The Italian Society Indication for Rhinologists during Covid-19: Italy Phase 2

Dear Editor,

SARS-CoV-2 is highly contagious, with a huge impact on the healthcare systems worldwide; medical staff, and rhinologists in particular, are at high risk of viral contamination. Indeed, due to the exposure of airway and mucosal surfaces and the possibility of generating aerosols, many head and neck, as well as otolaryngologic oral diagnostic, and surgical procedures are high-risk. Therefore, the Italian Rhinologic Society proposed some brief and clear indications to go through the so called “fase 2” (“phase 2”) in our country.

Personal Protective Equipment

Clinicians and staff should wear personal protective equipment (PPE): filtering facepiece (FFP2/3) mask, water-resistant overcoat, boot covers and cap, as well as an additional cup covering the headlight, protective glasses or face shield, and double gloves. All disposable material must be eliminated in the infectious waste circuit in the examination room, except for the protective glasses, which can be decontaminated and reused.[1] [2]

Outpatient Office

Patients should always be asked by phone about signs or symptoms suggestive of COVID-19 fever, coughing, wheezing, dyspnea, diarrhea, hyposmia and/or dysgeusia. The use telemedicine should be considered in patients who do not require a physical examination, to maintain relationships and support assessment.

Outpatient Visit

1. Patients in the waiting room should keep a distance of 1.5 m from each other;

2. patients should use a surgical mask;

3. only the necessary staff should be present in the outpatient office;

4. appropriate PPE must be worn;

5. unnecessary items must not be left in the visiting room.

6. only the patient must enter the examination room, with no accompanying person, unless the patient is under 18 years old or disabled (before the visit, the patient must wash her/his hands scrubbing all surfaces — including the back of the hands, in between the fingers, and under the nails — for at least 20 seconds, with soap and water or with alcoholic disinfectant, drying the hands with a clean cloth, single-use towel, or blow-dry);

7. patients should be placed in private rooms with negative pressure, if possible;

8. during the interview, the physician must keep a distance of 1.5 m from the patient;

9. after the patient leaves the room and before the next patient, thorough cleaning of all surface areas of the examination room must be performed. The surfaces must be disinfected with detergents, sodium hypochlorite, or alcoholic solutions;

10. the instruments used for the visit and not subject to sterilization must be disinfected;

11. a delay of at least 30 min must be observed before examining another patient;

12. during this period, the visiting office should be kept with open windows to obtain a complete environmental air change; and

13. offices without windows should not be used, as well as regular air-conditioning systems.

Rhinologic Functional Tests

At the moment, no test is suggested, especially in healthy outpatients. We strongly recommend against the performance of rhinomanometry, acoustic rhinometry and olfactometry; the self-rating nasal symptoms grading, using the Visual Analog Scale or validated questionnaires is the best way to approach these patients. The skin-prick test could be performed instead.

Post-COVID-19 patients could instead be tested both clinically and through functionality tests, and we recommend the evaluation of these patients after 3 consecutive negative swabs (the last one in the previous 48 h).

Endoscopic Examination

Nasal endoscopy is an aerosol-generating procedure that has a high risk of viral dissemination through the air. The nose and rhinopharynx seem to be the reservoir of the SARS-CoV-2 virus.[3]

Nasal endoscopy should be performed under the following conditions:

1. clinicians and staff should wear PPEs;

2. the nasal endoscope should be placed on a clearly separate table, and the camera must have a protective cover;

3. disposable protective sheaths must be used;

4. adequate topical preparation to make the examination more comfortable is recommended, and local sprays should be avoided. The use of pledges placed into the nasal cavity is preferred to provide decongestion and anesthesia;

5. decontaminate the endoscope after each use, following the usual decontamination procedures;

6. after the examination, the endoscope must be appropriately handled.

7. thorough cleaning of all surface areas of the examination room; and

8. do not remove the endoscope from the examination room without a protective cover.

Operating Room Setting

A nasopharyngeal swab within 4 days and 48 hours before surgery is mandatory.[3] In COVID-positive patients, surgery should be postponed, and the patient, referred to a multidisciplinary team for the management of COVID-19.

Urgent procedures should not be delayed due to the wait for the results of a swab. When a computed tomography (CT) scan is required in the usual preoperative assessment, a complementary chest CT scan must systematically be performed.[4]

Surgical Caution

Operating on the nasal mucosa in a COVID 19 patient, in particular with the use of powered devices, such as drills, microdebriders etc., poses a high risk for the entire operating room staff and recovery units, and may compromise the patient's ability to recover.

1. Keep as little staff as possible in the operating theater, particularly close to the patient's head;

2. personal protective equipment should be worn;

3. surgical procedures should be performed as fast as possible;

4. during intubation/extubation, all nonessential staff must leave the room and return when the airways are secured.

Endonasal Surgery

Endoscopic nasal surgeries, sinus and trans-sphenoidal surgery in particular, are very high-risk procedures, so indications should be strictly limited due to the risk of dissemination of viral particles. The use of PPEs is recommended for all operating-room staff. In the preoperative setting, whenever feasible, to decrease the viral load, the surgical candidates should be treated with a povidone-iodine (PVP-I) solution by nasal irrigation and oral wash.

Conflict of Interests

The authors have no conflict of interests to declare.

Italian Rhinologic Society Board - (https://www.societaitalianarinologia.it/home/index.php).

Bellussi, Luisa: IFOS executive board member, Rome, Italy ([e-mail]).

Cassano, Pasquale: Otorhinolaryngology, Università degli Studi di Foggia ([e-mail]).

Piemonte, Marco: ENT, Azienda Ospedaliera Universitaria, Udine ([e-mail]).

Scasso, Felice: ENT, Ospedale “Antero Micone” Asl 3 Genovese ([e-mail]).

Albera, Roberto: ENT, Università degli Studi di Torino ([e-mail]).

Bellocchi, Gianluca: ENT, Ospedale San Camillo, Rome ([e-mail]).

Della Vecchia, Laura: ENT, Azienda Ospedaliera-Universitaria “Ospedale Di Circolo E Fondazione Macchi” ([e-mail]).

Salamanca, Fabrizio: ENT, Casa di Cura Humanitas San Pio X ([e-mail]).

^∗ The members of the Italian Rhinologic Society board participated in the authorship of this article and are listed on page 2.

• References

• 1 Mady LJ, Kubik MW, Baddour K, Snyderman CH, Rowan NR. Consideration of povidone-iodine as a public health intervention for COVID-19: Utilization as “Personal Protective Equipment” for frontline providers exposed in high-risk head and neck and skull base oncology care. Oral Oncol 2020; 105: 104724 . Doi: 10.1016/j.oraloncology.2020.104724
• 2 Leboulanger N, Sagardoy T, Akkari M. , et al; French Association of Pediatric Otorhinolaryngology (AFOP); French Society of Otorhinolaryngology; Head, Neck Surgery (SFORL); Guidelines of the French Association of Pediatric Otorhinolaryngology (AFOP) and French Society of Otorhinolaryngology (SFORL). COVID-19 and ENT Pediatric otolaryngology during the COVID-19 pandemic. Eur Ann Otorhinolaryngol Head Neck Dis 2020; ••• :S1879-7296(20)30100-9 DOI: 10.1016/j.anorl.2020.04.010.
• 3 Givi B, Schiff BA, Chinn SB. , et al. Safety Recommendations for Evaluation and Surgery of the Head and Neck During the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg 2020; ••• DOI: 10.1001/jamaoto.2020.0780.
• 4 Fakhry N, Schultz P, Morinière S. , et al; French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL); French Society of Head and Neck Carcinology (SFCCF). French consensus on management of head and neck cancer surgery during COVID-19 pandemic. Eur Ann Otorhinolaryngol Head Neck Dis 2020; ••• :S1879-7296(20)30098-3 DOI: 10.1016/j.anorl.2020.04.008.