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\begin{document}

\title{There is no routine head and neck exam during~ the COVID-19 pandemic}



\author[1]{Jason Y K Chan et al.}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\par\null

On March 27, 2020, the Center for Disease Control reported that 85,356
individuals in the United States were infected with severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) -- exceeding, for the
first time, the number of cases in Wuhan, China, where the pandemic
began in November, 2019. US federal, state and local agencies are facing
an unprecedented public health emergency. The scale of the pandemic has
never been seen in US; the way forward uncertain.

In 2003, the Hong Kong SAR (HK) healthcare system was thrust into a
similar crisis, responding to an outbreak of SARS coronavirus 1
(SARS-CoV-1), that developed in Guangdong Province, China late in 2002.
Lessons from how HK physicians adapted their practices to this new
disease may hold important lessons for the many countries now facing the
pandemic .

Based upon experience and evidence from SARS-CoV-1 and early-experience
with SARS-CoV-2, we provide our perspective and guidance on mitigating
transmission risk during head and neck examination, upper airway
endoscopy, and head and neck mucosal surgery including tracheostomy. We
set out below, recommendations that every physician performing head and
neck examination should consider. The goal is to protect healthcare
workers (HCW), caregivers, patients, and the community at large in this
Personal Protective Equipment (PPE) limited environment, while
conforming to their local guidelines.

Early on in the 2003 SARS epidemic, the risk of nosocomial spread of
infection to HCW posed a critical challenge. At the Prince of Wales
Hospital, HK, a single infected patient caused an outbreak, of which
over 50\% were HCW, devastating human resources to treat and contain the
infection . Seventeen years later HK was inflicted with SARS-CoV-2 late
January 2020. A benefit of SARS-COV-1 in HK HCW has been the modus
operandi since 2003: including wearing surgical masks in hospital wards,
wearing gowns and surgical masks in outpatient clinics and scrubs only
in the operating room. The resultant individual and institutional
appreciation of infection control measures have served HK well in the
current pandemic, relative to other countries, with no HCW COVID-19
nosocomial infections to date \textsuperscript{1}.

In the 2003 SARS-CoV-1 outbreak in HK, an otolaryngologist died after
being infected during a routine head and neck examination. In 2020, the
first COVID-19 physician fatality was an otolaryngologist in Wuhan,
China. Patients with COVID-19 caused by SARS-CoV-2 can carry high viral
load in the nasal cavity, nasopharynx, and throat. The anatomic viral
distribution of these SARS-CoV viruses in the nasopharynx and mucosal
airways, coupled with these disquieting cases, indicate that head and
neck examinations and procedures must be approached cautiously with
thoughtful preparation and protections. HCW who have these exposures are
at heightened risk of transmission.

In the outpatient setting, all non-essential clinic visits should be
transitioned to virtual ``video-visits'' or postponed. This will reduce
the number of patients in the clinic, minimizing patient flow and
potential contamination and freeing up valuable medical resources. On
March 18, 2020, the Center for Medicare and Medicaid Services in the US
released recommendations to postpone all non-essential dental exams and
procedures until further notice.

Within the clinic, separate gown up and down areas must be designated to
prevent cross-contamination. Visual guides and mirrors for
self-visualization in these areas on the steps involved in gowning up
and gowning down have, from past experience, proven extremely useful
particularly for gowning down, where most HCW self-contaminate (Figure
1). Another critical area is the bedside examination of patients.
Currently, there are no CDC guidelines on respiratory and
aerosol-generating procedures within the scope of the head and neck
surgery, but our experience with SARS-CoV-1 highlights that these are
potentially high-risk examinations. Therefore, in HK, there is official
guidance for Otolaryngology departments to label several common head and
neck examination and procedures as having a potential risk of aerosol
generation. This designation carries implications on PPE allocations of
as seen in table 1.

Anesthetic practices vary but local anesthetic is commonly administered
via aerosolized spray in the head and neck examination and procedures.
This practice has been abandoned in HK since the SARS-COV-1 epidemic and
must be avoided in the current COVID-19 environment. Aerosol spray
should be replaced by topical local anesthetic on pledgets or dripped
via syringe. Table 1 shows guidelines of PPE use within the outpatient
clinic with a dedicated endoscopy room, including flexible laryngoscopy
- one of the most common procedures performed in head and neck
examination. Unless there is gross contamination there is no need to
change the gown, mask or eye protection between each patient.

For inpatient rounds, all physicians are recommended to wear a surgical
mask and scrubs which are changed daily prior to leaving the hospital.
Patient visitors to the hospital should be severely restricted, and
visiting hours cut, to minimize people flow and maintain social
distancing.

For all operative procedures, intubation represents an
aerosol-generating procedure as first learned during the 2003 SARS-COV-1
epidemic. Therefore, during intubation anyone in the operating room
should have appropriate PPE including a fit-tested N95 mask. This should
similarly apply to all open airway procedures such as direct
laryngoscopy where they may be a leak during ventilation, tracheostomy,
or laryngectomy.

Tracheostomies for patients with known COVID-19 should be delayed where
possible to minimize viral shedding from the patient, as we know from
SARS-COV-1, delaying the tracheostomy does not negatively impact the
patient. Guidance for a safe tracheostomy emerged from the 2003
epidemic. The following should be considered for tracheostomies in the
COVID-19 pandemic:

\begin{enumerate}
\tightlist
\item
  PPE: AAMI level 3 or waterproof apron on top of AAMI level I isolation
  gown, N95 mask, face shield, waterproof cap and disposable shoe
  covers. Powered air purifying respirators (PAPR) may be needed in
  cases with high viral load.
\item
  Minimize personnel: One intensivist, one surgeon, one nursing member.
\item
  Procedure: Use a negative pressure operating room. The patient should
  be completely paralyzed and preoxygenated. Stop ventilation before
  tracheotomy and only resume once tracheostomy tube balloon cuff is
  inflated
\item
  Post procedure: Gown down safely, and shower.
\end{enumerate}

Ideally, the procedure should be done in a negative pressure operating
room with senior personnel and not used as a training procedure. Cautery
use should be limited as this can produce small particles that may act
as a vehicle for the virus . Again, gowning down following the procedure
is of utmost importance and is often overlooked. Dry runs prior to the
actual procedure may also help reduce errors and prevent the
contamination of HCW.

For patients with a tracheostomy they should all be covered with a
closed system (Figure 2) identical to when a patient is connected to a
mechanical ventilator to minimize the aerosol generated that could cross
contaminate the surrounding patients and HCW given the suction
requirements of these patients . Humidified tracheostomy collars and
nebulized therapies must be avoided. All bedside procedures should be
performed in a separate treatment room away from patient cubicles with
all HCW wearing PPE. The requirements for PPE will be the same as in the
outpatient clinic.

In summary, with the use of these broad guidelines which reduces the
number of procedures and patients seen, coupled with an appreciation
that the head and neck examination cannot be taken lightly in the
current pandemic, the risk of exposure and contamination in clinics of
patients, HCW and in particular, physicians performing a head and neck
examination should be reduced.

\par\null

\textbf{Figure Legends:}

\textbf{Figure 1}: The red diagram on the left represents the steps in
gowning up and the green diagram on the right illustrates the gowning
down steps which needs great care. These are readily available in all
gown up and gown down areas with a mirror

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/HED-20-0451-Fig/HED-20-0451-Fig}

\end{center}
\end{figure}

\textbf{Figure 2}: a) The closed suction kit used with a tracheostomy on
the open ward. B) The black arrow points to the heat moisture exchange
and the blue arrow to the closed suction kit.

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/HED-20-0451-Fig-(2)/HED-20-0451-Fig-(2)}

\end{center}
\end{figure}

\textbf{Tables:}\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
\begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Normal head and neck examination\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Procedures in the Endoscopy Room\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Procedures in the Endoscopy Room\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Procedures in the Endoscopy Room\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Procedures in the Endoscopy Room\strut
\end{minipage} & \begin{minipage}[b]{0.12\columnwidth}\raggedright\strut
Procedures in the Endoscopy Room\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Flexible laryngoscopy/} \textbf{Nasoendoscopy}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Oral \& nasal \& ear Open Suction}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Change of tracheostomy tube}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Endoscopic guided insertion of feeding tube}\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\textbf{Change of tracheoesophageal prosthesis}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Hand hygiene}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Surgical mask}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
NA\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{N95 mask}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Isolation gown}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
No\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AAMI level 1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AAMI level 1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AAMI level 1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AAMI level 1\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
AAMI level 1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Disposable gloves}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Yes\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Eye protection}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Visor / Face shield*\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Face shield\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Face shield\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Face shield\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Face shield\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Face shield\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
\textbf{Hair cover}\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Optional\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Optional\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Optional\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Optional\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Optional\strut
\end{minipage} & \begin{minipage}[t]{0.12\columnwidth}\raggedright\strut
Optional\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table 1}. Recommended personal protective equipment for
different procedures in an Otolaryngology clinic. These procedures are
usually done in bundle by a single Otolaryngology specialist for the
most prudent use of appropriate PPEs.

* N95 and Face shield are only for deep throat examinations (e.g.
checking of tonsil mass, ulcer at retromolar trigone region) usually
done with flexible laryngoscopy in the endoscopy room

\par\null

\textbf{Full author list}

Jason Y K Chan, FRCSEd (ORL)\textsuperscript{1}

*Raymond K Y Tsang, FRCSEd (ORL) MS\textsuperscript{2}

K W Yeung, FRCSEd (ORL)\textsuperscript{3}

Victor Abdullah, FRCSEd (ORL)\textsuperscript{4}

Peter Ku, FRCSEd (ORL)\textsuperscript{4}

Eddy W Y Wong, FRCSEd (ORL)\textsuperscript{1}

Nishchay Mehta FRCS (ORL-HNS), PhD\textsuperscript{5}

Ryan K. Orosco, MD\textsuperscript{6}

F Christopher Holsinger, MD\textsuperscript{7}

\textsuperscript{1} Department of Otorhinolaryngology, Head and Neck
Surgery, The Chinese University of Hong Kong, Shatin, N.T.,

\textsuperscript{2} Division of Otorhinolaryngology -- Head and Neck
Surgery, Department of Surgery, The University of Hong Kong, Pok Fu Lam,
Hong Kong SAR

\textsuperscript{3} Department of Ear, Nose and Throat, Tuen Mun
Hospital, Tuen Mun, Hong Kong SAR

\textsuperscript{4}Department of Ear Nose \& Throat, United Christian
Hospital, Affiliated Teaching Unit of the Chinese University of Hong
Kong, Kwun Tong, Hong Kong SAR

\textsuperscript{5}Royal National Ears Nose and Throat Hospital,
University College London Hospitals Trust, London, UK

\textsuperscript{6}Division of Head and Neck Surgery, University of
California -- San Diego, La Jolla, CA, USA

\textsuperscript{7}Division of Head and Neck Surgery, Stanford
University, Palo Alto, CA, USA

* Co-first author

\par\null

\textbf{References}

\textbf{}1. Keeping the Coronavirus from Infecting Health-Care Workers
2020. Gawande A. (Accessed Mar 26, 2020, at
\url{https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers}).{}

2. Cheng VC, Chan JF, To KK, Yuen KY. Clinical management and infection
control of SARS: lessons learned. Antiviral Res 2013;100:407-19.

3. Drosten C, Gunther S, Preiser W, et al. Identification of a novel
coronavirus in patients with severe acute respiratory syndrome. N Engl J
Med 2003;348:1967-76.

4. CMS Adult Elective Surgery and Procedures Recommendations: Limit all
non-essential planned surgeries and procedures, including dental, until
further notice 2020. Anonymous . (Accessed Mar 20, 2020, at
\url{https://www.cms.gov/files/document/31820-cms-adult-elective-surgery-and-procedures-recommendations.pdf}).

5. Wei WI, Tuen HH, Ng RW, Lam LK. Safe tracheostomy for patients with
severe acute respiratory syndrome. Laryngoscope 2003;113:1777-9.

6. Chan JYK, Lam W. Practical Aspects of Otolaryngologic Clinical
Services During the 2019 Novel Coronavirus Epidemic: An Experience in
Hong Kong. JAMA Otolaryngol Head Neck Surg 2020;.

\textbf{}

\selectlanguage{english}
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