Background: To show how to safely perform nasopharyngeal and / or oropharyngeal swabs for 2019-Novel Coronavirus. Methods: The video describes in detail the dressing and undressing procedures of health personnel, with the appropriate personal protective equipment. Technical notes for the execution of the nasopharyngeal and oropharyngeal swab are also provided, to avoid sampling errors. Results: The undressing phase is the procedure with the highest risk of self-contamination for the health worker. Following the various steps as shown in the video, there were no cases of contagion among the otolaryngology team appointed to perform the swabs for SARS-CoV-2 testing. Conclusions: This study demonstrates the technical feasibility of safely performing nasopharyngeal and/or oropharyngeal swabs for identification of SARS-CoV-2 viral RNA.
IntroductionThe ongoing worldwide pandemic due to COVID-19 has forced drastic changes on the daily lives of the global population. This is most notable within the healthcare sector. The current paper outlines the response of the head and neck oncologic surgery (HNS) division within our academic otolaryngology department in the state of Alabama.MethodsData with regard to case numbers and types were obtained during the pandemic and compared with time matched data. Our overall approach to managing previously scheduled and new cases, personal protective equipment (PPE) utilization, outpatient clinic, and resident involvement is summarized.DiscussionOur HNS division saw a 55% reduction in surgical volume during the peak of the COVID-19 pandemic. We feel that an early and cohesive strategy to triaging surgical cases, PPE usage, and minimizing exposure of personnel is essential to providing care for HNS patients during this pandemic.
Background. The firsts European case series are detecting a very high frequency of chemosensitive disorders in COVID-19 patients, ranging between 19.4% and 88%.Methods. Olfactory and gustatory function was objectively tested in 72 COVID-19 patients treated at University Hospital of Sassari.Results Overall, 73.6% of the patients reported having or having had chemosensitive disorders. Olfactory assessment showed variable degree hyposmia in 60 cases and anosmia in 2 patients. Gustatory assessment revealed hypogeusia in 33 cases and complete ageusia in 1 patient. Statistically significant differences in chemosensitive recovery were detected based on age and distance from the onset of clinical manifestations.Conclusion. Olfactory and gustatory dysfunctions represent common clinical findings in COVID-19 patients. Otolaryngologists and head-neck surgeons must by now keep this diagnostic option in mind when evaluating cases of ageusia and nonspecific anosmia that arose suddenly and are not associated with rhinitis symptoms
The 2019 novel coronavirus (COVID-19) pandemic has created significant challenges to the delivery of care for patients with advanced head and neck cancer requiring multimodality therapy. Performing major head and neck ablative surgery and reconstruction is a particular concern given the extended duration and aerosolizing nature of these cases. In this manuscript, we describe our surgical approach to provide timely reconstructive care and minimize infectious risk to both the providers, patients, and families.
Health crises have become a popular topic of discussion. In the wave of the ongoing pandemic, experts have suggested the role of vaping and other tobacco product use exemplifying the vulnerability of the population to contract the COVID-19. We discuss some of the events that led up to these conclusions and also offer a unique insight into another form of tobacco use that is potentially propagating its spread especially in the South Asian region – chewed tobacco. Both of these have been a perennial issue that head and neck cancer surgeons have been dealing with. Governments and Head and Neck cancer care providers now have an opportunity to deal with a common enemy in the midst of this pandemic.
Background: COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of healthcare personnel. Methods: The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging Head and Neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular. Recommendations: Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred. Conclusion: These guidelines are intended to help clinicians caring for HNC patients appropriately allocate resources during a healthcare crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.
Kimberley L Kiong MBBS 1 , Theresa Guo MD 1 , Christopher MKL Yao MD 1 , Neil D Gross MD 1 , Matthew M Hanasono MD 2 , Renata Ferrarotto, MD 3 , David I Rosenthal MD 4 , Jeffrey N Myers MD 1 , Ehab Y Hanna MD1, Stephen Y Lai MD 1 1 Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 2 Department of Plastics and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 3Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States. 4Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States Corresponding author: Stephen Y Lai, MD PhD Professor Patient Safety Quality Officer The University of Texas MD Anderson Cancer Center Department of Head and Neck Surgery Division of Surgery 1515 Holcombe Blvd, Unit 1445 Houston, TX 77030 email@example.com This work did not receive any grant support and has not been presented at any meeting Running title: Changing Head & Neck surgical practice during COVID-19 Keywords : Otolaryngology, Oncology, SARS-CoV2 Abstract: Background: The COVID-19 pandemic has changed healthcare, challenged by resource constraints and fears of transmission. We report the surgical practice pattern changes in a Head and Neck Surgery department of a tertiary cancer care center and discuss the issues surrounding multidisciplinary care during the pandemic. Methods: We report data regarding outpatient visits, multidisciplinary treatment planning conference, surgical caseload, and modifications of oncologic therapy during this pandemic and compared this data to the same interval last year. Results: We found a 46.7% decrease in outpatient visits and a 46.8% decrease in surgical caseload, compared to 2019. We discuss the factors involved in the decision-making process and perioperative considerations. Conclusions: Surgical practice patterns in head and neck oncologic surgery will continue to change with the evolving pandemic. Despite constraints, we strive to prioritize and balance the oncologic and safety needs of patients with head and neck cancer in the face of COVID-19. IntroductionThe rapid spread of the novel coronavirus 2019 (COVID-19) has disrupted healthcare systems globally. Some of the biggest challenges include shortage of hospital beds, healthcare workers and personal protective equipment (PPE). Given these constraints, there has been a simultaneous push for a reduction in elective clinical practice, to further reduce transmission and conserve resources 1.Cancer care is generally not considered elective and decision making about when to initiate or delay treatment during the pandemic has raised complex ethical and resource utilization issues. Yet amidst the pandemic, patients continue to develop and seek treatment for cancer. Head and neck cancers (HNC) can challenge essential functions such as eating, speaking and breathing. Tumor doubling time ranges between 15 to 99 days 2,3 and delaying treatment decreases survival and contributes to adverse outcomes 4,5. As such, there are recommendations for prompt initiation of treatment of HNC after diagnosis and to reduce the total treatment package time6,7. In an effort to limit the potential adverse effects of delaying cancer treatment during this pandemic, an increasing number of oncology guidelines have been developed, both general and specific to HNC 8,9.At the University of Texas MD Anderson Cancer Center (MDACC), our Head and Neck surgical practice has gradually changed as a result of evolving internal and external guidelines (Table 1). Harris County, Texas reported its first COVID-19 case on March 5th, 2020. Since then, the number of cases has been steadily rising with the current incidence at 35 per 100,000 residents in Texas 10. At the institutional level, MDACC has taken many pre-emptive actions and policy changes in response to the growing pandemic (Table 1).The institutional policies described have served to limit hospital attendances in anticipation of a surge in COVID-19 cases in the region. The number of new patients visits to the institution have decreased from 782/week in the first week of March to 207/week in the last week of March (-73.5%) while systemic treatment appointments, indicative of patients already in the process of treatment, have remained fairly stable (3864 to 3288 visits, -14.9%). As a downstream effect, the number of diagnostic imaging visits has decreased from 9616 to 3971 (first and last weeks of March respectively, -58.7%). Surgeries within the institution have shown a more drastic decrease, from 463 to 149 cases per week (-67.8%). Current institutional census at the time of writing (April 7th, 2020) shows 55% general bed occupancy and 35% ICU occupancy. The numbers will continue to change in response to the development of COVID-19 within the region, as we have not yet reached the peak of infection. Predictive models have suggested that the peak in COVID-19 cases will occur at the end of April11 and there are institutional plans on standby to repurpose physical facilities and the workforce to shift focus from oncology care to COVID-19 treatment if needed.In the context of the developing pandemic and tightening institutional guidelines, we seek to understand the early impact of the COVID-19 pandemic on head & neck oncologic surgery practices. We performed a review of outpatient clinic and surgical caseload within the MDACC Head and Neck Surgery department during the pandemic and compared this to the same time period in the preceding year, along with the deviations in management of patients due to COVID-19.
UpdatesA general consensus exists on coronavirus diffusion by droplet transmission, especially the aerosolisation during hospital procedures like intubation or bronchoscopy might represent a big concern, exposing other patients and health-care staff to an increased risk of infection In this context, the general otolaryngology procedures may determine an aerosolisation with nosocomial amplification of the infection.In particular flexible and/or rigid nasolaryngoscopy may include some maneuvers such as puffing out your cheeks, talking, swallowing some coloured water or poking out your tongue. Further, the introduction of the endoscope may cause sneezing and cough.These risks can increase when in-office surgical procedures are applied to cure urgent and emergent pathologies such as epistaxis, removal of foreign bodies in upper aero-digestive tract, cricothyroidotomy as well as elective procedures such as biopsies, inferior turbinoplasty etc.Based on the available evidence, it appears that SARS-CoV-2 can be transmitted by asymptomatic carriers, which contributes to its basic reproduction number and pandemic potential1.Zou et al2 showed higher viral loads after symptom onset, with higher viral loads detected in the nose than in the throat. Further in the asymptomatic patients, the viral load was similar to symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients.The common work-load of a ENT are symptoms related to upper airways inflammations or infections. Sore throat with or without fever, sneezing, hoarseness may be prodromic symptoms of a COVID-19 infection in the incubation period3. Moreover, the coughing patients with a negative chest X-ray is one of the most consultation required.Direct contact of droplet spray produced by coughing, sneezing or talking involves relatively large droplets containing organisms and requires close contact usually within 1 m 4. Indirect contact may take place after the droplets are removed from the air by surface deposition5.Han et al6 studied the dynamic features of bio-aerosolisation by sneezing. The velocity of the airflow exhaled by sneeze is much larger than that of breath and cough. Moreover, the total number of droplets generated during sneeze is also larger than that of other respiratory activities. According to the study on flow dynamics and characterization of cough, the maximum velocity of exhaled airflow can be found at t = 57–110 ms for different persons which is most likely to occur at 100 ms. Usually, sneeze lasts 0.3–0.7 s, so t = 100 ms is in the duration of the sneeze. As the velocity of the airflow exhaled by sneeze is really high, it can be assumed that the droplets that are exhaled at t =0–100 ms will not re-enter the measurement zone before t=100 ms. The high-speed airflow and corresponding turbulence produced by sneeze may also lead to a large number of droplets, i.e. the number of the droplets generated by sneeze is about 18 times larger than that of cough. Further, the size of sneezing droplets is 341.5–398.1 µm for unimodal distribution and 73.6–85.8 µm for bimodal distribution. After the droplets are exhaled into the indoor environment, the evaporation effects will strongly influence the size and mass of the droplets. The final equilibrium diameter of expiratory droplets after evaporation is highly dependent upon the temperature and relative humidity of the environment. In the indoor environment, the relative humidity and temperature are much lower than those in the respiratory tract. So the volatile content of these droplets will keep evaporating and result in the shrinkage of the droplets.Definitively, these findings demonstrate that the routine activities of an otolaryngologist are constantly at high risk of contagion in COVID-19 epidemic areas.Taking a look at the current Italian situation, the experience of the region Veneto demonstrated that the application of COVID-19 screening also in asymptomatic people can reduce the contagion spreading. Thus, it seems clear that extend the screening to all health-workers included otolaryngologists could be a valid strategy to reduce the onset of a worst case scenario, the hospital outbreak.In conclusion, the professional exposure to SARS-CoV-2 is really high for the otolaryngologist and nurse staff, even in in-office settings. Personal protective equipments are strongly recommended as well as for health-workers in close contact with infected patients.REFERENCESZhu W, Xie K, Lu H, Xu L, Zhou S, Fang S. Initial clinical features of suspected Coronavirus Disease 2019 in two emergency departments outside of Hubei, China. J Med Virol. 2020 Mar 13. doi: 10.1002/jmv.25763. [Epub ahead of print]Zou L, Ruan F, Huang M et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med. 2020 Feb 19. doi: 10.1056/NEJMc2001737. [Epub ahead of print]Lauer SA, Grantz KH, Bi Q et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 Mar 10. doi: 10.7326/M20-0504. [Epub ahead of print]Leder K, Newman D. Respiratory infections during air travel. Intern Med J. 2005 Jan;35(1):50-5.Chao CYH, Wan MP, Sze To GN. Transport and removal of expiratory droplets in hospital ward environment. Aerosol Sci Technol 2008;42, 377 – 394.Han ZY, Weng WG, Huang QY. Characterizations of particle size distribution of the droplets exhaled by sneeze. J R Soc Interface. 2013 Sep 11;10(88):20130560.
Dear Editor,The COVID-19 infection can be diagnosed from a variety of upper and lower respiratory sources including the oropharynx (OP), nasopharynx (NP), sputum, and bronchial fluid [1-3]. In general the most sensitive detection of COVID-19 is obtained by the collecting and testing of both upper and lower respiratory samples .However, bronchoscopy is a highly technical procedure requiring advanced diagnostic tools as well as well-trained staff which are not always available. Furthermore the collection of sputum and particularly BAL via bronchoscopy increases the biosafety risk to healthcare workers through the creation of aerosol droplets.Upper respiratory specimens such as OP and NP swabs are easy to collect especially in limited resource settings. They should be collected within the first few days from the onset of symptoms since RNA positive rates peak in upper respiratory tract specimens at 7–10 days after symptom onset and then they steadily decline .In China during the COVID-19 outbreak, Wang et al reported that oropharyngeal (OP) swabs (n = 398) were used much more frequently than NP swabs (n = 8). However, the COVID-19 RNA was detected only in 32% of OP swabs, compared to NP swabs (63%).It appears to be extremely important to properly collect nasopharyngeal swabs reaching the posterior rhinopharyngeal tonsil region. This implies the presence of a regular nasal cavity floor. Some anatomical variants, such as nasal septum deviation, can prevent reaching of the nasopharynx and therefore to collect a proper sample. Numerous studies of nasal septal deviation have revealed a wide range of prevalence [6,7]. In 1978, Gray reported a prevalence of 48% to 60% in neonates .1 In adults, a recent international study found a prevalence of approximately 90% . Sooknundun et al. reported a clinically relevant septal deviation prevalence of 15% to 25% .Current national and international guidelines do not include any special recommendations in the execution of the rhinopharyngeal swab in patients with documented nasal pathology or in patients in which a bilateral nasal fossa obstacle is encountered. We believe that in these selected cases the ENT support should be mandatory in order to obtain a representative sample. Furthermore the use of endoscopes could be very useful in the direct visualization of obstacles and to guide safely the swab toward the rhinopharynx. This would possibly also reduce the false negative rate which is reported to be more than 30% .
Introduction: The COVID-19 pandemic caused by the SARS-CoV-2 virus has put healthcare workers at risk when exposed to aerosolized viral particles during upper airway mucosal surgery. The objective of this review was to discuss topical preparations that could be utilized preoperatively to help to decrease viral load and potentially reduce the risks of viral transmission. Methods: PubMed/MEDLINE database review of articles studying topical preparations with virucidal activity against coronaviruses. Results: Povidone – Iodine (PVP-I) solutions ranging from 0.23% to 7% have been found to demonstrate highly effective virucidal activity against a broad range of viruses including several coronaviruses responsible for recent epidemics: SARS-CoV-1, MERS-CoV.
The Coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world, placing unprecedented strain on the healthcare system. Healthcare resources including hospital beds, ICUs, as well as personal protective equipment (PPE) are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID-19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.
On March 27, 2020, the Center for Disease Control reported that 85,356 individuals in the United States were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – exceeding, for the first time, the number of cases in Wuhan, China, where the pandemic began in November, 2019. US federal, state and local agencies are facing an unprecedented public health emergency. The scale of the pandemic has never been seen in US; the way forward uncertain.In 2003, the Hong Kong SAR (HK) healthcare system was thrust into a similar crisis, responding to an outbreak of SARS coronavirus 1 (SARS-CoV-1), that developed in Guangdong Province, China late in 2002. Lessons from how HK physicians adapted their practices to this new disease may hold important lessons for the many countries now facing the pandemic .Based upon experience and evidence from SARS-CoV-1 and early-experience with SARS-CoV-2, we provide our perspective and guidance on mitigating transmission risk during head and neck examination, upper airway endoscopy, and head and neck mucosal surgery including tracheostomy. We set out below, recommendations that every physician performing head and neck examination should consider. The goal is to protect healthcare workers (HCW), caregivers, patients, and the community at large in this Personal Protective Equipment (PPE) limited environment, while conforming to their local guidelines.Early on in the 2003 SARS epidemic, the risk of nosocomial spread of infection to HCW posed a critical challenge. At the Prince of Wales Hospital, HK, a single infected patient caused an outbreak, of which over 50% were HCW, devastating human resources to treat and contain the infection . Seventeen years later HK was inflicted with SARS-CoV-2 late January 2020. A benefit of SARS-COV-1 in HK HCW has been the modus operandi since 2003: including wearing surgical masks in hospital wards, wearing gowns and surgical masks in outpatient clinics and scrubs only in the operating room. The resultant individual and institutional appreciation of infection control measures have served HK well in the current pandemic, relative to other countries, with no HCW COVID-19 nosocomial infections to date 1.In the 2003 SARS-CoV-1 outbreak in HK, an otolaryngologist died after being infected during a routine head and neck examination. In 2020, the first COVID-19 physician fatality was an otolaryngologist in Wuhan, China. Patients with COVID-19 caused by SARS-CoV-2 can carry high viral load in the nasal cavity, nasopharynx, and throat. The anatomic viral distribution of these SARS-CoV viruses in the nasopharynx and mucosal airways, coupled with these disquieting cases, indicate that head and neck examinations and procedures must be approached cautiously with thoughtful preparation and protections. HCW who have these exposures are at heightened risk of transmission.In the outpatient setting, all non-essential clinic visits should be transitioned to virtual “video-visits” or postponed. This will reduce the number of patients in the clinic, minimizing patient flow and potential contamination and freeing up valuable medical resources. On March 18, 2020, the Center for Medicare and Medicaid Services in the US released recommendations to postpone all non-essential dental exams and procedures until further notice.Within the clinic, separate gown up and down areas must be designated to prevent cross-contamination. Visual guides and mirrors for self-visualization in these areas on the steps involved in gowning up and gowning down have, from past experience, proven extremely useful particularly for gowning down, where most HCW self-contaminate (Figure 1). Another critical area is the bedside examination of patients. Currently, there are no CDC guidelines on respiratory and aerosol-generating procedures within the scope of the head and neck surgery, but our experience with SARS-CoV-1 highlights that these are potentially high-risk examinations. Therefore, in HK, there is official guidance for Otolaryngology departments to label several common head and neck examination and procedures as having a potential risk of aerosol generation. This designation carries implications on PPE allocations of as seen in table 1.Anesthetic practices vary but local anesthetic is commonly administered via aerosolized spray in the head and neck examination and procedures. This practice has been abandoned in HK since the SARS-COV-1 epidemic and must be avoided in the current COVID-19 environment. Aerosol spray should be replaced by topical local anesthetic on pledgets or dripped via syringe. Table 1 shows guidelines of PPE use within the outpatient clinic with a dedicated endoscopy room, including flexible laryngoscopy - one of the most common procedures performed in head and neck examination. Unless there is gross contamination there is no need to change the gown, mask or eye protection between each patient.For inpatient rounds, all physicians are recommended to wear a surgical mask and scrubs which are changed daily prior to leaving the hospital. Patient visitors to the hospital should be severely restricted, and visiting hours cut, to minimize people flow and maintain social distancing.For all operative procedures, intubation represents an aerosol-generating procedure as first learned during the 2003 SARS-COV-1 epidemic. Therefore, during intubation anyone in the operating room should have appropriate PPE including a fit-tested N95 mask. This should similarly apply to all open airway procedures such as direct laryngoscopy where they may be a leak during ventilation, tracheostomy, or laryngectomy.Tracheostomies for patients with known COVID-19 should be delayed where possible to minimize viral shedding from the patient, as we know from SARS-COV-1, delaying the tracheostomy does not negatively impact the patient. Guidance for a safe tracheostomy emerged from the 2003 epidemic. The following should be considered for tracheostomies in the COVID-19 pandemic:PPE: AAMI level 3 or waterproof apron on top of AAMI level I isolation gown, N95 mask, face shield, waterproof cap and disposable shoe covers. Powered air purifying respirators (PAPR) may be needed in cases with high viral load.Minimize personnel: One intensivist, one surgeon, one nursing member.Procedure: Use a negative pressure operating room. The patient should be completely paralyzed and preoxygenated. Stop ventilation before tracheotomy and only resume once tracheostomy tube balloon cuff is inflatedPost procedure: Gown down safely, and shower.Ideally, the procedure should be done in a negative pressure operating room with senior personnel and not used as a training procedure. Cautery use should be limited as this can produce small particles that may act as a vehicle for the virus . Again, gowning down following the procedure is of utmost importance and is often overlooked. Dry runs prior to the actual procedure may also help reduce errors and prevent the contamination of HCW.For patients with a tracheostomy they should all be covered with a closed system (Figure 2) identical to when a patient is connected to a mechanical ventilator to minimize the aerosol generated that could cross contaminate the surrounding patients and HCW given the suction requirements of these patients . Humidified tracheostomy collars and nebulized therapies must be avoided. All bedside procedures should be performed in a separate treatment room away from patient cubicles with all HCW wearing PPE. The requirements for PPE will be the same as in the outpatient clinic.In summary, with the use of these broad guidelines which reduces the number of procedures and patients seen, coupled with an appreciation that the head and neck examination cannot be taken lightly in the current pandemic, the risk of exposure and contamination in clinics of patients, HCW and in particular, physicians performing a head and neck examination should be reduced.
Background: The Coronavirus disease – 2019 (COVID-19) pandemic is a global health crisis and Otolaryngologists are at increased occupational risk of contracting COVID-19. There are currently no uniform best-practice recommendations for Otolaryngologic surgery in the setting of COVID-19.Methods: We reviewed relevant publications and position statements regarding the management of Otolaryngology patients in the setting of COVID-19. Recommendations regarding clinical practice during the Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks were also reviewed.Results: Enhanced personal protective equipment (N95 respirator and face shield or powered air-purifying respirator, disposable cap and gown, gloves) is required for any Otolaryngology patient with unknown, suspected, or positive COVID-19 status. Elective procedures should be postponed indefinitely, and clinical practice should be limited to patients with urgent or emergent needs. Conclusion: We summarize current best-practice recommendations for Otolaryngologists to ensure safety for themselves, their clinical staff, and their patients.
The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities.There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists and otolaryngologists. Health workers represent between 3.8% to 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter).All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55-65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Healthcare facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for cancer patients.For those who are working with COVID-19 infected patients’ isolation is compulsory in the following settings: a) unprotected close contact with COVID-19 pneumonia patients: b) onset of fever, cough, shortness of breath and other symptoms (gastrointestinal complaints, anosmia and dysgeusia have been reported in a minority of cases).For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (e.g.; rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia) it is strongly recommended that all healthcare personnel wear personal protective equipment (PPE) such as N95, gown, cap, eye protection and gloves.The procedures described are essential in trying to maintain safety of healthcare workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.