Cough, dyspnea, sore throat, rhinorrhea, nasal congestion, throat congestion, tonsils edema, enlarged cervical lymph nodes or dizziness are symptoms that otolaryngologist could encounter while examining patients with COVID-19 [10,11,12]. It was recently reported that COVID-19 led to hyposmia/anosmia and taste disturbances. South Korea, China and Italy presented that a significant number of individuals with COVID-19 was affected by hyposmia/anosmia. A few cases were also detected in Germany. There are also reports implying that COVID-19 may present as isolated anosmia. These patients could be the source of the rapid spread of COVID-19 [13].
Recommendations for Clinical and Endoscopic Examination
The risk of contamination is very high in upper respiratory examinations. In Chinese patients, SARS-Cov-2 was detected in 63% of nasopharyngeal swabs, in 46% of the fiberoptic bronchoscopic brush biopsies and in 93% of bronchoalveolar lavage fluid specimens. Higher viral loads were detected in the nose than in the throat. In spite of that, recommendations for clinical and endoscopic examination can be very controversial because adequate PPE to all staff involved in patient care cannot be available everywhere. Disruption of supply chains and depletion of stock of PPE can drive anxiety in health professionals [14,15,16]. Head and neck surgeons, otolaryngologists, maxillofacial surgeons, and anesthetists are at high risk of contamination and infection by SARS-CoV-2 when assisting patients with tracheostomy or performing a rhinoscopy or a laryngoscopy because of the generation of aerosols. Fortunately, tracheostomy is unlikely to be required for the majority of patients. All patients must be examined by ENT surgeon wearing PPE such as N95 or FFP2 mask or PAPR, gown, cap, eye protection, and gloves (Table 1) [4, 14]. For tracheostomy, all staff must keep PPE with a PAPR throughout the procedure [17].
Table 1 Necessary personal protection equipment Operating on Patients with COVID-19 (Fig. 1)
In preparation for the COVID-19 pandemic, Wong et al. [18] reviewed OR (operating room) outbreak response measures. Several recommendations can be implemented worldwide, others must be adapting according to the resource availability. An OR with a negative pressure environment is ideal to reduce dissemination of the virus. A high frequency of air changes (25 per hour) reduces viral load within the OR. Separate ORs can be designated for surgery in patients suspected or confirmed to have COVID-19. Each OR must have its own ventilation system with an integrated high-efficiency particulate air filter. Traffic and flow of contaminated air can be minimized by locking all doors to the OR during surgery, with only one possible route for entry and exit. All health care personnel must be trained in the use of PPE. Postoperative visits must be suspended and replaced by phone calls to reduce movement of staff around the hospital. Ti et al. [19] recommend that an OR with a negative pressure environment with separate access must be used to operate suspected or confirmed cases of COVID-19 infection. They also advocate that the same room and the same anesthesia machine should be used for all COVID-19 patients during the epidemic. During the surgical procedure, a runner wearing PPE is stationed outside the OR in case other drugs or equipment are needed. In Indian setup, this will be a big challenge to set up separate OR as per norms for every hospital, medical colleges and for private practitioners. Chlorine-containing disinfectant (2000 mg/L) was used to clean the OR floor and wipe the surface of all reusable medical equipment. All medical devices, such as surgical instruments, were soaked for 30 min in 2000 mg/L chlorine-containing disinfectant, then sealed and collected into double-layer disposable medical waste bags in the cleaning room and sent to the designated disinfection area. After the OR was cleaned, the air purification system was shut down after 30 min of continuous operation of negative pressure laminar flow. Then, an ultra-low volume of 3% hydrogen peroxide (20–30 mL/m) was used to closed fumigate the OR for 2 h. Finally, the negative pressure ventilation of the OR was turned on again. All medical staff who were involved in surgical procedure were required to have a SARS-CoV-2 virus detection test (reverse transcription polymerase chain reaction of nasopharyngeal swabs) and CT scans once every 2 weeks [20].