With COVID 19 sweeping across the world leaving mayhem in its wake, different perspectives arise as doctors the world over grapple with the pandemic. Being at the forefront of the management of the disease, about which no definitive therapy or vaccine seems forthcoming in the near future, most medical personnel are in danger of falling prey to the virus.
ENT surgeons (otolaryngologists) form a unique group among the medical fraternity treating this disease as they often come across patients with atypical symptoms and also because their area of expertise often carries the highest viral load. This makes them far more vulnerable to infection and also means that they have to be the most cautious. This article tries to recapitulate COVID 19, its etiopathogenesis, symptomatology, and specific precautions from an ENT perspective.
KNOWING THE DISEASE
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With the replication of the virus, the infected person becomes ill with COVID 19 (coronavirus disease 2019). This presents a large variation in the clinical picture. A flu-like picture may dominate in the manifestation stage with a sore throat, fever and a dry cough. However, some patients remain largely asymptomatic while yet others present with atypical symptoms like hyposmia, anosmia or diarrhoea. According to Chinese data, 80% of patients are mildly ill with 15% developing serious respiratory symptoms with pneumonia, respiratory failure and death. The risk of infectivity and death, however, remains much higher than the seasonal flu and shows a significant increase with attendant comorbidities like diabetes mellitus, hypertension, cardiac disease and malignancy. A significant increase in mortality is also seen with increasing age. A hypothesis has been suggested that some patients inhale a significant viral load directly into the lungs and thus have significantly higher morbidity and mortality.
CHALLENGES OF AN ENT SURGEON
Due to the symptoms first manifesting in the upper respiratory tract, ENT surgeons can often be the first clinician sought by a patient. They are thus exposed to high viral loads as they are at a very close distance from the areas of highest viral load in trans nasal and transoral examinations. In addition, these examinations can trigger a gag or cough reflex which is further dangerous.
Also, due to their area of expertise ENT surgeons are often called upon for `difficult airway management` in addition to anaesthesiologists. While most COVID 19 patients do not require tracheostomies, those that do carry a further risk for the operating ENT surgeon as any aerosol-generating procedure carries a higher risk. In addition, tracheal secretions are found to be highly infective as well.
Routine ENT surgeries involve dealing with areas of high viral load and hence any surgery in these areas carry attendant risk. Risk is further increased due to release of aerosolised particles particularly during endoscopic procedures which form a significant chunk of ENT surgeries at present. The middle ear carries a large viral load in any upper respiratory tract disease and hence middle ear surgery carries risk as well. Drilling procedures on the mastoid during middle ear surgery also result in egress of viral particles in the air.
Reports from China indicate that procedures like trans sphenoidal hypophysectomy have been a leading cause of infection and death in ENT surgeons.
ANOSMIA AS AN ATYPICAL SYMPTOM
Sudden onset of a total loss of smell (anosmia), without any accompanying rhinitis, has been observed as an atypical symptom in COVID 19. It is seen to persist up to a late stage in around two-thirds of all patients who test positive. While the pathomechanism by which the virus affects the olfactory bulb has not been accurately established, a sudden onset anosmia/hyposmia in a person without any other symptom should be taken as a suspicion to run a COVID test.
RECOMMENDATIONS FOR ENT PRACTICE
Several recommendations have been put in place by ENT associations the world over. They include:
- Screening of patients at the entry to the clinic with due emphasis on travel and exposure history
- Nose and mouth protection to be provided to patients who present with coughing and sneezing.
- Protective face vizor in addition to the N95 mask to be worn by the examining clinician.
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- Any nasal or oral anaesthetic spray which can induce a gag reflex in the patient to be avoided. Pledgets to be used instead
- A complete ENT examination may be avoided in favour of a symptom related one.
- Upper aerodigestive tract endoscopies to be avoided as far as possible.
- Video and telephonic consultations to be held as far as possible
- Planned surgeries to be deferred to a later date if possible
- In case of emergency surgeries, the use of PPEs by staff in the OR should be mandatory.
- Staff in the OR should be limited to the minimum requirement.
- Special care to be taken during intubation and extubation if GA is unavoidable. Bag and mask, intubate under plastic drape if possible. Seal the airway. Avoid the use of high-pressure oxygen, CPAP etc if possible
- Modify techniques to operate under plastic drape whenever possible
- Bag specimens immediately
- Wake the patient in the OR when possible
- Ensure recovery is isolated.
- Put a mask on the patient as soon as possible
- Sufficient time to allow clean up and air circulation in OR with proper disinfection of all surfaces.
Thus, not only do otolaryngologists represent a particularly exposed group of doctors but with their expertise, they have a significant role to play in the pandemic. It is therefore paramount that they stay healthy so that they can help the maximum number of patients.
REFERENCES
- www.ncbi.nlm.nih.gov: JC Luers: The COVID 19 Pandemic and otolaryngology: What does it come down to?
- www.entandaudiologynews.com: Eric Levi: COVID 19 Tips and Insights
- www.entnet.org: Otolaryngologists and the COVID 19 Pandemic
- www.facs.org: American College of Surgeons -COVID 19 guidelines for Triage of otolaryngology patients
