[Updated March 26, 2020] CMS released a new statement on March 18, 2020, “CMS Adult Elective Surgery and Procedures Recommendations” intended to provide clarity and a framework for physicians and local facilities to make decisions relating to the performance of elective surgical and medical procedures. They recommend “Limiting all non-essential planned surgeries and procedures, including dental, until further notice” based on preservation of needed resources and the safety of patients and medical personnel. They included a table designed to give guidance to physicians and facilities on how to proceed based on situational acuity and the patient’s health. They make it clear that conditions will vary considerably in different areas of the United States. The agency has listed reasonable factors that should be considered in the decision-making process.
There is evolving evidence that otolaryngologists are among the highest risk group when performing upper airway surgeries and examinations. A high rate of transmission of COVID-19 to otolaryngologists has been reported from China, Italy, and Iran, many resulting in death.
Viral density is greatest in the nose and nasopharynx. Instrumentation in and through these areas would expectedly lead to increased risk. Surgery and endoscopic evaluation in these areas typically involves the application of various sprays, which can aerosolize the viral elements on the mucosa. During surgical procedures, the addition of powered debriders and shavers as well as drilling further promotes possible infectious microdroplet diffusion through the operating room or office.
While these recommendations do not specifically address procedures necessary in certain circumstances for a complete otolaryngologic exam, such as flexible laryngoscopy with or without stroboscopy and nasal endoscopy, these criteria can be extended to that type of procedure. Following personal verbal communication with CMS leadership yesterday, March 18, 2020, prior to the release of these recommendations, it was clear that they are in favor of utilizing the same principles outlined for surgical procedures to these examinations. This would favor delaying strictly routine examinations, while allowing examinations necessary based on the acuity of the situation and the availability of adequate PPE.
Given available evidence, including the incidence of false negative testing, we recommend extreme caution when advising procedures or surgery occurring through a transnasal or trans-oral route. Healthcare providers should practice standard universal precautions when evaluating and treating these anatomical areas. During in-office examinations, topical medications are more safely applied using pledgets rather than by spray. Unless emergent, surgical procedures should only be undertaken after ascertaining the COVID-19 status and then performed using either N95 respirator masks with either goggles or a face shield or PAPR.
Overall, these recommendations represent a well-thought-out process that offers flexibility based on specific patient needs and regional conditions. Please become familiar with this document and use it as a basis to aid in decision-making for each individual patient.