LSU Department of Otolaryngology-Head and Neck Surgery

Introduction    

April 9, 2020: The COVID-19 pandemic has profoundly affected every aspect of care provided by otolaryngologists in Louisiana and worldwide.  Daily, we are learning new details about the disease.  We strive to manage under circumstances in which our usual health care methods, tools, and resources have either become scarce, or have been rendered unavailable to us in this new and unfamiliar context.  In order to provide the very best care possible, and to protect our patients, our staff, and each other from harm, it is imperative that otolaryngologists stay current with the rapidly emerging body of literature on this disease. It is also critical that we innovate, collaborate, and seek best practices in rendering care in this new and fluid paradigm.

To help our Louisiana Otolaryngology colleagues meet these truly unique challenges, we have organized this library of the most up-to-date literature guiding our actions.  We hope it can offer a ray of light in these uncertain times. This library, which contains references to important recent publications, discoveries, communications, and other valuable information sources, has been assembled with input from LSU Otolaryngology faculty, fellows, residents, alumni, and staff. It will continue to grow and change as our understandings of COVID-19 evolve. We hope it will be rendered unnecessary in short order, but our intention is to continue to build it and refine it until that day arrives. Meanwhile, we must keep in mind that this COVID experience, even after the pandemic has long passed, will likely bring previously unforeseen changes to our discipline, and will present opportunities for positive and valuable change in the future. Let us embrace both the challenges and the opportunities. 
 

Isaac Erbele, MD, Fellow in Neurotology and Skull Base Surgery

Daniel Nuss, MD, FACS, George D. Lyons Professor and Chair
 

COVID and general otolaryngology

• Handbook of COVID-19 Prevention and Treatment.  Recommendations from firsthand experience from China.  Dr. Nuss's executive summary of the document can be found here.
• Summary of ENT relevant articles collected and evaluated 3/20/20
• Stanford otolaryngology's urgent communication regarding the risks of COVID-19 to ENT providers (mid-March 2020).  Of particular note is the anecdote of 14 health care workers becoming COVID positive following a transnasal pituitary operation, and the subsequent recommendation for Powered, Air Purifying Respirators (PAPR) for endoscopic endonasal procedures [though this anecdotal report was later found to be incomplete].  The academic article from the same group is found here.
• CMS and AAO-HNS/F position statements for limiting care to time-sensitive and emergent problems
• Safety considerations and PPE recommendations for clinical head and neck evaluations
• Podcast: Lessons from Hurricane Katrina on rebuilding after COVID-19.  A discussion between Dr. Nuss, Dr. Paul Friedlander (Tulane Otolaryngology Department Chair), and Dr. James Denneny (CEO/Executive Vice President AAO-HNS/F)
• American College of Surgeons (ACS) recommendations for re-starting elective procedures.
• Italian ENT surgical and clinical experiences

COVID biology and testing

• Post-convalescent COVID testing.  Median duration of positive test was 12 days (minimum 4, maximum 34)
• Viral shedding 2-3 days before symptomatic.  Possible spread in the asymptomatic
• Decrease in viable virus 7 days after symptoms for mild cases
• Improved ICU mortality with anticoagulation
• Hypothesis on COVID testing probabilities

Personal protective equipment

• Emory's recommendations for PPE use and conservation, along with printable PPE guideline cards
• CDC guidelines on extended use and reuse of N95 masks
• Guidelines for use of N95 masks beyond manufacture's shelf life

Airway management

• LSU tracheostomy guidelines for COVID positive patients.  Includes supporting references.
• Tracheostomy checklist
• Intubation recommendations from the University of Toronto (link updated to academic article)
• Recommendations for tracheostomy technique in setting of COVID from ENTUK
• Considerations and indications for tracheostomy from the AAO-HNS/F. Recommendations include delaying tracheostomy in COVID patients until there is a negative COVID test or 2-3 weeks after intubation, and delaying first tracheostomy tube change until after COVID negative status.
• Tracheostomy recommendations from the New York Head and Neck Society
• Management of head and neck patients with tracheostomies or laryngectomies
• Italian elective tracheostomy experience

Otology

• Otology cases by level of urgency and recommendations for PPE
• Considerations for safely performing otology procedures
• Prioritizing otologic surgery cases
• Droplet management with drilling

Head and neck

• Message from American Head and Neck Society: Endocrine Section to endocrine patients
• Radiation Oncology guidelines for head and neck cancer patients

Rhinology

• Experimental evaluation of the risks of aerosolization with endonasal instrumentation
• Wuhan endonasal pituitary case report .  Initial reports of intraoperative super-spreading may have been inaccurate.

Pediatrics

• Best practice recommendations for pediatric otolaryngology during the COVID-19 pandemic
• Initial experience from Seattle Children's Hospital
• COVID-19 and pediatric patients, Harvard medical school
• Pediatric otolaryngology recommendations from French Association of Pediatric Otolaryngology [English]
• Local protocols collected by the lnternational Pediatric Otolaryngology Group (14 Apr)

Trauma

• Maxillofacial trauma management recommendations

Shared decision making for proceeding with non-elective cases

• We have instituted a Resource Utilization Committee to review all proposed surgical cases.  Prior to proceeding to the operating room, cases are ethically reviewed for their potential impact on hospital resources, risk of transmission of COVID, and risks of delay of care.

Additional resources for otolaryngologists

• Cochrane resource library
• The American Academic of Otolaryngology resource library
• Literature reviews of all COVID literature by Washington University in St. Louis medical students and PhD candidates.  Updated daily.
• Current COVID statistics for the state of Louisiana
• COVID tracking project.  Based out of the Atlantic and used by journalists, policymakers, and academics, they provide national COVID statistics rivaling what's available at the CDC.  Raw data is available to download in csv files.