base surgery
considered that tracheostomy in patients with severe forms
                                                                  Endoscopic sinus and skull base surgery are some of the
of COVID-19 can also be detrimental. In fact, data in the
                                                                  most widely performed procedures in otolaryngology and
literature demonstrate that in COVID-19 patients who un-
                                                                  are considered high-risk operations for viral spread and in-
derwent an extended period of mechanical ventilation, the
                                                                  fection of the operator 47. The reasons are the high viral load
tracheostomy might not be beneficial, and can increase the
                                                                  in the upper airways, and especially aerosol generation dur-
risk of SARS-CoV-2 infection in healthcare workers 43.
                                                                  ing endonasal instrumentation, like suctioning, drilling and
Table II summarises the most important factors reported
in the literature regarding the timing of tracheostomy in         use of debrider and bipolar diathermy 48.
COVID-19 patients.                                                Many cases of surgeons developing COVID-19 symptoms
The execution of a tracheostomy can be done in sedated            after endoscopic surgery in patients without clinical mani-
and intubated patient or in awake patients by local anaes-        festations of infection have been reported from China, Iran,
thesia. It can be surgical (generally performed by otolaryn-      Italy and Greece 49. Spock et al. 50 proposed a COVID-19
gology specialists) or percutaneous (usually performed by         management algorithm to stratify urgent and non-urgent
anaesthesiologists). The latter is not preferable since air-      cases requiring endoscopy procedures, dividing patients
flow must be maintained during the procedure and droplet          into non-neoplastic and neoplastic.
emission is higher 44. Instead, during surgical tracheosto-       During the first weeks of the pandemic, several strategies
mies it is possible to stop the airflow, although a large quan-   to limit aerosols produced during endoscopic sinus surgery
tity of droplets and aerosol is usually generated after the       (ESS) have been proposed. Tsagkovits et al. 47 suggested
aperture of the trachea and mechanical ventilation. In this       to place the surgical instruments on the thorax of patient
scenario, the risk of exposure for surgeons, nurses and oth-      and to wrap an otomicroscope drape around the patient in
er healthcare personnel in operating room is very high. The       order to isolate the head and the body. According to Spock
procedure can be done bedside in ICU, although the most           et al. 50 patients can be fitted with a rigid facial mask modi-
recommended setting is the operating room using negative          fied with a hole in correspondence of the nose, then placing
pressure, when possible, even if this involves transfer from      a glove over the cutout (called 2-port VENT mask). Jones
ICU and additional risk of exposure for medical staff.            and colleagues 51 used a modified bronchoscopy mask over
During the procedure, healthcare personnel protection is          the face of patient; this tool, connected to a suction unit to
of utmost importance; some authors also suggest adopting          reduce spread of aerosols and droplets, allowed the intro-
powered air-purifying respirators (PAPRs) in addition to          duction of endoscopic instruments and orotracheal tube.
the standard PPE 45,46.                                           After these first attempts, the main recommendations re-
The surgical kits and cannulae of different sizes must be         ported in the literature during endoscopic surgery are the
ready before the beginning of procedure to reduce entrance        following 52: a) Perform the procedure with a skilled sur-
of other personnel in the operating room.                         geon, dedicated operating room team (nurse and anaesthe-
During the surgical procedure, and especially before open-        siologist) and set of precision instruments; b) Minimise the
ing the trachea, it is important to perform deep muscular         spread of the virus from bone drilling, cauterisation and
blockade, reduce the oxygen-percentage of the inflated air        exposure to the heat generated by light from the endoscope;
to 21%, push the tube as caudally as possible to avoid cuff       c) Especially for anterior skull base pathologies, use ESS
breach and hyper-inflate the tube cuff to ensure lower air-       only when it constitutes the best option with regards to ex-



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M. Ralli et al.




posure, resection and morbidity. In fact, in many cases of                       formed as soon as possible. Most upper aerodigestive
anterior skull base pathologies, minimally-invasive tran-                        tract malignancies grow rapidly and quickly metastasise
scranial approaches may remain a better option to reduce                         to locoregional lymph nodes. Treatment delays of 20-30
the spread of virus during surgery.                                              days are often associated with tumour upstaging and worse
                                                                                 overall survival 57. In addition, delayed treatment can result
Otologic and neurotologic surgery
                                                                                 in a more aggressive tumour resection. On the other side,
During the initial phases of the pandemic, there was no
                                                                                 otolaryngology specialists are at high risk of infection due to
clear consensus on the safety of otologic surgery and
                                                                                 exposure to respiratory droplets. Furthermore, in head and
causes of contagion during it. The initial hypothesis was
                                                                                 neck cancers alternative treatments to surgery are lacking.
that mucosal lining of the Eustachian tube, middle ear and
                                                                                 For example, for cancers arising from the oral cavity or
mastoid should be polluted by the virus from the upper
                                                                                 advanced laryngeal cancers or human papillomavirus
airway and drilling the mastoid bone can produce droplets
                                                                                 (HPV)-negative oropharyngeal squamous cell carcinoma
and aerosols 53. Moreover, in animal models and cadaveric
                                                                                 (OPSCC) or salivary gland malignancies, surgery is the
simulation it was demonstrated that drilling bony micro-
                                                                                 main treatment and there are no accepted neoadjuvant
spicules could penetrate the cornea as a possible means for
                                                                                 treatment options 58. During the first phases of the pandemic,
viral transmission 54 and transconjunctival spread of COV-
                                                                                 when diagnostic tests were limited and vaccines were not
ID-19 55. The operative microscope offers protection for the
                                                                                 available, some authors suggested to favour radiation and
eyes of surgeon, but the drilling exposes all healthcare per-
                                                                                 chemotherapy for head and neck neoplasms if oncologic
sonnel in the operating room. Otologic procedures are gen-
                                                                                 outcomes were comparable to surgery 59. For these reasons,
erally elective surgeries and should be postponed. For clini-
                                                                                 head and neck cancer management during the COVID-19
cal conditions that cannot be postponed, several algorithms
                                                                                 pandemic represented a challenge for surgeons and all
and classifications have been proposed to stratify otologic
                                                                                 specialists involved in the treatment of these pathologies.
procedures 56. Table III summarises the otologic and neu-
                                                                                 To reduce the risk of missing or delayed oncological
rotologic procedures and provides a decisional algorithm.
                                                                                 diagnosis, oncology centres began performing a selection
Head and neck oncologic surgery                                                  of scheduled visits by examining the symptoms reported
Oncological activity is generally considered nonelective,                        and previous medical history 26. The most frequent criteria
and diagnostic or treatment procedures should be per-                            found in the literature to select patients were history of


Table III. Decisional algorithm to perform or postpone oncological surgery.
 Type of urgency         Time of treatment                    Pathology                                            Type of surgery
 Urgent/emergency        Performed as soon       Complicated mastoiditis (lateral sinus  Surgical procedures should be performed under the presumption
                         as possible within       thrombophlebitis, neuromeningeal        that patients are COVID-19 positive. Enhanced PPE is mandatory
                            24-48 hours          damage, temporomandibular arthritis)           with a strong preference for use of PAPR. Clinical staff
                                                Cholesteatoma with lateral semicircular     should be limited to essential personnel (i.e., senior attending
                                                   canal (LSC) fistula and associated     anaesthesiologist, experienced attending surgeon and registered
                                                               symptoms                  nurse) in a negative-pressure operating room with high-efficiency
                                                                                                                 particulate air filtration
 Semiurgent              Performed as soon          Acute facial nerve paralysis           Preoperative COVID-19 test should be performed 48 hours prior
                        as possible but may         Temporal bone malignancy                surgery and repeat testing the day of surgery if rapid tests are
                        be performed in over   High-volume cerebrospinal fluid leak     available. However, surgical procedures should be performed under
                              48 hours         Postmeningitic cochlear implantation      the presumption that patients are COVID-19 positive. PPE should
                                                                                                                         be used
 Semielective             Performed within   Cholesteatoma with persistent infection or Semielective cases may proceed following COVID-19 testing 48
                            3-6 months                        progression                 hours prior to surgery, strict quarantine pending test results, and
                                                 Paediatric cochlear implantation                         repeat rapid test the day of surgery
                                               Bilateral otitis media with effusion in
                                                                children
                                                 Low-flow cerebrospinal fluid leak
 Elective                Performed after 6             Dry/stable perforation            Elective surgical cases should be postponed in efforts to decrease
                               months                      Stapes surgery                          patient interaction and exposure to the contagion
                                                      Ossicular reconstruction
                                                    Adult cochlear implantation
                                                Bone anchored hearing prosthesis




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Figure 3. Flowchart for patient selection before an outpatient visit.


malignant cancer, dysphonia and persistent dysphagia,                   this context, otolaryngology activity implies a high risk
cervical masses of new onset, dyspnoea, recent body                     of contagion during outpatient visits, surgery or urgent
weight loss and bleeding from the upper aerodigestive tract.            conditions. The correct use of PPE and a reduction of non-
Figure 3 shows a suggested flowchart for patient selection.             urgent visits and elective surgery are considered the main
Surgery can be postponed (6-8 weeks) for only a few                     strategies to limit contagion. On the other hand, the fear
head and neck cancer types, including well-differentiated               of contagion by patients caused a delay of treatment in
thyroid cancers, non-progressive skin cancers (basocellular             urgent or oncological conditions that, in some cases, may
carcinoma), slow-growing salivary gland cancers and                     lead to a most severe clinical situation. As of today, it is
nodules in the salivary glands not classified as malignant              impossible to predict when the COVID-19 pandemic will
during preoperative assessment 25.                                      end; therefore, national healthcare systems worldwide
The COVIDSurg Collaborative group 60 evaluated 1137                     should focus on strengthening medical services to also
consecutive patients with head and neck cancer in 26                    guarantee medical care for non-urgent patients, while
countries and reported evidence of de-escalation of surgical            still limiting the risk of contagion among patients and
treatment for oropharynx and larynx tumours. For these                  healthcare providers.
neoplasms, nonsurgical therapy was favoured, especially
during the initial phases of the pandemic. The authors                  Conflict of interest statement
concluded that an important change has come with the                    The authors declare no conflict of interest.
advent of vaccines and improvement of infection control
practices and neck surgery may be considered safe for                   Funding
patients during the pandemic.                                           This research did not receive any specific grant from
                                                                        funding agencies in the public, commercial, or not-for-
                                                                        profit sectors.
Conclusions
The spread of COVID-19 in the last two years has led to                 Authors’ contributions
profound changes in the behaviour and in the organisation               MR: writing original draft, supervision; AC: writing
of healthcare systems to guarantee medical assistance.                  original draft; VD’A, RG and PP: literature review; AS
Upper airway tract symptoms (coughing and sneezing)                     and GR: critical revision of the manuscript; PG and PC:
are the most frequent route of transmission of the virus. In            supervision.



                                                                                                                                    S65
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Availability of data and materials                                                17
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