New Zealand ENT News

From my ENT colleagues and for my ENT colleagues across the Tasman as of 31st March 2020. THINGS CHANGE ALL THE TIME, RAPIDLY. THIS ADVICE MAY BE INVALID IN A FEW DAYS.

Note the risk management of Aerosol-Generating Procedures and preoperative assessment. PLEASE CHECK YOUR OWN LOCAL GUIDELINES.

Aerosol Generating Procedures in the COVID era


You will be treating a COVID positive patient. Think about the safety of any aerosol generating procedure in this new COVID era. Modifications need to be made to mitigate the risks of spreading the virus. We need to protect the patient and healthcare staff.

What do we know?

The upper respiratory tract (the nose, nasopharynx, mouth, oropharynx, larynx, trachea and bronchi) are areas with high viral load. Evidence suggest that viral load in the nose and nasopharynx of non-symptomatic carriers are as high as those with symptoms. A patient could have no symptoms and yet carry the same amount of virus in the nose, and oral secretions. Data from China and Europe suggests that ENT surgeons have been unexpectedly hit hard with high numbers falling ill and some have died due to the virus. Studies have shown that tracheobronchial secretions carry the highest concentration of virus and followed by mucous and saliva. In some patients the virus can be detected in saliva weeks after the symptom onset. The virus has not been detected in urine or breastmilk.

What does this mean?

If you are an anaesthetist, ENT surgeon, Head & Neck surgeon, dental, maxillofacial surgeon, respiratory physician or anyone else doing procedures in the Airway mucosa, you must modify your procedures based on COVID risks. Any procedures involving the nose, oral cavity and airway pose a risk of dissemination of virus. Any general anaesthetic involving bag and masking, ventilation, intubation, supraglottic airway device, nasal surgery (rhinoplasty, septoplasty sinus surgery, adenoidectomy), oral surgery (maxillofacial, dental, tonsillectomy) and airway interventions (bronchoscopy, laryngoscopy) etc are all high risk aerosol generating procedures (AGPs).

What must we do?

1. Risk assess the patient. Can we get a COVID status on the patient? If we cannot get a COVID test pre-procedure, assess the risk based on history and examination (contact with positive COVID, travel history, etc.). Some institutions may afford you the luxury of doing 2 tests 48 hours apart to confirm the status. This is not possible in all places. Tests are not perfect so they may give a false reassurance and false negatives.

2. Risk assess the procedure and modify accordingly. Can we delay the procedure? Do we have other alternatives? Can we modify the surgical approaches? Can we use a different technique or tool to reduce the aerosolisation?

What if we have to proceed with the procedure?

Modify and mitigate the risks as a team. Communicate. Communicate. Communicate.

Consider 3 possible levels of risk:

These are suggestions. You need to check your local area guidelines.

GREEN: standard precaution for negative COVID patients and non aerosol generating procedure. Surgical mask, eye cover, & gloves for a non-ENT procedure. Eg. Neck dissection, thyroidectomy, etc.

YELLOW: for AGPs with negative COVID or very low suspicion of COVID. N95 mask, face shield, long sleeve gowns and gloves. Eg for mastoidectomy, FESS or tonsillectomy. Should intubation fall into this category?

RED: for COVID positive AGPs. PAPRs and the maximal PPE available at your institution. Eg. an urgent FESS in a COVID positive patient.

This diagram from the Canadian Society of Otolaryngology Head & Neck Surgery. THIS MAY NOT BE POSSIBLE IN EVERY PART OF THE WORLD.

Pre-operative considerations

Mask on the patient. Isolation. Reduce staff contact. One family member, one staff, reduce movements. Reduce exposure to other patients. Do not wait at holding bay or waiting room. Bring patient from emergency or ward direct to operating theatre.


Standard precautions. Assess level of risk Green, Yellow or Red. Reduce staff contact. Bag and mask, intubate under plastic drape. Seal the airway. Consider avoiding high flow oxygen, CPAP, Laryngeal mask etc. CHECK WITH YOUR LOCAL ANAESTHESIA TEAM.


Modify techniques. Can you operate under a plastic drape? Example here. Any mucosal specimens (eg sinus debris, tonsils etc, need to be placed in a sealed container immediately). Pictures of modifications to surgical techniques below. Modify your technique accordingly so as to mitigate the risks to the staff in theatre. Reduce personnel present. Add suction device. Negative pressure theatre. Check theatre airflow. Meticulous PPE. Buddy up so someone is always catching you and checking on you. Modifications offered here. CHECK YOUR LOCAL AREA GUIDELINES.

Modification to oral surgery under a plastic drape.

Emergence & Recovery

Wake the patient in theatre. Avoid coughing in recovery. Mask on patient. Go to an isolated area in recovery. One staff member to recover. Then straight to the ward. ASSESS RISK AND DISCUSS WITH YOUR LOCAL AREA TEAMS.


Time to allow clean up and air circulation in theatre. Wipe down everything based on levels of risk.


Communicate, Communicate, Communicate. In my experience, every single time I ask the team to do a COVID run or simulation, new gaps in knowledge and practice are identified and resolved. Morale and team work is strengthened.

Practice it. This is our new normal for the next few months.


COVID19 and ENT Surgeons

ENT Surgeons and the COVID19 Pandemic

Updated 22nd March 2020

Key findings from literature as of today.

1. ENT surgeons are at higher risk and have higher rates of contracting the virus SARS-CoV2.

2. Thought to be due to high virus load in nose, nasopharynx and oropharynx, even in asymptomatic carriers hence we may be examining and operating on asymptomatic patients with high viral load.

3. Airway procedures are aerosol-producing activities therefore placing staff at risk (nasoendoscopies, cautery, even oral examinations). Delay if possible.

4. Urgent need for protection with N95 masks, gowns and gloves in clinic. We should ask authorities to provide ENT clinics with them.

5. Any airway intervention, in particular but not limited to, sinonasal surgeries, adenotonsillectomies, laryngobronchoscopies should be delayed if clinically appropriate. Severe, urgent, cancer, critical airway cases may go ahead on a case by case basis and intraoperative risk reduction strategies should be employed (masks during intubation, reduce personnel in theatre, N95 masks, smoke suction, etc.)

6. Testing is still limited in Australia and at this stage we cannot screen everyone for COVID19.

7. Ultimately we should screen all patients pre clinic or pre op but that’s not possible yet.

8. Please be reasonable and be cautious. There are still many patients requiring emergent and urgent ENT services. This does not mean we stop all ENT services. Please be supportive of your emergency colleagues. Wear a full PPE gear. Here’s a snapshot of ASOHNS recommendations. Full statement linked below.

9. Data is limited and imperfect. We are in a pandemic. Time to use whatever limited data we have to inform practice. Time to learn, support and not criticise colleagues.

10. Look out for anosmia. See this. Could be a red herring, could be true. Don’t know yet but be aware.

Resources to support the above statements:

1. Interview with Dr Jason Chan on managing ENT Services during Pandemic in Hong Kong. Excellent.

2. News of China Experience with higher number ENT Surgeons infected.

3. Paper on nasal viral load. Just as high in asymptomatic patient.

4. Paper on asymptomatic carriers.

5. Fever and cough are most common symptoms. But asymptomatic period really uncertain.


7. ENT UK general guidance.

8. American Academy Recommendations. Specific mention of high virus carrier rate in the nose, nasopharynx and oropharynx.

9. Reliable personal sources have also reported the following: transsphenoidal pituitary case in Wuhan infecting 14 health care workers. One ENT surgeon in the UK has died, 2 intubated and 1 on ECMO.

10. COVID19 repository of papers, guidelines etc collated by Australian Crit Care clinicians.

11. Australian Society of Otolaryngology Head & Neck Surgery recommendations.

11. British Laryngological Society President.

12. SkyNews on 2 intubated ENT Surgeons in the UK.

13. Suggested modifications to Sinus surgeries. Pre and post op concerns discussed. 12 minute lecture.

14. American Academy update recommendations 23 March 2020.

15. Be kind. Be kind. Be kind. This is an unprecedented Medical Emergency. We need to give every staff member the support that they need. This is the new normal for the next 3 months at least.

Life in a Pandemic

IMG_8005Brace. Brace. Brace.

The next couple of weeks and months will be tough for all of us. There is no need for panic or hysteria but there is need to prepare. The flu pandemic in 1918 tore through the globe and killed somewhere between 20-50 million people. At that time, world travels were not as common as today, but the virus still managed to spread through the planet. Today we have the ability and the opportunity to alter the progress of this pandemic. We have the ability to cope with the severity of illness thanks to medical advances and we are able to coordinate the community response through communication and connectedness. Your personal act today has social repercussions to those in your community.

There are many great websites, articles and information out there which I have listed at the end of this article. I am going to focus on what we can do in the next few weeks. Time is of the essence.

COVID-19 is the disease name for a severe respiratory illness caused by the virus SARS-CoV2. On 31st Dec 2019, the World Health Organisation (WHO) received the first report of a pneumonia of unknown cause from Wuhan, China. The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020. On 11 February 2020, WHO announced a name for the new coronavirus disease: COVID-19. On the 11th of March, The WHO says “we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction. We have therefore made the assessment that COVID-19 can be characterized as a pandemic.” The WHO is worried about our lack of action.

The virus spreads rapidly through droplet and contact surfaces. Symptoms become obvious a couple of days later. The COVID-19 test takes time. Many are not tested as there are some limitations to access (cost in some countries) or resources (not enough testing kits). We don’t know a lot about this virus because it is novel. We have not seen this virus before. We have no immunity to it. We have no vaccines for it. All we know based on what we see happening in China, South Korea, Japan and Italy is that the virus causes a respiratory illness. Eighty percent of patients get a mild form while the rest get severe form and the severity is strongly associated with advanced age (up to 8% mortality in those above 80 years old) and comorbidities (diabetes, hypertension and chronic illness).

Containment lines have been broken. The virus has entered multiple countries. The case rates in each countries are skyrocketing. It is not just the flu. It is a lot worse. South Korea, which has reported the lowest coronavirus death rates, has a COVID-19 death rate more than eight times higher than that of the flu. We are rapidly realising that inaction may mean death. The modelling and projections I am seeing is very concerning.

What can we do now?

Mitigate the spread. Slow the spread. Flatten the curve. The hospital system and health services can only cope with a fixed amount of resources. If we had a massive spike of COVID-19 cases, the hospitals will not be able to cope with the tsunami. There will be many deaths. But if we spread out the same number of cases over a longer period of time, the hospital will be better able to handle the wave. This is flattening the curve.

Practical steps:

Wash your hands. Do not steal alcohol hand sanitiser from hospitals or health care facilities. They need them! Soap and water for 20 seconds has been shown to be effective against the virus. Wash your hands as regularly as you possibly can.

Hand sanitiser with at least 60% alcohol is good but in short supply.

Do not touch your face. The virus enters through nose, mouth and eyes.

Reduce physical contact with others. Less than 15minutes face to face. Less than 2 hours in the same room. Keep a distance. No hand shakes. Wave.

Cough into your elbow. But don’t do an elbow handshake after that!

Do not touch public surfaces and properties (door handles, lift buttons, etc). Use a wipe, tissue, etc.

Wipe surfaces with alcohol, detergents, soap and water.

Avoid crowded places.

Close down big meetings.

Work from home if possible.

Stay at home.

Only do essential activities: essential work, health, finance, groceries, supplies, etc. No retail, shopping, amusement parks, etc.

Essentially quarantine yourself as much as you possibly can.

What do we do if we are in lock down like Italy?

There will be various levels of “lock down”. Essential services will continue to run, so do not worry, stockpile or hoard necessary items.

Look after each other. Phone calls, FaceTime, whatsapp, texts, email, social media. #SocialDistancing does not mean Social Isolation. With all the communication tools we have today we must continue to be engaged with each other.

Keep yourself mentally and physically healthy. Read books, meditate, write. Walk around the neighbourhood with your family. Talk on the phone more with people you have not spoken to due to your busyness.

Be kind and pay attention especially to those in the edges of your community. Do the grocery for the elderly family member. Provide practical help for single parents who have to stay home. Cook extra food for someone who can’t afford food as their work is closed down.

Do not overwhelm the health services with things that can wait. The health system needs to cope with COVID-19 tsunami. Attention and resources to non-urgents need to be devoted to COVID-19 cases. Do not overwhelm the front line clinicians (GP, Emergency, Respiratory units, Infectious Diseases, ICU etc.) One exhausted or ill doctor, nurse, clerk, physio, etc mean that some patients may not get the care they need.

If you’re an “Upstairs Clinician”, please support your front line “Downstairs” colleagues. You know what I mean. Watch out for burnout and exhaustion. There will be many emotionally challenging decisions that have to be made during this time. One ED, ICU, Respiratory Physician, or nurse is probably worth 10 ENT surgeons in this pandemic (personal value opinion 😉 )

Listen to your leaders. Not a time to argue over non-essential matters.

Learn from China, Hong Kong, Taiwan, Singapore, Japan, Italy.

Be kind.

Be kind.

Be kind.

We will get through this together. We can flatten the curve together and reduce the mortality rate from this pandemic.

Some helpful sites below. (I married an Infectious Diseases Specialist. I read what she reads. Thanks dear.)

Global Daily Update from WHO…/novel-coronavirus-2…/situation-reports

Global Stats

Australian stats

Local (Victoria) Daily Update from Chief Health Officer…

Local (Victoria) Info for the public

Coronavirus in children…

Coronavirus explained to kids by Nanogirl (NZ)

My favourite public health promotion video from this hilarious Italian Nonna

Practical Guide to self-isolation/quarantine




Tongue ties, Lip ties. Frequently asked questions.

I sincerely empathise with the many mothers who are struggling with breastfeeding and who are confused about the role of tongue ties in breastfeeding, swallowing, sleep and speech. I hope I can write something of value to help you navigate this issue. This is written as an opinion piece, not a scientific paper. This is an evolving subject and as more evidence is gathered, my opinion and practice patterns will change. For those clinicians (ENT surgeons, paediatricians, neonatologists, dentists, myofunctional therapist, speech pathologist, lactation consultant, etc.) scrutinising my opinion, please be mindful that in the midst of this clinical debate, we have a parent and a child who needs information and support. This is my personal opinion and not those of any organisations I am associated with. I am neither “anti” nor “pro” tongue and lip ties. I am pro better understanding of the condition. I am pro better care for the parent and child. I am pro better treatment for the child.


Who Am I?

I am a Paediatric Otolaryngologist and Adult Head & Neck surgeon in Melbourne, Australia. I trained in Melbourne and went on to do 3 years of fellowships in Canada, Brisbane and Auckland. I trained in Adult Head & Neck Cancer, Facial Plastic & Reconstructive Surgery, and Paediatric Otolaryngology. My area of focus is the Airway, Sleep and Head & Neck Tumours across the lifespan. I subspecialise in assessing and treating conditions of the airway, breathing, swallowing, sleep apnoea, salivary glands, and head & neck tumours. I am part of the complex airway team, saliva control team and vascular anomalies clinic at the Royal Children’s Hospital Melbourne. I have an Academic Tertiary Hospital appointment and a private practice. I share this with you so you know my perspective. I do turbinate reduction, sinus surgery, rhinoplasty, adenotonsillectomy, airway reconstruction, head & neck tumour excision, tongue base surgery, mandibulectomy, neck dissection, salivary gland surgery, and other complex head and neck surgery as required. I see tongue and lip tie as a small part of the big picture. I am obliged to take a global perspective and treat the whole child, not just the tongue tie.


What’s the trend?

Google trend analytics shows a markedly increased number of search of the word “tongue tie”. The Australian Medicare Benefits Schedule code for tongue tie release under 2 years of age has gone from 702 patients in the one year period of 1998-1999 to 9,714 in the 2017-2018 period.  This is not even accounting for procedures done in private dental clinics and wards that may not be recorded under MBS. From a literature evidence point of view, the number of yearly published articles on tongue ties have gone from 0-7 articles per year in the 70s and 80s to 27-44 articles per year in the last 5 years. Most of them are case reports, reviews and opinions. Only 8 randomised controlled trials and 10 systematic reviews have been published in the last 10 years.

There is an undeniable exponential increasing trend in tongue tie diagnosis and treatment. Is this because we are giving birth to more babies with tongue ties, or is it because of overdiagnosis and overtreatment? Or is it simply a better understanding of the condition? Just like any medical trend, we go through pendulum swings of underdiagnosis to overtreatment before finally arriving at an evidence based reasonable practice. Sadly there are, in some geographical and online communities, an overwhelming push for tongue and lip tie release procedures. Certain practitioners are strongly advocating for tongue tie release and charging a high fee for these procedures that may or may not be necessary. Performing procedures that may not be necessary is harmful for the child. On the other hand, some practitioners are declining all tongue tie referrals and therefore undertreating kids who may need the procedure. This also is harmful for the child, the mother and the breastfeeding dyad. I have seen some amazing results from tongue tie releases, but I’ve also seen some ordinary outcomes. I’ve seen many who are referred to me after having several procedures.


Where are you in the spectrum between super-believers and super-skeptics?

Please, if you are a medical, dental or allied health professional, be mindful of your own biases of overdiagnosis or underdiagnosis. There’s a lot we know and a lot we do not know yet about tongue and lip ties. Some of our strong beliefs may be founded on limited evidence.


What is a tongue tie?

Tongue tie (or tongue frenulum or ankyloglossia) is a band of tissue (fascia) between the floor of mouth and the underside of the tongue. Dr Nikki Mills from Auckland, New Zealand has performed meticulous anatomical dissection on this anatomical region1,2 (Disclosure: Dr Mills is a friend and colleague of mine). Her study shows various different configurations of tongue ties, some superficial, others much deeper while the tongue musculature and neurovascular bundle are situated extremely close to the mucosal surface. The terms anterior and posterior tongue tie are confusing. Posterior tie does not mean it is inserting to the posterior surface of the tongue. It is a band of fascia that is situated more posteriorly than the anterior tongue tie. You may not see it but you should be able to feel it when you challenge the tongue. The grades of tongue tie (Corrylos grading) has not been completely validated, meaning, we have not studied if different grades (or class) is related to different functional limitations. It’s a description, not a measure of severity.

What is confusing about these labels and grades is that in practice we sometimes think in black and white. Does the baby have or not have a tongue tie? Is the tongue tie anterior or posterior? This black and white thinking is not helpful. We all have tongue ties to a variable degree. We all have this frenulum to a certain degree. The question is whether that tongue tie is restrictive or not. Can I use the tonsils as a comparison here? We all have tonsils. Some have bigger tonsils than others. Some big tonsils do not cause trouble. Some small tonsils cause trouble. The size of our tonsils has not been shown to accurately be related to the severity of sleep apnoea. If I removed every tonsil I see, including the asymptomatic ones, then I’m unnecessarily overservicing and harming patients. If I decline all tonsil referrals as I do not believe tonsils cause trouble, then I am also causing harm to those patients I have declined to treat. I cannot set up a Tonsil Centre to remove every tonsil referred to me, neither can I refuse all tonsil referral. The tonsil has to be assessed in the context of the whole patient. The presence of a tongue tie does not necessarily mean that it is causing harm to the child. We need to look at the impact of the tongue tie on the child as a whole. We also need to appreciate and accept that some tongue ties are problematic and need to be released.


What’s the Impact of Tongue and Lip Tie?

There is also confusion around the impact of the tongue tie on suck, swallow, sleep and speech.  I would like to divide and simplify the impact into 2 general categories based on age: the infant and the older child. In the neonatal and infancy period, breastfeeding and latching is a critical function of the lip and tongue. In the older child, speech articulation and some association with sleep disordered breathing has been reported.

The baby who struggles with breastfeeding may have a tongue and/or lip tie, or they may have nasal obstruction or other possible neurological conditions. Suck – swallow-breathe reflex is an inherent reflex in an infant, so if there are limitations in the first few months, an assessment of the swallow and breathing needs to be performed by trained maternal child health nurse, lactation consultant, GP, neonatologist, paediatrician, paediatric ENT surgeon, speech pathologist or anyone else with experience. Lip tie may cause an incomplete and ineffective lip seal suction around the breast, a tongue tie may restrict the suction effect of the body of the tongue around the nipple.

In the older child, tongue tie may restrict the movement of the body of the tongue and it is thought that it positions the tongue lower down on the floor of the mouth therefore over time, resulting in a tongue that is positioned more posteriorly, a mandible that is retruded and a maxilla that takes a high arched roof position. These craniomaxillofacial changes area associated with obstructive sleep apnoea. Tongue tie in this situation may be an association, not a causation. To reverse these changes, the complete airway need to be assessed, not just the tongue tie. Releasing the tongue tie without dealing with the turbinates, septum, adenoids, tonsils or tongue base is missing the big picture.


So my child has a tongue tie. Do they need their tongue tie released?

Well, it depends on whether your child has symptoms such as difficulty latching, myofunctional disorder, obstructive sleep apnoea, or speech articulation issue. Your child needs an assessment by a GP, paediatrician, speech pathologist, dentist, lactation consultant, oromyofunctional therapist or paediatric ENT surgeon. I’ve got a tongue tie. I seem to be doing fine (ok, ok, some of you may disagree).


So my child has sleep apnoea. Do they need their tongue tie released?

Is it simple snoring, or true apnoeas? Is it allergic rhinitis causing mouth breathing or central sleep apnoea? Is it the tone of the tongue, the size of the tonsils, adenoids and turbinates? Be assessed completely by a specialist. Tongue tie may be an association and a confounder, not a cause of sleep apnoea. I have had kids referred to me for tongue tie release when their main issue is laryngomalacia or floppy larynx.


So my child has a lisp. Do they need their tongue tie released?

Is it a lisp, a stutter, an articulation error, a VPI speech or a hearing-impaired speech? Have your child assessed by a speech pathologist, audiologist, paediatrician, paediatric ENT surgeon or a specialist in the area. Sometimes, speech therapy is all you need.


So my child needs a tongue tie and upper lip tie release. What is your technique?

There is no particular technique that has been proven to be superior to others. At the end of the day, the tie has to be completely released to it’s deep attachments. These deep attachments may be between the fibres of genioglossus or intrinsic muscles of the tongue adjacent to the neurovascular bundle. There have been reported cases of significant complications when the muscle belly or vascular bundle has been cut inadvertently.


My personal technique: under General Anaesthesia and with the use of magnifying loupes I use scissors and fine bipolar diathermy at low wattage to ensure accuracy and prevent collateral thermal injury to the submandibular duct, sublingual glands and neurovascular bundle. By vision and palpation I divide the tongue tie fibres down to the muscle. I palpate for a complete give or release. I then close the mucosa over the area with dissolving sutures. Local anaesthetic is then infiltrated. Oral intake and tongue exercises are commenced immediately. They will be a little sore for 2-3 days but they can eat and drink normally, return to daily activities and commence tongue exercises immediately.


I am concerned about my child, what do I do next?

Many specialists do care. I have listed many options: Family Practitioners (GP), maternal child health nurse, lactation consultant, oromyofunctional therapist, speech therapist, paediatrician, dentist, ENT Surgeons, etc. There is good evidence that in the right patient for the right reason, tongue and upper lip tie release is effective in treating breastfeeding difficulty, speech and swallowing difficulties, and even sleep disordered breathing. We have to be careful though as this does not necessarily apply to every patient. As parents you have the best interest of your child at heart. Sometimes you need to see 2 or 3 specialists before arriving at the right advice that you are comfortable with. At the end of the day, you need to decide what is best for your child.


Concluding remarks

I hope I have given you some things to consider. This is not a perfect article. I do not have the perfect opinion. Many will disagree and that is fine. Ultimately my job as a paediatric ENT surgeon is to provide safe care, information and education. We need to do a lot more research in this arena. In the mean time I have a duty of care to provide the safest care to the child and parent in front of me based on my training and expertise in Paediatric Airway, Sleep and Head & Neck Surgery.