Indian Journal of Health Sciences and Biomedical Research KLEU

REVIEW ARTICLE
Year
: 2021  |  Volume : 14  |  Issue : 1  |  Page : 3--11

Infection control measures during COVID-19 pandemic – An otorhinolaryngological and head-and-neck perspective


Santosh Kumar Swain, Sanjay Kumar 
 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India

Correspondence Address:
Dr. Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswa- 751 003, Odisha
India

Abstract

Otorhinolaryngologists and head-and-neck surgeons are considered as high-risk group of health-care workers due to their nature of work for exposure to the respiratory tract. During routine assessment and treatment of patients, otorhinolaryngologists and head-and-neck surgeons with their assisting staffs inevitably come in contact with secretions of the respiratory tract which may become aerosolized at time of the sneeze or cough. All otorhinolaryngology patients must be considered as potential carriers of COVID-19. A great emphasis must be given on the history such as flu-like symptoms, travel history, and contact history with potential carriers which will help triage patients into high risk. This review article discusses the infection control measures by otolaryngological and head-and-neck perspective during COVID-19 pandemic so will serve as template for otolaryngologists and head-and-neck specialist at the time of this outbreak.



How to cite this article:
Swain SK, Kumar S. Infection control measures during COVID-19 pandemic – An otorhinolaryngological and head-and-neck perspective.Indian J Health Sci Biomed Res 2021;14:3-11


How to cite this URL:
Swain SK, Kumar S. Infection control measures during COVID-19 pandemic – An otorhinolaryngological and head-and-neck perspective. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 May 10 ];14:3-11
Available from: https://www.ijournalhs.org/text.asp?2021/14/1/3/308956


Full Text



 Introduction



COVID-19 is an infectious condition of the respiratory tract caused due to the novel virus called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).[1] The World Health Organization (WHO) officially declared COVID-19 as a global pandemic on March 11, 2020.[2] COVID-19 patients often need otorhinolaryngology and head-and-neck consultations for different reasons ranging mild flu to tracheostomy. Otorhinolaryngologists play a vital role in treatment of the several concerned clinical manifestations of COVID-19 patients. Health-care workers have high chance for this viral infection, and there is mounting evidence that otorhinolaryngologists are one of the highest risk groups among the doctors and health-care workers.[2],[3] They have high-risk exposure due to dealing with upper airway regions such as nose, nasopharynx, oral cavity, oropharynx, larynx, and trachea. An asymptomatic patient may spread this infection through saliva where this patient acts as a potential carrier for COVID-19.[4] Hence, appropriate infection control measures are required to prevent the spread of infections to otorhinolaryngologists and assisting health-care workers. This objective of this review article is to discuss infection control measures in COVID-19 pandemic related to the otorhinolaryngological and head-and-neck surgical procedures along with its epidemiology and preventions.

 Methods of Literature Search



Current research articles regarding COVID-19 pandemic were searched through a multiple systematic approach. First, we conducted an online search of the Scopus, Pub Med, SCOPUS, Medline, and Google Scholar databases. The abstracts of the published articles were identified by this search method and other articles identified manually from citations. This manuscript reviews the details of infection control measures in COVID-19 pandemic related to the otorhinolaryngological and head-and-neck procedures along with its epidemiology and preventions. This review article presents a baseline for further prospective trials towards the controlling of the infections transmissions in clinical practice in relation to otorhinolaryngology and head-and-neck surgery. It will also help as a spur for further research in the COVID-19 infection and so protect from such fatal viral infection.

 Epidemiology



In the current pandemic, the global attention is mainly on the infected patients and frontline health-care workers. COVID-19 is a highly contagious infection of the respiratory system due to novel virus SARS-CoV-2. The first case of COVID-19 was reported in Wuhan, China, in late December 2019 where the outbreak of this novel coronavirus happened and now called SARS-CoV-2 which spread worldwide in short span of time. The death percentage among 2684 COVID-19-positive cases was around 2.84% as of January 25, 2020 and the median age of the patients who died was 75 (age range, 48–89 years).[5] By February 27, 2020, more than 82,000 COVID-19-positive cases and more than 2800 deaths have been documented, of which around 95% of the cases and 97% of deaths were in China.[6] By March 26, 2020, there were 462,684 cases of the COVID-19 documented in 199 countries.[7]

 COVID-19 Virus



Coronaviruses causing COVID-19 are large, encapsulated, or enveloped positive-strand RNA virus [Figure 1] which can be classified into four genera such as alpha, beta, delta, and gamma. Out of these four types, alpha and beta are known to infect human beings.[8] The size of coronavirus ranges from 60 nm to 140 nm with spike-like projection from the surface as a crown-like appearance under electron microscope, hence the name coronavirus.[9] The spikes over the surface of the virus are made up of glycoprotein, which act as critical for binding to the host cell receptors and play a vital role in severity of the infections of the host.[8] The majority of the human receptors for glycoprotein of this virus, human angiotensin-converting enzyme 2 are found mainly in the lower respiratory tract rather than the upper respiratory airway.[10] Because of the scarcity of the receptors in the upper respiratory tract, the clinical symptoms related to upper airway are less. The incubation period of COVID-19 ranges from 1 to 14 days with a median of 5–6 days. A recent study documents that the incubation period may extend to 24 days in COVID-19 infection.[10] A longer incubation has implication in quarantine policies and prevention of the spread of the disease. The SARS-CoV-2 virus is primarily transmitted via droplets. However, it is also seen in blood and stool, so it raises the questions regarding its multiple modes of transmission.[11]{Figure 1}

 Transmission of Infections



The primary mode of transmission of the COVID-19 is by droplet spread where the droplets carry virus.[12] In the United States of America, the community transmission was the major mode of transmission in March 2020. Because of the weight, the droplets stay airborne for a few seconds and move only a short distance before falling over the surfaces. However, during certain procedures such as bag-mask ventilation or during bronchoscopy procedure, the virus becomes aerosolized and increase chance of transmission. The airborne SARS-CoV-2 found to cause environmental contamination in COVID-19 patients inside the room with negative pressure with virus being seen on several surfaces including exhaust vents.[13] At beginning phase of this pandemic, a 41% rate of the nosocomial transmission was seen with health-care workers showing 29% of the patients.[14] Asymptomatic patient may spread by saliva which acts potential carriers for COVID-19.[4] In otolaryngological practice, health-care providers often use endoscopes for examining the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx. During performing the endoscopy, they have high chance to exposure of the respiratory or gastrointestinal fluids from the patients. Infection contaminated fluids from the patients may splatter during introducing or removal of the endoscope and doing precleaning. Patients' saliva may be contaminated with pillow or bed sheets during the procedure.[15] There is risk of infections for surgeon,assistants and anesthetist during performing the surgical procedures. The most common source of contracting the infection among health-care workers in India is workplace. In India, majority deceased (approximately 57%) were physicians and general practitioners, whereas approximately 27% of death were from different surgical fields.[16]

 Aerosol Generating Otorhinolaryngological Procedures



The aerosols generating interventional procedures include office-based nasal endoscopy, drainage of the peritonsillar abscess, placement of the nasal packing, foreign body removal from the nose and airway, tracheostomy, tracheostomy care, and powered instrumentation in mucosal part of the head-and-neck surgery.

 Endoscopic Sinus Surgery



The viral load of the SARS-CoV-2 is more inside the nasal cavity than in the oral cavity and oropharynx, regardless of the symptoms of the patient, i.e., patient is asymptomatic or symptomatic.[17] During endoscopic sinus surgery or endoscopic skull base surgery, there are possibilities of aerosolization of the mucus and virus including surgical instruments such as microdebrider, microdrill, and saline irrigation to nasal cavity and sinuses or for cleaning the nasal endoscope. This aerosolization enhances the risk to endoscopic sinus surgeons for transmission of the infections to otorhinolaryngologists.[18] Proper personal protective equipment (PPE) towards aerosol exposure must be used during such sinonasal surgeries and procedures at the outpatient department (OPD) during applying anesthetic and topical nasal decongestants through pledgets for diagnostic nasal endoscopy.[19]

 Tracheostomy



Performing tracheostomy on COVID-19 patients or suspected patients for COVID-19 imposes challenges not only to otorhinolaryngologists but also to the entire health-care team. If the tracheostomy is not an emergency, this can be reviewed by a multidisciplinary team and risk versus benefits of this surgery, and also the associated health-care team should be assessed. Bedside tracheostomy at the intensive care unit (ICU) with negative pressure is ideal for performing this procedure for needy patients. Negative pressure of the ICU with adjacent anterooms are suitable as these anterooms help to lower the escape of the infected air and also act as additional barriers for unnecessary entry of the health professionals without proper PPE. Bedside tracheostomy avoids unnecessary transport of the patients and frequent connections and disconnections of the ventilator circuits during transfer.[20] The bedside tracheostomy should be well planned at the ICU because of the limited space, below optimal positioning of the patient and limited transfer of the surgical instruments. In case of planning tracheostomy at the operating room (OR), it should be undertaken in negative OR at a well-demarcated area inside the OR complex with proper route for transferring the patients. During tracheostomy, patient is adequately sedated or even paralysed to eliminate the chance of coughing during the time of the procedure.[21] Ventilation should be paused (apnea) at the end-expiration when making the opening on the trachea where the ventilation circuit is disconnected. A nonfenestrated cuffed tracheostomy tube is better and keeps the cuff inflated to stop the spread of the virus through the upper airway. Tracheostomy suctioning should be done by a closed suction system with a viral filter. Heat moisture exchanger device can be used instead of tracheostomy collar at the time of the weaning for preventing virus spread or re-infection of the patient. Tracheostomy tube changing should be avoided until the viral load is as low as possible. In ICU patients with COVID-19 infections, early tracheostomy should be avoided because of the higher viral load. Early tracheostomy is not associated with improved mortality or less ICU stay.[21] Different studies showing tracheostomy in COVID-19 pandemic and its preventing measures to transmission of the infection to the health-care workers [Table 1].[22],[23],[24]{Table 1}

 Patient with Tracheostomy Tube



Tracheostomy tube of the patient should be covered by trach collar for preventing aerosol from trachea.[25] The tracheostomised patients in ICU who are connected with a closed ventilator circuit, standard droplet contact precautions should be used for a patient who endotracheally intubated with ventilator as appropriate. This type of closed strategy has been also used in Honk Kong in this current outbreak.[26]

 Microlaryngeal Surgery and Rigid Bronchoscopy



Microlaryngeal surgery, rigid bronchoscopy, and laryngotracheal reconstruction are very high-risk procedure during the current COVID-19 pandemic and make a high chance of the transmission of the infections to the otolaryngologists and head-and-neck surgeons because of the aerosol generation and prolonged gas flow.[25] Every effort should be made to shorten the procedure for minimal exposure of the virus to the health-care workers. Hence, only urgent airway procedures should be undertaken. All these airway patients should be treated as infective. There should be very minimal number of the expert persons present in the operation room for performing the procedure, so that it will prevent transmission of infection to other health-care personnel inside the theater. Adequate PPE must be used for all airway procedures (rigid bronchoscopy and laryngeal surgery) with suspected, unknown, or positive COVID-19 status. Routine direct laryngoscopy, bronchoscopy or tracheoscopy should be postponed in this COVID-19 pandemic specifically in stable patients without any airway symptoms.

 Head-and-Neck Cancer



Head-and-neck examinations often include handling of the mucous membrane such as oral cavity and sinonasal area. The examination of the head-and-neck cancer patient should be done by an experienced person as a more focused assessment needed in less time. During managing head-and-neck cancer, it is important to rule out the COVID-19 infection before going for radiotherapy. Patient must use mask. There should be separate new clinic for head-and-neck cancer patients for reducing transmission of infection between the staff, less time for patient appointment time and lower the patient-staff contact.[27] Endoscopic assessment of the sinonasal tract, oropharynx, hypopharynx, and larynx are important part of the head-and-neck examination procedures and these are routinely done by otolaryngologists with use of N95 mask, face shield and PPE. These procedures are considered as aerosol generating procedures. Hence, examination should be confined to the patients with clear indication. Proper doffing and disposal of the PPE must be done as per guidelines.

 Otologic Surgery



The upper airway respiratory mucosal lining is continuous with eustachian tube, middle ear, and mastoid air cells. Hence, the COVID-19 infections can spread easily to the mastoid and middle ear from the upper respiratory tract via eustachian tube.[28] Mastoid bone drilling produces droplets and aerosols with significant clouds. If a virus present in aerosols, it can infect all the OR staffs. The contaminated mist may be viable for several hours, particularly in closed spaces, so caution is warranted. This is why mastoidectomy is a high-risk surgery in this COVID-19 pandemic. Hence, any patient undergoing mastoid surgery or ear surgery should be tested for COVID-19 infection before surgery. Mastoidectomy is considered as a high-risk procedure. Hypotensive anesthesia is useful to reduce bleeding tendency which help to minimize the aerosolization by blood and mastoid fluids. Piezoelectric drill is an alternative for mastoid drilling and also reduces aerosolization.[28] If possible chisel and hammer can be used for cutting the mastoid bone. If the patient is positive, the ear surgery can be postponed till patient has negative from this disease.

 Facial Trauma



Otolaryngologists and head-and-neck surgeons often attend the trauma patients for managing the injury of the head-and-neck region. Management of the facial trauma is done on the basis of triage protocol. If the treatment of the facial trauma is required, treat the patient as COVID-19 positive and proceed with adequate PPE. Lacerations injuries in mucosal surface should be treated as high risk.[29] If surgery is planned for facial trauma, infection status of the patient should be confirmed first and then definitive surgery is done. In areas with shortage of medical capacity and manpower, nonoperative approaches can be considered as much as medically acceptable.

 Managing Epistaxis Patient



Before managing epistaxis patient, all patients should be considered as COVID-19 positive.[30] Full PPE should be worn by all the heath care personnel involved in the management of the epistaxis. Conservative management like pinching the nose and/or nasal packing along with controlling the co-morbidities should be tried immediately. If epistaxis persists, bilateral anterior or posterior nasal packing should be done. Surgical intervention should be avoided unless required.

 Pediatric Otolaryngology Patients



Many otorhinolaryngologists see pediatric patients. One study involving 72,314 patients at the Chinese Center for Disease Control and Prevention revealed <1% of the cases were in the pediatric age of 10 years or less.[6] Pediatric patients with COVID-19 infection usually have relatively minimal symptoms in comparison to adults and many are asymptomatic.[31] One study from a children's hospital of Wuhan, China documented 15% of the COVID-19-positive pediatric patients have no symptoms.[32] This data underscores the role of the pediatric patients in community transmission. Hence, the otolaryngologists should be aware of risk of the spread of infection from children to health-care workers and other patients. The patients should be separated at the waiting area. Furthermore, avoid nonurgent procedures and switch to the telehealth if feasible.

 Flexible Laryngoscopy



In COVID-19 pandemic, the flexible laryngoscopy shows a risk of the infections to the otolaryngologists, assisting staffs and also patients during this procedure. Otolaryngologists must maintain a distance from the patient who underwent the flexible laryngoscopy. Clinician should maintain hand hygiene before and after patient interaction in each case. The flexible laryngoscopy has restricted indications during COVID-19 pandemic as it has a high risk for viral transmission to the health-care workers and other surrounding personnel.[29] It should be only performed in critical condition of the patient such as airway obstruction to find out the site of obstructive pathology and doing some intervention in compromised airway. When performing such procedure, the otolaryngologists must wear the PPE such as filtering facepiece 2 mask, gown, head cap, face shield, and protective goggles. In case of flexible laryngoscopy, a small opening can be made on the mask for entry of the flexible laryngoscope and so the examiners can be protected from aerosols.

 Ear, Nose, and Throat Foreign Body Removal



Ear, nose, and throat (ENT) foreign bodies are common in pediatric age groups. If child comes with foreign body in the ear, nose, throat, or aerodigestive tract, the parents are usually with full of anxiety. The clinicians cannot defer the removal of the foreign bodies. All the efforts should be done to remove the foreign body from ear and nose in OPD itself. If the foreign bodies at the esophagus or tracheobronchial area, interventions should be done under general anesthesia.[30] This should be done with full PPE.

 Neck Abscess



Neck abscess should be managed at the minor OR adjacent to the OPD as it is possible. If there is progressive swelling of the neck abscess either at any part including retropharyngeal space requires surgical drainage with adequate PPE in the OR.[30]

 Acute Mastoiditis



Acute mastoiditis should be treated medically. If possible needle aspiration can be done for sub-periosteal abscess.[30] Computed tomography (CT) scan should be done only if the symptoms progress despite the conservative medications.

 Nasal Bone Fracture



In case of the undisplaced nasal bone fracture, treatment should be conservative. Intervention can be done under general anesthesia in case of a communicated displaced fracture or with nasal septal hematoma.

 Orbital Abscess



In case of orbital infection with normal vision, conservative treatment is employed. When the vision is deteriorating in orbital abscess/periorbital abscess and conservative treatment has failed, an external approach may be preferred over the endoscopic approach with adequate PPE.[30]

 Biopsy



Biopsy of the benign lesions is usually avoided in the current COVID-19 pandemic. Fine needle aspiration cytology can be done for the diagnosis. In case of laryngeal or hypo-pharyngeal primaries, endoscopic biopsy can be done. Image-guided (CT/ultrasonography) biopsies should be encouraged. Direct laryngoscopy for biopsy should not be recommended in this pandemic. However, it can be done with the use of appropriate PPE in case of need.[20]

 Bell's Palsy/Sudden Sensorineural Hearing Loss/Meniere's Disease



As per current literature, high doses of steroids are required in certain otorhinolaryngology conditions such as Bell's palsy or sudden sensorineural hearing loss or Meniere's disease. However, in case of patient with COVID-19 infections, such high-dose steroids are usually not recommended.[14] In such cases, intratympanic steroids are useful as in Meniere's disease or sudden sensorineural hearing loss. However, there are no studies regarding potential outcome of COVID-19 patients with intratympanic steroid. In usual practice of intratympanic steroid injection, the patient is to spit and not swallow for 20 min after the injection.[14] This spitting should be avoided during COVID-19 pandemic as spitting generates aerosol containing viruses.

 Intensive Care Unit



In ICU, all the health-care workers should wear full PPE. There should be no entry of any relatives of the patients. Barrier nursing technique should be employed.[30] The shifting of the patients in and out to be done by two teams where one team outside and one in inside. Biomedical waste disposal should be done with all care as per the local Government rule. Aerosol generating procedures in the ICU should be minimized or done with full PPE and N95 respirator. These procedures should be done in separate room for preventing exposure of the entire ICU.

 Otolaryngologists Dealing with High-Risk Patients



High-risk patients are patients with active SARS-CoV-2 infection, patient with influenza-like symptoms, and patients under evaluation for SARS-CoV-2 infection. In these cases, patient must use mask and health-care workers should use N95 mask, goggles or face shield and gown with double gloves.[33] The low-risk patients are those who are asymptomatic and untreated or SARS-CoV-2 negative in 48 h proceeding of the surgery if possible or test the patients within 48 h of the procedure. In low-risk patients, clinicians should wear N95 mask and eye protection by goggles or face shield with gowns and double gloves. In case of the soft tissue surgery, surgeon is exposed to the blood which can have a viral count, but if blood is not aerosolized by the use of the energy device, it will be expected as low risk. Suctioning the smoke and aerosolized tissue is recommended.[34] There is no study for infectiousness of the aerosolized blood with SARS-CoV-2 yet.

 Postsurgical Care



Proper care should be taken when doing external dressing and nasal endoscopic suctioning. In case of tracheostomy patient, avoid the use of high flow oxygen. During postoperative care, clinician should use full PPE as per hospital guideline. All the possible arrangement should be done for senior staffs to work in day time. After tracheostomy, postprocedure care plan should be properly done for protection of the other surrounding patients and health-care workers. Majority of the tracheostomy can be avoided or delayed even more than 2 weeks because of the high infectious risks of this procedure.[35] There should be proper care until the acute phase of infection has passed. Clinicians should avoid early tracheostomy of COVID-19 patients because of the high viral load that may be present at this period.[36]

 Precautions at the Outpatient Department



OPD of the Otolaryngology is the place which has high risk for exposure of health-care workers to respiratory pathogens. During routine evaluation and treatment of the patients at OPD, otolaryngologists, and other health-care workers will inevitably come in contact with respiratory secretions, saliva, or blood. Such things can also occur during nasal or laryngeal endoscopy. The Otolaryngologists or attached paramedical staffs above the age of 65 years should avoid seeing the patients. Persons with co-morbid conditions such as hypertension, diabetes mellitus, cardiac diseases, chronic kidney diseases, chronic liver diseases, chronic obstructive pulmonary disease, bronchial asthma, malignancies, and those under chemotherapy should avoid patients suffering from ENT diseases at the OPD.[37] Pregnant health-care workers also should not attend the OPD. Travel history, contact history, and temperature testing should be done at the place of registration. All the patients with cough, fever, and anosmia/hyposmia or dysgeusia should be referred to the Flu clinic. If the patient is adult, he or she should enter alone to the clinic at the time of visit to avoid gathering. Hand sanitizer should be present at the entrance place of the hospital/clinic. Patient is allowed inside the clinic only if he or she is wearing the face mask. If any diagnostic nasal endoscopy or fiber-optic nasopharyngolaryngoscopy required, it can be done through a tiny opening of the mask of the patient which prevent transmission of the aerosols from the patient [Figure 2]. Patients should maintain adequate distancing. Patients are also instructed not to touch any furniture, door handles, tabletops, etc., at the time of registration. The clinicians should avoid the use of mobile phones and laptop and try to keep minimum equipment in the consulting chamber. There should be frequent cleaning of the doorknobs and tables. The spectacles, eyewear, mobile, etc., should be sanitized after OPD time. Sanitization or fumigation of the consultation chamber should be done after OPD timing. If otolaryngologist came across with COVID-19-positive patients, should be quarantined for 14 days. However, using with adequate PPE and lack of infections, such quarantine is not required.{Figure 2}

 Personal Precautions for Clinicians



All the doctors and health-care workers should wear 3 layers surgical mask preferably N95 mask. They should wear goggle, face shield, and disposable examination gloves, OT gown (in case PPE not available) and shoe cover [Figure 3]. Clinicians should use hand sanitizers after examination of each patient. Clinicians should minimize the examination of the nasal cavity, oral cavity, oropharynx, and larynx. If any endoscopy is required, should be done with PPE. Clinicians should try to avoid air condition inside the consultation chamber and the room should be well ventilated, and door of the consulting room should be always open.[30] Each patient should wash their hands by sanitizer before entering the consultation chamber. There should be triage area in OPD which should be strictly maintained. The health-care workers such as otolaryngologists and paramedical staff working in the hospital should know details of the PPE. PPE is equipment and clothing designed for protecting the wearer from spread of infections or injury. The PPE (N95 mask, gown, gloves, and face shield) should be used by health-care workers during direct care to the COVID-19 patients.[38] When a health-care workers performing aerosol generating procedures on COVID-19 patients should use PPE (N95 mask, eye protection with goggles or head shields, gown, and gloves). When health-care workers visit the ward or room with COVID-19, should wear PPE (N95 mask, gowns, and gloves).[38] No PPE is required by any health-care workers during any activity which does not involve contact with COVID-19 patients. If patients have respiratory symptoms, health-care workers should maintain spatial distance of at least one meter and use medical mask.{Figure 3}

WHO calculated that approximately 89 million medical masks are needed for managing COVID-19 per month along with 76 million examination hand gloves and 1.6 million medical goggles (WHO2020).[39] This is a big financial implication towards the world economy.

 Conclusion



COVID-19 pandemic has put a tremendous impact on the entire society including doctors and other health-care workers. The clinical service providers on the frontline at hospital settings are at a great risk. Otolaryngologists and head-and-neck surgeons play an indispensable role in the management of the COVID-19 patients due to their nature work which are at high risk of exposure. They usually deal with nose, paranasal sinuses, nasopharynx, oropharynx, hypopharynx and larynx where viral load is high. This puts otorhinolaryngologists and head-and-neck surgeons at an increased risk of infections.COVID-19 pandemic has spread to more than two hundred countries of the world, so health-care workers particularly otorhinolaryngologists and head-and-neck surgeons are facing difficult situations for safety of their patients and themselves. They play a vital role in patient care during this pandemic where they are exposed to this dreaded infections due to their nature of their specialty. The use of appropriate PPE helps to prevent SARS-CoV-2 infection during the otorhinolaryngological procedures. Establishment of the strategies for otorhinolaryngological and head-and-neck surgical procedures is needed for prevention of surgeons, assisting staffs, and patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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