In December 2019, Wuhan City, the capital of Hubei province in China, became the center
of an outbreak of pneumonia of unknown etiology. By January 7, 2020, Chinese scientists
had isolated a novel coronavirus: severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2; previously known as 2019-nCoV), from patients with viral pneumonia (COVID-19).
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Due to the Public Health Emergency of International Importance declared by the World
Health Organization (WHO) on January 30, 2020, caused by SARS-CoV-2 and the confirmation
of the first cases of COVID-19 in Brazil (2 confirmed cases in the state of São Paulo
by February 29, 2020), the Brazilian Association of Otorhinolaryngology and Cervico-Facial
Surgery (Associação Brasileira de Otorrinolaringologia e Cirurgia Cervico-Facial,
ABORL, in Portuguese) made a public announcement to guide otorhinolaryngologists in
care protocols in their offices.
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Coronaviruses are a relatively common family of respiratory viruses and the second
most frequent cause of common cold after rhinoviruses. In the recent decades, they
have been related to more serious outbreaks, such as severe acute respiratory syndrome
(SARS) in 2002 and Middle East respiratory syndrome (MERS) in 2012.
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There are seven identified coronaviruses that affect humans. The most common are α
coronavirus 229E and NL63 and β coronavirus OC43 and HKU1, the viruses responsible
for the SARS-CoV and MERS-CoV outbreaks respectively. Recently, a novel coronavirus
has been identified, which was initially named 2019-nCoV and then SARS-CoV-2 on February
11, 2020, as it was found to be genetically related to SARS-CoV. The disease caused
by the new coronavirus was named COVID-19.
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In practice, the healthcare system cannot sustain an uncontrolled outbreak, and stronger
containment measures are now the only realistic option to avoid the total collapse
of the intensive care unit (ICU) system. Hence, over the last 2 weeks, clinicians
have continuously advised authorities to augment containment measures.
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While regional resources are currently at capacity, the central Italian government
is providing additional resources, such as transfer of critically ill patients to
other regions, emergency funding, personnel, and ICU equipment. The goal is to ensure
that an ICU bed is available for every patient who requires one. Other healthcare
systems should prepare for a massive increase in ICU demand during an uncontained
outbreak of COVID-19.
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Vaccine development and research into medical treatment for COVID-19 are under way,
but results are many months away. Meanwhile, the pressure on the global healthcare
work force continues to intensify. This pressure takes two forms: the first is the
potentially overwhelming burden of illnesses that stresses the capacity of health
systems, and the second is the adverse effects on healthcare workers, including the
risk of infection.
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Many healthcare workers have conditions that elevate the risk of severe infection
or death if they become infected with SARS-CoV-2; hence, organizations will need to
decide whether such workers, including physicians, should be redeployed away from
the highest risk sites. It is not possible to entirely eliminate the risk, but prudent
adjustments may be warranted. New sites may need physician and nurse expertise, including
telemedicine services, patient advice lines, and augmented telephone triage systems.
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While healthcare workers often accept an increased risk of infection as part of their
chosen profession, they often exhibit concern about family transmission, especially
involving family members who are elderly, immunocompromised, or have chronic medical
conditions. While the US Center for Disease Control and Prevention (CDC) and Occupational
Safety and Health Administration provide clear recommendations, it is evident that
more is required to optimize safety in the current environment.
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In line with the current positions of the WHO and the CDC, the Brazilian Academy of
Rhinology (Academia Brasileira de Rinologia, ABR, in Porutugese) advises to avoid
the use of systemic corticosteroids for the treatment of patients with influenza-like
symptoms during the COVID-19 pandemic. Regarding the use of topical nasal corticosteroids,
current evidence shows no harm, and its use can be continued in patients who were
already using this medication chronically. However, due to the lack of conclusive
studies on COVID-19 and extrapolating the consequences of systemic corticosteroid
treatment, the ABR advises that the chronic use of topical nasal corticosteroids be
maintained and continue to be indicated, and in the occurrence of fever or other symptoms
suggestive of flu, the physician may consider its temporary discontinuation. As for
the use of topical nasal corticosteroids in acute viral infections, there are conflicting
recommendations from the American (2016) and European (2020) guidelines; therefore,
the ABR advises that the use of topical nasal corticosteroids in acute viral conditions
should be avoided in the context of COVID-19. The ABR recommends not performing nasal
or nasal sinus surgery during the COVID-19 pandemic. In cases of urgent or extremely
necessary surgery, we suggest performing a test to identify the presence of SARS-CoV-2
with another test 24 hours later. In patients with COVID-19 or when it is impossible
to perform the test, the use of a of surgical gown with personal protective equipment
(PPE) and powered air-purifying respirator is recommended. On March 20, 2020, the
Brazilian Federal Council of Medicine (Conselho Federal de Medicina, CFM, in Portuguese)
recommended canceling appointments, examinations, and elective surgical procedures
due to the COVID-19 pandemic. The CFM also warned that if it is not possible to cancel
the procedures, the physicians can perform them provided that they comply with the
determinations of the local authorities and technical director of the service, as
well complying witg the recommended hygiene, individual protection, and contact restriction
protocols.
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Our colleagues in Iran have reported that at least 20 ear, nose, and throat (ENT)
specialists are currently hospitalized with COVID-19, with 20 more in isolation at
home. They are only testing people who have been admitted to the hospital; thus, the
20 specialists at home are not confirmed cases, but they have classic symptoms. A
previously healthy 60-year-old facial plastic surgeon died from COVID-19 3 days ago.
A young, otherwise healthy ENT chief resident had a short prodrome, rapidly decompensated,
and died. The deceased was are not tested for the presence of SARS-CoV-2, but all
his colleagues and faculty believe the cause of death was COVID-19.
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For this reason, otolaryngologists and head and neck surgeons should take special
precautions in the diagnostic and therapeutic manipulation of the upper airways and
digestive tract to avoid contamination.
Beyond caring for individual patients, oncology clinicians will face the heavy reality
of rationing care. As the pandemic progresses, there will come a point when channeling
a large amount of resources to an individual patient will be in direct conflict with
the greater social good. If an oncology patient with late-stage disease or with comorbid
health conditions such as heart or lung dysfunction acquires COVID-19 and requires
mechanical ventilation, the prognosis is likely to be very poor. According to a recent
retrospective study from Wuhan, China, only 1 one patient survived among 32 who were
seriously ill with confirmed COVID-19 and required mechanical ventilation.
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Thus, we believe it is imperative to have proactive end-of-life and palliative care
discussions with cancer patients who may become infected with COVID-19. Although these
practices should be a part of routine oncology care, such discussions with all cancer
patients have become even more vital in these times. It is our duty to not only educate
but also provide resources to help patients make decisions regarding treatment during
this period of uncertainty. With dwindling resources, oncologists must also consider
carefully what treatments are most likely to be successful, symptom-relieving, or
lifesaving, and consider those patients likely to get the greatest benefit from treatments.
Proactive discussions surrounding these challenging decisions should occur among disease-specific
groups, medical ethicists, and palliative care teams.
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Reports indicate that the SARS-CoV-2 virus particles are in extremely high concentrations
in the nasal cavity and nasopharynx, and can be a significant source of transmission.
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This characteristic property of the virus places healthcare professionals who examine
and manipulate these areas at particular risk. Otolaryngologists and their surrounding
staff are especially vulnerable to viral transmission directly through mucus, blood,
and aerosolized particles when examining or operating in these areas. There is evolving
evidence from China, Italy, and Iran that otolaryngologists are among the groups with
the highest risk of contracting the virus while performing upper airway procedures
and examinations if not using proper PPE. This dilemma puts otolaryngologists in a
difficult situation when presented with patients with time-sensitive and emergent
problems that require surgery.
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The Brazilian Association of Laryngology and Voice (Academia Brasileira de Laringologia
e Voz, ABLV, in Portuguese), concerned about the damage caused by COVID-19 and following
the same line of warnings issued by other scientific societies around the world, such
as the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), made some
recommendations related to endoscopic examinations of the upper airways and digestive
tract, which include nasal video-endoscopy, video-laryngoscopy, video-laryngostroboscopy,
video-nasofibro-laryngoscopy, and swallowing video-endoscopy. It is worth mentioning
that otorhinolaryngologists and head and neck surgeons are the medical specialties
most exposed to contact with this virus due to their frequent manipulations of the
upper airways and digestive tract, both in out- and inpatients. The recommendations
below are especially valid for communities with a high prevalence of COVID-19:
During the pandemic, the physicians should avoid conducting elective endoscopic examinations.
They should make sure that the examination is absolutely necessary at the time and
should not be postponed.
The physician should wear PPE, such as gloves, long-sleeved aprons (preferably waterproof
and disposable), goggles, and N-95, PFF2, or superior masks. If the physician has
an assistant in the room, they should also be properly protected. Goggles are essential
because it is known that conjunctival contamination is possible.
The environment should be ventilated, allowing the dispersion of aerosols to the external
environment.
The physician should consider the use of vasoconstrictors and topical anesthetics
to reduce the chance of coughing or sneezing, which can generate aerosols that remain
in suspension longer than droplets. Despite the uncertain epidemiological role, the
feasibility of aerosolized transmission of SARS-CoV-2 has recently been demonstrated.
Physicians should change gloves after treating each patient and sanitize their hands
with alcohol gel after the procedure.
Endoscopy should, if possible, be performed using video-documentation to maintain
distance from the patient. Avoid direct visualization using the eyepiece.
The physician should avoid touching surfaces during the examination.
The physician should avoid companions in the room unless strictly necessary.
Material processing must follow the ABORL Operation Protocol (
https://www.aborlccf.org.br/imageBank/Manual-POP.pdf
) or high-level disinfection with immersion in disinfectant according to Resolution
of the Collegiate Board of Directors (Resolução da Diretoria Colegiada, RDC, in Portuguese)
No. 6, from March 1st, 2013.
The physician should use 70% alcohol, sodium hypochlorite solution, or other disinfectant
indicated for this purpose to clean the entire surface near the patient and on equipment
and bottles that may possibly be contaminated (anesthetic or decongestant bottles,
for example).
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The most frequently reported signs and symptoms of patients admitted to the hospital
include fever (77–98%), cough (46–82%), myalgia or fatigue (11–52%), and shortness
of breath (3–31%) at the onset of the illness..
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Among 1,099 hospitalized COVID-19 patients, fever was present in 44% at hospital admission,
and it developed in 89% during hospitalization.
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Other less commonly reported respiratory symptoms include sore throat, headache, cough
with sputum production, and/or hemoptysis. Some patients have experienced gastrointestinal
symptoms, such as diarrhea and nausea, prior to developing fever and lower respiratory
tract signs and symptoms. The fever course among patients with COVID-19 is not fully
understood; it may be prolonged and intermittent. A limited number of reports describe
identification of asymptomatic or subclinical infection on the basis of detection
of SARS-CoV-2 RNA or live virus from throat swab specimens of contacts of confirmed
patients.
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There is already good evidence from South Korea, China, and Italy that significant
numbers of patients with proven COVID-19 infection developed anosmia/hyposmia. In
Germany, it is reported that more than two thirds of confirmed cases have anosmia.
In South Korea, where testing has been more widespread, 30% of patients testing positive
have had anosmia as their major presenting symptom in otherwise mild cases.
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Future studies may certainly consolidate more clinical evidence of the presence of
anosmia/hyposmia in the COVID-19 pandemic.
In view of the aforementioned information, clinical evidence and common sense should
prevail in decision making.