www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
SPECIAL
ARTICLE
An
update
on
COVID-19
for
the
otorhinolaryngologist
---a
Brazilian
Association
of
Otolaryngology
and
Cervicofacial
Surgery
(ABORL-CCF)
Position
Statement
夽
Joel
Lavinsky
,
Eduardo
Macoto
Kosugi
,
Eduardo
Baptistella
,
Renato
Roithmann
,
Eduardo
Dolci
,
Thais
Knoll
Ribeiro
,
Bruno
Rossini
,
Fabrizio
Ricci
Romano
,
Rebecca
Christina
Kathleen
Maunsell
,
Edson
Ibrahim
Mitre
,
Rui
Imamura
,
Adriana
Hachiya
,
Carlos
Takahiro
Chone
,
Luciana
Miwa
Nita
Watanabe
,
Marco
Aurélio
Fornazieri
,
Marcus
Miranda
Lessa
,
Geraldo
Druck
Sant’Anna
∗Associac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial(ABORL-CCF),SãoPaulo,SP,Brazil Received2April2020;accepted4April2020
Availableonline11April2020
KEYWORDS
Coronaviruses; Otolaryngologist; ENTdisease
Abstract
Introduction:Wearefacingapandemicwithagreatimpactworldwide,asaresultoftherapid spreadofthenovelcoronavirus(COVID-19).Themedicalcommunityisstillgetting toknow behaviorofthisvirusandtheconsequencesfromapopulationpointofview.Allthisknowledgeis extremelydynamic,sosomebehaviorsarestillnotwellestablished.Otorhinolaryngologistshave acentralroleinthemanagementofthissituation,inwhichtheymustassessthepatient,avoid contaminationtoandbyhealthprofessionalsandotherpatients.Thus,therecommendationsof theBrazilianAssociationofOtorhinolaryngologyandCervical-FacialSurgery(ABORL-CCF)have themainobjectiveofreducingthespreadofthenewcoronavirusduringotorhinolaryngological careandassistinginthemanagementofthesepatients.
Methods:Reviewofthemainrecommendationsofnational andinternationalscientific soci-eties,decisionsbygovernmentagenciesandclasscouncils.Thetopicswillberelatedtothe generalaspectsofCOVID-19,personalprotectiveequipment,careinpatientassistance, endo-scopicexam routinesandthemanagementofsinonasal,otologicalandpediatricevaluations relatedtoCOVID-19.
夽 Pleasecitethisarticleas:LavinskyJ,KosugiEM,BaptistellaE,RoithmannR, DolciE,RibeiroTK,etal.AnupdateonCOVID-19for
theotorhinolaryngologist---aBrazilianAssociationofOtolaryngologyandCervicofacialSurgery(ABORL-CCF)PositionStatement.BrazJ Otorhinolaryngol.2020;86:273---80.
∗Correspondingauthor.
E-mail:geraldodruck@gmail.com(G.D.Sant’Anna).
PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2020.04.002
1808-8694/©2020PublishedbyElsevierEditoraLtda.onbehalfofAssociac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial. ThisisanopenaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).
Results:TheuseofpersonalprotectiveequipmentisconsideredcrucialinroutineENTcare. Werecommendpostponingappointments,examsandelectivesurgeriestoreducethespread ofCOVID-19.Similarly, we recommendchangingroutines inseveralareas ofotolaryngology. Additionally,guidanceisprovidedontheuseoftelemedicineresourcesduringthepandemic period.
Conclusions:WearestillatthebeginningoftheCOVID-19pandemicandscientificevidenceis stillscarceandincomplete,sotheseABORL-CCFrecommendationsforotorhinolaryngologists maybeupdatedbasedonnewknowledgeandthepatternofthenewcoronavirusspread. © 2020 Publishedby Elsevier EditoraLtda. on behalf ofAssociac¸˜ao Brasileira de Otorrino-laringologiaeCirurgiaC´ervico-Facial.ThisisanopenaccessarticleundertheCCBYlicense
(http://creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Coronavírus;
Otorrinolaringologista; Doenc¸aORL
Atualizac¸ãosobreoCOVID-19paraootorrinolaringologista---umdocumentosobrea posic¸ãodaAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial (ABORL-CCF)
Resumo
Introduc¸ão:Estamos diante de uma pandemia de grande impacto mundial como resultado darápidapropagac¸ãodonovocoronavírus,COVID-19.Acomunidademédicaestáainda con-hecendoocomportamentodessevíruseasrepercussõesdopontodevistapopulacional.Todo esseconhecimentoéextremamentedinâmico,porissoalgumascondutasaindanãoestãobem estabelecidas.O otorrinolaringologista tem um papel centralnomanejodessa situac¸ão em quedeveavaliaropacientee,evitaracontaminac¸ãodosprofissionaisdasaúdeedosdemais pacientes.Dessaforma,asrecomendac¸õesdaAssociac¸ãoBrasileiradeOtorrinolaringologiae CirurgiaCérvico-Facial(ABORL-CCF),têmporobjetivoprincipalreduzirapropagac¸ãodonovo coronavírusduranteoatendimentootorrinolaringológicoeauxiliarnomanejodessespacientes. Método: Revisãodasprincipaisrecomendac¸ões dassociedadescientíficasnacionais, interna-cionais,decisõesdeórgãosgovernamentaisedeconselhosdeclasse.Ostópicosserãorelativos aosaspectosgeraisdoCOVID-19,equipamentosdeprotec¸ãoindividual,cuidadosno atendi-mentoaopaciente,asrotinasdosexamesendoscópicoseomanejodeaspectosnasossinusais, otológicosepediátricosrelacionadosaoCOVID-19.
Resultados: Éconsideradocrucialousodeequipamentodeprotec¸ãoindividualnoatendimento otorrinolaringológicode rotina.Recomendamospostergar atendimentos, examesecirurgias eletivasparadiminuirapropagac¸ãodoCOVID-19.Damesmaforma,recomendamosmudanc¸a derotinasemdiversasáreasdaotorrinolaringologia.Alémdisso,orientac¸õessobreousodo recursodatelemedicinaduranteoperíododevigênciadapandemia.
Conclusões:EstamosaindanoiníciodapandemiadoCOVID-19easevidênciascientíficassão ainda escassas,porisso essasrecomendac¸ões da ABORL-CCFpara osotorrinolaringologistas podemsofreratualizac¸õesbaseadasnosnovosconhecimentosenopadrãodedisseminac¸ãodo novocoronavírus.
©2020Publicado porElsevier EditoraLtda.em nome deAssociac¸˜ao Brasileirade Otorrino-laringologia eCirurgiaC´ervico-Facial.Este ´eum artigo OpenAccess sobuma licenc¸aCC BY
(http://creativecommons.org/licenses/by/4.0/).
Introduction
DuetothePublicHealthEmergencyofInternational Impor-tanceestablishedonJanuary30,2020bytheWorldHealth Organization(WHO)1,2causedbythenovelcoronavirusand
theconfirmation ofcases ofthe diseaseofthe new coro-navirusinthenationalterritory,3theBrazilian Association
ofOtorhinolaryngologyandCervico-FacialSurgery (ABORL-CCF,Associac¸ãoBrasileiradeOtorrinolaringologiaeCirurgia Cérvico-Facial)has decidedto go publish guidelines aim-ing at updating and guiding otorhinolaryngologists. These recommendationsarebasedoncurrentknowledge:further updatesmayberequiredasthispandemicevolves.
About
Coronavirus
Coronavirusesbelongtoafamilyofrelativelycommon respi-ratoryviruses,beingafrequentcauseofthecommoncold, secondonlytorhinovirus.Inthepastfewdecades,theyhave been linkedtomoresevere outbreaks,suchasthe Severe AcuteRespiratorySyndrome(SARS)of2002andtheMiddle EastRespiratorySyndrome(MERS)of2012.OnDecember31, 2019,therewasawarningtoWHOthatseveralpneumonia caseswereoccurring inthecity ofWuhan(Hubei,China), whichwerelaterassociatedwiththenewcoronavirusstrain. Seven human coronaviruses have been identified: the most common Alphacoronavirus 229E andNL63 andBeta
coronavirusOC43andHKU1;thoseresponsibleforthe afore-mentionedSARS-CoVandMERS-CoVoutbreaks;andnowthe newcoronavirus,initiallynamed2019-nCoV,laterchanged on February 11, 2020 to SARS-CoV-2, as it is genetically relatedtoSARS-CoV.Thediseasecausedbythenew coron-aviruswasnamedCOVID-19.
About
the
transmission
Thevirustransmissionoccursfrompersontoperson,through respiratory droplets or contact. Anyone who had close contact(approximately1m)withsomeoneinfectedcanbe exposed to the infection. Given the particularity of the consultationsatotorhinolaryngologicaloffices,withthe per-formanceofspecificphysicalandendoscopicexamsthatcan generaterespiratorydroplets,otorhinolaryngologistsareat riskforinfection.
About
the
symptoms
Themain symptomsrelatedtoCOVID-19arefever,cough, dyspneaandfatigue.Itisimportanttoemphasizethe pos-sibilitythattheindividualisanasymptomaticcarrier.Some regionsoftheworldaremoreaffectedthanothers,further increasingtheneedfor professionalcare.Itis noteworthy tomentionothersymptomsthatmayalsobepresent,such asanosmiaandtastealterations.
About
personal
protective
equipment
(PPE)
During outpatient visits, we recommend wearing a surgi-calmask,eyeprotection,long-sleevegownandglovesand that these personal protective equipment be usedfor all consultations.
Duringendoscopicotorhinolaryngologicalexams,we rec-ommendusingaN95mask,PFF2orhigher,eyeprotection, long-sleeved gown and gloves. Likewise, personal protec-tiveequipmentmust beworninallotorhinolaryngological exams.
About
medical
consultations
TheBrazilianMedicalAssociation(AMB,Associac¸ãoMédica Brasileira)releasedanoteonMarch19,2020 recommend-ing thesuspension of elective outpatientcare throughout thecountry,aswellasthepostponementofelective surg-eries,ifpossible.Onthefollowingday,theFederalCouncil ofMedicine(CFM,ConselhoFederaldeMedicina)reinforced therecommendationofsuspendingelectivemedical consul-tations,butconsidered thatifthisisnotpossible,doctors cancarrythemoutaslongastheyareinaccordancewith the determinations of the local authorities and the Ser-viceTechnical-Director,respectingtherecommendedrules ofhygiene,individualprotectionandcontactrestriction.
The otorhinolaryngologistisattheforefrontofcarefor acuterespiratoryinfectionsandwealsounderstandthatour patientswillcontinue tohave otherdiseases withspecific demands and treatments that cannot be postponed, such asrecentpostoperativeoroncologicaldiseases.Therefore, therecommendation is torestrict thenumber ofelective
face-to-faceconsultations,maintainingonlythetreatment ofpatientswithdiseaseswhosetreatmentcannotbe post-poned during this crisis period. We advise performing a telephonescreening of patients withscheduled consulta-tionsorthosewhorequestelectiveappointments.Patients withfever,cough,suddenanosmiaand/orflu-likesymptoms withoutdyspneashouldbeinstructedtoundergohome isola-tionfor14days.Patientswithdyspneaorseveresymptoms, ontheotherhand,shouldbeinstructedtoseekemergency care in referral hospitals. If the doctor and the patient agree,electiveconsultationsduringtheCOVID-19crisismay becarriedoutinthewaysprovidedbyTelemedicine, accord-ingtothenewresolutionbyCFMandtheMinistryofHealth (describedindetailinthesectionontelemedicine).Incase ofelectiveconsultationsthatcannotbepostponed,we sug-gestschedulingappointments at longerintervals between patients,in ordertoavoid the crowdingof peopleat the receptionorwaiting room.Intheabsenceof face-to-face careduringthisperiod,wesuggestthatdoctors,ifpossible, offeracommunicationchannelwithpatients,whichallows foradequaterecommendations.
About
care
at
the
unit
reception
Itisimportantthatsomeguidelinesrelatedtopatientcare befollowed, such asasking about the presence of fever, cough,dyspneaandsneezinguponpatientarrival.We rec-ommend offering a surgical mask to patients with these symptoms.
Employeesattheofficereceptionshouldalsowear surgi-calmasksinthissituationandcleantheirhandsthoroughly withsoapandbyrubbingthemwithanalcohol-based formu-lation(gelalcoholorsolution)frequently.Weadvisekeeping thereceptionwellventilatedandprovidingdispenserswith alcohol-basedformulations(ingelorsolution)andtissuesin placeswitheasyaccessforpatientsandcompanions.
We recommend providing conditions for simple hand hygiene:sinkwithliquidsoapdispenser,papertowelholder, papertowels, and trash cans withlids that open without manual contact. Clean and disinfect frequently touched objectsandsurfaceswith70%alcohol,sodiumhypochlorite solutionoranotherdisinfectantindicatedforthispurpose. Werecommendthatpamphletsorpostersbemadeavailable onthe respiratory etiquette: when coughing or sneezing, coveryournoseandmouthwithyourflexedelboworwith atissueanddiscard itafteruse; aftercoughing or sneez-ing,washyour handswith soapand wateror gel alcohol; avoidtouchingeyes,noseandmouthwithoutadequatehand hygiene.
About
care
during
the
consultation
with
an
otorhinolaryngologist
It is important to highlight that many infectious patients areasymptomaticoroligosymptomaticand,therefore,the use of personal protective equipment (PPE) is strongly recommendedtotreatallpatients.The useofthe above-mentioned PPE should not lead to the neglect of basic respiratoryhygienecare, especiallyhand hygiene. Do not circulatethroughtheofficewearingPPE.
We recommend making dispensers with alcohol-based formulations(ingelorsolution)availableinplacesthatare easilyaccessibletodoctorsandpatients.Cleananddisinfect frequentlytouchedobjectsandsurfaces,withalcohol70%, sodium hypochlorite solution or other disinfectant agent indicatedforthispurpose, inadditiontoperforming stan-darddisinfectionproceduresforexaminationmaterial.
About
endoscopic
otorhinolaryngological
examinations
Here are the recommendations related to endoscopic otorhinolaryngologicalexaminations(nasalvideoendoscopy, videolaryngoscopy, video-laryngeal stroboscopy, video-nasofibrolaryngoscopy,video endoscopyof deglutitionand otherfunctionalevaluations).
Duringthispandemic period,avoid conductingelective testsandmakesurethatthetestisabsolutelynecessaryat themomentandshouldnotbepostponed.
Keep the environment ventilated,allowing the disper-sion of aerosols to the external environment.3 Consider
usingvasoconstrictorsandtopicalanestheticstoreducethe chanceofcoughingorsneezing,whichcangenerateaerosols and remain in suspension for a longer period than the droplets.4,5Despitetheuncertainepidemiologicalrole,the
possibilityofSARS-CoV-2transmissionbyaerosolshasbeen recentlydemonstrated.6---8 Changegloves for each patient
andrubalcoholgelonthehandsaftertheprocedure.The endoscopyshould,ifpossible,beperformedwithvideo doc-umentationtomaintainsomedistancefromthepatient;it isrecommendedtoavoiddirectviewingthroughthe opti-calsystem and touchingsurfaces duringthe exam. There shouldbe no patientcompanion in theroom, unless it is strictlynecessary.
The processingof thematerialsmust followtheABORL Operation Protocol available at https://www.aborlccf. org.br/imageBank/Manual-POP.pdf, or high-level disinfec-tionwithimmersionindisinfectantagentsaccordingtoRDC N.6 of March 01, 2013. Finally, use 70% alcohol, sodium hypochloritesolutionorotherdisinfectantindicatedforthis purposeontheentiresurfacenearthepatient,inequipment and containers that may possibly be contaminated (e.g., anestheticordecongestantcontainer).
About
the
sinonasal
aspects
Viralupperrespiratorytractinfections(URTIs)arethe sec-ondleadingcauseofanosmia,withspontaneousrecoveryin mostcases.A recentstudy reportedonly5.1% anosmiain patientswithCOVID-19.
However,anecdotalevidenceofanosmiain30%of COVID-19 patients in Daegu, South Korea, and 2/3 of COVID-19 patientsinHeinsberg,Germany,alerteddoctorstothe pos-sibilityof anosmiabeingan alarm symptom forCOVID-19. Although thereis norobust evidence, we advisethat the presenceof sudden anosmia(with or without ageusiaand without concomitant nasal obstruction) may suggest the occurrenceofCOVID-19inthisscenarioofpandemicand sus-tainedtransmissionoftheSARS-CoV-2virus,andsuggestthat patientsintheseconditionsshouldbeinstructedtoundergo
home isolation for 14 days andwait for the resolution of anosmia,whichseemstobetemporaryinmostcases.
In line with the current positions of the World Health Organization and the North-American Centers for Disease ControlandPrevention,weadviseavoidingtheuseof sys-temiccorticosteroidsforthetreatmentofpatientswithflu syndromewhiletheCOVID-19pandemicisineffect. Regard-ing the use of topical nasal corticosteroids, the current evidenceshows noharmanditsusecan bemaintainedin patientswhohavealreadyusedthismedicationchronically undermedicaladvice.However,duetothelackof conclu-sivestudiesinrelationtoCOVID-19andextrapolatingfrom therecommendationsofsystemiccorticosteroids,weadvise thatchronictopicalnasalcorticosteroidusebemaintained andcontinuetobeindicated,andintheoccurrenceoffever or other symptomssuggestiveof flusyndrome,the doctor mayconsidertemporaryinterruption.Fortheuse of topi-calnasalcorticosteroidsinacuteviralinfections,thereisa conflictingrecommendationfromtheAmerican(2016)and European(2020)Guidelines,soweadviseavoidingtheuse oftopicalnasalcorticosteroidsinacuteviralconditionsin thiscontextofCOVID-19.
Regarding nasal irrigation with saline solution (NISS), thereisnoscientificevidenceonthebenefitsorharmsofits useinCOVID-19.InpatientswithCOVID-19,aswellasother viralURTIs,theuseofNISScanbebeneficialforsymptomatic relief,removal ofsecretions and prevention ofsecondary bacterialcomplications,suchasacuterhinosinusitis,being considered an option (andnot a recommendation)by the American(2016)andEuropean(2020)Guidelines.However, itwasdisclosedthattheNISScouldfacilitate theentryof theSARS-CoV-2virusintothelowerairwayorthatitcould spreadthevirusthroughtheenvironment,butwithout sci-entific evidence to supportit. Therefore, we recommend thatchronicNISSusebemaintainedandcontinuetobe indi-cated.TheindicationofNISSinacuteinfectiousconditions shouldbeassessedona case-by-casebasisin thiscontext ofCOVID-19,asitisconsideredanoptionbytheguidelines. However,wereinforcetheneedforadequatehygienization ofthehands,nasalirrigationinstrumentsandthe environ-mentin whichtheNISS istobeperformed. Regardingthe sinonasalendoscopicsurgeries,especiallythoseusingdrills ormicrodebriders,therehave beenreportsofinfectionof theentireteamintheroombyapatientwithCOVID-19in China,evenwiththeuseofadequateprotectiveclothingand N95masks.Therefore,inaccordancewiththeCFM,we rec-ommendnotperformingnasalorsinonasalsurgeriesinthe contextoftheCOVID-19pandemic.Inurgentcasesorincase ofextremenecessitytoperformthesurgery,wesuggest per-formingthetesttoidentifythenewcoronavirus(COVID-19) usingthenew24-hourtest.InpositivecasesforCOVID-19or ifitisimpossibletoperformthetest,oneshouldwearPPE withpowered,air-purifyingrespirators.
About
the
otological
aspects
Asthereisanapparentpreferenceofthecoronavirusforthe upperairway mucosa,whichis alsopresent inthe middle earmucosa,thereisanincreasedriskofcontaminationby thecoronavirus inotological surgeriesandprocedures.9---11
Although the main route of transmission of the COVID-19 virus is through the respiratory system, thereis some
evidenceoftransmissionthroughblood,althoughthisriskis likelytobelow.Previouspublicationshavealready demon-stratedthepresenceofothertypesofcoronavirusesinthe middleearincasesofacuteinfection.Wedonotpresently knowwhetherthemiddleearmucosaandmastoidcellsare affectedbyCOVID-19.Consideringtheintenseinvolvement ofthenoseandrhinopharynx,whichcanpotentiallyleadto middleearcontaminationviatheauditorytube,inaddition topreviousevidenceofothertypesofcoronavirusespresent inthemiddleearduringupperairwayinfections,itis plau-sibletoconsiderthe contaminationof thesestructuresby COVID-19.12
Theformationofaerosolsduetotheuseofsurgicaldrills shouldalsobeconsideredand,ifthevirusispresent,itcan infect everyone in the operating room, by maintaining a contaminating closedenvironment for hours.13,14 Although
themaskspreventtheinhalationofparticles,standardeye protection maynot adequatelyprevent the surgeon’seye exposure.Thus,otologicalprocedures,includingaspiration andmastoidectomy,mustbeconsideredashavingahighrisk ofcontamination.
The following are considered otological emergen-cies, requiring immediate surgical procedure: acute complications ofdiseases ofthe middleearwitha riskof death(intra-cranialabscessesandotogenicmeningitis),and thepresenceofaforeignbodyintheear(batteries,dueto theriskofchemicalleakage)andmalignanttemporalbone tumors.
Mastoiditis and complications of middle ear diseases without improvement afterclinical treatments, traumatic peripheral facial paralysis or secondary to middle ear disease (acute otitis media and cholesteatoma) without improvementwithclinical treatmentsandeartrauma are consideredurgenciesandmayrequiresurgicalprogramming within72h.
Otogenicextracranialabscesses(subperiosteal abscess) should be treated clinically and preferably punctured, avoiding major surgical procedures, except if there is evidenceof greater risk of complications. Foracute mas-toiditis,curettageshouldbeperformedwheneverpossible, insteadofusingdrills.Iftheuseofdrillsisessential,itis nec-essarytoreducetherotationtotheminimumpossibleand usepowerfulandadequatesuctiontoreduceaerosolization. Vestibularschwannomasurgeryshouldnotbeconsidered urgent,unlessthereispotentiallyfatalbrainstem compres-sion.Aretrosigmoidapproach,andnotatranslabyrinthine one,shouldbeusedtominimizedrainagetimeandexposure tothemiddleearmucosa.
Forcases ofbenign otologicalneoplasia,perilymphatic fistula due to barotrauma and post-meningitis cochlear implantindication,thereisthepossibilityofsurgical post-ponementforupto30dayswithoutmajordamage,always withspecializedmedicalmonitoring. Someotological neo-plasmscanwait upto3monthswithout worseningof the prognosis.
Theothersurgicalproceduresthatdonotshowa worsen-ingoftheprognosisduetopostponement,suchastreatment of uncomplicated cholesteatoma, tympanoplasty with or without ossicular reconstruction, middleear implantsand bone-anchored prostheses, cochlear implants (except for urgent indications, temporal bone fracture and children withprelingualdeafnessatriskofworseningtheprognosis),
vestibularsurgeriesandventilationtubescanbepostponed formorethan3months,alwayswiththerecommendation ofalertmonitoringbytheotolaryngologist.
The recommendation is that, wheneverpossible, mas-toidectomies should be avoided due to the high risk of aerosolspreadandcontaminationofsurgicalteams.Ifthe procedureisabsolutelynecessary,itshouldbeconsideredas ifthepatientwaspositiveforCOVID-19,duetothe impos-sibility of carrying out tests on all patients and the high possibilityoffalsenegatives,andpowerfulaspirators with afilteringsystemmustbeused.
In most otological surgeries (although not desirable) the performance of the operation by the main sur-geon only is feasible (foreign body removal, drainage of abscesses/mastoiditis,myringotomywithorwithout place-mentofa ventilationtube, myringoplasty, tympanoplasty, andevenmastoidantrostomies),minimizing theexposure ofothermedicalcolleaguesandotherhealthprofessionals. Ofcourse,itisnottheidealsituationinsurgicalprocedures, butthecurrentsituationrequirestheleastpossibleexposure ofprofessionals,onanexceptionalbasis.Whenearsurgery isurgentoressential,itshouldbepreferablyperformedby themostexperiencedearsurgeonavailableattheservice.
Regarding the useof corticosteroids for the treatment of Sudden Deafness and for Meniere’s disease, it is rec-ommendedavoiding systemicuse, due tothe high risk of prognosis worsening in patients infected with COVID-19, eveniftheyareasymptomatic.Ifnecessary,carefuluseof intra-tympaniccorticosteroidsshouldbepreferred,asthey have much lowersystemic absorption, but there are still nostudies demonstratingthe safetyof this application in patientswithCOVID-19.Thus,itis recommended explain-ingitclearlytothepatient,showingrisksandbenefits,and requestingthepatient’ssignedconsent.Contrarytowhatis usuallyindicatedregardingtheuseofintratympanic corti-costeroids,thepatientmustbeinstructednottospitsaliva toavoidthedispersionofaerosolscontainingviruses.
Fornon-traumaticperipheralfacialparalysis,especially Bell’s,therehavebeenstudiesthatshowedanimprovement of85---96%ofcaseswiththeuseofsystemiccorticosteroids againstaworseprognosisduetonon-use.15 Inthesecases,
whenever possible, the test for COVID-19 and treatment withcorticosteroidsshouldbecarriedout,ifthetestis neg-ative.Still,it isrecommendedexplainingitclearlytothe patient,showingtherisksandbenefits,andrequestingthe patient’ssignedconsent.Incasesofnecrotizingexternal oti-tis,itisbelievedthatCOVID-19infectionshouldnotaffect thetreatmentwithintravenousantibiotics,buthospital dis-chargeisrecommendedwithintheshortestpossibleperiod, followedbyambulatoryorat-hometreatment.
About
the
pediatric
aspects
Infectedchildrenareusuallyasymptomaticand,when symp-tomsarepresent, theyhavefever, drycough andfatigue, withfewhavingupperrespiratorysymptoms,includingnasal congestionandrhinorrhea.Somepatientshaveexperienced gastrointestinalsymptoms,includingabdominaldiscomfort, nausea,vomiting,abdominalpainanddiarrhea.Therefore, most infected children have mild clinical manifestations and a good prognosis, thus becoming possible vectors of
COVID-19.Consequently, we must considerall children as potentialcarriersofCOVID-19.
Forthisreason,werecommendthatthechild’s orophar-ynx be examined only if it is essential for the clinical diagnosis or can lead to a change in the therapeutic approach.Itisrecommended,atthemoment,carryingout asfew tests as possible and avoiding repetition, restrict-ingtheirperformancetoimminentsituationsofrespiratory failurerisk.Ifalaryngotracheoscopyand/orbronchoscopy isnecessaryintheoperatingroomduetosuspectedlesions belowthevocalfolds,donotperformnasofibrolaryngoscopy at the bedside in wards and intensive care units, where therewillbedispersionofaerosols,withagreaternumber ofexposedindividuals.16
Inthecaseofserviceswithresidentsorfellows,thecases shouldbediscussed,andtheexamsanticipatedtobecarried outaccording tothenorms andwiththe useof complete PPE.At the timeof theexamination, it is importantthat asfew peopleaspossible arepresentin theroom(health professionals and the child’s family members). When the endoscopicexaminationisperformedinasuspectedor con-firmedcaseofCOVID-19,theprocedureroommustundergo terminalcleaning.Hence theimportanceoftestingbefore theprocedure,ifpossible.Considerthepossibilityofother complementaryexamstoelucidatethediagnosis,andexams suchasultrasoundsandCTscansshouldbepreferred, par-ticularlyforsuspectedneoplasmsandabscesses.
In cases of pharyngotonsillitis, the oroscopy is rec-ommended only if essential for clinical diagnosis. The prescription of antibiotics in children over 3 yearsof age isrecommendediftherewasapictureofodynophagiaand fever in the previous 24h, in the absence of cold symp-toms(coughandrunnynose)associatedornotwithpainful adenomegaly.17
Insubperiostealabscesses(orbitalcomplicationsofacute rhinosinusitis), after the implementation of clinical mea-sures, if there is a risk of visual impairment, drainage throughexternalaccessisrecommendedwheneverpossible. Inrelationtoforeignbodies,especiallybatteriesinany site,removalisindicated.Foreignbodiesinthenose, phar-ynx and airways should be removed as usual, given the possibilityof short-termcomplications, particularlyinthe caseofrespiratoryobstructions.
In cases of respiratory failure,consider performing an endoscopicexaminationwhenitisessentialforthediagnosis and it has an impact on patient treatment responsive-ness and discharge. The child must have, in addition to stridor, the following signs or symptoms of severity: a fallin oxygensaturation, cyanosis,apnea. Examples: sus-pectedseverelaryngomalacia,bilateralvocalfoldparalysis, bilateral choanalatresia, laryngeal membrane, neoplastic obstruction, post-intubation obstruction after maximized clinicaltreatmentand2extubationfailures,emergency dif-ficultintubation.The other situationsshould bediscussed onacase-by-casebasis withthe emergencymedicine col-league.Insomesituations,thepatientmaynotshowsignsof severityatthemoment,butwithanimminentriskthatwill preventdischarge. Examples:foreignbodiesintheairway orpatientswithpreviousknowndiseases,suchaslaryngeal strictureacquired duringendoscopictreatment (dilations) andrecurrent laryngeal papillomatosis. In thesecases, in hospitalizedpatientsorthosewithacutesymptomsthatwill
betakentotheoperatingroom,wesuggestthatthe COVID-19testingortheviralprofilebedonebeforehand,whenever possible.Inthelattercases,ifthechildhasatracheostomy, endoscopicexaminationshouldbepostponeduntiltheend ofthepandemic. Inpatientswithpost-extubation laryngi-tiswithtwoextubationfailuresafterclinicaltreatment,an endoscopicevaluationshouldbeperformed inthe operat-ingroom(diagnosticandtherapeuticlaryngotracheoscopy). According tothe lesion severityand the patient’sclinical condition,considerperformingatracheostomyatthesame surgicaltime.
Inthemanagementofdysphagia,individualized decision-making is suggested, taking into account whether the symptoms justify the examination to rule out anatomical alterationsatthemomentandwhethertheexaminationat thecurrentmomentwillchangetheconductinthefollowing daysorweeks.
About
the
performance
of
tracheostomies
With the progressive increase in the number of COVID-19 cases, it isexpected that manypatients will require oro-trachealintubation andprolongedmechanical ventilation. Inthiscontext,theneedforatracheostomycanbe consid-eredbythecareteams.Itsindications,benefitsandrisksto thepatientandthesurgicalteammustbediscussedamong theinvolvedteams.
Inseverecasesthatrequireinvasiveventilatorysupport, orotrachealintubationistheinitialchoiceinpatientswith COVID-19.18 In case of emergency surgical access to the
airwayduetointubationdifficulty, asituationthatshould alwaysbeanticipatedtoallowadequateactionincaseitis necessary,acricothyroidotomyisrecommended,19 surgical
orbypuncture,followedbyatracheostomyassoonas pos-sibleafterairwaystabilization.Intheseemergencycases, thesame precautionsmentioned belowmustbetakenfor tracheostomy.
In the pediatric age range, emergency situations with difficult intubation should be anticipated and respiratory failure quickly identified, being the most frequent cause of cardiorespiratory arrestin children. Childrenexpected torequiresurgical accesstothe airwayshouldpreferably bemanagedinasurgicalenvironment,withanintravenous accessthatallowsadequateairwaymanagementand hyper-oxygenation, with positive-pressure ventilation through a facemask,withorwithouttheaidofanoropharyngeal can-nulaforstabilization.Inthecaseofpatientswithdifficult ventilation andintubation, a laryngealmask may beused temporarilyand,ifavailable,bronchoscopy-guided intuba-tion.Inthesecases,oneshouldfollowthesameguidelines forPPEuse.Puncturecricothyroidotomyindicationin chil-dren isextremelyrare,whichallowsoxygenation,butnot ventilation.CurrentAPLS(AdvancedPediatricLifeSupport) guidelinesindicatetheuseofneedlecricothyroidotomy in childrenolderthan5years.Inchildrenunder1yearofage, tracheostomyisrecommended;andfrom1to5yearsold, cricothyroidotomyorsurgicaltracheostomy.
The moment of elective tracheostomy indication in patients with prolonged orotracheal intubation is a con-troversial subject. In these cases, the tracheostomy is considered to prevent laryngotracheal stenosis, to
accelerate weaning from mechanical ventilation and to facilitate the cleaning of respiratory secretions. Elective tracheostomycanbeindicatedfromthe4thtothe21stday, mostcommonlybetween10and14daysofintubation.
Inthepediatricagegroup,trachealintubationisbetter toleratedandtheidealtimetoindicateatracheostomyhas notbeen well established,although some authorssuggest that, ifthere is noprospect of weaning frommechanical ventilation after 2 weeks, it should be considered. When maintainingprolongedintubation,careshouldbetakento usetubesoftheadequatesize,withcuffpressure measure-ment,ifused,andtomaintainthechild’scomforttoavoid tubemovement anddamagetothelaryngealandtracheal mucosa.Theindicationfortracheostomyinchildrenismore related to the lack of perspective to resolve mechanical ventilationdependence.
In general, it is believed that thereareno benefitsof an early tracheostomy in patients with COVID-19. Since the mean time of mechanical ventilation in the patient with COVID-19 is approximately 21 days, many of these patientscouldbe consideredcandidates for conversionto tracheostomy. On the other hand, the tracheostomy is a procedureconsideredanaerosolgenerator,representingan increased risk of transmissionof SARS-CoV-2 tothe surgi-cal team and to the hospital environment throughwhich thepatientwillmove.Unlikedroplets, whichduetotheir weightand the effectof gravity have a limited transmis-sionfield,aerosolscanremaininsuspensionforalongtime andtravellongerdistances,withanincreasedriskofvirus transmission.Thisoccursnotonlyduringtheprocedure,but alsointhepostoperativeperiod,sincethehandlingofa tra-cheostomy,withtheneed forfrequentaspirationsandthe riskofdecannulationwiththeneedforrepositioning, gen-eratesaerosols. Therefore,whenconsidering carrying out theprocedure,itisimportanttotakeintoaccountpatient severity,theirprognosisandtheriskofcareteam contami-nation,whicharecrucialforfightingthepandemic.
Therefore, we suggest avoiding the elective tra-cheostomy wheneverpossiblein a patientwithCOVID-19. When tracheostomy is considered necessary, the follow-ingarerecommended:avoidusinganelectricorultrasonic scalpelastheymayfavortheformationofaerosols;donot useventilationroomswithpositivepressure,astheyfavor thedispersionof aerosols;wheneverpossible,use closed-circuit suction systems and antiviral filter and operating roomswithnegativepressure.Intheirabsence,userooms withnormalpressureandkeepthedoorsclosed;thesurgical teammust consistofthe leastpossiblenumber of profes-sionals.Inapatientwithprolongedintubation,curarization issuggested,especiallywhenremovingthetubeandplacing thetracheostomycannula,tominimizetheriskofcoughing, whichpromotesaerosolization.Anothercareprocedure sug-gestedbytheBrazilianSocietyofThoracicSurgery18 isthe
discontinuationofmechanicalventilation,deflatingthe tra-cheal tubecuffanditsdisconnectionfromtheventilation systemBEFOREthetrachealincision.Afterinsertionofthe tracheostomy cannula andcuff insufflation, the mechani-cal ventilation system can be connected, and ventilation restarted.
Thecareandhandlingofthetracheostomycannula,such asaspirationandstrapchanges,particularlyinchildrento avoidobstructions,shouldbecarriedoutwithalltheabove
mentionedPPE,whilethereisariskofCOVID-19 contamina-tion.Theagilityinthisinformationcanfacilitatedischarge asearly aspossible duringthepandemic period.Itis sug-gested,duringthepandemicperiod,reducingthefrequency ofchangestoaminimum,andforthat,itisnecessaryto pro-videguidancetocaregiversaboutwarningsignsforchanges andwhentoseekin-personcare.
About
the
use
of
telemedicine
TheregulationofTelemedicineinBrazilduringthe COVID-19pandemic has been influenced by Ordinance N.188 of February3,2020oftheMinistryofHealth,declaringaPublic HealthEmergencyofNationalImportance(ESPIN)asaresult ofCOVID-19,LegislativeDecreeN.6ofMarch20,2020ofthe NationalCongressrecognizingtheStateofPublicCalamity witheffectuntilDecember31, 2020,LetterN.1756/2020 ofMarch19,2020of theFederal CouncilofMedicine rec-ognizingthepossibilityandethicsofusingTelemedicineas an exceptional situation and while the measures to fight COVID-19last,andOrdinance N.467 ofMarch20,2020of theMinistryofHealthregulatingTelemedicineactionsasa meansoffightingtheESPINasaresultofCOVID-19.20
Simi-larly,consideringthatduringthispandemicperiod,thehigh incidenceandprevalenceofotorhinolaryngologicaldiseases remains, but there is a need to reduce physical contact betweendoctorsandpatients(without impairingthe nec-essarycareforadequateassistance)andtheneedtoreduce thecirculationofpeople.
Therefore,at thepresent time,thereisthe possibility of wide and comprehensive use of Telemedicine, includ-ingTeleguidance,Telemonitoring,Teleinterconsultationand Teleconsultation,aimingtoacompleteandhumanecarefor isolatedpatientsorthoseunabletohave physical/face-to-faceaccesstothedoctor,withtotalprofessionalautonomy anddiscretionaryjudgmentregardingtheform,methodand contentofcare/treatment,aimingatbroadhealthcareand lifeprotection,increasedbythecurrentstateofnecessity. We recommendobtaining the adequate express autho-rization from the patient or legal advisors to use non-face-to-faceassistancethroughTelemedicine, explain-ingthe method limitations relatedto not performingthe fullphysicalexamination.Theexpressauthorizationcanbe obtainedbyrecordedvideo,writtenmessageorsignatureof aspecificconsentformmadeavailablebyABORL-CCF. Spe-cialcareshouldalsobetakenwiththestorage,transmission anduse of patientdata, respecting the ethicaland legal responsibilitiesofconfidentiality andprofessionalsecrecy, includingtheuseoftechnologicaltoolsthatguaranteethis protection.Thereis thepossibilityofprovidingassistance andcarebymeansof‘‘online’’(synchronous)or‘‘offline’’ (asynchronous,incaseofgreaterneed)consultations, aim-ingat the most effective way of protectingthe patient’s health andlife. It is essential toproperly record medical appointmentsinthepatient’smedicalrecord(electronicor physical), even if the appointments are recorded. It also emphasizesthatthereis noobligationtorecord consulta-tions.
Weadvisethatanalternativetoface-to-faceassessment beofferedinatimelymannerincaseswherethelimitation ofanincompletephysicalexaminationmayincreasetherisk
ofanincorrectdiagnosis.Moreover,logisticservicescanbe usedtosendmedicalprescriptionsandcertificatesor pro-videmedicalprescriptionsandcertificatesindigitalformat with electronic signature through ICP-Brazil certificates. Charging for distance healthcare is allowed and remote care is also allowed for newpatients without a diagnosis ofCOVID-19.Werecommendnotaffiliatingwith intermedi-arycompanies(websitesor applications)withasuspicious character,whichmayendupunscrupulouslyexploringand demeaningmedicalwork.Itisimportanttonotethatthese determinationsandauthorizationsareofanexceptionaland transitorynature.
Final
considerations
Therecommendationscontainedinthispublicationreflect the acquired knowledge and the scarce evidence about COVID-19 todate. If newevidence emerges that justifies achangeinconduct,thispublicationmaybeupdated.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgements
Wewouldliketothanktheparticipationofthemembersof theAcademiaBrasileiradeOtorrinolaringologiaPediátrica
(ClaudiaSchweiger, Melissa Avelino, José Faibes Lubianca Neto, Nayara Soares Lacerda, Debora Bressan Pazinatto), membersof the Sociedade Brasileira de Otologia (Renato ValérioRodriguesCal,LuizRodolphoPennaLimaJr.,Fayez BahmadJr.,MarcioCavalcanteSalmito,MauricioNoschang LopesdaSilva,ArthurMeninoCastilho,MiguelAngelo Hyp-polito,JoãoPauloPeralValente,RobinsonKojiTsuji,Melissa FerreiraVianna),members oftheAssociac¸ãoBrasileira de Laringologia e Voz (Natasha Braga, Karen Vitols Brandão, Daniel D’Avila), members of the Academia Brasileira de Rinologia(OtávioPiltcher,CarlosAugustoCorreiade Cam-pos, Gabriela Ricci Lima Luz Matsumoto, Henrique Faria Ramos,ThiagoSerrano)andthemembersoftheProfessional DefenseCommitteeofABORL-CCF.
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