ENT and COVID-19 forSlideshareScribd.ppt

August 2020 presentation on ENT in the UK and COVID, focussing on the issues that existed at the time, in the midst of the pandemic, but without the benefit of current hindsight

1. Mr Chee Toh BSc FRCS (ORL-HNS)
Consultant ENT/Head & Neck Surgeon
West Hertfordshire Hospitals NHS Trust

2. A bit of ramble through the view of
COVID-19 from the ENT perspective
The beginning
The reaction in the ENT sphere
The middle
Working out what things had to be done
Working out how things had to be done
The recovery
Working out how to go forwards
Anosmia and other things

4. My February ski trip
- to Northern Italy

6. Didn’t happen!
Due to teach for a week for tour operator w/c 29
th

February
21
st
February 2020 – anyone returning from
Lombardy and Veneto must self-isolate if flu-like
symptoms
25
th
February 2020 – anyone returning from Northern
Italy (north of Pisa) must self-isolate if flu-like
symptoms
Cancelled it in case 
And…8
th
March - almost all of Northern Italy
quarantined

7. What happened instead

8. ENT-UK (BAORL-HNS)
Official ENT response slow to start…
Then 23 letters to members starting 20
th

March
Dedicated COVID-19 page 23
rd
March
Sections for each subspecialty and grouping
of relevant information

9. Letter to members 1
20
th
March 2020
“We have published evidence from other countries including
China and Italy and current evidence in the UK that the risks to
healthcare workers, particularly in ENT, oral surgery and eyes are
higher due to the proximity to the upper airway to the face of the
patient.”
ENT PPE
Avoid – clinics, contact, transfer, surgery
Restrict – number of visits, generation of
aerosols, staff numbers
Abbreviate – waiting times, treatment duration

10. Letter to members 2
23
rd
March 2020
Struggle for PPE for ENT
PHE not recognising ENT as being at particular
risk – Trusts follow PHE
Guidance on fibreoptic nasoendoscopy and
aerosol generation
Remote triaging of urgent suspected head and
neck cancer referrals during Covid-19
pandemic…

11. Letter to members 3
24
th
March 2020
Updated ENT-UK PPE guidelines for all
nasal/throat examination
Guidelines for changes to ENT practice
BAETS guidelines for thyroid cancer services
Initial guidance for head and neck cancer
management BAHNO
Aerosol generating procedures in ENT – clinic
examination, clinic procedures, operations on
upper aerodigestive tract
Measures to adopt, early Radiology

12. Letter to members 4
25
th
March 2020
“We are very pleased to announce that Public Health England (PHE) has
accepted the need for Personal Protective Equipment (PPE) to be used in all
ENT-related procedures during the COVID-19 pandemic, and has agreed to
change their list of Aerosol-Generating Procedures (AGPs) to reflect this. PHE
has also agreed to ENT UK's PPE request for all patient contact for
examination and procedures, not just for suspected or confirmed COVID-19.”
Otological procedures
COVID-19 Epistaxis management
Advice for patients with new onset anosmia
Global Tracheostomy Collaborative
recommendations for safe practice

13. My reaction

14. Letter to members 5
26
th
March 2020
BAPO statement on SARS Cov2 and Paediatric
Otolaryngology Provision

15. Letter to members 6
27
th
March 2020
“I am pleased to announce that Public Health England has agreed and
confirmed in writing to me the following recommendations: upper-airway
procedures such as nasal endoscopy, laryngoscopy and other interventions
in our specialty are to be considered Aerosol Generating Procedures (AGPs),
requiring full prescribed PPE, including an FFP3 respirator. They have also
agreed that we are seeing widespread transmission of COVID-19 in the
community, and therefore advise that appropriate PPE should be used in
relation to AGPs undertaken in ANY patient. Clinicians should plan to group
patients requiring these procedures, all of whom should be assumed
infected, to avoid changing respirators between patients and thereby
preserve stock. In the absence of an FFP3 respirator, the Health and Safety
Executive has confirmed that an FFP2 or N95 equivalent respirator would
offer adequate levels of protection. However, it is important to note that
FFP3 is officially the prescribed rating. Their official letter and guidance are
expected shortly, but please be safe and take care of yourselves in the above
mannerTonsillitis and Quinsy COVID guidelines”
ENT UK COVID-19 Adult Tonsillitis & Quinsy
Guidelines

16. Letter to members 7
30
th
March 2020
‘It is with great sadness that we record the passing of our friend and colleague
Amged, but it is with gratitude that we remember his life and contribution. After
completing his otolaryngology training in the East of Scotland, Amged honed his
skills in paediatric otolaryngology as a fellow in Edmonton, before being
appointed consultant otolaryngologist at Queen’s Hospital Burton, leading their
paediatric service. His contributions as surgeon and associate medical director –
instrumental in the merger of Burton and Derby Hospitals – are well known…

17. My next purchase

18. ENT and COVID-19
Wuhan province noted ENT doctors more likely to contract COVID
First death of ENT doctor 20
th
January
Liang Wudong
62 yo ENT doctor Hubei province
Died 25
th
January
Indonesian ENT specialist
East Jakarta
Died 21
st
March
2 UK ENT Consultants on ventilators
Reported 22
nd
March
55yo died but 52yo survived
Both from ethnic minority (Sudan and Sri Lanka)
Professor of ENT in Tehran reported 20 ENTs hospitalized
Of Medscape list of 1800 healthcare workers (not just doctors)
from 64 countries worldwide who died, 18 are ENT surgeons

19. Why ENT?
Widespread narrative on aerosol generating
procedures
Actually it’s more complex
Like other infections or even poisons, it’s all
about extent of exposure ie viral load contracted
So, for a given patient with a given level of
infectivity…

20. The Four Horsemen of the
Apocalypse
Proximity of
exposure
Duration of
exposure
Aerosol
generation
Open/unprotected
airway

21. Which hospital specialties are at particular risk?
Ward full of COVID patients
Intensivists
General medical/respiratory ward
Outpatient (open/unprotected airway when prevalence is high):
Emergency Department
Proximity to head and duration of exposure: dentists,
dermatology, ENT, ophthalmology, OMFS, plastics
Aerosol generation: dentists, bronchoscopy, OGDS
Theatre (when prevalence is high)
LA head and neck operations/procedures with unprotected
airway
GA tracheostomy and upper aerodigestive tract operations with
protected airway: ENT, OMFS
Anaesthetists bagging patients, inserting/removing
endotracheal tube or laryngeal mask airway

22. Stepping down services 1

23. Stepping down services 2
23
rd
March effectively NHS wide directive
To keep patients at home
To free up staff and facilities and resources
Cancel all elective procedures
Cancel all elective investigations
Cancel all elective outpatients
Return all routine New referrals not yet seen
Discharge all routine FOL patients
Vet all urgent referrals before seeing
Telephone by default and F2F only selected

24. Redeployment

25. NHS Grand Plan for redeployment
Table 4 Doctors suitable to work in critical care - Adult critical
care patients (COVID & non-COVID patients)
Clinical team leader/supervisor
No supervision required - ITU consultants, Anaesthetic consultants with
significant ITU experience
Remote supervision - Anaesthetic consultant without significant ITU
experience, Paediatric intensive care consultants with previous adult
experience, ITU ST4+
On-site supervision
Limited supervision - General medical consultants, Paediatric intensive care
specialist trainees and fellows, ENT specialists (consultant and ST3+)
Close supervision
Other doctors with previous ITU experience
Direct supervision
All other doctors

26. COVID Resources
https://icmanaesthesiacovid-19.org/clinical-guidanc
e
https://www.brit-thoracic.org.uk/about-us/covid-19-i
nformation-for-the-respiratory-community/

27. Luckily we peaked!

28. The situation in the NHS then
UK hospitals were never overwhelmed
Nightingales were never needed in anger
6 weeks from lockdown many of us were tentatively
moving towards carefully stepping back up
All scheduled routine outpatients New or FOL
received at least a telephone appointment
More F2F slots created
All discharged elective surgery patients were
recovered into the system
All Priority 1a/1b/2 patients operated on

29. Some specifics to consider
Tracheostomy
PAPR
Head and neck cancer work continued
Emergency work continued
Guidance to minimise admissions of emergencies
FESS in the COVID era
Mastoidectomy in the COVID Era

30. Tracheostomy
Guidelines for minimising aerosol generation
Percutaneous or surgical
Sequence and timing for stopping/starting ventilation,
advancing/withdrawing ETT
Precautions for emergency, awake or LA
SGUL shield to reduce spray aerosolization
COVIDTrach audit interim report 22
nd
May 52% of 564
patients successfully weaned from mechanical
ventilation
PAPR

31. PAPR
•Powered air-purifying
respirator
•Recommended for
aerosol generating
surgery of the upper
aerodigestive tract –
microdebriders/drills,
Coblation/Celon,
laryngeal/tracheal
work
•Up to 10x protection
factor of FFP3
disposable face mask

32. Head and neck cancer work
continued
ENT UK audit 23
rd
March to 18
th
May
1568 new referrals triaged
3.1% new referrals had cancer diagnosis
BAHNO initial recommendations
Focus on patients with higher likelihood of cancer
eg telephone vs F2F
Best utilisation of diagnostic capacity
Cessation of most thyroid cancer surgery
Try for day-case surgery or reduced LOS surgery
Radiotherapy alternatives
Minimise F2F FOL

33. HaNC-RC v.2 (2019)
Symptom Based Risk Calculator for Head And Neck
Cancer Referrals v2
All symptoms should be present for 3 weeks or more,
apart from stridor which is an acute presentation
An urgent suspicion of cancer (2 weeks) referral will be
recommended if probability is 7.1%, the optimal
≥
threshold point for this model.
Routine referral is recommended for threholds less
than 2.2%.
For moderate risk probabilities (2.2%-7.09% an urgent-
6 weeks referral is recommended).

34. ENT Emergency Work continued
ENT UK audit 6
th
April to 31
st
May
~2300 emergency cases 73 centres
~1600 epistaxis
61% no cautery
51% non-dissolvable packs
~700 tonsillitis/quinsies

35. Guidance to minimise admission of
emergencies
Epistaxis
Encourage use of Floseal and Nasopore
Quinsy
Encourage maximal medical treatment to avoid
drainage
Fish bone
?

36. FESS in the COVID era
Microscope Drape Method
to Reduce Aerosolization
Surgical tent is created using
a microscope drape which is
secured around the head and
upper torso

37. Mastoidectomy in the COVID Era
2 Microscope Drape
Method to Reduce
Aerosolization

38. Getting up and running 1
Outpatients
All patients vetted – default by telephone/Zoom, F2F if
necessary (currently only at Watford)
Investigations prior to F2F as appropriate
F2F patients screened at door: questions and non-
touch temperature, must wear mask, one carer if
necessary
One-way route through where possible
Short wait and short duration consultations with
social distancing maintained when possible
Special precautions for nasoendoscopy

39. Getting up and running 2
Theatre
Swab within 72 hours
Self-isolation 3/7 to 14/7 as recommended
RCS England and RCoA surgical prioritisation
categories (1a, 1b, 2, 3, 4)
ACS MeNTS scoring may be used to inform this (21
factors across procedure/disease/patient)
Green elective and Blue all-comers Zoning
Additional COVID consent
Getting up and running is being hampered by new
policies and procedures, with extra time needed for
PPE and infection control precautions and multiple
layers of assurances to surmount

40. Sudden Severe SNHL
Anecdotal increase in number of presentations
?embolic
Oral steroids if no longer COVID symptoms,
consider intratympanic steroids also
Please continue to refer

41. Paediatric Multisystem Inflammatory Syndrome
temporally associated with SARS-CoV-2 (PIMS-TS)
Systemic inflammatory condition with features
similar to Kawasaki disease and toxic shock
syndromes
May present to ENT with cervical lymphadenitis
and persistent pyrexia
Also neutrophilia, lymphopenia, multi-organ
failure, cutaneous manifestations, GI symptoms
Refer to Paeds!

42. Anosmia
Damage to olfactory nerve endings and bulb
90% recover within 3 weeks
If like other post-viral, of the remaining 10%, 1/3 recover within
6 months, further 1/3 recover by 18/12
Smell training
https://www.fifthsense.org.uk/
https://abscent.org/
Lemon, rose, eucalyptus, clove
INS steroids after 2 weeks if nasal symptoms, consider po
steroids if no longer COVID symptoms, refer if not
recovering

45. That’s all folks!
Thank you for listening
[email protected]
NHS [email protected]