Society e-Blasts & COVID-19 Alerts
Update - May 25, 2020
From the President
Time has passed since my last communication to our membership. I am acutely aware of the surge in COVID related information that is circulating in many forms – recommendations, advice from provincial medical organizations, a plethora of virtual meetings and the social media frenzy.
As such, I have been trying to minimize your inboxes from the CSO but thought it was time to alert you to some important updates related to CSO sponsored recommendations, our annual meeting and planned webinars.
- CSO Sponsored Recommendations
As you are all aware, there are numerous recommendations and publications related to COVID-19 at the local, provincial, national and international levels that are conflicting. The advice and recommendations we get from our Infection Prevention and Control (IPAC) colleagues is quite frequently different, even at hospitals in the same region. When you talk to your local colleagues, the measures used in one hospital can be quite different than another hospital in the same region which creates a lot of uncertainty and anxiety. I have heard from many of our members how helpful the tracheotomy recommendations were in helping them advocate locally so we have created additional recommendations we hope are helpful for our members and all Canadian otolaryngologists in thinking about how they will start their practices again.
Dr. Karen Kost and members of our Laryngology Committee created a document for “Safely Resuming Laryngoscopy in Canada” with a Preamble and Recommendations available by clicking the links and are available on our website in the COVID-19 Resources section on Starting Practice.
Dr. Yvonne Chan led a taskforce of community and academic otolaryngologists from across Canada with IPAC input on “Return to Otolaryngology – Head & Neck Surgery Clinic Practice During the COVID-19 Pandemic” available here and on our website.
We frequently scan documents for salient points but I would suggest you take some time to read, digest and think about the information in these documents. It is impossible to come up with evidence-based recommendations for every point in these documents and the advice given is based on expert review of available literature and in many cases, common sense. We welcome constructive feedback and will treat all of our recommendations as “living documents” that need to be updated and changed as new information becomes available.
I want to sincerely thank our leads (Karen and Yvonne) and the task force members for their incredible diligence and fast work in getting these documents ready for our members. You may not realize the time and effort that goes in to creating these documents, but I can assure you it is substantial, and we owe a debt of gratitude to these people. I am also reaching out to our subspecialty committees to see if they will help create recommendations that will be valuable and practical in the Canadian context.
The recommendations will hopefully get our practices going again and keep our patients, staff, learners and all of us safe. The recommendations and what we actually do will obviously change depending on how things ramp up, local circumstances related to COVID-19 prevalence and government regulations.
- Annual Meeting
As many of you have probably heard, the Government of New Brunswick has banned any large meeting taking place in 2020. We have therefore cancelled our planned in person meeting re-scheduled to November 7-10, 2020. Instead, we are planning a virtual meeting that will start in the fall. I don’t know about you, but is difficult to stay “tuned in” to a virtual meeting for more than an hour or two at a time so we plan on breaking up the sessions over many weeks/months to provide interesting content in a format that will hopefully appeal to our members. We will pick times so that you can still go about your day-to-day practices and still tune in to the live event or if you want, watch the recording later. We will culminate on November 7th or 8th with a virtual Annual Business Meeting. This is a work in progress so please stay tuned for details.
We will be hosting some webinars in the near future related to the laryngoscopy and starting practice taskforces. Other webinars are in the planning process and I hope you will find them helpful. Stay tuned for details by email.
Please contact me if you have any questions (ian.wi[email protected]).
As always, my very best wishes to you and your families. Stay safe and well!
Ian Witterick, CSOHNS President
COVID 19 - April 2020
April 26, 2020
New Updates on COVID-19 Resource Information and the ABOHNS’ Online Portal for Board Eligibility
I hope you and your families enjoyed the weekend and are staying healthy.
We have received very positive comments about the communications and recommendations/guidelines the members of our society have produced to help you during the pandemic. Thank you to all our members and our colleagues in other specialties who have been so helpful with these efforts. We continue to update our website with resources we hope you will find helpful, www.entcanada.org/news-events/covid-19-alerts/
- The Canadian Association of Head and Neck Surgical Oncology (CAHNSO) Executive has prepared excellent guidelines for management of head & neck cancer during the COVID-19 pandemic; availablehere or download the PDF CAHNSO-Guidelines-COVID
- Coping with the anxiety, worry and uncertainty associated with the pandemic is stressful. I asked Dr. Jon Hunter, a psychiatrist at Sinai Health, to give our department’s Grand Rounds on April 3, 2020, on strategies to manage our own mental health during the pandemic. I thought he provided very practical advice and resources; the virtual presentation is available at the following link if you are interested –Managing Strain with Covid
- American Board of Otolaryngology – Head and Neck Surgery (ABOHNS) Update – We received word from Dr. Brian Nussenbaum, Executive Director of the ABOHNS, that the online portal to apply for Board Eligibility has opened. The introductory letter from the ABOHNS including their policies and application checklist is available here.
Stay well, stay safe and stay actively engaged in your hospital; you can make a difference for your own health, the health of your colleagues and most importantly the health of your patients and families.
Ian Witterick, CSOHNS President
COVID-19 - March 2020
March 27, 2020
I want to thank all of you who are thinking of solutions to help protect all of us during the COVID-19 pandemic. I have been impressed by the ingenuity, collegiality and responsiveness of our OHNS community across the country in sharing ideas and rallying to help our patients, our colleagues and our health care system.
It will come as no surprise to our members that it would be very difficult to run a successful annual meeting in Fredericton, currently scheduled for June 6-9, 2020. Your Executive Committee has made the decision to postpone the meeting to November 2020, likely November 7-10, 2020, in Fredericton. The exact dates still need to be worked out and we will send out more information in the coming months as we “re-tool” the planned events. A special shout out to our Program Chair, Dr. Vincent Lin, CPD/CME Chair, Dr. Yvonne Chan, Local Arrangements Chair, Dr. Greg Thompson and General Manager, Ms. Donna Humphrey who have put in countless hours in planning this meeting – with their organizational skills, it should “be a breeze” to re-organize J.
I am frequently asked to comment on the most appropriate level of personal protective equipment (PPE), especially for nasopharyngoscopy and urgent upper airway surgery. It seems many jurisdictions are not able to get sufficient quantities of PPE and have to make difficult choices. Viral testing prior to urgent surgery is not available in many centres, let alone testing twice before urgent surgery. Many colleagues are meeting resistance from their local infection control colleagues over the necessity of wearing N95 masks and other appropriate PPE for nasopharyngoscopy.
To help our specialty with some of these questions and provide what is felt to be reasonable and thoughtful advice at this time, a multispecialty group led by Dr. Brian Westerberg has produced a document titled Guidance for Health Care Workers Performing Aerosol Generating Medical Procedures during the COVID-19 Pandemic available here. This document has been endorsed by the CSO-HNS Executive Committee and we would encourage you to look at it and let us know any questions, comments or concerns. Similar to the tracheotomy guidelines released on March 23, 2020, we hope this guidance will help protect you and support you in advocating for, and instituting system change.
There are many in our profession who are suffering and stressed physically, mentally and emotionally. Many are feeling pushed and unsupported. We are an amazing specialty with so much talent across the country and so much to offer at this time. Please reach out to your colleagues, form communities of knowledge, advocate for what you need, “prepare for the worst but hope for the best”. Continue to provide the excellent standard of care that you always do!
Stay healthy, be knowledgeable, stay positive, don’t be afraid to call a friend for advice and send virtual “hugs” to your colleagues. Above all, remember to support your families – they are worried and suffering along with you, often in silence.
It is a real honour to serve as your President; my sincere thanks for your support!
Ian Witterick, CSOHNS President
P.S. – Lots of info on our “COVID-19 Resources” web page
March 23, 2020
I wanted to update you on two things:
1. Recommendations from the CSO-HNS Taskforce on Performance of Tracheotomies During the COVID-19 Pandemic
A CSO-HNS task force led by Dr. Doron Sommer with multi-specialty involvement from otolaryngology-head & neck surgery (Canadian and US input), general surgery, critical care and anesthesiology has developed a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic. Please see the link to this guideline here: PDF Document
The task force recognizes there are current shortages of Personal Protective Equipment (PPE) including N95 masks as well as Powered Air Purifying Respirators (PAPRs) mentioned in these recommendations. The task force hopes this information will help in the discussion with your hospital leadership as to the importance of this equipment to safely perform tracheotomies as outlined in these recommendations. This is a time of uncertainty and we want to take every opportunity to aid in maximizing your safety. I want to sincerely thank Dr. Sommer and the members of the task force for developing these recommendations in a thoughtful and timely fashion using best available evidence at this time.
2. Shortages of N95 Masks
I have heard from numerous colleagues across the country about the shortage of N95 masks and many hospitals will be running out them soon (i.e. this week). There are a lot of “interesting” options being discussed on the internet but one option (unproven) from Boston Children’s Hospital looks plausible. A YouTube video detailing this “MacGyver” option is available at: https://youtu.be/Es_iY5WJdmI
Stay well and please let me know if you have any questions or comments.
Ian Witterick, CSOHNS President
March 21, 2020
I know all of you are being bombarded with emails and information about COVID-19 so my sincere apologies for adding to your inbox. Following the initial email two days ago I have received a lot of questions about head and neck procedures and performance of tracheotomies. A group of Canadians is working on a tracheotomy document but I thought I would share with you information that I think is relevant and will hopefully help in your decision making and discussion with your hospitals.
Guidelines from Stanford University published in ENT Today on March 20, 2020 available at: https://www.enttoday.org/article/otolaryngologists-may-contract-covid-19-during-surgery/
Recommendations from the OHNS department at University Health Network led by Ralph Gilbert in Toronto for head & neck oncologic procedures:
- All procedures that include any instrumentation of the upper airway including the oral cavity and nasopharynx should be treated as high risk procedures and all staff in the operating room should be protected with PPE. For nursing and surgical staff this includes N95 masks, eye protection, gowns and gloves. Surgical staff may use loops if required for the surgical procedure.
- All other procedures should be managed as per operating room standard.
- Where possible we should work to minimize the number staff in the room during the aforementioned procedures, this includes residents and fellows who are not required for performance of the surgical procedure.
- All patients that are scheduled for surgical procedures of the upper airway including the oral cavity will undergo COVID-19 screening 48hrs prior to the planned surgical procedure, should they test positive, their procedures will be deferred until screened negative.
- COVID-19 screening can take place at a regional COVID-19 testing centre closest to the patient.
- For high risk procedures as defined above; the department recommends that oral cavity and nasal sites be separated from the remainder of the surgical sites for procedures such as neck dissection and parotidectomy. Techniques include the application of adhesive and sterile drapes.UK recommendations re tracheotomy during the COVID-19 pandemic available at:
UK recommendations re tracheotomy during the COVID-19 pandemic available at: https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic
Pandemic Planning Clinical Guideline for Patients with Cancer from Cancer Care Ontario courtesy of Jon Irish – PDF Document.
The AAO-HNS website also has useful information and resources available at www.entnet.org
I am involved with statements that will be coming out from the American Head and Neck Society and North American Skull Base Society but they are similar to the above so have not included them here.
I am sure most of you have started to consider what would happen if all of the otolaryngologists at a given hospital were quarantined/self-isolated/hospitalized and how you would manage. If you have not started to think about a plan, I would urge you to start a discussion with your local leadership.
My sincere best wishes to all of you and your families to stay well.
Please email me at [email protected] if you have any questions or concerns.
Ian Witterick, President CSO-HNS
March 19, 2020
I hope you are well and coping with the current COVID-19 crisis. I wanted to alert you to a few things you probably already know.
- COVID-19 may present as sudden loss of smell before the other more typical symptoms develop – be wary.
- Nasal endoscopy and sinus/anterior skull base surgery carries significant increased risk of contracting/spreading the virus.
There has been information circulating by email and social media about the dangers of sinonasal and oral cavity procedures. Most hospitals have cancelled elective surgeries and are prioritizing life or limb procedures.
An AAO-HNS bulletin circulated this afternoon helps summarize the situation and I wanted to make sure our members had this information (my apologies for any duplication of information).
“CMS [Centers for Medicare & Medicaid Services] released a new statement last night, March 18, 2020, “CMS Adult Elective Surgery and Procedures Recommendations” intended to provide clarity and a framework for physicians and local facilities to make decisions relating to the performance of elective surgical and medical procedures. They recommend “Limiting all non-essential planned surgeries and procedures, including dental, until further notice” based on preservation of needed resources and the safety of patients and medical personnel. They included a table designed to give guidance to physicians and facilities on how to proceed based on situational acuity and the patient’s health. They make it clear that conditions will vary considerably in different areas of the United States. The agency has listed reasonable factors that should be considered in the decision-making process.
There is evolving evidence that otolaryngologists are among the highest risk group when performing upper airway surgeries and examinations. A high rate of transmission of COVID-19 to otolaryngologists has been reported from China, Italy, and Iran, many resulting in death.
Viral density is greatest in the nose and nasopharynx. Instrumentation in and through these areas would expectedly lead to increased risk. Surgery and endoscopic evaluation in these areas typically involves the application of various sprays, which can aerosolize the viral elements on the mucosa. During surgical procedures, the addition of powered debriders and shavers as well as drilling further promotes possible infectious microdroplet diffusion through the operating room or office.
While these recommendations do not specifically address procedures necessary in certain circumstances for a complete otolaryngologic exam, such as flexible laryngoscopy with or without stroboscopy and nasal endoscopy, these criteria can be extended to that type of procedure. Following personal verbal communication with CMS leadership yesterday, March 18, 2020, prior to the release of these recommendations, it was clear that they are in favor of utilizing the same principles outlined for surgical procedures to these examinations. This would favor delaying strictly routine examinations, while allowing examinations necessary based on the acuity of the situation and the availability of adequate PPE [Personal Protective Equipment].
Given available evidence, we recommend extreme caution when advising procedures or surgery occurring through a transnasal or trans-oral route. During in-office examinations, topical medications are more safely applied using pledgets rather than by spray. Surgical procedures should be performed only after ascertaining the COVID-19 status and if positive performed only with PAPR [Powered Air-Purifying Respirator].
Overall, these recommendations represent a well-thought-out process that offers flexibility based on specific patient needs and regional conditions. Please become familiar with this document and use it as a basis to aid in decision-making for each individual patient.”
I want to express my sincere gratitude to all of you who have stepped up to help our patients and healthcare system as the pandemic evolves. We have so many leaders in our specialty who are helping at local and provincial levels. There are many “unsung heros” who are giving of their time and expertise in these troubled times. Please don’t forget our amazing residents and fellows who are the front line in our academic institutions – they are doing a great job and deserve our sincere thanks.
My very best wishes to you and your family to stay healthy.
Ian Witterick, CSO-HNS President