COVID-19 (coronavirus disease) - ENT, Hearing & Balance



Coronavirus disease (COVID-19) is caused by a new strain of Coronavirus (SARS-CoV-2) discovered in 2019 and not previously identified in humans. Common symptoms include fever, cough and shortness of breath. On 11 March 2020 the World Health Organization (WHO) declared the current COVID-19 outbreak a pandemic. 

For authoritative information about the science underpinning the epidemic see: https://coronavirusexplained.ukri.org/en.

Here we have gathered important resources, guidance and advice statements from international organizations and societies related to COVID-19, and the management of patients with ENT, hearing and balance problems by ENT and Audiology professionals. We are working on updating the information below as soon as new guidelines become available.  

Guidelines are underpinned by Evidence. In the current pandemic, high-quality evidence is sparse but that which is available is collected below. Information is also provided on new, emerging evidence from trials in progress and newly completed studies.

Guidelines

Many organizations, including professional bodies, are producing guidelines based on the best available evidence, however limited that may be. Here we provide a curated list of guidance relevant to ENT, hearing and balance problems in a variety of languages. We will expand and update this list as further guidance and evidence become available. If you are aware of other resources that should be included, please let us know.

General guidelines

Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) - CSO-HNS Position Paper on Sinus and Skull Base Surgery during the COVID-19 Pandemic (14/07/20)

ENT UK - COVID-19 pandemic and pregnancy for ENT trainees (06/07/2020)

British Association of Oral & Maxillofacial Surgeons (BAOMS) - Restarting elective OMF surgery COVID-19 recovery phase (08/06/2020)

CSO-HNS - Return to Otolaryngology-Head and Neck Surgery Clinical Practice During the COVID-19 Pandemic (23/05/2020)

ENT UK - Exiting the pandemic 3: a graduated return to elective ENT within the COVID-19 pandemic (20/05/2020)

ENT UK - Exiting the pandemic 2: consent and pre-operative assessment for ENT surgery (05/05/2020)

ENT UK - Exiting the pandemic 1: guidance for resuming ENT services (29/04/2020)

ENT UK - Telephone triaging guideline (17/04/2020)

ENT UK - Clinical guide to surgical prioritisation during the coronavirus pandemic (ENT specific) (17/04/2020)

Royal College of Surgeons of England (RCS) - Guidance for surgeons working during the COVID-19 pandemic (20/03/2020)

Personal protection equipment (PPE)

BAOMS - FP3 Masks With Valves should be avoided to reduce risk to patients during close interactions when a clinician is unknowingly COVID Positive (15/05/20)

ENT UK - FFP3 Masks With Valves should be avoided (14/5/2020)

BAOMS - Reuse of FFP3 and advice as we move from emergency to urgent care provision (22/04/20)

RCS - COVID-19: Good Practice for Surgeons and Surgical Teams (03/04/2020)

Public Health England - Guidance COVID-19 personal protective equipement (PPE) (02/04/2020)

Including advice on:

- Aerosal Generating procedures

- Operating theartres and operative procedures

- Collection of nasopharyngeal swab(s)

National Health Service (NHS) - Government Advice on PPE, Infection Control, Aerosol Generation from NHS (27/03/2020)

Centers for Disease Control and Prevention (CDC) - CDC recommendations on how to extend the life of N95 masks (27/03/2020)

ENT UK - PPE for the Covid-19 Pandemic Survey (26/03/2020)

ENT Canada - Guidance for Health Care Workers Performing Aerosol Generating Medical Procedures during COVID-19 Pandemic (26/03/2020)

ENT UK - FFP3 respirator usage: current ENT UK recommendations (25/03/2020)

ENT UK - Guidance PPE for patients with emergency oropharyngeal and nasopharyngeal conditions whose COVID status is unknown (25/03/2020)

ENT Canada - Personal Protective Measures in the Princess Margaret Head and Neck Cancer Clinic (24/03/2020)

Western Australia ENT - Recommendations for PPE for Aerosol Generating Procedures during COVID-19 pandemic (24/03/2020)

Boston Children's Hospital - N95 mask alternative (20/03/2020) (video)

BAOMS - Guidance for Personal Protective Equipement for OMFS Procedures during Covid19 Crisis (20/03/2020)

The Netherlands National Institute for Public Health and the Environment - N95 mask reprocessing (18/03/2020)

Decontamination of equipment

ENT UK - PPE for nasal endoscope decontamination during the COVID-19 pandemic (27/03/2020, updated 09/04/2020)

Specific guidelines

Conditions

Ear

ENT UK - Otology: a graduated return to the provision of elective ENT services during the COVID-19 pandemic (15/07/2020)

ENT UK - Surgical Prioritisation in Otology (02/07/2020)

ORL - Prioritizing otologic surgery during the COVID-19 Pandemic (14/04/2020)

BSHAA - Coronavirus - advice for practitioners (01/04/2020)

Audiology

BAA, BSA, BSHAA, AIHHP - Audiology and Otology Guidance during COVID 19 (01/05/2020)

ASHA - A COVID-19 Update from ASHA's Chief Staff Officer for Speech-Language Pathology (20/04/2020)

BAA, BSA, BSHAA, AIHHP - COVID-19 Audiology services during the pandemic: Joint guidance from the UK's professional bodies (09/04/2020)

BTA - Tinnitus Services and COVID-19

Please see materials provided by colleagues at the British Academy of Audiology (24/03/2020) and American Academy of Audiology

EHIMA - Coronavirus-pandemic: Message by the EIHMA President to professionals and users of hearing intruments (24/03/2020)

NHS England - COVID-19 prioritisation within community health services (20/03/2020)

Nose

AFR/SFORL - Consultations and medical treatments in rhinology in the context of the COVID-19 epidemic. Guideline of clinical practice of the French Association of Rhinology (AFR) and of the French Society of Otorhinolaryngology (SFORL) (14/04/2020)

ERS - Risk for Otorhinolaryngologists (01 to 04/04/2020)

Alteration in sense of smell/taste

ENT UK - Guideline for management of COVID-19 anosmia (19/05/2020)

American Academy of Otolaryngology - Head & Neck Surgery (AAO-HNS) - Anosmia, Hyposmia, and Dysgeusia Symptoms of Coronavirus Disease (22/03/2020)

ENT UK - Loss of sense of smell as a marker of COVID-19 infection (21/03/2020)

International Federation of Oto-Rhino-Laryngological Societies (IFOS) - Alerte anosmie COVID-19 (20/03/2020) (French)

Epistaxis

ENT UK - COVID-19 Epistaxis Management (25/03/2020)

Throat

British Laryngological Association (BLA) - BLA & ENT UK Guidelines (endorsed by RCSLT): A graduated return to elective activities for laryngology within the COVID-19 pandemic (17/04/2020)

Tonsilitis and quinsy

ENT UK - COVID-19 Adult Tonsillitis & Quinsy Guidelines (27/03/2020, updated 06/04/2020)

Head and neck

ENT UK - Exiting the pandemic - The Head and Neck Society (05/06/2020)

CAHNSO - Canadian Association of Head and Neck Surgical Oncology (CAHNSO) Guidelines for Management of Head & Neck Cancer During the COVID-19 Pandemic (03/04/2020)

SFORL - French Consensus on mangement of head and neck cancer surgery during COVID-19 pandemic. Guidelines of clinical pratice of the French Society of Head and Neck Carcinology and the French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL) (03/04/2020)

IFOS - Cancerérologie ORL et COVID-19: état des lieux (25/03/2020) (French)

ENT UK - Initial guidance for head and neck cancer management during Covid-19 (24/03/2020)

BAHNO - Proposed guidance for laryngectomy surgery during the COVID-19 pandemic (24/03/2020)

British Association of Endocrine & Thyroid Surgeons (BAETS) - BAETS statement on COVID-19 and Thyroid Cancer Services (24/03/2020)

ENT UK - Remote triaging of urgent suspected head and neck cancer referrals during Covid-19 pandemic (23/03/2020)

Kaiser Permanente Northern California - NCAL HN Oncological Surgery in COVID Era (22/03/2020)

BLA - Covid-19 Important Guidance (20/03/2020)

ENT UK - Initial guidance for head and neck cancer management during Covid19 pandemic (18/03/2020) - MEMBERS ONLY

University of Toronto - Pandemic Planning Clinical Guidelines for Patients with Cancer (10/03/2020)

Global Surgery - CovidSurg - Cancer

Procedures

Aerosol-generating procedures (AGP) in general

ENT UK - Ten key guidance points: Aerosol Generating Procedures (AGPs) within the ENT clinic (30/06/2020)

ENT UK - Aerosol Generating Procedures (AGPs) within the ENT clinic (09/06/2020)

ENT UK - Aerosol-generating procedures in ENT (23/03/2020)

Stanford University - COVID-91 Statement (20/03/2020)

Stanford University - Precautions for Endoscopic Transnasal Skull Base Surgery During the COVID-19 Pandemic

Tracheostomy

National Tracheostomy Safety Project (NTSP) - Multidisciplinary COVID-19 tracheostomy guidance (30/04/2020)

ENT UK - Management and care of tracheostomised patients with prolonged disorders of consciousness during the COVID-19 crisis (28/04/2020)

CSO-HNS - Recommendations from the CSO-HNS Taskforce on Post-Operative Care following Tracheotomy During the COVID-19 Pandemic (28/04/2020)

BLA (British Laryngological Society) - BLA tracheostomy guideline (15/04/2020)

SFORL - Tracheostomy in the context of COVID-19 positive patient, Guidelines of clinical pratice of the French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL) (03/04/2020)

SFORL - Post-tracheostomy care in the context of COVID-19 positive patient, Guidelines of clinical pratice of the French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL) (03/04/2020)

AAOHNS - Position Statement: Tracheostomy Recommendations During the COVID-19 Pandemic (27/03/2020)

CSO-HNS - Recommendations from the CSO-HNS Taskforce on Performance of Tracheotomy during the COVID-19 Pandemic (22/03/2020)

IFOS - Alert COVID-19 endoscopie et fibroscopic ORL, chirurgie endonasal, tracheotomie et soins de tracheotomie (21/03/2020) (French)

ENT UK - COVID-19 Tracheostomy Guidance (23/03/2020, updated 6/4/2020)

ENT Canada - Recommendations from the CSO-HNS Taskforce on Performance of Tracheostomy During the COVID-19 Pandemic (23/03/2020)

NTSP - NTSP considerations for tracheostomy in the Covid-19 outbreak (20/03/2020)

ENT UK - Tracheostomy guidance during the COVID-19 Pandemic (19/03/2020)

Wei WI et al. Safe tracheostomy for patients with severe acute respiratory syndrome*. Laryngoscope 2003:113;1777-9

Nasendoscopy and laryngoscopy

CNP ORL - ENT consultations and Flexible Nasoendoscopy / Laryngoscopy in the context COVID-19. Guidelines of clinical practice of the French ENT National Professional Committee (CNP ORL) (03/04/2020)

ENT UK - COVID-19 Adult Nasoendoscopy (FNE) and Possible Upper Aerodigestive Tract Fish Bone Investigation (01/04/2020)

Frauenfelder C, Butler C, Hartley B, Cochrane L, Jephson C, Nash R, et al. Practical insights for paediatric otolaryngology surgical cases and performing microlaryngobronchoscopy during the COVID-19 pandemic. Int J Pediatr Otorhinolaryngol. 2020;134:110030. doi:10.1016/j.ijporl.2020.110030

ENT UK - Nasal endoscopy and laryngoscopy examination of ENT patients (23/03/2020)

IFOS - Alert COVID-19 endoscopie et fibroscopic ORL, chirurgie endonasal, tracheotomie et soins de tracheotomie (21/03/2020) (French)

Otological procedures

ENT UK - Guidance for undertaking otological procedures during COVID-19 pandemic (25/03/2020)

Standford University - COVID-19 and Ear Surgery

Audiological diagnostic and therapeutic procedures

Please see materials provided by colleagues at the British Academy of Audiology.

Patient subgroups - paediatrics

ENT UK - A Graduated Return to Elective Paediatric ENT within the COVID-19 Pandemic (20/05/2020)

ENT UK - Paediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2 (PIMS-TS): What an ENT surgeon needs to know (19/05/2020)

ENT UK - Paediatric Tracheostomy and Tracheostomy Long-Term Ventilated Care during the COVID Pandemic (09/04/2020)

AFOP/SFORL - Pediatric Otorhinolaryngology and COVID-19. Guideline of clinical practice of the French Association of Pediatric Otorhinolaryngology (AFOP) and of the French Society of Otorhinolaryngology (SFORL) (08/04/2020)

ENT UK - Experience of a Paediatric Otolaryngologist: navigating the current challenges (26/03/2020)

BAPO - BAPO statement on SARS Cov2 and Paediatric Otolaryngology Provision (26/03/2020)

Frauenfelder C, Butler C, Hartley B, Cochrane L, Jephson C, Nash R, et al. Practical insights for paediatric otolaryngology surgical cases and performing microlaryngobronchoscopy during the COVID-19 pandemic. Int J Pediatr Otorhinolaryngol. 2020;134:110030. doi:10.1016/j.ijporl.2020.110030

This list has been compiled from a number of sources. These are detailed here.

Evidence

New evidence

New evidence from a variety of study types is likely to be published in the coming days and weeks.  Cochrane has launched a COVID-19 Register. Cochrane's COVID-19 Study Register is a freely-available, continually-updated, annotated reference collection of human studies on COVID-19, including interventional, observational, diagnostic, prognosticm, epidemiolgical, and economic designs.

Cochrane ENT, in collaboration with Cochrane Oral Health, is working on three fast-tracked systematic reviews of antimicrobial mouthwashes (gargling) and nasal sprays to protect patients and healthcare workers:

  1. Use of antimicrobial mouthwashes (gargling) and nasal sprays by healthcare workers to protect them when treating patients with suspected or confirmed COVID-19 infection (Protocol).
  2. Antimicrobial mouthwashes (gargling) and nasal sprays administered to patients with suspected or confirmed COVID-19 infection to improve patient outcomes and to protect healthcare workers treating them (Protocol).
  3. Antimicrobial mouthwashes (gargling) and nasal sprays to protect healthcare workers when undertaking aerosol-generating procedures (AGPs) on patients without suspected or confirmed COVID-19 infection (Protocol).

The full reviews are currently in peer review.

Trials in progress

For a register of COVID-19 related trials that are in progess and may – or may not – have yet published results (links are included when results are available) please see Covid-19 TrialsTracker.

Data from trials

Cochrane's partner Vivli is collecting and sharing data from COVID-19 related clinical trials (published data and individual patient data from published and unpublished trials); see here.

Existing evidence

There are many reliable sources of evidence that have been appraised and synthesised. These include the following:

Cochrane general COVID-19 resources and news

Cochrane has an extensive collection of resources related to COVID-19 and these are available here.

Cochrane COVID-19 Special Collections

Cochrane Special Collections, of relevance to the care of ENT, hearing and balance patients, are available as follows:

Cochrane COVID-19 Rapid Reviews

Cochrane is engaging with a range of stakeholders to build a bank of important questions emerging from the COVID-19 pandemic, including the World Health Organization (WHO), the Australian National Health and Medical Research Council (NHMRC), the UK National Institute for Health Research (NIHR) and the Brazilian Ministry of Health. The first 60 questions underwent a very early prioritisation process to allow work to begin immediately on urgent reviews. The remaining questions will undergo a rapid prioritisation process with stakeholders. The list of suggested topics can be found here. Some of these are underway, others will be prioritized for later completion.