The risk for otolaryngologists, head and neck, and maxillofacial
surgeons
The first reported physician fatality related to COVID-19 in Wuhan,
China, was that of an otolaryngology physician on January 25,
2020.8 In
Wuhan epidemic statistics, health workers represented 3.8% of the
infected, 14.8% had severe disease and the overall mortality rate was
of
0.6%.1, 4, 9 On
the other hand, in Italy, 20% of responding healthcare workers were
infected, and some have
died. 10 People
in contact with symptomatic patients, such as health personnel, are the
most susceptible to infection. The most commonly infected healthcare
personnel worked in general
wards.11
Human-to-human spread occurs through respiratory secretions (although
fecal-oral spread has also been confirmed) so healthcare personnel that
manage patients with diseases of the aerodigestive tract (dentists,
otolaryngologists, head and neck surgeons, gastroenterologists,
pneumonologists, respiratory therapists, speech therapists, and
infectious disease physicians) or ophthalmologists are the most
susceptible healthcare workers to become infected (risk ratio of
2.13).1, 12, 13 Therefore
it was rapidly recognized that there is a particular need for protective
measures in these professional
groups.14
In cases of COVID-19 patients with known respiratory disease, protective
measures are usually followed by surgeons. However, a significant number
of patients do not have fever nor respiratory symptoms (13-30%), so
surgeons should apply respiratory protective strategies for all
patients. This is especially true in tropical countries, were symptoms
can simulate other viral infectious diseases such as
dengue.15 The
classical symptoms of the infection are fever, dry cough and shortness
of breath. The syndrome rarely resembles a classical “cold” or with a
runny nose that helps distinguish it from the common viral flu.
Nonetheless, precautions must be taken for all patients with flu-like
symptoms.
Recent reports from sites around the world have shown that anosmia and
dysgeusia are significant symptoms associated with the COVID-19
pandemic. Anosmia, in particular, has been seen in patients ultimately
testing positive for the coronavirus with no other symptoms. For this
reason, the American Academy of Otolaryngology (AAO-HNSF) has proposed
that these symptoms be added to the list of screening tools for possible
COVID-19
infection. (https://www.entnet.org/content/aao-hns-anosmia-hyposmia-and-dysgeusia-symptoms-coronavirus-disease)
All procedures that have the potential to aerosolize aerodigestive
secretions, such as nasolaryngoscopy, endotracheal intubation,
non-invasive ventilation, transnasal endoscopic surgery and high-speed
handpieces or ultrasonic instruments, increase the risk of infection and
should be avoided or employed only when
mandatory.1, 16 There
is no information regarding any potential risk for electrocautery smoke
or transoral laser resection generated smoke but it would be reasonable
to take appropriate precautions in these settings too.
Due to the characteristics of the virus, the standard protective
measures of daily workflow do not prevent the infection, and specific
masks (N-95 or FFP2 or higher) or powered air-purifying respirator
(PAPR), other PPE and dedicated sterilization measures should be
implemented to avoid the
infection.17, 18 However,
one case series report that none of 41 health workers that had contact
with aerosolized secretions of COVID-19 positive patients and employed
standard PPE, developed an infection. It suggests that the rate of
infection, when standard measures are employed, is considerably lower
than when they are not used or are used
improperly.12, 19 One
of the more important reasons to explaining healthcare workers infection
may be related to the lack of PPE and education about its correct
use.9 It
has been suggested that standard measures properly followed are more
successful than the quick implementation of complex protection
strategies.12, 20
Pregnancy, age over 55 years, some chronic diseases (chronic hepatitis,
renal diseases, diabetes mellitus, autoimmune diseases and cancer)
represent risk factors for developing severe acute respiratory distress
syndrome (ARDS); affected health workers should not take care for
infected
patients.21 There
is no information about intrauterine or transplacental transmission to
the
newborn.22, 23
The disease also imposes a physical, mental and emotional burden to
healthcare
workers.24 Most
physicians caring for infected patients and for patients considered
“suspicious” for infection become more quickly exhausted. There is
also a specific risk associated with “health anxiety”; a phenomenon
defined as “anxiety that occurs when perceived sensations of
changes are interpreted as symptoms of being
ill .”25 This
occurs commonly in daily life, but in times of infectious diseases
outbreaks, this phenomenon can produce detrimental effects. Today,
(accurate, but often also incorrect) information about the clinical
course, rate of complications and mortality of COVID-19 is incessantly
emphasized and widespread through media and social networks. This
increases the frequency and severity of health anxiety, characterized by
catastrophic misinterpretation of sensations, wrong beliefs about the
disease’s consequences and dysfunctional
coping.25, 26 As
more information is received and more ensues, excess anxiety results in
a loss of the ability to make rational decisions. Specifically for
surgeons, this situation could have two polar effects: firstly, some
people may see doctors as a source of contagion and avoid them (and
thus, medical assistance); secondly, other people may see them as source
of security and visit them repeatedly, putting a further burden on
strained health services. Both situations increase the risk for
surgeons: in the first case, they can be threatened in public areas and
in the second their capacity to help may be overwhelmed. An
infection-related xenophobia is also a potential risk for foreign
surgeon’s
practice.11, 27
Finally, the impact of financial concerns of healthcare workers on their
wellbeing and performance should not be underestimated.