Telehealth in the times of SARS-CoV-2 infection for the otolaryngologist.

OBJECTIVE: In response to the American Academy of Otolaryngology - Head and Neck Surgery's recommendations to limit patient care activities in the times of SARS-CoV-2, many elective surgeries have been canceled without patient clinics transitioning to virtual visits. With regulations for telemedicine loosened, new possibilities for the practice of otolaryngology have opened. To address the uncertain duration of this pandemic, a review was conducted of current literature on use of telemedicine services in the current SARS-CoV-2 pandemic and in previous national emergencies to reveal the role telemedicine can play for otolaryngology practices. DATA SOURCES: Pubmed articles with an independent search query were utilized. METHODS: Literature review performed by one author searched for all published English-language literature on telehealth in the SARS-CoV-2 era. Articles were considered for discussion if they provided relevant developments for telemedicine in the context of the SARS-CoV-2 pandemic. RESULTS: Telemedicine can be up-scaled in the current SARS-CoV-2 pandemic where exposure containment is of the utmost priority. With patient interaction possible through virtual communication, telemedicine allows continued patient care while minimizing the risk of viral spread. In the realm of otolaryngology, telemedicine has been used in the past during disasters with other studies demonstrating high diagnostic concordance with inpatient visits. Many institutions have recognized the potential for such care as they begin utilize both virtual visits and in-person care during this pandemic. CONCLUSION: To limit the spread of SARS-CoV-2, we support the AAO-HNS recommendation for the adoption of novel ways to employ telemedicine in this era. Many emergency departments and health care systems have the infrastructure necessary for synchronous video telemedicine visits that can be leveraged to provide quality care with patients. With the continued need to socially distance, telemedicine can protect both physicians and patients from unnecessary exposure to the virus.

Diagnostic accuracy and management concordance of otorhinolaryngological diseases through telehealth or remote visits: A systematic review & meta-analysis.

INTRODUCTION: COVID-19 has led to delays in providing healthcare in both emergency and non-emergency settings, especially in surgical subspecialties which rely heavily on referrals and in-person visits. Without an established telehealth infrastructure, many otorhinolaryngological departments experienced decreases in consultations. Telemedicine has attempted to bridge the gap between pre- and post-pandemic periods by creating a safe avenue of communication between otorhinolaryngologists and patients. This review hopes to address the accuracy of telemedicine in patient diagnosis and management. METHODS: Searches were conducted since study conception until June 30, 2022, on multiple databases including PubMed, SCOPUS, and CINAHL for this systematic review and meta-analysis. Diagnostic accuracy, management accuracy, kappa, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were meta-analyzed by comparing virtual visits to in-person visits (gold standard). RESULTS: Nineteen studies were included in this review. A total of 1518 patients were included across all studies. When comparing virtual visits against in-person visits, accurate diagnosis was made in 86.2% [82.1,89.9, I2 = 73.5%, P < 0.0001] of patients and management accuracy was 91.5% [86.1,95.7, I2 = 81.8%, P < 0.0001] when treating patients. Kappa value determining interrater reliability was 0.8 [0.7,0.9, I2 = 81.8%, P < 0.0001]. CONCLUSION: Our data suggest that diagnostic and management concordance is above 80% when comparing diagnosis and management strategies in patients who underwent both telehealth and in-person visits with an otorhinolaryngologist. In uncomplicated patients, telehealth might be a reliable source for diagnosis and management however, in-person consultation is likely still required for pathologies in which physical exam, imaging or procedural elements represent a vital component of the work-up.

Otolaryngologic Presentations to Emergency Departments During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.

OBJECTIVES: To perform a systematic review of otolaryngologic presentation rates to emergency department settings before and after lockdown due to the COVID-19 pandemic. SOURCES: PubMed, Scopus, and CINAHL. METHODS: A systematic search was conducted following PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) for studies describing otolaryngologic presentations to emergency department and rapid access clinic settings both in the before-lockdown and after-lockdown periods. The start of after-lockdown period varied based on initiation of lockdown, ranging from March 1st to June 1st of 2020 across general emergency department studies. RESULTS: A total of 14 studies were included in this review. About 10 were general emergency departments, 3 were specifically pediatric emergency departments, and 1 study focused on the geriatric population (>65 years). A total of 13 790 patients were included, with 9446 in the before-lockdown period (68.5%) and 4344 in the after-lockdown period (31.5%). Meta-analysis of proportions for otolaryngologic presentations across general emergency departments was performed. Comparison of weighted proportions found significant differences between before-lockdown and after-lockdown presentation rates for infectious etiologies, tonsillitis specifically, foreign bodies, non-infectious airway issues, and epistaxis among these studies. CONCLUSIONS: The increased proportions of various non-infectious presentations (eg, epistaxis, foreign bodies, and airway issues) following lockdown might be associated with proportional decreases in infectious pathologies, given decreased social contact to prevent SARS-CoV-2 transmission. Overall, it is important for otolaryngologists to recognize what presentations might more commonly be seen and require evaluation and potential intervention in light of a global pandemic.

Evaluating the management timeline of tracheoesophageal fistulas secondary to button batteries: A systematic review.

INTRODUCTION: During the SARS-CoV-2 pandemic, the incidence of pediatric button battery (BB) ingestions has risen. Children have spent more time at home from school, while many parents try to balance working from home and childcare. Additionally, the amount of electronics powered by BB has increased. Tracheoesophageal fistula (TEF) secondary to a retained aerodigestive BB is a devastating development. Management is challenging, and the clinical timeline of watchful waiting versus surgical intervention for TEF is poorly defined in the literature. METHODS: In accordance with PRISMA guidelines, databases searched include PubMed, Scopus, and CINAHL from database date of inception through August 13, 2021. All study designs were included, and no language, publication date, or other restrictions were applied. Case series and reports of TEFs secondary to BBs were included. Clinical risk factors and outcomes were compared between the spontaneous closure and surgical repair groups. RESULTS: A total of 79 studies with 105 total patients were included. Mortality was 11.4%. There were 23 (21.9%) TEFs that spontaneously closed and 71 (67.6%) that underwent surgical repair. Median time to spontaneous closure compared to surgical repair was significantly different (8.0 weeks [IQR 4.0-18.4] vs. 2.0 weeks [IQR 0.1-3.3], p<0.001). Smaller TEFs were more likely to spontaneously close versus being surgically repaired (9.3 mm ± 3.5 vs. 14.9 mm ± 8.3, p=0.022). Duration of symptoms before BB discovery, BB size, time between BB removal and TEF discovery, and location of the TEF were not statistically different between the spontaneous closure and surgical repair groups. CONCLUSION: A TEF secondary to BB ingestion is a potentially deadly complication. Timing of reported TEF spontaneous closure varies significantly. While smaller TEFs may be amenable to healing without surgical repair, no other significant factors were identified that may be associated with spontaneous closure. If clinical status permits, these data suggest a period of observation of at least 8 weeks prior to surgical intervention may be practical for many BB-induced TEFs.

Concerns and Needs of Patients With Head and Neck Cancer in the COVID-19 Era.

OBJECTIVE: To evaluate the concerns and needs of patients and survivors of head and neck cancer (HNC) in the COVID-19 era. STUDY DESIGN: Prospective cross-sectional survey. SETTING: Contact lists of 5 North American HNC advocacy groups. METHODS: A 14-question survey was distributed to the contact lists of 5 HNC advocacy groups evaluating patient and survivor needs and concerns related to their cancer care and COVID-19. RESULTS: There were 171 respondents, with 75% in the posttreatment period. The most common concern was contraction of COVID-19 (49%). More patients in active treatment preferred in-person visits than those in the early (≤5 years) and late (>5) survivorship period (72% vs 61% vs 40%, P < .001). A higher percentage of late survivors preferred virtual visits (38% vs 28%, P = .001). In total, 91 (53.2%) respondents sought emotional support outside of immediate family and friends. This included cancer support groups (36.2%), the medical team (29.7%), and other sources outside of these (34.1%), including faith-based organizations and online communities. A higher proportion of women than men (62% vs 41%, P = .001) were seeking emotional support outside of immediate family and friends. CONCLUSIONS: During the early stages of the COVID-19 pandemic, patients with HNC who were actively undergoing treatment had increased need for support resources and preferred in-person provider visits. Alternatively, a higher percentage of patients >5 years from treatment preferred virtual visits. Emotional support outside of family and friends was sought out by a majority of respondents. Further research is needed to determine what support and educational resources are needed to best aid these various populations.

Review of the use of nasal and oral antiseptics during a global pandemic.

A review of nasal sprays and gargles with antiviral properties suggests that a number of commonly used antiseptics including povidone-iodine, Listerine®, iota-carrageenan and chlorhexidine should be studied in clinical trials to mitigate both the progression and transmission of SARS-CoV-2. Several of these antiseptics have demonstrated the ability to cut the viral load of SARS-CoV-2 by 3-4 log10 in 15-30 s in vitro. In addition, hypertonic saline targets viral replication by increasing hypochlorous acid inside the cell. A number of clinical trials are in process to study these interventions both for prevention of transmission, prophylaxis after exposure, and to diminish progression by reduction of viral load in the early stages of infection.

The Evolution of Care of Cancers of the Head and Neck Region: State of the Science in 2020.

Cancers that arise in the head and neck region are comprised of a heterogeneous group of malignancies that include carcinogen- and human papillomavirus (HPV)-driven mucosal squamous cell carcinoma as well as skin cancers such as cutaneous squamous cell carcinoma, basal cell carcinoma, melanoma, and Merkel cell carcinoma. These malignancies develop in critical areas for eating, talking, and breathing and are associated with substantial morbidity and mortality despite advances in treatment. Understanding of advances in the management of these various cancers is important for all multidisciplinary providers who care for patients across the cancer care continuum. Additionally, the recent Coronavirus Disease 2019 (COVID-19) pandemic has necessitated adaptations to head and neck cancer care to accommodate the mitigation of COVID-19 risk and ensure timely treatment. This review explores advances in diagnostic criteria, prognostic factors, and management for subsites including head and neck squamous cell carcinoma and the various forms of skin cancer (basal cell carcinoma, cutaneous squamous cell carcinoma, Merkel cell carcinoma, and melanoma). Then, this review summarizes emerging developments in immunotherapy, radiation therapy, cancer survivorship, and the delivery of care during the COVID-19 era.

Viral Infections of the Upper Airway in the Setting of COVID-19: A Primer for Rhinologists.

BACKGROUND: Viral respiratory tract infections are associated with a significant burden of disease and represent one of the leading causes of mortality worldwide. The current Coronavirus Disease 2019 (COVID-19) pandemic highlights the devastating toll that respiratory viruses have on humanity and the desperate need to understand the biological characteristics that define them in order to develop efficacious treatments and vaccines. To date, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has infected nearly 600 times more people and resulted in 200 times more deaths relative to Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and Middle Eastern Respiratory Syndrome Coronavirus (MERS-CoV) combined. OBJECTIVE: Through this review, we aim to summarize the key characteristics of respiratory viruses that hold global significance, with a focus on SARS-CoV-2. Our goal is to disseminate our current knowledge of these infectious agents to otolaryngologists, in particular rhinologists, practicing in the COVID-19 era. METHODS: The general and clinical characteristics of selected respiratory viruses along with available viral treatments and vaccines are reviewed. RESULTS: There has been significant progress in our understanding of the epidemiology and pathogenesis of various respiratory viruses. However, despite the advancement in knowledge, efficacious vaccines and antiviral treatments remain elusive for most respiratory viruses. The dire need for these scientific discoveries is highlighted by the recent COVID-19 pandemic, which has prompted investigators worldwide to conduct clinical trials at an accelerated timeline in an effort to reduce the morbidity and mortality associated with SARS-CoV-2 infection. Rhinologists will continue to remain on the front-lines of pandemics associated with respiratory viruses. CONCLUSION: In light of these unprecedented times, the need to understand the nuances of these viral respiratory pathogens, especially SARS-CoV-2, cannot be overemphasized. This knowledge base is of particular importance to otolaryngologists, whose expertise in the upper airway coincides with the anatomic tropism of these infectious agents.

The Prevalence of Olfactory Dysfunction in the General Population: A Systematic Review and Meta-analysis.

BACKGROUND: Olfactory dysfunction (OD) is common and has been reported as an early indicator of COVID-19. However, the reported prevalence of OD in the general population varies widely depending upon the metric used to assess olfaction.Methodology/Principal: To perform a systematic review and meta-analysis of the prevalence of OD in the healthy general population, review the various assessment metrics used, and compare pooled OD prevalence rates. RESULTS: A total of 175,073 subjects were identified (mean age 63.5 years, range 18 to 101) with an overall OD prevalence of 22.2% (95% CI 14.8-30.6). OD prevalence was significantly greater using objective olfactory assessments, compared to subjective measures (28.8%, CI 20.3-38.2 versus 9.5%, CI 6.1-13.5, p < 0.001). The prevalence of OD was greater using expanded identification tests (>8 items) compared to brief test with ≤8 items (30.3%, CI 16.2-46.5 versus 21.2%, CI 12.3-31.8). Prevalence was higher in studies with a mean age greater than 55 years compared to those with a mean age of 55 years or less (34.5%, CI 23.4-46.5 versus 7.5%, CI 2.6-14.5, p < 0.001). CONCLUSIONS: The reported prevalence of OD in the general population depends on the testing method and population age. OD prevalence was greater in studies using objective tests, expanded identification tests, and in those with older subjects.

Emergent and urgent otologic surgeries during the SARS-CoV-2 pandemic: a protocol and review of literature.

OBJECTIVE: To review guidelines for otologic procedures during the SARS-CoV-2 pandemic and to present a protocol for emergent or urgent mastoidectomy at our institution. DATA SOURCES: Guidelines regarding emergent and urgent otologic procedures from otolaryngologic societies are reviewed. We described a protocol for emergent or urgent mastoidectomy at our institution. CONCLUSION: Patients requiring urgent or emergent mastoidectomy during the COVID-19 pandemic require prompt treatment. We make the following recommendations: Emergent or urgent otologic procedures should be performed in a contained environment, such as a tent created by the microscope drape. The surgical team should practice using instruments in the tent setup to prepare for real cases. Otologic procedures should adhere to guidelines set for high-risk procedures.

Is SARS-CoV-2 (COVID-19) postviral olfactory dysfunction (PVOD) different from other PVOD?

BACKGROUND: The SARS-CoV-2 virus continues to spread rapidly across the globe afflicting many with Coronavirus Disease 2019 (COVID-19). As the infection rates rise, a growing number of SARS-CoV-2 positive individuals have been reported to complain of olfactory disturbances at an alarming rate. Postviral olfactory dysfunction (PVOD) is a well-known phenomenon that may explain the olfactory dysfunction reported by SARS-CoV-2 infected individuals. METHODS: A scoping literature review was performed to identify studies that investigated the mechanisms of postviral olfactory dysfunction. Studies demonstrating pathophysiological, histological, immunochemical, and epidemiological outcomes of PVOD were included. RESULTS: Fourteen studies were included in addition to one international news article. Three studies reported destruction of the olfactory epithelium following intranasal inoculation of various viral strains in mice. Three studies isolated pathogenic, anosmia inciting viruses (Parainfluenza virus, Human Coronavirus, Rhinovirus) through nucleic acid amplification. Eleven studies demonstrated female predilection in patients with PVOD and COVID-19 associated olfactory dysfunction, of which the majority were over 50 years old. CONCLUSIONS: PVOD and COVID-19 associated olfactory dysfunction demonstrates considerable similarities in epidemiological trends and disease sequela of other viruses to suggest identical pathophysiological mechanisms. Further studies such as intranasal inoculation and histological biopsies are needed to support our hypothesis.

Head and neck survivorship care in the times of the SARS-CoV-2 pandemic.

With the arrival of the coronavirus disease (SARS-CoV-2) in the United States, care practice paradigms have drastically changed. Data from China suggest that the new virus poses additional risks as case fatality of patients with cancer was higher at 5.6% compared to 2.3% of the general population. There are three proposed major strategies to address care for patients with cancer in this SARS-CoV-2 pandemic with postponing treatment for those with stable cancer, increasing personal protection provisions for patients with cancer, and increasing monitoring if a patient becomes infected with SARS-CoV-2. In this present commentary, we discuss the unique mental health challenges and burdens of patients with head and neck cancer in the times of the SARS-CoV-2 pandemic and approaches to mitigate these stressors through telemedicine to reduce future burdens to the patient and the health care system.

Bronchoscopy, laryngoscopy, and esophagoscopy during the COVID-19 pandemic.

BACKGROUND: The United States now has the highest death toll due to COVID-19. Many otolaryngology procedures, including laryngoscopy, bronchoscopy, and esophagoscopy, place otolaryngologists at increased risk of coronavirus transmission due to close contact with respiratory droplets and aerosolization from the procedure. The aim of this study is to provide an overview of guidelines on how to perform these procedures during the coronavirus pandemic. METHODS: Literature review was performed. Articles citing laryngoscopy, bronchoscopy, esophagoscopy use with regard to COVID-19 were included. RESULTS: Laryngoscopy, bronchoscopy, and esophagoscopy are all used in both emergent and elective situations. Understanding the risk stratification of cases and the varied necessity of personal protective equipment is important in protecting patients and health care workers. CONCLUSIONS: Summary guidelines based on the literature available at this time are presented in order to decrease transmission of the virus and protect those involved.

Tracheostomy protocols during COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in the implementation of rapidly changing protocols and guidelines related to the indications and perioperative precautions and protocols for tracheostomy. The purpose of this study was to evaluate current guidelines for tracheostomy during the COVID-19 pandemic to provide a framework for health systems to prepare as the science evolves over the upcoming months and years. METHODS: Literature review was performed. Articles reporting clinical practice guidelines for tracheostomy in the context of COVID-19 were included. RESULTS: A total of 13 tracheotomy guidelines were identified. Two were available via PubMed, five in society or organization websites, and six identified via health system websites or other sources. Five were from Otolaryngology-Head and Neck Surgery specialties, six from Anesthesiology and one from Pulmonary/Critical Care. All (100%) studies recommended postponing elective OR cases in COVID-19 positive patients, while seven recommended reducing team members to only essential staff and three recommended forming a designated tracheostomy team. Recommendations with supporting references are summarized in the article. CONCLUSIONS: Tracheostomy guidelines during the COVID-19 pandemic vary by physician groups and specialty, hospital systems, and supply-chain/resource availability. This summary is provided as a point-in-time current state of the guidelines for tracheotomy management in April 2020 and is expected to change in coming weeks and months as the COVID-19 pandemic, virus testing and antibody testing evolves.