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Table of Contents
Year : 2020  |  Volume : 22  |  Issue : 2  |  Page : 45-49

Sensible awareness for otolaryngologist in managing aerodigestive foreign bodies in time of COVID-19

ENT Department, Bahrain Defence Force, Royal Medical Services, Military Hospital, Riffa, Bahrain

Date of Submission21-May-2020
Date of Decision27-Jun-2020
Date of Acceptance13-Jul-2020
Date of Web Publication30-Dec-2020

Correspondence Address:
Dr. Muneera Abdulla Al Khalifa
ENT Department, Bahrain Defence Force, Royal Medical Services, Military Hospital, Riffa
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SJOH.SJOH_20_20

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Background: In the time of COVID-19, the world came to a cease, however medical emergencies are ceaseless. Aerodigestive tract foreign bodies are one of the frequent emergencies in otolaryngology. Within the era of COVID-19, otolaryngologists have been documented to be at high risk of infection. Due to high viral load in the respiratory epithelium, the examination and extraction of foreign bodies in the aerodigestive tract places the otolaryngologist at high risk. Objective: The objective was to highlight the appropriate way of handling aerodigestive foreign bodies in the time of COVID-19 pandemic to insure safety of all involved medical staff. Methods: This was a systematic review of related international published guidelines. Results: A simplified flowchart is suggested to help guide the triaging of emergency patients with aerodigestive foreign body in the COVID-19-affected area. Conclusion: COVID-19 is a highly contagious infection that places health-care workers, especially the workers dealing with the aerodigestive tract at high risk. An appropriate management of these cases is essential to protect the health-care workers.

Keywords: Aerodigestive foreign bodies, COVID-19, otolaryngologist

How to cite this article:
Al Khalifa MA, Abdulkarim NY. Sensible awareness for otolaryngologist in managing aerodigestive foreign bodies in time of COVID-19. Saudi J Otorhinolaryngol Head Neck Surg 2020;22:45-9

How to cite this URL:
Al Khalifa MA, Abdulkarim NY. Sensible awareness for otolaryngologist in managing aerodigestive foreign bodies in time of COVID-19. Saudi J Otorhinolaryngol Head Neck Surg [serial online] 2020 [cited 2022 Dec 4];22:45-9. Available from: https://www.sjohns.org/text.asp?2020/22/2/45/305461

  Introduction Top

December 2019 marked the emergence of new respiratory disease that defies every existing criterion. In Wuhan, Hubei Province, China, a group of patients was diagnosed with acute respiratory distress syndrome. By January 2020, 41 admitted patients had been confirmed to have what was so-called novel coronavirus 2019 (nCoV-2019).[1] In February 2020, the World Health Organization selected COVID-19 as a title for the disease caused by severe acute respiratory syndrome coronavirus 2.[2]

Although the transmission modes of COVID-19 are still under investigation, one mode of transmission was conveyed by the World Health organization in their briefing in March 29, 2020. That is through droplets and close contact.[3] Respiratory droplets are droplet particles >5–10 μm in diameter and are transmitted within 1 m from the infected individual.[4] However, in the perspective of COVID-19, airborne transmission may occur in settings, which generate aerosols, such as nasal endoscopy, bronchoscopy, tracheostomy, and intubation.[3]

With the breakout of COVID-19, alarming figures of infection among the health-care workers started to show out. On February 24, the China's National Health Commission reported that 3387 health-care workers have confirmed infected COVID-19 with 0.6% deaths.[5] One month later, on March 26, 2020, 6414 health-care workers were reported to be infected by the Italian National Health Agency.[6]

Health-care workers involved in aerosol-generating procedures in the area of head and neck are considered at high risk for contracting COVID-19 infection. China Newsweek reported one of the first widespread incidents in Wuhan, among health-care workers. Where a patient underwent transsphenoidal endoscopic pituitary surgery in early January 2020 that resulted in the infection of more than 14 members of the health-care team.[7]

Various organizations and committees throughout the medical field stated practice guidelines to protect health-care workers during the pandemic of COVID-19. As many elective procedures and nonurgent cases are being withheld during the pandemic, a number of head and neck emergencies remain standing.

Foreign bodies in the aerodigestive tract account as one of the otolaryngology-related emergencies. Whether it is accidental or not, efficient care is warranted to avoid morbidity and mortality. In the time of COVID-19, special care is required when allocating foreign bodies in the aerodigestive tract, especially due to the high viral load in the respiratory epithelium.[8] In this article, relevant practice guidelines related to aerodigestive tract foreign bodies are reviewed. It is necessary to mention that these are presumably confirmed cases of aerodigestive foreign bodies that are referred to otolaryngologists by emergency physicians.

  General Consideration Top

Due to the high infectious rate of the COVID 19 whether patient is symptomatic or asymptomatic,[9],[10] all patients presenting to the emergency room in an endemic are should be suspected to have COVID19 until proven otherwise.

This is further emphasis in the pediatric age group where reported data showed that 25% of COVID-19-infected children might present with upper respiratory tract infection characteristics or 15% maybe asymptomatic.[11],[12]

A simplified flowchart is suggested here to help guide the triaging of emergency patients with aerodigestive foreign body in COVID-19-affected area [Figure 1]. The general condition of the patient plays a vital role. If the patient is unstable with compromised airway, then the health-care workers should manage the patient immediately after dispensing the highest COVID-19 personal protective equipment (PPE) available. A senior expert ought to manage the airway.[13] On the other hand, if the patient's condition is stable permitting time for COVID-19 screenings proceed with management after the test results. Since otolaryngology examination is considered high risk and due to the reported cases of the false-negative real-time reverse transcription polymerase chain reaction results, standard protection is always recommended even in confirmed non-COVID-19 patients.[14],[15],[16],[17]
Figure 1: Flowchart for aerodigestive tract foreign bodies' management

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  Personal Protective Equipment Top

Safeguarding and preservation of all health-care workers through reinforcement of hand hygiene, social distancing, and proper donning and doffing of PPE is crucial.[18] The Occupational Safety and Health Administration defined PPE as “specialized clothing or equipment, worn by an employee for protection against infectious materials.”

Constituents of PPE as recommended by the World Health Organization are as follows:[18]

  • Disposable gloves
  • Impervious gown/apron
  • Face shield/eye protection goggles
  • Filtering facepiece respirators 2 or 3 (FFP2/FFP3)/N95/powered air-purifying respirator.

PPE usage should be based on the risk of exposure to help preserve the supply and avoid shortage.[18] In circumstances where the depletion of the PPE is a standing problem, alternative strategies are suggested by the Centers for Disease Control and Prevention[19] and the World Health Organization.[18]

Nasal endoscopy, oropharyngeal examination, rigid esophagoscopy, and bronchoscopy are all considered high-risk procedures due to the risk of aerosol generation. Consequently, standard PPE is suggested in confirmed non-COVID-19 patients, and full aerosol PPE is recommended in patients with unknown COVID-19 status or confirmed COVID-19.[14],[15],[18],[20],[21],[22]

  Protection during Nasal or Oropharyngeal Foreign Body Removal Top

In cases that can be managed in the emergency room and are confirmed to beCOVID-19 free, standard PPE with disposable gloves, eye protection, N95/FFP2/ FFP3, and gown are commended. Video screen endoscopy is also advisable if needed to allow distance. When local anesthesia is warranted, it should be applied using carefully place pledgets with avoidance of sprays. All the equipment used has to be disinfected with care.[22],[23],[24]

In a patient that is suspected or confirmed COVID-19 and can be managed without general anesthesia, primarily place the patient in the isolation room. Insure the room is occupied with the least number of medical personals needed. The most senior expert is recommended to manage the patient while wearing disposable gloves, impervious gown, face shield/eye protection goggles, and filtering facepiece respirators (FFP2/FFP3)//N95/powered air-purifying respirator. Video endoscopes and disposable endoscopes are advised where available and needed. After removal of the foreign body, the patient is then handed to the infection control team for further management or guidance, with subsequent follow-up if necessary. All equipment and the room must be disinfected with cautious handling.[22],[23],[24]

  Protection during Rigid Esophageal, Bronchial, or Nasal/Oropharyngeal Foreign Bodies under General Anesthesia Top

General anesthesia is considered in settings where the aerodigestive tract foreign body removal failed under local anesthesia or in a pediatric patient. General anesthesia is also needed for bronchoscopy and esophagoscopy. The latter procedures are all considered high-risk aerosol-generating procedures.

Hence, in confirmed non-COVID-19 cases, the standard PPE as mentioned above is applicable for all involved staff. Furthermore, all mentioned procedures should be performed in negative pressure operating rooms. The current air exchange rates in each institute operating and procedure rooms should be noted to estimate the time interval needed for aerosol-generating procedures to be cleared.[21],[22],[23],[24]

In confirmed COVID-19 cases or unknown COVID-19 status, the patients' transfer in and out of the operation room must be handled with carefulness. Minimal number of staff with high expertise is required to conduct the procedure with the least operative time. Prior planning of each personal role is also essential. During intubation, only the anesthesia team should be in the room. Procedure must be conducted in the negative pressure operating room. In situations where negative pressure rooms are not available, the patient should be referred to a hospital where a negative room exists if applicable. If the patient's transfer is not possible, exceptional measures can be taken. As an illustration, the National Centre for Disease Control of India suggested in their COVID-19 outbreak guidelines to utilize 3–4 exhaust fans to create negative pressure by driving the air out of the room.[25]

All surgical staff must dispense disposable gloves, impervious gown, face shield/eye protection goggles, filtering facepiece respirators (FFP2/FFP3)/N95/powered air purifying respirator, and head cover. The infection control team is anticipated to manage the patient after successful removal of the foreign body with follow-up if required.[21],[22],[23],[24],[26]

  Conclusion Top

It is unmistakable that COVID-19 suspended routine otolaryngology procedures nonetheless emergencies can never be suspended. It is difficult times that no doubt require a strong health-care system. Beforehand planning and adherence to workplace guidelines will help protect the otolaryngologists that face a high risk of exposure in their work field.


We thank Dr. Mohammed Alshehabi and Dr. Mai Nasser for their contribution and support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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