Original Research—Research Article

Otolaryngology–
Head and Neck Surgery

Approaching Otolaryngology Patients 2020, Vol. 163(1) 121–131

Ó The Author(s)

During the COVID-19 Pandemic Reprints and permission:

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DOI: 10.1177/0194599820926144
http://otojournal.org

Chong Cui, MD1,2*, Qi Yao, MD, PhD3*, Di Zhang, MD, PhD4*,

Yu Zhao, MD1,2*, Kun Zhang, MD1,2, Eric Nisenbaum, MD, MSc5,
Pengyu Cao, MD, PhD1,2,6, Keqing Zhao, MD, PhD1,2,6,
Xiaolong Huang, MD3, Dewen Leng, MD3, Chunhan Liu, MD4,
Ning Li, MD, PhD7, Yan Luo, MD8, Bing Chen, MD, PhD1,2,
Roy Casiano, MD5, Donald Weed, MD5, Zoukaa Sargi, MD, MPH5,
Fred Telischi, MD5, Hongzhou Lu, MD, PhD6, James C. Denneny III, MD9,
Yilai Shu, MD, PhD1,2, and Xuezhong Liu, MD, PhD5

Abstract Keywords
Objective. To describe coronavirus disease 2019 (COVID-19) COVID-19, SARS-CoV-2, personal protective equipment
patient presentations requiring otolaryngology consultation (PPE), health care worker (HCW), infection control mea-
and provide recommendations for protective measures based sures, preexamination, tracheotomy
on the experience of ear, nose, and throat (ENT) departments
in 4 Chinese hospitals during the COVID-19 pandemic. Received March 27, 2020; accepted April 2, 2020.
Study Design. Retrospective case series.
Setting. Multicenter.

C
oronavirus disease 2019 (COVID-19) is an infectious
Subjects and Methods. Twenty hospitalized COVID-19 patients respiratory disease caused by the novel virus severe
requiring ENT consultation from 3 designated COVID-19
hospitals in Wuhan, Shanghai, and Shenzhen were identified.
1
Data on demographics, comorbidities, COVID-19 symptoms ENT Institute and Otorhinolaryngology Department of the Affiliated Eye
and severity, consult reason, treatment, and personal protec- and ENT Hospital, State Key Laboratory of Medical Neurobiology,
Institutes of Biomedical Sciences, Fudan University, Shanghai, China
tive equipment (PPE) use were collected and analyzed. 2
NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai,
Infection control strategies implemented for ENT outpatients China
3
and emergency room visits at the Eye and ENT Hospital of Department of Otorhinolaryngology, Chinese and Western Medicine
Fudan University were reported. Hospital of Tongji Medical College, Huazhong University of Science and
Technology, Wuhan, China
Results. Median age was 63 years, 55% were male, and 95% 4
Department of Otolaryngology, The Third People’s Hospital of Shenzhen,
were in severe or critical condition. Six tracheotomies were Longgang District, Shenzhen, China
5
performed. Posttracheotomy outcomes were mixed (2 Department of Otolaryngology, University of Miami Miller School of
deaths, 2 patients comatose, all living patients still hospita- Medicine, Miami, Florida, USA
6
Department of Infectious Diseases, Shanghai Public Health Clinical Center,
lized). Other consults included epistaxis, pharyngitis, nasal Shanghai, China
congestion, hyposmia, rhinitis, otitis externa, dizziness, and 7
Department of Infectious Disease, Huashan Hospital, Fudan University,
tinnitus. At all hospitals, powered air-supply filter respirators Shanghai, China
8
(PAPRs) were used for tracheotomy or bleeding control. Department of Hospital-Acquired Infection Control, Eye and ENT
PAPR or N95-equivalent masks plus full protective clothing Hospital, Fudan University, Shanghai, China
9
American Academy of Otolaryngology–Head and Neck Surgery,
were used for other complaints. No inpatient ENT provi- Alexandria, Virginia, USA
ders were infected. After implementation of infection con- *These authors contributed equally to this work.
trol strategies for outpatient clinics, emergency visits, and
surgeries, no providers were infected at the Eye and ENT Corresponding Author:
Hospital of Fudan University. Yilai Shu, MD, PhD, ENT Institute and Otorhinolaryngology Department of
the Affiliated Eye and ENT Hospital, State Key Laboratory of Medical
Conclusions and Relevance. COVID-19 patients require ENT Neurobiology, Institutes of Biomedical Sciences, Fudan University, Shanghai,
consultation for many reasons, including tracheotomy. 200031, China.
Otolaryngologists play an indispensable role in the treat- Email: [email protected]
ment of COVID-19 patients but, due to their work, are at
Xuezhong Liu, MD, PhD, Department of Otolaryngology (D-48), University
high risk of exposure. Appropriate protective strategies can
of Miami Miller School of Medicine, 1666 NW 12th Avenue, Miami, FL
prevent infection of otolaryngologists. 33136, USA. Email: [email protected]
122 Otolaryngology–Head and Neck Surgery 163(1)

acute respiratory syndrome coronavirus 2 (SARS- identify and triage patients and ensure appropriate protec-
CoV-2).1-4 As of March 26, 2020, a total of 462,684 cases of tion during outpatient and inpatient otolaryngology care.
COVID-19 have been reported in 199 countries and regions.5 Wuhan was the epicenter of the SARS-CoV-2 outbreak in
On March 11, 2020, the World Health Organization (WHO) China, while Shanghai and Shenzhen are large metropolitan
declared COVID-19 a global pandemic.6 centers that were also affected by the pandemic. This article
Due to lack of adequate awareness and sufficient infec- aims to review the otolaryngologist experience treating
tion control plans during the early stages of the pandemic, COVID-19 patients in these cities and to propose appropri-
many health care workers (HCWs) were infected. In particu- ate protective measures based on these experiences.
lar, HCWs in ‘‘noninfectious disease’’ specialties such as
otolaryngology were infected at higher rates than colleagues Methods
in the same hospitals.3,7,8 According to the data of Italian Study Design and Participants
National Health Agency, 6414 health care workers have This case series was approved by the Institutional Ethics
been infected with SARS-CoV-2 as of March 26, 2020.9 Committee of The Third People’s Hospital of Shenzhen,
Otolaryngologists are by the nature of their work at high Wuhan Chinese and Western Medicine Hospital, and
risk for exposure to respiratory pathogens. During the Shanghai Public Health Clinical Center. All COVID-19
course of routine evaluation and management of patients, patients admitted to Wuhan, Shenzhen, and Shanghai hospi-
otolaryngologists and their staff will inevitably come into tals from January 14, 2020, to March 20, 2020, who received
direct contact with upper respiratory tract secretions or consultation in one of these respective ENT departments
blood, which may become aerosolized during an inadvertent were included. Oral consent was obtained from patients. The
sneeze or cough.10 Such events can occur during a nasal 3 hospitals—Chinese and Western Medicine Hospital of
and upper airway endoscopy, while performing a nasal cul- Tongji Medical College, Huazhong University of Science and
ture or nasopharyngeal swab for SARS-CoV-2, or simply Technology (one of the designated hospitals for COVID-19
during routine examination of the oral cavity and orophar- in Wuhan); Shenzhen Third People’s Hospital (the only des-
ynx, exposing the health care provider to potentially infec- ignated hospital in Shenzhen); and Shanghai Public Health
tious agents. Clinical data indicate that approximately half Clinical Center of Fudan University (the only designated hos-
of the patients with COVID-19 do not have fever during pital for adults in Shanghai)—are responsible for the treat-
early stages of the disease, with some patients presenting to ment for COVID-19 patients as assigned by the government.
the otolaryngologist with fairly innocuous symptoms such The Eye and ENT Hospital of Fudan University is responsi-
as nasal congestion, sore throat, and hyposmia.3,11-14 Other ble for ENT consultation for COVID-19 patients in Shanghai
patients may present with or be followed for upper aerodi- assigned by the government. In response to the pandemic, the
gestive track malignancies. These patients commonly com- Eye and ENT Hospital of Fudan University also quickly
plain of cough and sore throat, and coexisting COVID-19 implemented a variety of protective strategies for ENT inpati-
infection may not be considered at presentation. This puts ent and outpatient care, including preappointment screening,
providers and other patients at high risk of infection due to triaging, restriction of nonurgent clinic visits and surgeries,
insufficient personal protective equipment (PPE) use unless telemedicine, and proper protective equipment. The infection
a high level of clinical suspicion is maintained. In the inpa- status and condition of patients and their ENT providers were
tient setting, critically ill patients with respiratory failure monitored through March 20, 2020.
commonly require endotracheal intubation and/or a tracheot-
omy for respiratory support. In a previous study, 6.30% (15/ Patient Selection and Management
238) patients required tracheotomy during the severe acute The subjects involved in this study were COVID-19 patients
respiratory syndrome (SARS) outbreak in Singapore.15 for whom ENT was consulted for tracheotomy or manage-
According to clinical statistics, 7.3% to 32% of patients with ment of ENT-related symptoms, including epistaxis, nasal
COVID-19 progress to a severe or critically ill condition, a congestion, allergic rhinitis, sore throat, hyposmia, dizzi-
number of whom may subsequently require tracheotomy for a ness, and tinnitus. Of the COVID-19 inpatients from
variety of reasons.3,4,7,11,16 Some of these patients may develop January 14, 2020, to March 20, 2020 (327 cases in
complications such as pharyngeal ulcers or bleeding from the Shanghai, 421 cases in Shenzhen, and 1500 cases in Wuhan
tracheotomy site, requiring further ear, nose, and throat (ENT) Chinese and Western Medicine Hospital), 20 patients met
care. Other emergent events unrelated to COVID-19 but occur- criteria and were included for study.
ring in COVID-19 patients such as epistaxis also require ENT
intervention. Given all of these possible routes of exposures, it Data Collection
is critical for ENT departments and providers to establish Data were obtained from 3 hospitals: Wuhan Chinese and
proper and sufficient infection control measures. Western Medicine Hospital (12 patients), Shenzhen Third
There is little in the literature documenting how ENT People’s Hospital (6 patients), and Shanghai Public Health
departments should approach otolaryngologic diseases in Clinical Center (2 patients), which had consultation from
patients infected with SARS-CoV-2 and how to best protect the Eye and ENT Hospital of Fudan University. Patients
otolaryngologists during the COVID-19 pandemic. It is not were hospitalized from January 14, 2020, to March 20,
clear how to best establish efficient strategies to carefully 2020. The medical records of patients were analyzed by the
Cui et al 123

research team. Clinical as well as treatment and outcome than reintubation. He was also in a coma as of the date of
data were obtained from data collection forms in the elec- data collection. The third patient underwent ST because of
tronic medical records. The data were reviewed by a team repeated extubation and reintubation and underwent ST for
of trained otolaryngologists. The recorded information the second time due to airway bleeding 9 days later.
included demographic data, comorbidities, severity classifi- Epistaxis occurred on day 7 after the second tracheotomy,
cation and symptoms of COVID-19, reason for ENT consul- which resolved after temporary packing with nondissolvable
tation, patient outcomes, provider protection level, and packing for 2 days. This patient eventually died on day 10
infection of HCWs during ENT consultation. Data from out- after the second ST. Overall, outcomes after tracheotomy
patient clinics, emergency room, emergency surgeries, elec- were mixed with 2 deaths, 2 patients comatose, and all
tive surgeries, and telemedicine encounters at the Eye and living patients still hospitalized.
ENT Hospital of Fudan University were also reviewed. Six of the 20 patients (30%) presented with unilateral (3
cases) or bilateral (3 cases) epistaxis. Two patients with
Statistical Analyses bilateral epistaxis had previously been on anticoagulants.
A descriptive analysis was performed. Categorical variables Five patients were using noninvasive assisted ventilation or
were described as frequency rates and percentages, and con- high-flow oxygen through nasal canula, and 1 patient had
tinuous variables were described using mean, median, and been treated with ECMO. Their noses were temporarily
interquartile range (IQR) values. packed with no further bleeding after removal of their pack-
ing 2 days later. No postprocedural complications occurred
Results in the 6 patients except in the 1 patient who was treated
Patient Characteristics with ECMO. He remained in a coma as of data collection.
The study population included 20 hospitalized COVID-19 Of the other 7 patients, 2 were evaluated for sore throats
patients seen as consults by otolaryngology. Median age and 2 for nasal congestion (1 of whom also had hyposmia).
was 63 years (range, 32-72 years), 11 of 20 (55%) were The last 3 patients presented with symptoms of rhinitis,
male, and 19 of 20 (95%) were in a severe or critical condi- otitis externa, and tinnitus, respectively. Other than the
tion. Of these patients, 7 of 20 (35%) were recommended hyposmia, the symptoms of these 7 patients were alleviated
for a tracheotomy after the consultation. The median age of or ameliorated with routine medical treatment (Table 2).
the tracheotomy group was 65.3 years, and all of them were
critically ill with 1 or more chronic diseases such as dia- Infectious Control in HCWs
betes, hypertension, and/or coronary artery disease (Table When treating patients for common otolaryngologic diag-
1). Six of 7 patients ultimately underwent a tracheotomy, noses or symptoms such as rhinitis, nasal congestion, hypos-
including 3 surgical tracheotomies (STs) and 3 percutaneous mia, sore throat, dizziness, tinnitus, and otitis externa, the
dilational tracheotomies (PDTs). The average intubation otolaryngology HCWs in the epidemic center (Wuhan) and
time for patients undergoing tracheotomy was 12.6 days. As other areas (Shenzhen, Shanghai) took third-level protection
of March 20, 2020, a total of 2 of 6 (33.3%) of these and second-level protection, respectively (Table 3 and
patients were hospitalized in improving condition, while 4 Figure 1). The second-level protective measures include
of 6 (66.7%) did not improve significantly. Three patients wearing medical protective masks equivalent to N95
underwent PDT for prolonged intubation after being unable respirators, eye protection such as goggles or face shields,
to be weaned from ventilation over 10 to 14 days. Of these work clothes, disposable isolation gowns and/or coveralls,
patients, 2 were still hospitalized at the time of data collec- shoe covers, gloves, and hair covers. The third-level protec-
tion and improving. The third patient presented with severe tion measures added a powered air-supply filter respirator
pneumonia, acute respiratory distress syndrome (ARDS), (PAPR) such as a positive pressure headgear or a compre-
sepsis, myocarditis, metabolic acidosis with decompensated hensive respiratory protective device according to expert
respiratory acidosis, electrolyte disturbances (hyperkalemia, consensus in China.17
hyponatremia), and sleep apnea-hypopnea syndrome. This Otolaryngologists performing a tracheotomy or proce-
patient was treated with continuous renal replacement ther- dures for control of hemorrhage in circumstances of tra-
apy (CRRT) and extracorporeal membrane oxygenation cheal/oral bleeding or epistaxis in patients infected with
(ECMO) accompanied by intra-airway hemorrhage before SARS-CoV-2 used third-level infection control measures
tracheotomy. Ten days after tracheotomy, the patient experi- whether in Wuhan, Shenzhen, or Shanghai. Importantly,
enced bleeding from the nose and mouth. Nineteen days proper technique for donning and doffing PPE must be
after tracheotomy, obstruction of ECMO flow occurred, and practiced to effectively protect otolaryngology providers
the patient died after recanalization. Another 3 patients (Figure 1). Under the guidance of trained staff in the isola-
underwent ST. The first was a cerebral infarction patient tion ward, providers disposed of the waste and sharps prop-
with atrial fibrillation, hypertension, diabetes, cerebral erly and disinfected personal supplies brought out from
hernia, and anemia who underwent tracheotomy to prevent the contaminated area after the procedures. Outer protec-
the occurrence of aspiration pneumonia. He remained in a tive equipment was removed at the entrance of the semicon-
coma after tracheotomy. Another patient experienced dys- taminated area. The inner protective equipment was
pnea after extubation, necessitating an emergent ST rather removed in the semicontaminated area and personal supplies
124
Table 1. Clinical Presentations of COVID-19 Patients With ENT Symptoms (N = 20).
Symptoms consulted by otolaryngologists
Clinical presentations Tracheotomy Epistaxis Pharyngitis Nasal congestion/hyposmia Rhinitis Dizziness and tinnitus Otitis externa Total No.

No./total No. (%) 7/20 (35) 6/20 (30) 2/20 (10) 2/20 (10) 1/20 (5) 1/20 (5) 1/20 (5) 20
Age, median, y 65.3 62 67 34 48 52 62 63
Sex, female/male, No. 1/6 4/2 0/2 2/0 1/0 0/1 1/0 9/11
COVID-19 phenotype, No.
Mild 0 0 0 1 0 0 0 1
Severe 0 5 1 1 1 1 1 10
Critical 7 1 1 0 0 0 0 9
Complaints and symptoms of COVID-19, No.
Fever 6 2 2 0 1 0 1 12
Cough 3 4 2 1 1 0 1 12
Fatigue 0 1 0 0 0 0 0 1
Shortness of breath 2 0 0 0 0 0 0 2
Chest congestion 1 1 1 0 0 1 0 4
Nasal congestion 0 1 0 1 0 0 0 2
Diarrhea 1 1 0 0 0 0 0 2
Comorbid disorder, No.
Hypertension 6 2 2 0 0 0 0 4
Diabetes 3 2 0 0 0 1 0 6
Coronary heart disease 2 0 0 0 0 0 0 2
Hyperlipidemia 0 1 1 0 0 0 0 2
Cerebrovascular disease 1 0 0 0 0 0 0 1
COPD 1 0 0 0 0 0 0 1
Valvular heart disease 0 0 1 0 0 0 0 1
Chronic kidney disease 0 1 0 0 0 0 0 1
Ménière’s disease 0 0 0 0 0 1 0 1
Hepatitis B infection 0 0 0 0 0 0 1 1
Abbreviations: COPD, chronic obstructive pulmonary disease; COVID-19, coronavirus disease 2019; ENT, ear, nose, and throat.
 Table 2. Managements of COVID-19 Patients With Otolaryngologic Complaints.
Complaints and symptoms Therapy for COVID-19 Length of Complications of Posttreatment Medical protection ENT
consulted by otolaryngologists before consultation Therapy for ENT symptoms intubation treatment outcome class for ENTs infectiona

Tracheotomy (n = 7)b
Prolonged intubation for Intubation, CRRT, ECMO PDT 16 days None Deceased 19 days later Third level None
16 days, intra-airway bleeding
Prolonged intubation for 10 days High-flow oxygen, intubation PDT 10 days None Improved but still Third level None
hospitalized
Prolonged intubation for 10 days Intubation PDT 10 days Lung secretions, Improved but still Third level None
discharge hospitalized
Prevention of hypostatic pneumonia None ST None None Lung infection Third level None
recovered, comatose
Dyspnea after extubation High-flow oxygen, ST 17 days None Comatose Third level None
noninvasive assisted
ventilation, intubation,
CRRT
Repeated extubation, Noninvasive assisted ST (32) 10 days Intra-airway hemorrhage Died of cardiac arrest during Third level None
then intra-airway bleeding ventilation, intubation, on day 9 after the a lung transplant 10 days
ECMO first ST, epistaxis after the second ST
occurred on
day 7 after the
second tracheotomy
Epistaxis (n = 6)
Unilateral (3) Noninvasive assisted Hemostasis with packing None Hemoptysis (3) Resolution of epistaxis (3) Third level None
ventilation (2), nasal
high-flow oxygen (1)
Bilateral (3) Noninvasive assisted Hemostasis with packing None Hemoptysis (2) Resolution of epistaxis (2) Third level None
ventilation (1), nasal
high-flow oxygen (1)
ECMO (1) Hemostasis with packing None None Resolution of epistaxis, Third level None
comatose (1)
Pharyngitis (n = 2) Noninvasive assisted Compound borax mouthwash (1), None Pharyngeal reflex (1) Symptoms alleviated (2) Third level (Wuhan)/ None
ventilation (2), CRRT (1), compound chlorhexidine mouthwash (1) second level (Shenzhen)
ECMO (1)
Nasal congestion (n = 1) None Oxymetazoline nasal spray None Sneeze Symptoms alleviated Third level (Wuhan) None
Nasal congestion and hyposmia (n = 1) None Renault Court nasal spray None None Nasal congestion alleviated, Second level (Shenzhen) None
hyposmia not alleviated
Rhinitis (n = 1) Nasal high-flow oxygen Fluticasone propionate nasal spray None Sneeze Symptoms alleviated Third level (Wuhan) None
Dizziness and tinnitus (n = 1) Nasal high-flow oxygen Betahistine in remission None None Symptoms alleviated Third level (Wuhan) None
Otitis externa (n = 1) Noninvasive assisted Mupirocin None None Symptoms alleviated Third level (Wuhan) None
ventilation

Abbreviations: COVID-19, coronavirus disease 2019; CRRT, continuous renal replacement therapy; ECMO, extracorporeal membrane oxygenation; ENT, ear, nose, and throat department; PDT, percutaneous dila-
tional tracheostomy; ST, surgical tracheostomy.
a
Health care workers (HCWs) in Wuhan and Shenzhen took their temperature 4 times every day and took nucleic acid tests twice spanning a 24-hour period. HCWs in Shanghai took their temperature twice
every day and took nucleic acid tests on days 7, 12, and 14.
b
One patient declined tracheotomy after comprehensive assessment of the patient’s condition.

125
 Table 3. Medical Protection for Otolaryngologists.a

126
Normal Medical Coverall
Medical protection surgical protective Goggles/face Work (protective Isolation Shoe Hair
class for HCWs Application or occasion mask maskb shield PAPR clothes clothing) gowns Gloves covers cover

First level Preexamination and triage of  s  s s 

outpatientsc
Normal outpatient, emergency,  s s  s  
wardc
Touring or cleaning in potentially      
contaminated area outside
isolation ward
Intubation, tracheostomy nasal/  s    
laryngeal endoscopy for
ordinary patients
Surgery on ordinary patientsc,d  s   
Medical observation area for   
HCWs
Close contact of tracheotomye,f  s  s  
Second level Normal consultation, physical     s   
examination, nursing or
sampling in isolation wardf
Transport or accompanying       
examination of suspected or
confirmed patients
Third level Intubation, tracheostomy, nasal/   s     
laryngeal endoscopy for
suspected or confirmed
patientsg
Surgery on suspected or   s   s   
confirmed patientsc,g,h
Abbreviations: HCW, health care worker; PAPR, powered air-purifying respirator
a
 indicates priority selection; s indicates selection if necessary. Blanks cells indicate not selected.
b
The same or higher level of protective masks as N95 masks.
c
Medical protective masks and normal surgical masks are not used at the same time.
d
The work clothes here are scrubs.
e
Protective clothing or isolation gowns could be used according to the possibility of infection after close contacts.
f
Generally, the isolation gowns and protective clothing are not used at the same time. Some operations may contaminate protective clothing. For nursing or when moving between different isolation patients, it
is recommended to use isolation gowns in addition to protective clothing; when in close contact with a tracheostomy, protective clothing or isolation gowns could be used according to the possibility of infection
after close contacts.
g
If PAPR is selected, medical protective masks and goggles/face shield are not used.
h
Wear an isolation gown if necessary (when prone to contamination).
Cui et al 127

The procedure of
The procedure of taking o
wearing

Figure 1. Medical protection of health care workers. Example of provider wearing first-level (a), second-level (b), and third-level (c) pro-
tection. (d) Protocol for donning and doffing personal protective equipment.

were disinfected again.18 Furthermore, careful attention was day and took nucleic acid tests twice spanning a 24-hour
given to proper hand hygiene and avoiding contact with the period. HCWs in Shanghai took their temperature 2 times
eyes, nose, and mouth. The otolaryngology health care every day and took nucleic acid tests on days 7, 12, and 14,
worker was then quarantined in designated isolation locations a total of 3 times. At the time of data collection, no otolaryn-
for 14 days after the consultation. Health care workers in gologists who participated in the care of the patients in this
Wuhan and Shenzhen took their temperature 4 times every study had become infected with SARS-CoV-2.
128 Otolaryngology–Head and Neck Surgery 163(1)

Figure 2. Algorithm for triage of patients during the coronavirus disease 2019 pandemic. (a) Recommended precheck and triage algorithm
for outpatient clinics and emergency room. (b) Recommended algorithm for preoperative triage.

The 3 hospitals in Wuhan, Shenzhen, and Shanghai were 2020, to March 20, 2020 compared to the same period of
designated for treatment of COVID-19 patients, and so their 2019. In lieu of normal patient visits, 5765 telemedicine
outpatient clinics and emergency departments were closed. encounters were performed. No further HCW or patient
However, the Eye and ENT Hospital of Fudan University infections have occurred.
cares for one of the largest numbers of ENT patients in
China and continued to do so throughout the pandemic. Discussion
Since the announcement of obvious human-to-human trans- In this clinical study of 20 COVID-19 patients seeking ENT
mission on January 20, 2020, the Eye and ENT Hospital of consultation, 5 patients who had previously been endotra-
Fudan University reduced its large number of outpatient cheally intubated were converted to a tracheotomy and 1
visits immediately by eliminating nonurgent visits, stopped patient underwent a tracheotomy only. Otolaryngologists
elective surgery, avoided upper aerodigestive tract endo- performed a tracheotomy for these patients for management
scopic examinations as much as possible, developed outpati- of secretions, repeated endotracheal intubation, and long-
ent and emergency room triage flowcharts (Figure 2), and term endotracheal intubation. Data from non-COVID-19
improved staff training on infection control measures. In the infected critically ill patients suggest that early tracheotomy
preexamination areas for the emergency rooms, outpatient (within 10 days of intubation) has been associated with
clinics, and inpatient wards, HCWs used first-level protec- more ventilator-free days, shorter intensive care unit (ICU)
tion measures consisting of work clothes, isolation gowns, stays, shorter duration of sedation, and lower long-term
hair cover, normal surgical masks, and gloves when neces- mortality rates, although other studies have found that
sary. Second-level protection was used in the isolation ward timing of tracheotomy does not affect important clinical out-
and third-level protection in the operating room and when comes.19,20 In this study, 4 of the 6 patients (66.7%) who
performing invasive procedures. The protection level can be underwent tracheotomy subsequently were in a coma (2
adjusted according to the specific type of encounter and cases) or died (2 cases), which underscores the fact that in
working areas (see Table 3 for details). We developed and this small patient cohort, most patients did not achieve clini-
followed these procedures and then gradually increased out- cal benefit from the tracheotomy performed. Another report
patient appointments, tumor-related surgery, and then finally from China also suggests against benefit from tracheotomy
open elective surgery according to the pandemic situation. for COVID-19 patients.21 There are also data from the
At present, our clinic and surgical volume has returned to SARS treatment experience suggesting that tracheotomy
baseline. One-fourth as many outpatient visits and one-sixth was not associated with significant improved outcome.22
as many elective surgeries were performed from January 20, Tracheotomy is also associated with a number of potential
Cui et al 129

complications, including tracheal bleeding. Without specific taken for evaluation, treatment, or throat swab sampling of
treatment for the infection, the mortality rate once a patient patients in the isolation ward. The utilization of PPE in
goes into severe or critical ARDS is as high as 70%, which second-level protection and third-level protection here
also may argue against proceeding with tracheostomy on roughly corresponds to standard PPE and enhanced PPE,
patients with COVID-related ARDS.23 Taken in combina- respectively, as previously described by the Centers for
tion with our clinical experience in China, we recommend Disease Control and Prevention (CDC).15,29 Wuhan was the
that long-term intubation should not on its own be an indi- epicenter of the pandemic, with a higher incidence of dis-
cation for tracheotomy in COVID-19 patients, as the risk to ease than Shenzhen and Shanghai. As such, during consulta-
patients and providers likely outweighs any marginal bene- tion of COVID-19 patients with sore throat and nasal
fits in this scenario. Rather, tracheotomy should only be congestion, otolaryngologists in Wuhan and Shenzhen
used in specific situations such as airway obstruction where adopted third-level and secondary-level infection control
the potential for successful extubation is otherwise compro- plans, respectively, with no resulting provider infections at
mised or in circumstances where tracheotomy placement either hospital. These clinical results suggest that the adop-
might positively affect a patient’s potential for successful tion of such graded protection measures is feasible and
weaning of minimal ventilatory support. These scenarios do effective. Health care workers could choose different-level
require careful consideration when medical resources protection according to disease prevalence, the degree of
including ventilators are in limited supply in the setting of exposure risk, and the availability of PPE. While in this
widespread community infection. In agreement with recent study all otolaryngology providers were quarantined for 14
recommendations released by ENT UK, we believe such days after caring for COVID-19 positive patients, the ulti-
clinical situations should be evaluated in a multidisciplinary mate lack of infection of any of these providers may indi-
fashion such that consensus among specialists regarding cate that such quarantine is not necessary if appropriate PPE
potential for clinical benefit following tracheotomy as and other infection control measures are used. Serial tem-
weighed against the risk of the procedure is agreed upon perature checks and viral testing could be used instead to
prior to proceeding with the procedure.24 confirm providers are not infected without having to remove
In this study, 30% of consults were for epistaxis. This them from the workforce, a key concern given the potential
finding may be associated with the patients breathing dry volume of COVID-19 patients requiring care. Further study
cold air (due to hospitals turning off heating systems to is necessary to determine what is the minimum sufficient
minimize airborne transmission), long-term oxygen inhala- level of PPE to prevent infection with COVID in different
tion, using anticoagulants, acquired coagulopathies second- clinical scenarios.
ary to severe illness, and comorbidities such as hypertension It is not always possible to identify patients with SARS-
or diabetes. Given that the SARS-CoV-2 viral load has been CoV-2 infection on clinical presentation alone as early
found to be highest in the nose, any intervention involving symptoms are nonspecific. This can lead to high-risk expo-
the nasal cavity—particularly those that could produce aero- sures in the outpatient setting if high clinical suspicion is
solized blood or secretions—should be considered high risk, not maintained. In 1 example, a patient who was seen in the
and appropriate PPE should be used accordingly.25 otolaryngology department for a sore throat and mild cough
SARS-CoV-2 is very infectious, with a control reproduc- was subsequently diagnosed with COVID-19, illustrating
tion number that may be as high as 6.47 (95% CI, 5.71- the importance of careful triage of outpatients.30 Some evi-
7.23), which is higher than the SARS transmission number dence also indicates that hyposmia or loss of smell may be
in 2003.26,27 As previously discussed, ENT providers may an early symptom of SARS-CoV-2 infection, which may be
be subjected to high-risk exposures in a variety of different particularly relevant to otolaryngologists.13,14 In our cohort,
scenarios. For this reason, it is important that health workers there was at least 1 case of a mild severity patient who ini-
in ENT departments use standard precautions consistently tially presented to an otolaryngologist for hyposmia. At the
when providing care to COVID-19 patients. Rigorous Eye and ENT Hospital of Fudan University, proactive
implementation and adherence are crucial for the control of implementation of a variety of protective strategies immedi-
outbreak situations. Based on our previous experience of ately at the start of the outbreak resulted in no HCW infec-
performing tracheotomy during SARS, no medical or nur- tions occurring despite high exposure risk, indicating the
sing staff member was infected after carrying out the proce- effectiveness of these policies. Notably, as the overall pre-
dure while taking all the precautions and wearing the valence of disease stabilized, the hospital was able to
appropriate protective apparel.15,22,28,29 Medical units increase its clinical and surgical volume back to baseline
should provide graded protection for health care workers while still having no HCW infections. While this is in part a
according to the job position, work area, and the level of reflection of the success of national disease control mea-
exposure risk.17 PPE is the most obvious aspect of infection sures in China, it also suggests that with proper patient
control. PPE must be correctly selected and used in a safe screening, protective equipment, and training, even a high-
manner. Based on expert consensus in China, HCWs risk specialty such as otolaryngology can practice safely and
adopted third-level protection measures when performing effectively in the midst of the COVID-19 pandemic.
invasive procedures such as tracheotomy or control of There were some limitations to our study. As with all ret-
bleeding. The second-level protection measures can be rospective studies, the conclusions that can be drawn are
130 Otolaryngology–Head and Neck Surgery 163(1)

limited by the observational and heterogenous nature of the pneumonia in Wuhan, China [published online February 7,
data. There are also only 20 subjects included in this study. 2020]. JAMA.
As such, this may not fully display the clinical characteris- 4. Huang C, Wang Y, Li X, et al. Clinical features of patients
tics of COVID-19 patients requiring ENT consultation. It infected with 2019 novel coronavirus in Wuhan, China.
also limits the conclusions that can be drawn regarding the Lancet. 2020;395(10223):497-506.
feasibility and effectiveness of the protective measures 5. World Health Organization. Coronavirus disease 2019
taken by the otolaryngology providers participating in the (COVID-19) situation report–66. Published March 26, 2020.
diagnosis and treatment. Accessed March 27, 2020. https://www.who.int/docs/default-
source/coronaviruse/situation-reports/20200326-sitrep-66-covid-
Conclusions 19.pdf?sfvrsn = 81b94e61_2
We found that COVID-19 positive inpatients can require 6. World Health Organization. WHO director-general’s opening
intervention by an otolaryngologist for a variety of reasons, remarks at the media briefing on COVID-19. Published March
of which a tracheotomy was the most common in this study. 11, 2020. Accessed March 27, 2020. https://www.who.int/dg/
Otolaryngologists play an indispensable role in the treat- speeches/detail/who-director-general-s-opening-remarks-at-the-
ment of COVID-19 patients, but due to the inherent nature media-briefing-on-covid-19—11-march-2020
of their work, they are at high risk of exposure whether 7. McGoogan ZWJM. Characteristics of and important lessons
working in outpatient clinics, the emergency room, or inpa- from the coronavirus disease 2019 (COVID-19) outbreak in
tient wards. Appropriate use of PPE titrated to the level of China: summary of a report of 72 314 cases from the Chinese
exposure can prevent SARS-CoV-2 infection among otolar- Center for Disease Control and Prevention. JAMA. 2020;
yngologists. Establishment of strategies of caring for general 323(13):1239-1242.
ENT patients during the COVID-19 outbreak can protect 8. Patel ZM, Fernandez-Miranda J, Hwang PH, et al. Precautions
health care workers. for endoscopic transnasal skull base surgery during the
COVID-19 pandemic [published online March 19, 2020].
Author Contributions Neurosurgery.
Chong Cui, data acquisition, analysis, drafting; Qi Yao, data 9. The COVID-19 Task force of the Department of Infectious
acquisition, analysis, interpretation, design; Di Zhang, data acqui- Diseases and the IT Service Istituto Superiore di Sanità.
sition, analysis, interpretation, design; Yu Zhao, design, interpreta- Integrated surveillance of COVID-19 in Italy. Published
tion, revision; Kun Zhang, conception, revision; Eric Nisenbaum, March 26, 2020. Accessed March 27, 2020. https://www.epi
revisions for important intellectual content; Pengyu Cao, data acqui- centro.iss.it/coronavirus/bollettino/Infografica_26marzo%20ENG
sition; Keqing Zhao, conception, revisions; Xiaolong Huang, con- .pdf
ception, revisions; Dewen Leng, conception, revisions; Chunhan
10. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J.
Liu, conception, revisions; Ning Li, conception, revisions; Yan
Aerosol generating procedures and risk of transmission of
Luo, conception, revisions; Bing Chen, conception, revisions; Roy
Casiano, conception, revisions; Donald Weed, conception, revi- acute respiratory infections to healthcare workers: a systematic
sions, Zoukaa Sargi, conception, revisions; Fred Telischi, concep- review. PLoS ONE. 2012;7(4):e35797.
tion, revisions; Hongzhou Lu, conception, revisions; James C. 11. Guan WJ, Ni ZY, Hu Y, et al. Clinical characteristics of coro-
Denneny III, conception, revisions; Yilai Shu, conception, inter- navirus disease 2019 in China [published online February 28,
pretation, revisions; Xuezhong Liu, conception, interpretation, 2020]. N Engl J Med.
revisions. 12. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical
characteristics of 99 cases of 2019 novel coronavirus pneumo-
Disclosures
nia in Wuhan, China: a descriptive study [published online
Competing interests: James C. Denneny III, executive vice presi-
January 30, 2020]. Lancet.
dent and CEO, American Academy of Otolaryngology–Head and
13. Mao L, Wang M, Chen S, et al. Neurological manifestations
Neck Surgery.
of hospitalized patients with COVID-19 in Wuhan, China: a
Sponsorships: None.
retrospective case series study. medRxiv. 2020.
Funding source: This work was supported by National Natural 14. Baig AM, Khaleeq A, Ali U, Syeda H. Evidence of the
Science Foundation of China (No. 81822011, 81771013). COVID-19 virus targeting the CNS: tissue distribution, host-
virus interaction, and proposed neurotropic mechanisms. ACS
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