Secondary Logo

Journal Logo

REVIEW ARTICLES

Covid-19 and Otologic/Neurotologic Practices: Suggestions to Improve the Safety of Surgery and Consultations

Ayache, Stephane; Schmerber, Sebastien

Author Information
doi: 10.1097/MAO.0000000000002851
  • Free

Abstract

Since the first cases of Covid-19 were reported in China in December 2019, the SARS-CoV-2 virus has shown a high capacity of sustained transmission over the world (1). The high mortality rate, mainly due to the virus itself, could also, to a lesser extent, be explained by the sheer numbers of patients, overwhelming hospitals and leading to difficulty in providing optimal care (2,3). Many countries have adopted a mitigation strategy to combat the epidemic; physical distancing and mobility restrictions are the main objectives of the lock-down. The objective is to limit the spread of the virus among the population and to reduce the height of the epidemic peak by flattening the curve (2–4). This means spreading out the number of infected patients over a long period of time to prevent the virus from overwhelming our available critical care resources (3,4). Healthcare teams have had to postpone their nonemergency consultations and surgical activities to increase their medical resources that are redirected to infected patients.

The article aims to propose a strategy for organizing consultation and surgery for ear and lateral skull base diseases in the context of the current situation of active evolution of the pandemic; but also, in the future with the hope of a gradual recovery to normal practice as Covid-19 cases globally begin to plateau or decline.

BACKGROUND

The first case of pneumonia of an unknown origin was reported in Wuhan, China (5). A virus was identified in the bronchoalveolar fluids of a patient with pneumonia. This pan-Betacoronavirus, SARS-CoV-2, close to 96% identical to a bat SARS-like coronavirus of the bat, is responsible for the COVID-19 (3) (COrona, VIral Disease 2019). On March 11, 2020, the World Health Organization (WHO) declared Covid-19 an international health emergency (6) and announced a pandemic situation (7).

The main interhuman infection pathway is the projection of droplets coming from lower and upper airways (7–9). Stability of the virus coming from droplets on fomites (abiotic surfaces) has been confirmed for more than 72 hours, mainly on plastic, stainless steel, and paperboard (10).

Viral Infection Pathway and Its Application for Otolaryngologists

Early infection of healthcare workers has been reported from China and widely described in countries reporting the disease (11–15).

Otolaryngologists are particularly exposed to infection from anatomical areas where the virus is highly concentrated, mainly nasal fossa and nasopharynx (9,11,16) even from asymptomatic patients (9).

The middle ear and mastoid epithelium is similar to the respiratory epithelium of upper airways (17). Respiratory viruses have been identified by polymerase chain reaction (PCR) in middle ear effusions (18) causing acute otitis media without identified bacteria in the nasopharynx (19). Among other viruses (human rhinovirus, respiratory syncytial virus), human coronavirus RNA has been detected by RT-PCR in samples from otitis media with effusion (20,21). There has been no proof to date to show the presence of SARS-CoV-2 in the middle ear and mastoid (22). But, the coexistence of the same viral pathogens in the nasopharynx and the middle ear could raise the issue of a potential risk of viral load in the middle ear in Covid-19 positive patients (23).

Another crucial point is the ability of the virus to remain alive in the air (10,11) and to be transmitted through aerosols.

Infection through aerosols may be possible in the case of exposure to high concentrations of aerosols in a relatively closed environment (24–26).

An aerosol is a suspension of particles in a gas. A virus excreted by a patient can dissolve in an aerosol, leading to the formation of a bio-aerosol (27). Bio-aerosols measuring 1 to 5 μm constitute an airborne transmission path (11). Those of smaller size are deposited on surfaces. The persistence of SARS-CoV-2 for more than 8 hours in air samples collected 1 m away from an infected patient suggests a very high risk of airborne transmission of the virus (11,28), as well as the evidence of airborne SARS-CoV-2 particles smaller than 5 μm for at least 3 hours (10).

Droplets projected during coughing or sneezing, usually 1 to 5 mm in size, can reach 1 to 2 m. Aerosols can reach several hundred meters and have already been confirmed as a dissemination means among other viruses (H1N1, SARS, MERS) (27,29–32). A study published in the New England Journal of Medicine reports a high probability of survival and transmission of the virus as aerosols for 3 hours (10).

The size of aerosol particles is inversely proportional to the air speed. All physiological (coughing, sneezing) and mechanical (intubation, endoscopy, noninvasive ventilation) procedures produce aerosols (11). Among these mechanical procedures, high-speed drills are used for mastoidectomy. They can generate aerosols of bone, mucosa, fluids, and blood (33). Some have theorized that, if Sars-CoV-2 is present in the mastoid, mastoidectomy using a high-speed drill could be dangerous for people inside the operating room and expose health workers to viral infection (17). Transcanal endoscopic approaches could help by limiting bone drilling of the mastoid and the external ear canal (34,35).

Norris et al. have compared surgical masks and N95 masks in preventing inhalation of bone dust. The N95 surgical respirator showed statistically less particulate exposure when compared with control testing. Standard surgical masks did not display any benefit for preventing transmission of bone dust (36). N95 masks have been shown to significantly decrease particulate exposure by filtering 95% of droplets and aerosols of less than 0.3 μm (National Institute for Occupational Safety and Health (NIOSH) (11)). In Europe, masks are classified as FFP1, FFP2, and FFP3 providing filtration of 80%, 94%, and 99% respectively. The FFP2 mask corresponds to N95 (37). FFP2 are more effective than surgical masks in preventing inhalation of the virus (38) but require correct fitting and respect for wearing times (39). The N95 mask can be covered by a regular surgical mask mainly to prevent soiling of the N95. In summary, a N95/FFP2 mask may be used in the operating room and outpatient clinics in case of contact with patients without COVID-19 negative confirmed status.

The authors have previously identified coronavirus in tears (20) as well as transconjunctival spread of COVID-19 (40). This highlights the importance of wearing airproof glasses and/or a full-face shield when using an endoscope or exoscope.

A clear plastic drape could be fashioned and used over the operative field to contain all aerosolized particles as an effective barrier to prevent wide travel or dissemination of aerosolized particles throughout the operating room as well as eye projection.

Screening for Covid-19

RT-PCR test (polymerase chain reaction) sensitivity for detection of viral RNA on nasal swab samples is low (56–83%) (41,42). Identification of the virus may also be delayed (41). The median duration of viral shedding in oropharyngeal samples has been reported between 8 and 37 days (median time: 20 d) from illness onset in surviving patients, and is detectable until death in nonsurviving patients (43). Positive tests have also been reported in patients with normal chest CT-scan results (44).

Chest CT-scan imaging has high sensitivity but limited specificity in early pulmonary symptoms (45,46). However, more than 50% of patients may have normal result in the first few days after the onset of symptoms (46). A normal chest CT scan can therefore not be considered strict criterion for excluding Covid-19 infection (47,48), despite greater sensitivity than PCR tests (49). Chest CT scans should therefore be reserved for symptomatic patients, but should not be deemed sufficiently reliable in asymptomatic patients (50).

No antibody testing is considered as being reliable enough until now, regarding sensitivity and specificity (51,52). Serological tests are not recommended in the context of early diagnosis of Covid-19 (53,54).

Protective equipment (masks, glasses, and/or full-face shield) may be used in clinics and operating room. With no short-term prospect of vaccine or even of effective treatment, this should be the concern of each healthcare worker, while the virus is actively circulating. In a recent article, Topsakal and Rompaey (17) report that “after the peak of this pandemic, restrictions on daily otological practice should somehow be adjusted to allow health services closer to the standards we are used to.”

The following recommendations are proposed in the context of active circulation of the virus. They may be subject to change over time according to the evolution of the pandemic. Furthermore, these recommendations should however be adapted to locations where Covid-19 is less present, according to the number of infected patients and the number of hospitalizations especially in intensive care units (55). Considering these criteria, patient screening and effective protection of health workers should be ensured, surgical criteria (Table 1) may be softened and discussed case-by-case in areas with low circulation of the virus.

TABLE 1
TABLE 1:
Timing of otologic/neurotologic practices during the covid-19 pandemic

Future recovery of surgical activity should be gradual and spread over time. Hospitals and clinics should keep appropriate capacities for hospitalizations and intensive cares, drugs, ventilators, PPE, and personnel (56). There should be a sustained reduction in the number of new infected patients in relevant geographic areas for at least 14 days before elective surgery is resumed (56).

STRATEGY FOR CLINICS AND OPERATING ROOMS

Most consultations and surgical procedures for ear diseases have been postponed (Table 2).

TABLE 2
TABLE 2:
Strategy for otologic/neurotologic practices during the covid-19 pandemic

Medical and paramedical workers with comorbidities (pregnancy, diabetes, uncontrolled hypertension, disease obstructive pulmonary disease, immunosuppression context), should avoid any contact with patients for whom the Covid-19 negative status is not known, especially in the operating room (57).

Outpatient Clinic

An initial triage of patients is performed during the phone appointment to limit the number of patients in outpatient clinics. The aim of this is to identify emergencies, screen for viral infection, and identify possible exposure to SARS-CoV-2. Telemedicine by phone consultation is also proposed if feasible to patients without urgent ENT symptoms.

In the waiting area, physical distancing by reducing and spacing the number of seats is crucial. Accompanying persons are not authorized except in special cases (pediatric consultation, disabled, or dependent patient).

Given the high proportion of asymptomatic but contagious patients (49,50), each patient may systematically be equipped with a surgical mask until he or she leaves the hospital or clinic.

Triage Zone

An initial orientation regarding the patient's Covid-19 status is performed by a nurse. The healthcare team may be equipped with Personal Protective Equipment (PPE) (cap, FFP2-N95 mask, glasses and full-face shield, gown, gloves, overshoes). A survey is submitted to each patient including specific questions (58,59):

  • 1) Patient environment (family context, professional activity, life in an institution)
  • 2) Comorbidities (cardiopulmonary, endocrine, autoimmune, immunosuppression)
  • 3) Current treatments (chemotherapy, corticosteroid therapy, nonsteroidal anti-inflammatory drugs)
  • 4) Context of Covid-19 infection (contact with an infected patient, history of recent screening)
  • 5) Symptoms (fever, headache, cough, chest pain, dermatological signs, anosmia, ageusia, nausea, vomiting, diarrhea and dyspnea, cyanosis, consciousness disorders)

Patients identified as suspects are isolated and referred to the infectious disease team. An RT-PCR test and a chest CT are performed.

Consultation Room

The number of staff in the consultation room may be limited to the practitioner. Contact with computer devices may be avoided, possibly using an additional staff member for data entry.

Each practitioner is equipped with PPE. Double gloves enable the practitioner to change the outer pair according to the care provided and in between the patients (60).

Nasal and oral examinations may be strictly limited. A nasal and laryngeal flexible fibroscopy should be performed only if absolutely necessary, because of the high risk of aerosolization (61). A nasal local anesthesia, without spray is mandatory to prevent sneezing and coughing. Use of a video fibroscopy and endoscopes if available instead of a microscope keep the practitioner's face away from the patient.

Single-use material (otoscopes, nasal speculums, and tongue depressors) are used as much as possible.

At the end of the consultation, the gloves and gown may be placed in a specific waste receptacle within the consultation room. Protective glasses are removed outside the room (60).

Disinfection of surfaces and room ventilation may be performed between each consultation, keeping in mind that the room is potentially considered to be contaminated for 3 hours (60). This parameter should be reconsidered, however, in the absence of flexible fibroscopy and protection of the patient with a mask.

Surgical and Nonsurgical Ear Pathologies

The treatments of nonsurgical emergencies (sudden hearing loss, idiopathic facial nerve palsy, vestibular neuritis) by oral steroids should be discussed. Corticosteroids would delay clearances of the virus and increase the mortality risk (62). The decision depends on the patient's risk–benefit balance.

Complicated acute otitis media without acute mastoidis with subperiosteal abscess should be treated by antibiotics first. The use of a ventilation tube should be decided in the case of failure of the medical therapy. If possible, for adults, the ventilation tube should be inserted under local anesthesia. If not or for children, the anesthesiologist should opt for endotracheal intubation as opposed to bag mask ventilation to reduce the risk of aerosolization of the virus (23).

We propose a classification for surgical indications into levels from 1 to 3, depending on the surgical delay. The aim of this classification is to limit the number of patients in operating rooms to what is strictly necessary considering the potentially dangerous evolution of the ear disease for the patient (Table 1). Cochlear implantation for sensorineural hearing loss after meningitis would be preferentially performed within 1 month of the original infection to avoid total cochlear obliteration (63).

Considering the future very gradual recovery of surgical activities under less restrictive conditions, surgical organization (except emergencies) will depend on the evolution of the disease and impact for patients. Surgeries for temporal bone malignancy, cholesteatoma, vestibular schwannoma (after multidisciplinary discussion), as well as cochlear and hearing aid implantation to support speech and language development in children could be considered as priorities.

Operating Room

Preoperative Screening

A recent article brings to light the value of a systematic PCR test 48 hours before surgery, followed by a strict quarantine and another PCR test on the day of surgery (17). This procedure could nevertheless be discussed. As reported above, PCR-test sensitivity is low (56–83%) (41,42) and diagnoses may be delayed (41). Double-negative PCR tests from nasopharyngeal swabs have also been reported among infected patients (64). Therefore, patients should be considered as Covid-19 positive in all cases and equipped with a surgical mask until and after general anesthesia.

Operating Room

An operating room under negative pressure would constitute additional or even ideal security in the current context (65). Coupling ventilation with an air-filtering system for particles is mandatory in each operating room. The airflow inside the room may guarantee a total air renewal of at least 25 times per hour to reduce the viral load in the air (66).

Circulation of staffs from the operating room may be limited. Doors may be closed and access limited (66,67). The preparation of surgical instruments and consumables before surgery may be as exhaustive as possible and available inside the operating room. A circulating staff equipped with a trolley placed in front of the door can if necessary recover some materials and consumables (66). At the end of the procedure, any single-use material has to be placed in a specific bin.

Surgical Team

Staff numbers may be limited, with no observers or students. A senior surgeon may perform procedures to reduce operating times. The entire team may be equipped with individual protections, particularly in case of temporal bone drilling: cap, protective glasses, full-face shield, sterile, and waterproof cloth around the neck, gloves, gowns, and overshoes.

At the end of surgical procedures, every staff member in the room may remove gloves and gowns before leaving the room (60). A shower should be taken before returning to their regular duties (65).

The identity of all room staff may be recorded to ensure traceability (66). Surveillance may be conducted over a long period through identification of functional signs and repeated oximetry. A chest CT scan and repeated PCR tests on nasal samples may be performed in the event of suspicious cases in staff (66).

Postoperative Room Cleaning

Room cleaning teams may be protected by Personal Protective Equipment (PPE) (N95 mask, gloves, gown, cap, and glasses). Cleaning may cover all surfaces of the room, video column, microscope (hooded), cables, computer equipment, and anesthesia equipment. Several effective disinfection solutions have been proposed (62–71% ethanol, 0.5% hydrogen peroxide, or sodium hypochlorite 0.1% for 1 min) (67,68). This extended cleaning and room ventilation time after surgery lead to significantly increased timeframes between surgical procedures (64,66).

Preoperative Simulation

Recent studies have reported that protection procedures and donning-doffing PPE sequences are misunderstood by nearly 90% of teams, including practitioners (69,70). Organizing preoperative simulations could improve procedures and safety of staff safety in operating rooms and consultation units (71–73).

Hospitalization and Postoperative Care

Outpatient hospitalization after middle ear surgery may be encouraged.

Postoperative care can be performed by the patient's family, after demonstration and acceptance, to avoid contact with health workers. A teleconsultation can then be arranged to answer questions from the patient and to organize a consultation if necessary.

CONCLUSION

In the current Covid-19 pandemic, otolaryngologists are at high risk of infection by the SARS-CoV-2 virus. Viral load in upper airways is very high. The middle ear and mastoid could, as noted in the literature, constitute a reservoir of virus. Current knowledge indicates the possibility of viral infection through droplets, contact with fomites, and aerosolization of the virus. Consultations and surgery for ear and lateral skull base pathologies potentially expose healthcare workers to infection. All procedures may be adapted and protections may be maximized to prevent infection of healthcare workers and other patients, with the spectrum of death and infirmity. These precautions should be implemented until effective treatments and a vaccine are found.

REFERENCES

1. World Health Organization (WHO) (2020). Coronavirus Disease 2019 (Covid-19). Situation Report-125: data as reported by national authorities by 10:00 CEST. Available at: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200524-covid-19-sitrep-125.pdf?sfvrsn=80e7d7f0_2. Accessed May 24, 2020.
2. Anderson RM, Heesterbeek H, Klinkenberg D, et al. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet 2020; 395:931934.
3. Tanne JH, Hayasaki E, Zastrow M, et al. Covid-19: How doctors and healthcare systems are tackling coronavirus worldwide. BMJ 2020; 368.
4. Thunstrom L, Newbold S, Finnoff D, et al. The benefits and costs of flattening the curve for COVID-19. Available at SSRN 3561934 2020.
5. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020; 395:497506.
6. World Health Organization. Coronavirus disease (COVID-19) outbreak (https://www.who.int).
7. Ng OT, Marimuthu K, Chia PY, et al. SARS-CoV-2 Infection among travelers returning from Wuhan, China. N Engl J Med 2020; [Epub ahead of print].
8. Fehr AR, Perlman S. Coronaviruses: An overview of their replication and pathogenesis. Coronaviruses 2015; 1282:123.
9. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020; 382:11771179.
10. Van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020; [Epub ahead of print].
11. Workman AD, Welling DB, Carter BS, et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies. Int Forum Allergy Rhinol 2020; [Epub ahead of print].
12. Petersen E, Hui D, Hamer DH, et al. Li Wenliang, a face to the frontline healthcare worker. The first doctor to notify the emergence of the SARS-CoV-2, (COVID-19), outbreak. Int J Infect Dis 2020; 93:205207.
13. World Health Organization (WHO) (2020). Coronavirus Disease 2019 (Covid-19). WHO calls for healthy, safe and decent working conditions for all health workers, amidst Covid-19 pandemic. Departemental news. Available at: https://www.who.int/news-room/detail/28-04-2020-who-calls-for-healthy-safe-and-decent-working-conditions-for-all-health-workers-amidst-covid-19-pandemic. Accessed April 28, 2020.
14. Stuckey MJ, Burrer SL, de Perio MA, et al. CDC COVID-19 Response Team. Characteristics of Health Care Personnel with Covid-19. United States, February 12–April 9. MMWR Early Release 2020; 69:477481.
15. Europe's doctors repeat errors made in Wuhan, China Medics say. Bloom News March 17, 2020.
16. Tran K, Cimon K, Severn M, et al. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012; 7:e35797.
17. Topsakal V, Rompaey VV, Kuhweide R, et al. Prioritizing otological surgery during the COVID-19 pandemic. B-ENT 2020; [In press].
18. Sawada S, Okutani F, Kobayashi T. Comprehensive detection of respiratory bacterial and viral pathogens in the middle ear fluid and nasopharynx of pediatric patients with acute otitis media. Pediatr Infect Dis J 2020; 38:11991203.
19. Ruohola A, Pettigrew MM, Lindholm L, et al. Bacterial and viral interactions within the nasopharynx contribute to the risk of acute otitis media. J Infect 2013; 66:247254.
20. Pitkäranta A, Jero J, Arruda E, et al. Polymerase chain reaction-based detection of rhinovirus, respiratory syncytial virus, and coronavirus in otitis media with effusion. J Pediatr 1998; 133:390394.
21. Pitkäranta A, Virolainen A, Jero J, et al. Detection of rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis media by reverse transcriptase polymerase chain reaction. Pediatrics 1998; 102 (2 pt 1):291295.
22. BSO: Guidance for undertaking otological procedures during COVID-19 pandemic. Available at: https://www.entuk.org/guidance-undertaking-otological-procedures-during-covid-19-pandemic. Accessed March 25, 2020.
23. Saadi RA, Bann DV, Patel VA, et al. A commentary on safety precautions for otologic surgery during the COVID-19 pandemic. Otolaryngol Head Neck Surg 2020; [In press].
24. Lake MA. What we know so far: COVID-19 current clinical knowledge and research. Clin Med 2020; 20:124127.
25. The National Health Commission of the People's Republic of China. Available at: http://www.nhc.gov.cn/xcs/zhengcwj/202002/8334a8326dd94d329df351d7da8aefc2.shtml. Accessed February 19, 2020.
26. Dexter F, Parra MC, Brown JR. Perioperative COVID-19 defense: An evidence-based approach for optimization of infection control and operating room management. Anesth Analg 2020; [Online ahead of print].
27. Wang J, Du G. Covid-19 may transmit through aerosol. Irish J Med Sci 2020; [Online ahead of print].
28. Booth TF, Kournikakis B, Bastien N, et al. Detection of airborne severe acute respiratory syndrome (SARS) coronavirus and environmental contamination in SARS outbreak units. J Infect Dis 2005; 191:14721477.
29. Yu IT, Li Y, Wong TW. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med 004;350:1731–9.
30. Adhikari U, Chabrelie A, Weir M, et al. A case study evaluating the risk of infection from middle eastern respiratory syndrome coronavirus (MERS-CoV) in a hospital setting through bioaerosols. Risk Anal 2019; 39:26082624.
31. Zhang H, Li X, Ma R, et al. Airborne spread and infection of a novel swine-origin influenza a (H1N1) virus. Virol J 2013; 10:204.
32. Kulkarni H, Smith CM, Lee Ddo H, et al. Evidence of respiratory syncytial virus spread by aerosol. Time to revisit infectioncontrol strategies? Am J Respir Crit Care Med 2016; 194:308316.
33. Jewett DL, Heinsohn P, Bennett C, et al. Blood-containing aerosols generated by surgical technique: A possible infectious hazard. Am Ind Hyg Assoc J 1992; 53:228231.
34. Ayache S, Beltran M, Guevara N. Anatomy of the external auditory canal. Comparative study of microscope versus endoscope. Rev Laryngol Otol Rhinol 2017; 138:9398.
35. Tarabichi M, Nogueira JF, Marchioni D, et al. Transcanal endoscopic management of cholesteatoma. Otolaryngol Clin North Am 2013; 46:107130.
36. Norris BK, Goodier AP, Eby TL. Assessment of air quality during mastoidectomy. Otolaryngol Head Neck Surg 2011; 144:408411.
37. Wong KC, Leung KS. Transmission and prevention of occupational infections in orthopaedic surgeons. J Bone Joint Surg Am 2004; 86:10651076.
38. World Health Organization (WHO). Infection prevention and control of epidemic and pandemic prone acute respiratory infections in health care. WHO Guidelines 2014.
39. Long Y, Hu T, Liu L, et al. Effectiveness of N95 respirators versus surgical masks against influenza: A systematic review and meta-analysis. J Evid Based Med 2020; 13:93101.
40. Xiao AT, Tong YX, Liu M. Evaluation of coronavirus in tears and conjunctival secretions of patients with SARAS-CoV-2 infection. J Med Virol 2020; [Epub ahead of print].
41. Xiao AT, Tong YX, Zhang S. False-negative of RT-PCR and prolonged nucleic acid conversion in COVID-19: Rather than recurrence. J Med Virol 2020; [Epub ahead of print].
42. Kokkinakis I, Selby K, Favrat B, et al. Covid-19 diagnosis: Clinical recommendations and performance of nasopharyngeal swab-PCR. Rev Med Suisse 2020; 16:699701.
43. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020; [Epub ahead of print].
44. Lan L, Dan X, Guangming Y, et al. Positive RT-PCR test results in patients recovered from COVID-19. JAMA 2020; [Epub ahead of print].
45. Zu ZY, Jiang MD, Xu PP, et al. Coronavirus disease 2019 (COVID-19): A perspective from China. Radiology 2020; [Epub ahead of print].
46. Kanne JP, Little BP, Chung JH, et al. Essentials for radiologists on COVID-19: An update radiology scientific expert panel. Radiology 2020; [Online ahead of print].
47. Yang W, Cao Q, Qin L, et al. Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19): A multi-center study in Wenzhou city, Zhejiang, China. J Infect 2020; [Online ahead of print].
48. Yang W, Yan F. Patients with RT-PCR confirmed COVID-19 and normal chest CT. Radiology 2020; [Online ahead of print].
49. Ai T, Yang Z, Hou H, et al. Correlation of chest CT and RT-PCR testing in coronavirus disease (COVID-19) in China: A report of 1014 Cases. Radiology 2020; [Epub ahead of print].
50. Araujo-Filho JAB, Sawamura MVY, Costa AN, et al. Covid-19 pneumonia: What is the role of imaging in diagnosis? J Bras Pneumol 2020; [Epub ahead of print].
51. Li Z, Yi Y, Luo X, et al. Development and clinical application of a rapid IgM-IgG combined antibody test for SARS-CoV-2 infection diagnosis. J Med Virol 2020; Online ahead of print.
52. Guo L, Ren L, Yang S, et al. Profiling early humoral response to diagnose novel coronavirus disease (COVID-19). Clin Infect Dis 2020; Online ahead of print.
53. Cassaniti I, Novazzi F, Giardina F, et al. Performance of VivaDiag COVID-19 IgM/IgG Rapid Test is inadequate for diagnosis of COVID-19 in acute patients referring to emergency room department. J Med Virol 2020; [Online ahead of print].
54. Specifications setting out the performance assessment methods applicable to serological tests detecting anti-SARS-Co-2 antibodies. Haute Autorité de Santé, France (HAS). Available at: https://has-sante.fr/upload/docs/application/pdf/2020-05/has_serological_tests_covid19_specifications.pdf. Accessed April 16, 2020.
55. Recommandations de Pratiques Professionnelles. Préconisations pour l’adaptation de l’offre de soins en anesthésie-réanimation dans le contexte de pandémie de Covid-19. Société Française d’Anesthésie et Réanimation (SFAR), version Mai 2020. Available at: https://sfar.org/download/recommandations-de-pratiques-professionnelles-preconisations-pour-ladaptation-de-loffre-de-soins-en-anesthesie-reanimation-dans-le-contexte-de-pandemie-de-covid-19-version-mai2020/?wpdmdl=26224&refresh=5eccde1159fe91590484497.
56. Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic n.d. Available at: https://www.asahq.org/about-asa/newsroom/news-releases/2020/04/joint-statement-on-elective-surgery-after-covid-19-pandemic (accessed April 21, 2020).
57. Kowalski LP, Sanabria A, Ridge JA, et al. COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and headand neck surgery practice. Head Neck 2020; [Epub ahead of print].
58. Zhu N, Zhang D, Wang W, et al. A novel coronavirus from patients with pneumonia in China. N Engl J Med 2020; 382:72733.
59. Gane SB, Kelly C, Hopkins C. Isolated sudden onset anosmia in COVID-19 infection. A novel syndrome? Rhinology 2020; [Epub ahead of print].
60. Van Gerven L, Hellings PW, Cox T. Personal protection and delivery of rhinologic and endoscopic skull base procedures during the COVID-19 outbreak. Rhinology 2020; [Epub ahead of print].
61. Chan JYK, Wong EWY, Lam W. Practical aspects of otolaryngologic clinical services during the 2019 novel corona virus epidemic: An experience in Hong Kong. JAMA Otolaryngol Head Neck Surg 2020; [Epub ahead of print].
62. Wei Z, Yisi L, Dongdong T. Potential benefits of precise corticosteroids therapy for severe 2019-nCoV pneumonia. Signal Transduct Target Ther 2020; 5:18.
63. Tinling SP, Colton J, Brodie HA, et al. Location and timing of initial osteoid deposition in postmeningiticlabyrinthis ossificans determined by multiple fluorescent labels 5. Laryngoscope 2004; 114:675680.
64. Wu X, Cai Y, Huang X, et al. Co-infection with SARS-CoV-2 and influenza a virus in patient with pneumonia, China. Emerg Infect Dis 2020; [Epub ahead of print].
65. Ti LK, Ang LS, Foong TW, et al. What we do when a COVID-9 patients needs an operation: Operating room preparation and guidance. Can J Anaesth 2020; [Epub ahead of print].
66. Wong J, Goh QY, Tan Z, et al. Preparing for a COVID 19 pandemic: Review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth 2020; [Epub ahead of print].
67. Peng PW, Wong DT, Bevan D, et al. Infection control and anesthesia: Lessons learned from the Toronto SARS outbreak. Can J Anesth 2003; 50:989997.
68. Kampf G, Todt D, Pfaender S, et al. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. J Hosp Infect 2020; [Epub ahead of print].
69. Phan LT, Maita D, Mortiz DC, et al. Personal protective equipment doffing practices of healthcare workers. J Occup Environ Hyg 2019; 16:575581.
70. John A, Tomas ME, Cadnum JL, et al. Are health care personnel trained in correct use of personal protective equipment? Am J Infect Control 2016; 44:840842.
71. Kurup V, Matei V, Ray J. Role of in-situ simulation for training in healthcare: Opportunities and challenges. Curr Opin Anaesthesiol 2017; 30:755760.
72. Mastoras G, Poulin C, Norman L, et al. Stress testing the resuscitation room: Latent threats to patient safety identified during interprofessional in situ simulation in a Canadian Academic emergency department. AEM Educ Train 2020; [Epub ahead of print].
73. Fent G, Blythe J, Farooq O, et al. In situ simulation as a tool for patient safety: A systematic review identifying how it is used and its effectiveness. BMJ Simul Technol Enhanced Learn 2015; 1:103110.
Keywords:

Consultations; Coronavirus; COVID-19; Lateral skull base; Otology; SARS-CoV-2; Surgery

© 2020, Otology & Neurotology, Inc.