Impact of COVID-19 Pandemic and Pattern of Patient Care in Otorhinolaryngology Practice in a Tertiary Referral Centre

Abstract

Aims-To study the effect of COVID-19 pandemic on patient load in a tertiary care centre and the innovations and methods used to improve the safety of the healthcare workers, to provide adequate treatment in the department of Otorhinolaryngology.

Materials and methods-This study was conducted in the Department of Otorhinolaryngology and Head and Neck Surgery, at a tertiary care hospital centre in North-East India. This study included data collected from the patient registers maintained in our department, and included data over a 4-month period, from April, 2020 to July, 2020. Age, gender, place of residence, clinical diagnosis and the operative procedure performed were included in the data profile for analysis. The above-mentioned registers were also reviewed to retrieve details about the rate of admission during the study period in the previous year. Data was collected and represented, in both descriptive and tabular forms, after proper statistical analysis.

Results-We found out that there is a drastic reduction in number of patients attending in our department of Otorhinolaryngology during this COVID-19 pandemic. Certain innovative methods for protecting healthcare workers from viral transmission were put into our practice based on the peer reviewed articles, from June,2020 and the rate of elective procedures and in-patient admissions were thus increased.

Conclusion- Knowledge of new innovative methods in Otorhinolaryngology will help overcome the difficulties faced during the current COVID-19 pandemic.

Introduction

Towards the end of 2019,there was an outbreak of pneumonia of unknown etiology, with the center of outbreak being Wuhan, the capital of the Hubei province in China[1]. By early January, 2020, Chinese scientists had isolated a novel form of coronavirus from patients with this viral pneumonia–severe acute respiratory syndrome coronavirus 2(SARS-CoV-2), previously called 2019-nCoV[1]. By January,2020,the World Health Organization(WHO) labelled this disease as a public health emergency of international concern(PHEIC) and in March, 2020,declared it as a pandemic[2,3]. On February 11, 2020, the WHO officially termed the disease caused by SARS-CoV-2 as coronavirus disease-19 (COVID-19)[1].

This virus has a high potential for human-to-human transmission and this led to the COVID-19 epidemic in China, followed by a subsequent global pandemic[1]. This virus has an extremely high rate of transmission.In an attempt to contain its spread,various restrictions were implemented, such as ban on international and interstate traveland government-mandated lockdowns[4]. Despite such stringent measures, there were a total of 638,146 confirmed cases and 30,039 deaths reported by WHO on 30^th March, 2020. Elderly,patients with features of severe acute respiratory illness (SARI) and patients with comorbidities were associated with a higher fatality rate[5].

India reported its first case of this disease in Kerala on 30^th January,2020,in a patient with travel history from Wuhan[6]. On 24^th March, 2020, the first COVID-19 case was detected in North-East India in a female patient who had travelled from UK to Imphal,Manipur[7]. Assam reported its first positive case on 31^st March, 2020[8].

Even though the main route of transmission of SARS-CoV-2 is through droplets and fomites,there is a potential risk of virus spread in smaller aerosols during various medical procedures causing airborne transmission[9–12].“Airborne transmission” refers to transmission of infection via small(< 5-10um) inspirable aerosols over extensive distances,whereas“droplet transmission” refers to transmission of infection by(larger) aerosols over short distances directly from the infected person to the susceptible person[13,14].Various procedures performed by Otolaryngologists to diagnose or treat patients may generate aerosols from areas of high viral shedding,such as the nasal and oropharyngeal cavity[12,15].

High titres of SARS-CoV-2 have been detected in the upper respiratory tract of both,asymptomatic and symptomatic individuals suffering from COVID-19[16].The viral load in the nose is far higher than that found in the throat[15] and thus,these sites are the primary source of infection and viral replication.Viral RNA has even been found in the blood of both symptomatic and asymptomatic COVID-19 patients, and such inhaled aerosol of blood may potentially transmit infection[15,17]. This distinctive feature of the virus poses particular risk for health care workers who examine and operate these areas.Thus,otolaryngologists,who frequently manipulate the upper airways and digestive tractare especially vulnerable to viral transmission.They are often exposed to contact with this virus,either directly through mucus and blood,or via aerosolized particles when examining or operating in these areas. Data from countries with high COVID-19 positive cases,  such as China, Iran, Italy and India, have shown that the group with the highest risk of contracting this virus are otolaryngologists and head and neck surgeons[16].

Thus, otorhinolaryngologists have been put in a quandary regarding management of acute and emergent problems requiring surgical intervention.It is highly recommended that otorhinolaryngologists take extra precautions while examining or operating on the upper aerodigestive tract, so as to avoid contamination.Hence use of appropriate PPE is advocated while doing routine examinations and surgical procedures.

To stabilize the health care system which is already overburdened with the rising number of cases,triaging of care is essential.While hospitals and health care workers are grappling with an increasing number of COVID-19 cases,there has been a decline in the number of non-COVID-19 patients visiting the out-patient and the emergency clinic,including the otorhinolaryngology clinic.

In this study,we have made a modest attempt to discuss the affect that COVID-19 pandemic has had on the Otolaryngology department at a tertiary care hospital-cum-referral center in North-East India.The primary aims were to quantify the patient admissions and the operative procedures carried out over the first four-months of the virus’ impact, in comparison with the previous year.We also analyzed patient visits based on age and their place of residence.

Methods

This study was conducted under the aegis of the Department of Otorhinolaryngology and Head and Neck Surgery,at a tertiary care hospital-cum-referral centre in North-East India. This study included data acquired from the out-patient register,emergency register, in-hospital admission register and the operation register maintained at the otolaryngology department, and included data over a 4-month period, from April, 2020 to July, 2020. We pulled records of these cases from the medical records department and reviewed them to understand the case report thoroughly. Demographics, age, gender, place of residence, date of admission,clinical diagnosisand the operative procedure performed were included in the data profile for analysis. The above-mentioned registers were also reviewed to retrieve details about the rate of admission during the study period in the previous year. Data was collected and represented,in both descriptive and tabular forms, after proper statistical analysis.Data was analyzed using proper statistical tools.

Results

A total of 1070 patients were examined in the Otolaryngology department(both in outpatient and in emergency) over a 4-month period,from April,2020 to July,2020.This number constituted 17.5% of total cases,compared to the previous year’s numbers during the same period(18707 cases).All the patients undergoing emergency procedures during April-July,2020,underwent COVID-19 testing and all the COVID-19 negative patients were operated in the emergency operation room taking standard aseptic precautions.The patients with an acute emergency,where COVID-19 report was not immediately available,were operated at the designated COVID-OT,taking all the protective measures as per the institutional guidelines i.e.,wearing N95 masks and PPE.[Table 1]

Table 1–Breakdown of cases in 2019 and 2020,over a 2-months period

Most of the patients were male,with a male to female ratio of 1.9:1.This was more than the previous year’s ratio of 1.4:1 between male and female patients.[Table 2]

Table 2-Breakdown of cases on the basis of gender

Most of the visits were from people residing in rural areas,with a ratio of 1.2:1.This value was lesser than the previous year’s rural to urban ratio of 2:1.[Table 3]

Table 3-Distribution of cases on the basis of place of residence of patients

Most of the patients were in the age group of 60-80 years,unlike in 2019,when most of the cases were in the age group of 40-60 years.[Table 4]

Table 4-Distribution of cases on the basis of age

The cases who underwent day-care,emergency and elective operative procedures during the period of 4-months,from April,2020 to July,2020 are tabulated below.[Table 5]

Table 5-Distribution of cases based on the intervention taken from April,2020 to July,2020

Discussion

Coronaviruses are approximately 0.125 µm in size and are frequently carried in respiratory droplets[15,17].The Healthcare Infection Control Practices Advisory Committee established SARS-CoV-2 as being transmitted through the droplet route,thereby making it an airborne pathogen[18].Airborne transmission is the inhalation of small particles called droplet nuclei,having a diameter of ≤5 µm,and they remain infectious over long distances(>1m)[18].SARS‐CoV-2 has been measured in air samples within 1m of an infected patient in 11 samples over 8 hours,suggesting a high risk for airborne transmission[19].These data appear to be supported by a recent study demonstrating that aerosolized particles of SARS‐CoV‐2 of <5 µm remain viable in air for at least 3 hours[11].There is also a dose‐response relationship between exposure and infection severity in COVID-19[20].In a study carried out by Workman et al,they simulated out-patient aerosol generating conditions.They demonstrated gross aerosol droplet contamination up to a distance of 66cm from the nares,with an inverse relationship between droplet size and distance traversed,in cases where no mask was used to cover up the patient[18].

Otorhinolaryngologists are often required to perform a range of endoscopic procedures, such as laryngoscopy, esophagoscopy, bronchoscopy and endonasal proceduresand this puts them at particular risk of acquiring this contagion.They are also required to carry out tracheotomies and tracheostomies to establish secure airways in patients with airway compromise. In a systematic review performed by Tran et al,they found that tracheal intubation was the most consistent and statistically significant procedure responsible for SARS-CoV-2 transmission to health care workers,due to its high aerosol generating capacity[21].

Aerosol generating medical procedures(AGMP) is defined as a medical procedure which has the potential to generate small(<5-10um) aerosols that can travel greater than 2 metre,and therefore an AGMP confers the potential for airborne transmission.In contrast,we defined droplet transmission as involving(larger) aerosols over short distances(<2m) directly from the infected person to the susceptible person via mechanisms such as coughing and sneezing[13,14].

To counter AGMP,various innovations from different countries has come up for the smooth running of the Otorhinolaryngology department. The need of reverse transcription-polymerase chain reaction(rt-PCR) for SARS CoV-2 testing in patients before any surgical procedures like tracheostomy etc is well documented[22].The innovations and practices are defined under each heading based on the anatomical and surgical areas of Otorhinolaryngology Head and neck surgery department.

Certain innovative practices that can be adopted in day-to-day practice of ENT that can safeguard the health of the practitioner have been proposed by various Otorhinolaryngologists worldwide Some of these are discussed below-

Telemedicine and Telehealth

During the coronavirus epidemic telemedicine has become the doctors’ first line defence mode of communication with the patient,to slow the spread of the corona virus,promoting social distancing and providing services by telephone or video conferencing[23].  This includes online consultations, telemonitoring, teleconferencing, chat box etc.[24]. Advantages of Telemedicineincludes convenience, low cost, and ready accessibility of health-related information and communication using the Internet and other associatedtechnologies[25].

Personal Protective Equipment (PPE)

Based on the Gavin Setzen et al[26],American Academy of Otolaryngology–Head and Neck Surgery,PPE is a critical kit to protect individuals from exposure and transmission of COVID-19.Every patient interaction has differing levels of theoretical risk of transmission based on anatomy and pathophysiology,with likelihood of aerosolization caused by a specific intervention,and the extent of exposure.Depending on the covid status of the patient and the assumed risk of aerosolization during an intervention,the requirement of appropriate level of PPE can be determined.

Closed Chamber ENT Examination Unit

Different studies promote use of a closed chamber with negative pressure system in addition to the usage of PPE kit for routine ENT examinations including endoscopic procedures so as to reduce the aerosol spread and contamination.Ibrahim Sayin et al.[27] modified a nasopharyngeal swab collection chamber into one such closed chamber for ENT examination.This isolated chamber is equipped with an air inlet,exhaust fan system connected with a HEPA filter for negative pressure creation,ENT instruments and a Bluetooth speaker with microphonefor communication.Sterilisation of the chamber is by using two UV-C lamps which is based on the previous study done by Bedell et al[28]that 5 minutes of exposure with a UV-C emitter resulted in undetectable levels of Middle East Respiratory Syndrome Coronavirus(MERS-CoV) in droplets or a percent reduction of >99.999%.Additional sterilisation with 78% ethanol of instruments is also done.The author promotes use of topical anaesthetic gel for oropharyngeal examination and anaestheticcotton pledgets for nasal cavity examination inorder to eliminate aerosol generation.

Nasal Endoscopy and Laryngoscopy

Workman et al.(2020) simulated aerosolization in a cadaver with the nasal mucosa coated with fluorescein over a range of endoscopic procedures[18].The literature concludes that diagnostic nasal endoscopy did not generate aerosols;but,coughing and sneezing which happens during patient examination was simulated using anintranasal atomizer devicewhich showed aerosol generation[18]. Hence nasal endoscopy should be considered as an AGMP.Use of a surgical mask and a modified VENT(Valved Endoscopy OfNose and Throat) mask can prevent all detectable spread of the particles[18].Endoscope-i Ltd,a team of surgeons and engineers in UK,has invented a new SNAP device for safe nasal endoscopy, in which a lumen is created in the mask through which an endoscope can be passed. Endoscope-i Ltd,also developed endoscope iPhone adapter which can be placed over the eyepiece of rigid endoscopes and the mobile phone can be placed and used as a mini screen for visualisation especially in an outpatient setup for nasal,ear and laryngeal endoscopies.(https://endoscope-i.com/)

Endonasal skull base surgery

Workman et al.(2020) also simulated surgical aerosolization during non-powdered instrumentation,suction microdebrider,and high-speed drilling after nasal fluorescein application in endoscopic sinonasal and skull base procedures.They found out that cold non-powered instrumentation and microdebrider use did not generate detectable aerosols,but use of high-speed drill produced significant aerosol contamination[29].They hypothesized that this may be due to the relatively low oscillation speeds and continuous local suction in case of microdebrider in comparison to a high speeddrill[18].

From the study conducted by Workman and his associates,we can hypothesize that cold non-powered procedures are less likely to result in droplet or airborne transmission,as the patient is paralyzed during the procedure.

Nasal Packing and Treatment of Epistaxis

Some studies evaluated the risk of aerosol contamination during the management of epistaxis by examining blood contamination of the physician’s protective equipment[29-31].All these studies showed that the management of epistaxis causes blood aerosol transmission to the treating physician who is in close proximity to the patient.These studies also evaluated that the aerosol spread was significantly reduced if the patient wore a surgical mouth-mask during nasal packing[29,30].A guideline for the epistaxis management in COVID-19 situation was promoted by Elgan Davies and his associates[32].They advised for initial conservative management with digital pressure for 15 minutes along with Tranexamic acid injection and control of risk factors like blood pressure etc for effectively managing epistaxis.If not controlled,use of bioresorbable dressing like NASOPORE should be used instead of conventional nasal gauze packing inorder to reduce aerosol generation.

Mastoid Surgery

During drilling of the mastoid bone,aerosolization of bone dust and irrigation fluid occurs.This can become a potential risk for transmission of disease.Different viruses,including coronavirus,have been documented in the middle ear mucosa during active infections[33,34].Mastoidand middle ear surgeries should be considered as a droplet-forming procedure and an AGMP.Adequate PPE and N95 mask should be used for conducting these procedures.Based on a recent cadaveric study,the authors suggested use of two drapes,Steri-Drape 1015(3M) and the C-Armor(Tidi) in addition to a microscope drape,to prevent contamination from the aerosols generated during the procedure.Using a microscope with face shield is difficult and the method mentioned above avoids the need of face shields[35].

Tracheotomy

Chow et al. conducted five tracheotomies using two horizontal anaesthetic screens and a clear sterile plastic sheet draped over the operative field.This helped create a closed sterile environment,preventing droplet infection,aerosol contamination and viral transmission.Droplet contamination was most severe over the central surface of the plastic sheet overlying the site of operation.In this way use of face shields may be spared as it gives rise to fogging and also hinders the use of a head light while operating[36].

Our study is aimed to quantify the impact of the COVID-19 pandemic on the day-to-day practice of Otorhinolaryngology at a tertiary care center in North-East India.This study revealed a drastic fall in the number of patients visiting the out-patient and the emergency clinic.There was also a drastic reduction in the number of elective surgeries.Due to government-mandated lockdown,which began on 25^th March 2020,some degree of reduction in volume of patients attending the Otolaryngology clinic was expected[37,38].Also,non-urgent and elective procedures were postponed due to the elevated occupational hazard associated with any otolaryngologic procedure[37].Another explanation for the fall in patient numbers may be the reluctance on the part of patients to seek medical care.This is due to the fear that the hospital or the health care worker might be a possible source of the SARS-CoV-2 contagion,as most of the otolaryngologic conditions require a close examination of the head and neck[38].This fear also plays a major role on the doctor’s self-perceived risk of acquiring this contagion from a patient.

There was approximately 75.5% decrease in the volume of patients compared to the previous year.This decline in patient numbers will have a definite impact on early diagnosis,prompt management and treatment of progressive diseases such as malignancies,thereby having a profound impact on the morbidity and mortality rates.

Most of the patients that sought medical care during this study period were in the age group of 60-80 years.This was unlike the findings of 2019,where,maximum cases were in the age group of 40-60 years.This can be explained by the fact that most of the elderly patients have associated comorbidities like hypertension,diabetes mellitus and chronic kidney disease and they need constant medical care for the same.The reduced number of cases amongst the young adults can be explained by the reduction in the number of trauma cases, including road traffic accidents,as a direct result of the strict,nationwide lockdown.

In our tertiary care centre,we have taken certain preventive measures to limit the exposure and spread of SARS-Cov-2,while providing the necessary care and treatment to the patients attending the Department of Otorhinolaryngology.First of all,the duty roster was changed accordingly so that minimum number of doctors and staffs will be on force at a time,in order to decrease the risk of exposure to COVID-19.All the patients attending the hospital have to maintain adequate social distancing in the waiting area.Hand sanitizers have been provided in the waiting area and all the patients and their attendants have to maintain hand hygiene.Only one patient at a time is allowed to enter the OPD through a one-way entry point.We have also limited the number of attendants accompanying the patient to one.We prepared ourselves with proper PPE kit along with N95 masks and face shield to examine patients.We have initiated non-contact thermal screening of all patients and their attendants,along with enquiring about any travel history to-and-from hotspot areas and contact history.If any patient is found to have elevated temperature or a positive history,he or she is sent to the Screening Area/Fever Clinic for further evaluation of COVID-19.If the patient has no positive history of COVID-19,patient is allowed to enter inside a closed cabin made of plastic curtains,where he/she is communicated with a two-way audio system regarding the otorhinolaryngological complaints.After which the patient is examined inside the cabin and given treatment accordingly.We classified patients into two groups,one requiring immediate/emergency intervention and the other not requiring immediate intervention.The patients requiring immediate intervention like cut neck injury,tracheostomy,foreign body esophagus,chronic otitis media with intracranial complications etc. are managed in COVID OT with full PPE kit irrespective of their COVID status.Non-emergency patient group including the elective OT cases are postponed and given advice through telephone regarding the treatment and follow up,thus decreasing the unnecessary exposure of patients and healthcare workers.Ward admissions were also limited to the patients requiring compulsory hospital care like old,debilitated patients with other comorbidities.We created an isolation area in our ENT ward where the patients are first kept after admission till the reverse transcriptase-polymerase chain reaction(RT-PCR) for SARS-CoV-2 report comes.In the isolation area,the patients are triaged and examined with us wearing full PPE kit.Once the report comes negative,patient is shifted to ENT ward.If the patient becomes COVID-19 positive,then he/she is shifted to COVID-19 ward.We made certain that the patients get appropriate treatment irrespective of his/her COVID-19 status.

This study is important as it will help quantify the impact of the COVID-19 pandemic on patient care and the limitations in patient management,and help explore alternative avenues to minimize these limitations.This is especially important to safeguard patients and providers,specially otolaryngologists,owing to the fact that most of the head and neck examination and common otolaryngologic procedures generate aerosols[38].Otorhinolaryngologists should be encouraged to use personal protective equipment(PPE) and N95 respirators,whenever they examine or perform any procedure involving the aero-digestive tract.N95 respirators are air‐purifying respirators that fulfil the filtering efficiency criteria set forth by the National Institute for Occupational Safety and Health N95 standard which filter with 95% efficiency large droplets and penetrating aerosols 0.3 µm in diameter,and thus,protect against droplet or airborne transmission[18].Training programs should be initiated to teach health care workers, including otolaryngologists, on how best to deal with patients during pandemics, proper use of telemedicine and the protective measures that should be taken during patient examination and surgeries.

Conclusion

This study revealed that COVID-19 has had a rapid and global impact on patients attending the Otolaryngology clinic. There was a marked reduction in the number of patients visiting the out-patient department, the number of patients admitted in the otolaryngology ward,the diagnostic procedures performed and the number of surgical procedures done. Most of the elective cases were cancelled in response to the pandemic. There was also a sharp fall in the emergency cases,which could be attributable to patients becoming more vigilant and careful regarding their health.This emphasizes the need for telemedicine as an alternative to face-to-face appointments in times of pandemic,setting-up a standard protocol regarding protective measures that need to be practiced, and the development of new health-care trends, so as to promote safe and efficient patient care.

Limitations-This study was carried out over a limited period of time, and at a time when the nationwide lockdown was in effect. This might play a factor in the drastic reduction in number of cases. Lastly, this was a single institution study and thus, cannot be a representative of the global findings. Nevertheless, the findings of this study may promote useful and innovative methods of patient care, such as triaging and telehealth, which will have a profound effect not only during this pandemic, but also beyond.

Declarations

Compliance with Ethical Standards:

Disclosure of potential conflicts of interest

Funding - No grant or financial  aid  availed.

Conflict of Interest: Authors declare that they have no conflict of interest.

Research involving Human Participants and/or Animals

Ethical approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.  Approval was taken from the Ethical committee of SSUHS (Srimanta sankaradeva University of health sciences)

Informed consent: Informed consent was obtained from all individual participants included in the study.

References

1. Guo YR, Cao QD, Hong ZS, et al. The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak - an update on the status. Mil Med Res. 2020;7(1):11. Published 2020 Mar 13. doi:10.1186/s40779-020-00240-0
2. Shultz J, Perlin A, Saltzman R, et al. Pandemic march: COVID-19’s first wave circumnavigates the globe. Disaster Med Public Health Prep. Published online April 16, 2020. doi: 10.1017/dmp.2020.103
3. World Health Organization. Statement on the Second Meeting of the International Health Regulations (2005) Emergency Committee Regarding the Outbreak of Novel Coronavirus (2019-nCoV). World Health Organization; 2020.
4. Khosrawipour V, Lau H, Khosrawipour T, et al. Failure in initial stage containment of global COVID-19 epicenters. J Med Virol. Published online April 16, 2020. doi:10.1002/jmv.25883
5. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak. J Autoimmun. 2020;109:102433.
6. COVID-19 pandemic in India [Internet]. En.wikipedia.org. 2020 [cited 5 June 2020]. Available from: https://en.wikipedia.org/wiki/2020_coronavirus_pandemic_in_India
7. Timeline of the COVID-19 pandemic in India [Internet]. En.wikipedia.org. 2020 [cited 5 June 2020]. Available from: https://en.wikipedia.org/wiki/Timeline_of_the_COVID-19_pandemic_in_India
8. COVID-19 pandemic in Assam [Internet]. En.wikipedia.org. 2020 [cited 5 June 2020]. Available from: https://en.wikipedia.org/wiki/COVID-19_pandemic_in_Assam
9. Organization W. Advice on the use of masks in the context of COVID-19: interim guidance, 6 April 2020. Apps.who.int. https://apps.who.int/iris/handle/10665/331693. Published 2020. Accessed July 9, 2020.
10. Bourouiba L. Turbulent Gas Clouds and Respiratory Pathogen Emissions. JAMA. 2020. doi:10.1001/jama.2020.4756
11. van Doremalen N, Bushmaker T, Morris D et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. New England Journal of Medicine. 2020;382(16):1564-1567. doi:10.1056/nejmc2004973
12. Wang W, Xu Y, Gao R et al. Detection of SARS-CoV-2 in Different Types of Clinical Specimens. JAMA. 2020. doi:10.1001/jama.2020.3786
13. Tellier R, Li Y, Cowling B, Tang J. Recognition of aerosol transmission of infectious agents: a commentary. BMC Infect Dis. 2019;19(1). doi:10.1186/s12879-019-3707-y
14. Jones R, Brosseau L. Aerosol Transmission of Infectious Disease. J Occup Environ Med. 2015;57(5):501-508. doi:10.1097/jom.0000000000000448.
15. Zou L, Ruan F, Huang M et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. New England Journal of Medicine. 2020;382(12):1177-1179. doi:10.1056/nejmc2001737
16. Position Statement AAO-HNS. Otolaryngologists and the COVID19 Pandemic [Internet]. Published Online, 2020, Mar 23 [cited 2020 Mar 24]. Available from: https://www.entnet.org/content/ aao-hns-position-statement-otolaryngologists-and-covid-19- pandemic
17. Fehr AR, Perlman S. Coronaviruses: an overview of their replication and pathogenesis. Methods Mol Biol. 2015;1282:1‐23. doi:10.1007/978-1-4939-2438-7_1
18. Workman AD, Welling DB, Carter BS, et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies [published online ahead of print, 2020 Apr 3]. Int Forum Allergy Rhinol. 2020;10.1002/alr.22577. doi:10.1002/alr.22577
19. Booth TF, Kournikakis B, Bastien N, et al. Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units. J Infect Dis. 2005;191(9):1472‐1477. doi:10.1086/429634
20. Watanabe T, Bartrand TA, Weir MH, Omura T, Haas CN. Development of a dose-response model for SARS coronavirus. Risk Anal. 2010;30(7):1129‐1138. doi:10.1111/j.1539-6924.2010.01427.x
21. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. doi:10.1371/journal.pone.0035797
22. Miles B, Schiff B, Ganly I et al. Tracheostomy during SARS‐CoV ‐2 pandemic: Recommendations from the New York Head and Neck Society. Head Neck. 2020;42(6):1282-1290. doi:10.1002/hed.26166
23. gov. https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/CDC-Activities-Initiatives-for-COVID-19-Response.pdf. Published 2020. Accessed July 9, 2020.
24. Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N et al. Telemedicine in the face of the COVID-19 pandemic. Atención Primaria. 2020;52(6):418-422. doi:10.1016/j.aprim.2020.04.003
25. López Seguí F, Franch Parella J, Gironès García X et al. A Cost-Minimization Analysis of a Medical Record-based, Store and Forward and Provider-to-provider Telemedicine Compared to Usual Care in Catalonia: More Agile and Efficient, Especially for Users. Int J Environ Res Public Health. 2020;17(6):2008. doi:10.3390/ijerph17062008
26. org. https://www.entnet.org/sites/default/files/uploads/guidance_for_return_to_practice_part_one_final_050520.pdf. Published 2020. Accessed July 9, 2020.
27. Sayin İ, Devecioğlu İ, Yazıcı Z. A Closed Chamber ENT Examination Unit for Aerosol-Generating Endoscopic Examinations of COVID-19 Patients. Ear, Nose & Throat Journal. 2020:014556132093121. doi:10.1177/0145561320931216
28. Bedell K, Buchaklian A, Perlman S. Efficacy of an Automated Multiple Emitter Whole-Room Ultraviolet-C Disinfection System Against Coronaviruses MHV and MERS-CoV. Infection Control & Hospital Epidemiology. 2016;37(5):598-599. doi:10.1017/ice.2015.348
29. Baig S, Rashid T, Saleem M. Protection from blood aerosol contamination when managing epistaxis: a study of the effectiveness of a patient mouth mask. Ear Nose Throat J. 2015;94(9):394–398.
30. Hassan S, Trotter M. Protection from epistaxis blood aerosol contamination: a novel use of a surgical facemask. European Archives of Oto-Rhino-Laryngology. 2003;260(5):242-243. doi:10.1007/s00405-002-0510-x
31. Wallace H, Harries P. Epistaxis and conjunctival contamination – are our ENT trainees at risk?. Annals of the Royal College of Surgeons. 2002;84(5):302-303. doi:10.1308/003588402760452574
32. org. https://www.entuk.org/sites/default/files/files/COVID%2019%20Epistaxis%20Management.pdf. Published 2020. Accessed July 9, 2020.
33. Buzatto G, Tamashiro E, Proenca-Modena J et al. The pathogens profile in children with otitis media with effusion and adenoid hypertrophy. PLoS ONE. 2017;12(2):e0171049. doi:10.1371/journal.pone.0171049
34. Alper C, Winther B, Mandel E, Hendley J, Doyle W. Rate of Concurrent Otitis Media in Upper Respiratory Tract Infections With Specific Viruses. Archives of Otolaryngology–Head & Neck Surgery. 2009;135(1):17. doi:10.1001/archotol.135.1.17
35. Carron J, Buck L, Harbarger C, Eby T. A Simple Technique for Droplet Control During Mastoid Surgery. JAMA Otolaryngology–Head & Neck Surgery. 2020. doi:10.1001/jamaoto.2020.1064
36. Chow V, Chan J, Ho V et al. Tracheostomy during COVID ‐19 pandemic—Novel approach. Head Neck. 2020;42(7):1367-1373. doi:10.1002/hed.26234
37. Kowalski LP, Sanabria A, Ridge JA, et al. COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and head and neck surgery practice. Head Neck 2020
38. Guidance for ENT during the COVID-19 pandemic 2020 [Available from: https://www.entuk.org/guidance-ent-duringcovid-19-pandemic