COVID‐19: Protecting our ENT Workforce

Abstract

As we write at the end of March 2020, the coronavirus disease 19 (COVID-19) pandemic is posing an urgent and significant threat to global health. It has become clear that the healthcare worker army that forms the front line are also at increased risk of exposure to the SARS-CoV-2 virus that causes this disease. In China, 3.8% of all cases of COVID-19 were in healthcare workers, but 14.8% of those had severe or critical disease.1 The SARS-CoV-2 virus predominantly resides in the airway, with high viral titres demonstrated in the nasal cavity and oral cavity.2 Pathological studies have shown that the SARS-CoV-1 virus, which caused the SARS outbreak between 2002 and 2003, can infect other areas of the head and neck, including the distal airway (lung, trachea and bronchus),3 parathyroid (but not thyroid) gland,3, 4 salivary ducts,5 brain4, 6 and pituitary gland.4 These are therefore the likely sites of infection with SARS-CoV-2. Unspecified coronaviruses have been demonstrated in the middle ear of patients with acute otitis media.7 Clinical experience shows that the virus can cause inflammation or even ulceration of respiratory epithelium (Figure 1). ENT specialists are particularly at risk of exposure, due to the wide range of examination and operative procedures they perform in the airway, each with the potential for generation of aerosols or droplets laden with viral particles. It is also apparent that the risk of exposure to the virus in an individual patient encounter is difficult to quantify. Emerging evidence shows that, unlike most viral infections, high viral titres can be present in the oropharynx of infected patients at or before the onset of symptoms,8 and the presence and transmission of the virus can also occur in asymptomatic individuals.9 Given our inability to use clinical symptoms or signs to gauge risk, any patient (whether symptomatic or asymptomatic) must currently be considered potentially infected. This uncertainty is compounded by the scarcity of evidence on the extent to which aerosols are generated from procedures for examination or instrumentation of the airway.10 It is imperative that the risk of infection to ENT specialists is recognised and appropriately managed. There can be no greater illustration of this than the recent sad loss of one of our ENT community in England. Other ENT colleagues around the world have suffered severe disease and death, presumably due to unwitting exposure to high doses of the virus without adequate personal protective equipment (PPE). Given this situation, the only sensible approach where risk is unquantified is to minimise exposure, or where exposure is necessary, to take universal precautions with appropriate PPE. ENT UK, the professional membership body representing ENT in the UK, was the first to publish guidance relating to this issue. They now host a dedicated webpage that is being regularly updated.11 Their recommendation to stop all non-essential ENT examination or procedures during the pandemic serves to reduce exposure of health workers, but also reduces exposure to patients who are now no longer entering a hospital environment, and reduces use of human or physical resources that may need to be redeployed during the pandemic. At the time of writing, all ENT departments in the UK already have, or are close to, stopping routine elective clinics and operating. For some, this even includes stopping diagnosis and treatment of head and neck cancer. When performing a potential aerosol generating procedure becomes necessary, which includes any examination or instrumentation of the oral or nasal cavity, the minimum PPE required is a visor (or goggles), disposable gown, gloves and a filtering mask. Filtering masks have been shown to protect against aerosols and coronoaviruses,12 and in the UK, the recommendation is for a mask meeting FFP3 European standards which specify a minimum 99% filtration.13 Where available, some may prefer to supplement this PPE with a hood or a powered air respirator mask. For procedures such as tracheostomy or emergency mastoid surgery, where an aerosol is likely to be generated, empirical modifications to technique have been suggested which are detailed on the ENT UK website.11 Our response to this issue is not only about protecting the physical health of our workforce, but also their mental health. Having to regularly confront unprecedented occupational exposure to risk is creating palpable anxiety in our ENT community, and the cognitive strain of new processes and procedures to manage this risk is generating fatigue. Concerns are also developing around stock and availability of PPE,14 with global demand outstripping supply. In low- and middle-income countries, provision of PPE may be limited or non-existent. While handmade cloth masks may be used, they have not been shown to provide adequate protection.11 Another way for us to overcome our uncertainty is to share information, opinions and relevant data. It has been encouraging to see how quickly information on managing patients with COVID-19 has been shared through personal communication and global networks of clinicians, allowing those areas that are only now seeing the upsurge in cases to be better informed, and therefore hopefully better prepared than perhaps their colleagues were in the countries where COVID-19 first hit. Journals also have their part to play in disseminating information. More than 30 publishers, including Wiley, the publisher of Clinical Otolaryngology, have signed an agreement led by the Wellcome Trust to make all research and supporting data relevant to the pandemic immediately open access and shared with the World Health Organization.15 The ENT research community has been quick to respond, with many relevant articles already published. Research bodies such as the National Institute for Health Research (NIHR) have prioritised funding and support for COVID-19-related research16 and supported the set-up of CovidSurg, a global collaborative platform of studies aiming to explore the impact of COVID-19 on surgical patients.17 We would encourage participation in these or similar opportunities to collate knowledge on this viral disease. It is important that we look after ourselves so that can continue to look after our patients. Mutual support, both within and between departments, and global information sharing are essential to get through these difficult times.

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