Society e-Blasts: COVID-19 Alerts
March 27, 2020 (latest eblast)
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
COVID-19 Update - 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
COVID-19 - 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
COVID-19 - 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