Eric Levi

UPDATE BELOW. It happened again the other day. I asked for an N95 mask for my airway operating list. One hospital provided, another said no. Yes, pre-op swabs are negative, but we know that there is a false negative rate and I spend 3-4 hours in multiple patients’ nose, oral cavity, oropharynx, larynx and trachea in one session. The risk for aerosolization is high and I, as the surgeon standing 15-30cm away from the patient’s mouth, am exposed. The mask has become yet another symbol. Not a symbol of freedom or anything, but a symbol of value and trust. How much does a hospital trust your clinical judgement as a frontline clinician?

I am an ENT surgeon. That means I spend a majority of my time face to face in clinic examining patients and performing awake flexible nasoendoscopies. In addition, I spend hours in the operating theatre debriding, cauterising, incising, suturing, debulking and manipulating the airway mucosa. This is the very definition of Aerosol Generating Procedure. Studies show that the viral load is high in the nasal, nasopharynx, oropharynx and tracheal secretions, which all happen to be my daily operating sites. In sinus surgery, oropharyngeal surgery such as tonsillectomy and in bronchoscopies, I am getting splashbacks of patient secretions on to my face mask and face shield. A rigid bronchoscopy or laryngeal surgery is probably the highest risk of aerosolization. The airway is open. Positive pressure ventilation is applied, and the air return is direct from the laryngotracheal lumen on to the surgeon’s face. I am inhaling the air that is expelled from the patient.

In the US, UK and Canada, the Otolaryngology Head & Neck Surgery Societies recommend N95 for all AGPs (links below). In Australia the ASOHNS (Australian Society of Otolaryngology Head & Neck Surgery) on recommendation from the Office of the Federal Chief Medical Officer only recommends standard surgical face mask for AGP (link below). This was back in April when case numbers were low. Here we are now in August in the heart of Melbourne outbreak having thousands of positive covid cases and more than a thousand active Health Care Worker infection. As the community numbers go up, the hospital admissions go up a couple of weeks later and health care worker numbers also follow.

On top of that, there are concerningly more data about COVID19 being an “opportunistic airborne” pathogen (short of calling it a true airborne pathogen), and the published data on the number of ENT surgeons around the world who have caught COVID and many who have succumbed to the disease (See link below).

What about the negative preop swab, you say? Well, the test is not 100% foolproof. There is a known false negative rate. A positive test is helpful to confirm and contact trace. A negative test is not a complete reassurance. One illustrative case in that paper was about a patient who had a mastoidectomy done who had a negative preop covid test. Surgery went on with standard precautions (not N95). The patient developed covid symptoms a few days post op. The patient and the surgeon were then tested and found to be covid positive. Unfortunately the surgeon died as they had comorbidities. This is tragic. Another case is that of a tracheostomy where 3 surgeons and 5 nurses subsequently tested positive.

AGPs are truly high-risk procedures for the surgical and anaesthetic team, even if the patient is low risk. Here in Melbourne our COVID numbers are high and there will be many asymptomatic carriers. As our Premier has said, “This is a public health bushfire, but we cannot smell the smoke or see the fire.”

I am not asking for the protocol for the whole country to be changed. The risk of an AGP as an ENT in Melbourne is much higher as compared to an ENT in Perth, Brisbane or Auckland. I am simply pleading for hospitals to understand that when a surgeon request an N95 for the team (7 staff members, 7 masks for the whole theatre session – we can put a standard mask over it to save money), it’s not to be fancy or to overreact. It’s because there is a real tangible risk. I would like my team performing a high risk AGP to be as safe as possible. What applies to ENT, also applies to Maxillofacial surgery, Dental surgery and any other respiratory mucosal interventions. None of us like wearing the N95. It’s uncomfortable. But we do it because it keeps us safe.

Please don’t say the evidence for N95 use is not strong. What evidence do you need more? Infected health care workers numbers? It’s a small financial investment that would potentially safe a few health care workers from being sick or being furloughed. Not for everyone, just for the high risk activities on covid unknown or covid negative patients. Melbourne today is not where Australia was back in April. We are geographically high risk now for the next few weeks/months.

I know I’m not a clever Public Health or Infectious Disease Physician who can interpret all sorts of epidemiological data, graphs and modelling. I am just a foot soldier on the front lines in people’s noses and mouths every single day. I hope requesting a mask from a hospital will not be met with resistance “Because the protocol says no.” My team down the bottom of the ladder here just need to know that we are valued enough that even an N95 is worth giving to us. We just want to go home safely to our families.

References.

American Guidelines. https://www.entnet.org/sites/default/files/uploads/guidance_for_return_to_practice_part_one_update_070120.pdf

Canadian Guidelines. https://www.entcanada.org/wp-content/uploads/Protocol-for-COVID-and-AGMP-3-iw-mailer.pdf

UK Guidelines. https://www.entuk.org/sites/default/files/COVID%20BAOMS%20and%20ENT%202nd%20update%20FINAL.pdf

https://www.gov.uk/government/publications/covid-19-personal-protective-equipment-use-for-aerosol-generating-procedures

Australian Guidelines. http://www.asohns.org.au/about-us/news-and-announcements/latest-news?article=88

High-Risk Aerosol Generating Procedures in COVID-19: Respiratory Protective Equipment Considerations.  https://www.entnet.org/sites/default/files/uploads/howard_high-risk_aerosol_generating_procedures_in_covid-19_respiratory_protective.pdf

Aerosol-generating otolaryngology procedures and the need for enhanced PPE during the COVID-19 pandemic: a literature review. https://journalotohns.biomedcentral.com/articles/10.1186/s40463-020-00424-7

International Registry of Otolaryngologist ‐ Head and Neck Surgeons with COVID‐19. https://onlinelibrary.wiley.com/doi/10.1002/alr.22677

 UPDATE 12th August 2020.

As of Monday 10th August, the Australian Society of Otolaryngology Head & Neck Surgery have upgraded their advice in line with the Federal Health Department Recommendations. N95 for AGPs.

http://www.asohns.org.au/about-us/news-and-announcements/latest-news?article=93

https://www.health.gov.au/sites/default/files/documents/2020/08/coronavirus-covid-19-guidance-on-the-use-of-personal-protective-equipment-by-health-care-workers-in-areas-with-significant-community-transmission-coronavirus-covid-19-guidance-on-the-use-of-personal-protective-equipment-by_0.pdf

The Victorian DHHS so far has not changed their advice (No N95 for AGP, covid clinic or hotel quarantine staff).

https://www.dhhs.vic.gov.au/personal-protective-equipment-ppe-covid-19

Let’s get some terminology correct. COVID19 is the disease. SARS-CoV2 is the specific name given to the actual new virus that has been identified as the cause of COVID19. SARS-Cov2 is a new novel virus from the Coronavirus family. In lay terms, coronavirus is the general term we use to refer to this virus. However, it is worth knowing that Coronaviruses are a large family of viruses that cause respiratory infections. These can range from the common cold to more serious diseases. COVID19 is a completely new disease. We have never met this virus before. Whatever we know about this virus is only 6 months old. We are still learning and discovering.

The virus, like any other virus, is a submicroscopic infectious agent that replicates inside the living cells of an organism. Virus needs a host and gets transmitted from host to host. As far as we know today, the SARS-CoV2 gets transmitted via droplets (not airborne based on current available evidence – which may change), meaning, it is not like a powder that floats in the air, but it travels in suspension form through mucous droplets. A sneeze or a cough can transfer the virus via droplets spread. This virus can hang around on surfaces and be passed on from hand to hand contact. Like any respiratory virus, it enters the mucosal lining of the airway (nose, mouth, throat) and possibly eye mucous membrane. There are studies showing that the virus is alive in mucous secretions, saliva and tracheal airway secretions. Once the virus enters the host through the airway lining, it appears to mainly affect the respiratory airway organs (nose, sinuses, throat, lungs), but in severe forms, the virus seem to also affect the blood system, the heart and other organs. Some autopsy studies show microemboli or small blood clots, affecting the brain, liver and heart.

Loss of taste and loss of smell are officially recognised as symptoms of COVID19. From the Australian Department of Health Website: “People with coronavirus may experience symptoms such as fever, respiratory symptoms (coughing, sore throat, shortness of breath) and other symptoms can include runny nose, headache, muscle or joint pains, nausea, diarrhoea, vomiting, loss of sense of smell, altered sense of taste, loss of appetite and fatigue.” The challenge is that smell and taste are subjective senses that are extremely difficult to scientifically measure, and not everyone with COVID19 will suffer from this deficiency. How good are most people in identifying reduced taste (hypogeusia), change in taste (dysgeusia), loss of taste (ageusia), reduced smell (hyposmia), change in smell (dysosmia), phantom smell (phantosmia) or loss of smell (anosmia).

Smell (olfactory) and taste (gustatory) are overlapping chemical senses. They rely on particles (odorants) to dissolve in respiratory mucous and bind to taste and smell receptors before being turned into an electrical signal that goes through the trigeminal and facial nerves to the brain. Complex magical scientific stuff. Taste and smell are culturally/socially driven and has various degrees of refinements in different people. What smells good to one person may not smell good to another. The taste palate of a sommelier will be very refined compared to a college student who lives on Mac and Cheese as routine. On top of that, we know that smell dysfunction affects 20% of the general population and is most commonly caused by sinonasal disease, upper respiratory tract infections, head trauma, normal aging, and neurodegeneration. Up to 45% of all anosmia in the general population are due to post-infectious cause (following a common cold, viral or bacterial sinusitis, etc.)

In this context, we meet a new virus that seem to attack the respiratory lining. No surprise that anosmia and ageusia are common presentation. One published study has attempted to design an anosmia reporting tool (Kaye et al Otolaryngology Head & Neck Surgery 2020). They found that anosmia was noted in 73% of patients prior to COVID19 diagnosis and was the initial symptom in 26.6%. Some improvement was noted in 27% of patients (average 7 days). About 85% of patients in their cohort improved within 2 weeks. Several similar studies show that anosmia and ageusia is hard to measure, not 100% accurate and has an uncertain progression in the disease. Another study (Meng et al. American Journal of Otolaryngology 2020) puts the rate of anosmia in COVID19 positive patients to be between 33.9% to 68%. Not everyone with anosmia has COVID19 and not everyone with COVID19 has anosmia. Anosmia is the initial symptom in a minority of patients with COVID19. Children are affected too. The good news is that it does not affect everyone. If it does, the effect seem to only last about 2 weeks for the vast majority of cases. Are there any long-term data on permanent loss of taste or smell? We do not know. The pandemic is only 6 months long and we certainly do not have any long-term data so far on anything related to COVID19.

What if one suffers from long term olfactory and gustatory dysfunction? Social anxiety, nutritional disturbances, and depression are well acknowledged consequences of smell disorders. Moreover, it has been suggested that olfactory function and depression are interdependent (Cummings Otolaryngology Head & Neck Surgery 2019). This means that identifying and treating olfactory and gustatory disorders become critical in the long run.

The stakes are even higher if the sufferer is a chef, food critique or wine professional. Smell and taste are the essence of their art and living. What can we do to help restore the sense of smell and taste in these professionals?

Let me be clear, there is a lot of data on general treatment for loss of smell and taste but none that is directly related to COVID19 anosmia and ageusia. We extrapolate the science to be applied to this particular context. Currently no specific data on successes or failures of any of these recommendations as it relates to COVID 19. But here are some thoughts extrapolated from anosmia research in the past:

1. Treat the COVID19. Get well from that. That’s the primary goal.
2. Loss of smell means inability to smell smoke or fire. Ensure that fire alarms and safety devices are available to warn the sufferer of danger.
3. Steroid oral medications and steroid nasal sprays have been shown to have some good effect for anosmia related to sinusitis. The results have not been universally perfect, but in general the treatment is safe and well tolerated. We do not have a strong scientific evidence to recommend a particular regime or dosing protocol. If smell and taste is critical, a trial of oral and nasal steroids could be considered if there are no contraindications. The nasal steroids need to be administered in Kaiteki position (Google it) to allow better delivery to the olfactory region high up on the roof of the nose.
4. Olfactory training for severe prolonged loss, or in the context of a smell and taste professional. Olfactory training is a therapeutic approach that involves repeated and deliberate sniffing of a set of odorants on a daily basis over a number of months (usually 3 to 9 months). One of the first studies in relation to the effects of repeated exposure was performed in 2004 using androstenone, and since this time numerous other studies have demonstrated beneficial effects in postinfectious, posttraumatic, idiopathic, and Parkinson-related olfactory dysfunction, as well as in healthy participants. At present, olfactory training is usually performed using four odorants, one from each of the following odor “categories”: flowery, fruity, spicy, and resinous. The current 4 odourants are: phenylethylalcohol (rose), eucalyptol (eucalyptus), citronellal (lemon), and eugenol (cloves). Twice daily for a minmum of 12 weeks, up to 32 weeks. A recent meta-analysis of 13 studies found that the duration of olfactory training was significantly related to its effectiveness (Hummel et al Position Paper on Olfactory Dysfunction https://www.rhinologyjournal.com/Documents/Supplements/supplement_26.pdf ). Quote from their paper : “Given the low associated cost and high safety of olfactory training, it is an attractive treatment modality, which can be employed with relative impunity.” This means that as long as you are not delivering dangerous chemicals up the nose, olfactory training is safe and will probably be beneficial.

Hope this answers some questions you may have in your mind. Remember:

Stay home if you can.

Stay masked if you have to leave the house.

Stay away from others.

We’ll get through this together.

37min overview on Management of Drooling/Sialorrhoea.

Aimed at Otolaryngology Head & Neck Surgery Trainees.

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This coronavirus pandemic has changed the way we live drastically. This coronavirus is forcing us to choose. To choose to confront ourselves in the stillness and quietness of our homes. When all the bells and whistles have been removed, when our conferences, meetings and speaking engagements have been stripped away from us, we are forced to face our own selves when no one is looking. We have been forced to be still. How are you?

We are all in difficult places. But even in our various forms of difficulties, we can choose to be positive despite the negativity. We can still choose authenticity rather than authoritarianism. We can choose collaboration and connection when we have very little control over what is occurring. We may not change our situations but we can choose to change the way we respond to these difficulties. We cannot control every single thing that happens around us, but we can collaborate and connect to get through all this together.

We’re all in this together. Choose to live well.

Evidence Based Medicine is the application of the best available evidence to the clinical problem at hand. We are living in a pandemic. We do not have the luxury of Randomised Controlled Trials. We do not have the luxury of prospective studies, time and resources. We use any good evidence we have, dissect it and see if it is fair and applicable. We rely on basic principles and extrapolate as necessary.

Here’s a paper that seems based on a good basic science foundation and appears to suggest a safe, cheap and readily available additional protection against the virus.

20200323 The use of Povidone Iodine nasal spray and mouthwash during the current COVID-19 pandemic Version 4.pdf

Your choice to take it up or not. You need to critique the evidence yourself.

Because of my front line exposure to examining and operating on patients whose noses and throats may be virus laden, I decided to do this simple nasal therapy.

The mixture has to be diluted. Also, ensure the betadine you’ve got is cleared for oral use/gargle. There are some preparation with phenol mix that should be avoided. Get 1 ml of Betadine (10% Providone Iodine) add 20mls of sterile water. Put the solution into a small nasal spray bottle. 2 sprays each nose, three times a day (before the morning session, right after lunch, and before reaching home). Simple, safe and may well be protective. Stings a little but that’s all.

We do so many online meetings and talks now. Here are 3 little tips to help you do well in front of your phone or computer.

Lights.

Camera.

Action.

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Lights

Keep a forward light directed on to your face. No back light. Natural light is great, make sure it’s from in front not from behind you. You can use a simple study table light shining at your face.

Camera

Keep your phone or computer camera at the same level as your eyes. Our tendency is to look down at the computer. Double chins and nostril hair! Elevate the computer on a platform or a stack of books or lower your seat. Put the phone on a tripod or prop it up on a stand. It’s easy. Changing the angle makes you look 100 times better. Also, please don’t move the camera. The people on the other side watching you camera shakes might get dizzy with all the movements you make.

Action

Look at the camera. Looking at your own image as you talk make you look to your listeners like you’re staring at something else. Get used to focusing on the camera. It also helps you to focus your thoughts as looking at your own image on the screen distracts you.

Other tips

In an online meeting or presentation, mute your microphone unless you need to talk. When listening to a presentation, you may also switch your video off so your image doesn’t distract the presentation and reduces the load on the wifi/servers. If you switch off your video in a presentation, you can do other stuff while you listen. In a meeting I would encourage you to have the video on so your presence and contribution in a meeting will be acknowledged.

Choose words carefully. Do not ramble on. It’s not exactly a normal face to face.

If you’re doing a presentation, you need to continue with creating emotion and intonation with your voice, but remember that your listeners are listening to you in their office, lounge or transport vehicles, avoid yelling and screaming. Speak like you’re speaking to a small intimate gathering.

If you’re a host of a meeting set the rules clearly about speaking in turns and allowing everyone a chance to speak.

Watch your background. Choose a virtual background if you needed to protect your room privacy.

Keep the environmental noise to minimum. Use headphones or ear pods to improve sound quality and stop you yelling at a computer. This also reduces the noise feedback that sometimes happen as the computer microphone captures its own speakers.

This is the simple set up on my desk. A cheap study light, an iPhone tripod and an elevated platform for the laptop.

Any other tips you’d like to add?

‪The nasopharynx goes back, not up. ‬

‪When you take a nasopharyngeal swab or insert nasogastric tube, NEVER aim upwards towards the brain. ‬

‪Go LOW and go SLOW.‬

‪Correct direction follows the floor of your nose not up towards the roof. ‬

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Some data out there would suggest that 10-15% of people who are infected by the coronavirus are health care workers (HCW). Let’s do a numbers game here. One nurse treats up to 4 patients. They’re the absolute front line. They spend hours caring for patients in close proximity. One allied health clinician or one doctor may be responsible for a handful of patients, somewhere in the order of 10-15 on the ward or up to 30 in a day in clinics. Knock one nurse out or one physiotherapist out or one anaesthetist or surgeon out and see the domino effect on health care service provision? One less nurse or doctor or clinician means a handful of patients are not getting the treatment they deserve. In addition, the remaining staff needs to take up the slack, putting the patients and staff at risk. I can see how difficult this is already in the emergency department where staff members have to be quarantined. One General Practitioner quarantined for 2 weeks would mean loss of service to hundreds of patients.

Now think about the ventilator capacity. Increasing ICU capacity is increasing care for the sickest of the sick. A ventilator is a machine that keeps breathing for the patient while the patient is intubated in an induced coma. These are reserved for the really sick patient. And so far, the mortality rate for intubated patients is in the order of 60% or more based on several papers.

Can you now see where the upstream and downstream challenge is? If we had all the money and time in the world to prepare for this pandemic we would increase all supplies of Personal Protective Equipment (PPEs) and increase ICU capacity all at the same time. But we don’t have time and we don’t have resources.

Which challenge should we prioritise?

The high complex end of delivering ventilators or the mass protection of all health staff with masks, gowns, gloves and face shields? I wonder if specific technical industries can be mobilised to produce ventilators while general industries can be mobilised to mass produce masks, gowns, gloves and face shields? Protecting health care worker means protecting the health service means providing timely efficient care means protecting the community. It’s all connected. It’s not just about the HCW. Ultimately it’s about keeping the patients safe.

I know that it’s a complex world. I know that this is all very challenging for every institution around the world. I know that it seems an oversimplification of the problem. I know that many people are already working on the solutions. I know that I’m asking a question so obvious that many would already have the answer. But help me. In this simple oversimplification of the problem comes ethical, clinical, leadership and resource challenges. There’s probably no simple answer. It’s a question that will be answered differently by different people in different countries. The reality is what limits our answers.

The most important asset in healthcare is its people. Do not lose the people keeping the care going.

How would you prioritise the solutions? I’m just a simple surgeon I need some suggestions.

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This pandemic is changing the world and changing us. This coronavirus has slowed us down and taught us to live differently, to live carefully. Live CARE-full-ly.

Things I do NOT miss: meetings, KPI, goals, budgets, admin, shopping, competition, keeping up with the Joneses, parties, conferences, presentations.

Things I miss: people, people, people.

Online telehealth clinics have taught me that my facial expression matters and words are precious.

Virtual meetings have taught me that we can communicate with less words.

Having completely zero social events on the calendar taught me the good and bad of just simply being with family.

Having no new fancy restaurants to visit taught me that the family dinner table is the most important engagement of love and sharing.

I feel that the rhythm of the planet has slowed down and finally my body and mind are in tune again. No more running to places. No more hurry. No more rushing.

I am still committed to my patients and my team. Whenever my team is on the forward line operating on virus-laden oronasopharyngeal mucosa, I am fully committed to the wellbeing of the patient and the safety of my crew. The intensity of focus at work is balanced by the solitude of rest at home. We are all in this together.

How is this pandemic changing you?

 

Here are a few fancy ENT words for you:

Olfactory (smell) disorder:

Anosmia: No smell (I can’t smell coffee)

Hyposmia: Reduced smell (I can smell coffee faintly)

Parosmia: Smelling a different smell (This coffee smells different)

Phantosmia: Smelling something that isn’t there (There’s a coffee smell but no coffee)

 

Gustatory (Taste) disorder:

Dysgeusia: dysfunction of taste

Parageusia: distortion of taste

Hypogeusia: reduced taste

Ageusia: No taste

ALSO, did you know that humans have 5 kinds of taste: sweet, salty, bitter, sour, umami (taste of MSG)

Read here from Europe the latest and so far the biggest study on smell and taste disorder in association with COVID19.

Key findings:

417 patients

85.6% had olfactory disorder, of which 79.6% of patients thought they were anosmic and 20.4% thought they were hyposmic. Phantosmia and parosmia concerned 12.6% and 32.4% respectively during illness.

The olfactory dysfunction appeared before (11.8%), after (65.4%) or at the same time as the appearance of general or ENT symptoms (22.8%).

The olfactory dysfunction persisted after the resolution of other symptoms in 63.0% of cases. For those who recovered their olfactory sense, 72.6% of these patients recovered smell within the first 8 days

88% gustatory disorder. Olfactory and gustatory disorders were constant and unchanged over the days in 72.8% of patients, whereas they fluctuated in 23.4% of patients.

Among the cured patients who had residual olfactory and/or gustatory dysfunction, 53.9% had isolated olfactory dysfunction, 22.5% had isolated gustatory dysfunction and 23.6% had both olfactory and gustatory dysfunctions.

What does this mean for us?
Keep an eye out for loss of smell as a possible early indicator prior to other symptoms. Resolution takes time. There’s still a lot we have yet to discover. Keep an open mind. This is not a protocol or policy. This is something we all should think about. Signals.

ENT Tips:

Check smell with coffee, mint, vinegar, chocolate lip balm, strawberry lip balm, etc. Check taste with salt, sugar, soya sauce (umami)