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\begin{document}

\title{False-Positive RT-PCR Screening for SARS-CoV-2 in the Setting of Urgent
Head and Neck Surgery and Otolaryngologic Emergencies During the
Pandemic: Clinical Implications}



\author[1]{Francisco J. Civantos MD FACS}%
\affil[1]{University of Miami Miller School of Medicine}%


\vspace{-1em}



  
  \date{June 14, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: There are no reports regarding false positive reverse
transcriptase polymerase chain reaction (RT-PCR) for novel coronavirus
in preoperative screening.

Methods: Pre-operative patients had one or two nasopharyngeal swabs,
depending on low or high risk of viral transmission. Positive tests were
repeated.

Results: Forty-three of 52 patients required 2 or more pre-operative
tests. Four (9.3\%) had discrepant results (positive/negative). One of
these left the COVID unit against medical advice despite an orbital
abscess, with unknown true disease status. The remaining 3 of 42 (7.1\%)
had negative repeat RT-PCR. Although ultimately considered false
positives, one had been sent to a COVID-unit postoperatively, and two
had urgent surgery delayed. Assuming negative repeat RT-PCR, clear chest
imaging, and lack of subsequent symptoms represent the ``gold
standard'', RT-PCR specificity was 0.97.

Conclusions: If a false positive is suspected, we recommend chest
computed tomography and repeat RT-PCR. Validated immunoglobulin testing
may ultimately prove useful.%
\end{abstract}%



\sloppy


Andrew P. Katz MD\textsuperscript{1}, Francisco J. Civantos MD
FACS\textsuperscript{1}, Zoukaa Sargi MD MPH\textsuperscript{1}, Jason
M. Leibowitz MD FACS\textsuperscript{1}, Elizabeth Nicolli MD
FACS\textsuperscript{1}, Donald Weed MD FACS\textsuperscript{1},
Alexander E. Moskovitz BA\textsuperscript{1}, Alyssa M. Civantos
BA\textsuperscript{2}, David M. Andrews MD\textsuperscript{1}, Octavio
Martinez MD\textsuperscript{1}, Giovana R. Thomas MD
FACS\textsuperscript{1}

~

\textsuperscript{1}Department of Otolaryngology, University of Miami
Miller School of Medicine, Miami, FL

\textsuperscript{2}Perelman School of Medicine at the University of
Pennsylvania, Philadelphia, PA

~

\textbf{Address correspondence and reprint request to:}

Francisco J. Civantos MD FACS

Sylvester Medical Office Building

1121 NW 14 St Rm 320

Miami, FL 33136

Phone: (305) 243-5276, E-mail: fcivanto@med.miami.edu

~

\textbf{Brief Running Title:} False positive preoperative COVID-19 tests

\textbf{Keywords:} COVID-19, pandemic, head and neck surgery, RT-PCR,
preoperative testing

\textbf{Funding and conflicts of interests:} None

\textbf{Acknowledgements:} The authors would like to acknowledge
Alejandro Mantero PhD for assistance with statistical review.

\textbf{ABSTRACT}

~\textbf{Background:} There are no reports regarding false positive
reverse transcriptase polymerase chain reaction (RT-PCR) for novel
coronavirus in preoperative screening.

~

\textbf{Methods:} Pre-operative patients had one or two nasopharyngeal
swabs, depending on low or high risk of viral transmission. Positive
tests were repeated.

~

\textbf{Results:} Forty-three of 52 patients required 2 or more
pre-operative tests. Four (9.3\%) had discrepant results
(positive/negative). One of these left the COVID unit against medical
advice despite an orbital abscess, with unknown true disease status. The
remaining 3 of 42 (7.1\%) had negative repeat RT-PCR. Although
ultimately considered false positives, one had been sent to a COVID-unit
postoperatively, and two had urgent surgery delayed. Assuming negative
repeat RT-PCR, clear chest imaging, and lack of subsequent symptoms
represent the ``gold standard'', RT-PCR specificity was 0.97.

~

\textbf{Conclusions:} If a false positive is suspected, we recommend
chest computed tomography and repeat RT-PCR. Validated immunoglobulin
testing may ultimately prove useful.

\emph{}

\emph{INTRODUCTION}

The World Health Organization designated the COVID-19 Coronavirus
Disease outbreak as a global pandemic on March 11,
2020.\textsuperscript{1} Three days later the Surgeon General
recommended that all elective surgeries be cancelled, and on March 20,
2020, elective surgeries were banned in the state of
Florida.\textsuperscript{2,3} The rapid and deadly spread of this
pandemic has led to a reconsideration of traditional treatment paradigms
in head and neck surgery, with an emphasis on protecting both the
patient as well as the treatment team.\textsuperscript{4,5,6} The virus
responsible for COVID-19, SARS-CoV-2, poses a particular risk to
providers involved in the care of otolaryngology patients due to
examinations and surgeries involving the nasopharynx, oropharynx, and
upper aerodigestive tract, which harbor high concentrations of viral
particles. Instrumentation of these areas may aerosolize viral
particles, further increasing the risk of infection for any member of
the surgical team.\textsuperscript{7,8}

In an effort to ensure the safety of both patients and providers
requiring urgent otolaryngology surgeries, the University of Miami has
adopted protocols in order to triage patients prior to head and neck
surgeries.\textsuperscript{6} In line with other institutions across the
globe, these protocols call for preoperative testing of asymptomatic
patients using reverse transcriptase polymerase chain reaction (RT-PCR)
given reports of asymptomatic carriers of SARS-CoV-2 capable of
transmission.\textsuperscript{9-16} Reports of the sensitivity of the
RT-PCR are limited, and the studies have relatively small sample sizes;
however, sensitivity is reported between 63\% and
78\%.\textsuperscript{17-19} Few papers report the specificity, but
specificity has been cited as high as
98.8\%.\textsuperscript{17}Sensitivity changes depending on the site of
collection, with oropharyngeal swabs lower than nasopharyngeal swabs,
but sputum and bronchoalveolar lavage with sensitivity reported as high
as 72\% and 93\%, respectively.\textsuperscript{19} Importantly, these
numbers may differ between and even within institutions due to the wide
variety of testing platforms that have different molecular targets for
the virus particle. It remains unclear how sensitive and specific RT-PCR
tests are for detecting SARS-CoV-2 in asymptomatic patients in the
preoperative setting.

In this article, we discuss the importance of considering the potential
for false positive results when testing these patients. False positive
tests carry serious implications for preoperative patients and providers
and can lead to changes in patient care that would not otherwise have
occurred. Our objective is to share our experiences with false positive
test results during preoperative screening, discuss the implications for
our patients, and offer our recommendations regarding these
circumstances.

\emph{METHODS}

All surgical cases scheduled at our medical campus between March 30,
2020 and April 24, 2020 were reviewed. Before surgery, these cases had
been presented to and approved by a Surgical Review Committee and were
deemed either emergent or urgent. Departmental policy regarding
preoperative screening evolved over this time period but solidified by
the second week of this study (for detailed explanation of policies,
refer to Civantos et al.\textsuperscript{6}). For procedures involving
mucosa of the upper respiratory tract, which pose high-risk for
aerosolization of virus if present, two negative tests were required
preoperatively with the second test recommended within 24 hours of
surgery. For surgeries not involving mucosa (i.e., low risk), only one
negative preoperative test was required.

Patients were tested preoperatively for SARS-CoV-2 infection on
nasopharyngeal swabs using RT-PCR with at least one RNA primer approved
by the Food and Drug Administration for testing. At the beginning of the
study period, tests were outsourced to LabCorp (Burlington, NC) and
Quest Diagnostics (Secaucus, NJ) laboratories, with turnaround time of
five to seven days. As time progressed, the process was effectively
streamlined by hospital administration, laboratory administration and
personnel, and the preoperative department. RT-PCR was transitioned to
testing in our own hospitals, with turnaround time of four hours or
less. The in-house test systems and molecular targets can be found in
Table 1. Multiple platforms were kept available due to supply chain
shortages with all systems during the pandemic. Obtaining testing
cartridges, kits, and reagents were a challenge in South Florida from
mid-March until early May. Thus, in order to ensure that our ability to
run RT-PCR for SARS-CoV-2 was not interrupted, several platforms were
kept available at all times.

Patients with discrepant results were those who had different results on
the first two preoperative tests (i.e., one positive and one negative).
All patients were closely followed perioperatively by their surgeons and
members of the committee to ensure the safety of the patient and all
healthcare personnel involved.

Data was analyzed using univariate analyses: percentages were used to
summarize categorical outcomes and sensitivity was calculated to
determine test performance. The study was granted exemption by the
University of Miami Institutional Review Board.

\emph{RESULTS}

In the study period, 52 patients were scheduled for surgery, of which 45
(86.5\%) were ``high risk'' procedures for SARS-CoV-2 transmission.
Forty patients (76.9\%) had mucosal pathology (e.g., malignant neoplasm,
infection, inflammation); 37 patients (71.1\%) carried current diagnoses
of head and neck cancer, including mucosal and cutaneous malignancies.
Ten patients (19.2\%) had a prior history of radiation to the head and
neck. There was no significant difference in the makeup of the groups
with and without discrepant results with regard to mucosal pathology,
current cancer diagnoses, or history of radiation (Table 2).

Forty-three (82.7\%) patients had at least two preoperative tests
performed. A total of 102 tests were performed: 52 (51.0\%) were for the
first preoperative test, and 43 (42.2\%) were the second preoperative
test, when applicable. An additional seven tests were performed beyond
the two initial tests: 2 were for patients with 2 previously negative
tests, due to unrelated surgical delays; the remaining 5 were for
patients with conflicting results on the first two tests.

Of the 43 patients with more than one preoperative test, four patients
(9.3\%) had discrepant results on the first two tests, with the clinical
implications for each discussed below (Table 3). One of these patients
left against medical advice and thus his true disease status is unknown.
For the remaining three out of forty-two patients (7.1\%), repeat RT-PCR
testing was negative. They remained asymptomatic from COVID-19 official
symptomatology,\textsuperscript{20} and chest radiographs were clear
without signs of interstitial pneumonia. For two of these patients,
positive tests were re-reviewed by clinical pathologists, and tests were
found to have achieved positivity with titers that were borderline, just
over the cutoff values. All three of these patients were discussed by
multi-disciplinary teams including infectious disease specialists,
otolaryngologists, intensivists, pulmonologists, and pathologists, which
ultimately concluded that the positive test were false positives.
Assuming this determination is correct, and using prior and subsequent
negative RT-PCR, chest imaging and close follow up of clinical course as
the ``gold standard'' in the absence of a true gold standard test, the
calculated specificity of this test in asymptomatic patients in the
preoperative setting is 0.97.

\emph{Patient \#1 -- Late-March} : A 60-year-old male with buccal
squamous cell carcinoma required composite oral cavity resection, neck
dissection, and free flap reconstruction. At the time of this patient's
surgery, testing turnaround was at least 3 days. Four days prior to
scheduled surgery, the patient had a negative RT-PCR drawn as an
outpatient. On the morning of surgery, a second RT-PCR was drawn due to
a policy change requiring two tests before surgery. A positive result
was reported on postoperative day (POD) 3. Chest computed tomography
(CT) with contrast was normal. He was moved to a designated COVID-19
ward. A repeat RT-PCR was performed on POD 4 with a negative result
reported on POD 5, and the patient was transferred out the designated
ward. During that time, he remained asymptomatic with 2 normal chest
radiographs.\textsuperscript{6}

Over the next month he developed no symptoms to suggest COVID-19 and
repeat a CT chest was negative.

\emph{Patient \#2 -- Mid-April:} An 81-year-old female was transferred
for recurrent aspiration pneumonia. She had originally been treated for
oropharyngeal squamous cell carcinoma by definitive chemoradiation,
followed by salvage pharyngectomy and tongue base resection with neck
dissection, and radial forearm free flap reconstruction. Her
postoperative course after discharge had been complicated by a
nonfunctional larynx and recurrent aspiration pneumonias, with multiple
admissions to outside hospitals over several months. On her current
admission to an outside facility, the decision was made for transfer to
our hospital for narrow-field laryngectomy and pectoralis major flap as
treatment for recurrent aspiration. Prior to transfer, she had two
negative COVID-19 RT-PCR tests, and an additional negative test on the
day of arrival (hospital day 1) with plans for surgery on hospital day
3. On hospital day 2, a second RT-PCR was performed per departmental
protocol, and the result was positive. A third RT-PCR on the morning of
hospital day 3 was negative, however surgery was cancelled due to
discrepant results. Three additional tests were drawn between hospital
days 3 and 7, which were all negative. Multiple chest CTs were stable or
improved, although abnormal given her underlying history of recurrent
aspiration pneumonia over 6 months. Discussion with our clinical
pathologists revealed that the positive test was based on weakly
positive titers. Given the multiple repeat negative tests, this was
deemed a false positive, and surgery was performed on hospital day 7. As
a result of the positive test, surgery was delayed 4 days while the
patient remained an inpatient.

\emph{Patient \#3 -- Mid-to-late April:} 63-year-old female with
melanoma of the cheek requiring wide local excision and sentinel lymph
node biopsy. Four days prior to scheduled surgery, an outpatient RT-PCR
was done and resulted positive. Immediate discussion with pathology
colleagues revealed a weakly positive titer, just above the level
necessary to be considered positive. The positive test had been
conducted at the affiliated institution, and the negative test was at
her primary hospital. One option discussed was to delay surgery for
three weeks anticipating possible development of COVID-19 symptoms.
However, with a negative CT chest for metastatic workup in the days
before surgery, the decision was to repeat two additional RT-PCR tests.
These were performed the following day and were both negative. The
patient was completely asymptomatic. Surgery proceeded with a three-day
delay. The process was quite stressful for the patient, whose surgery
was already delayed by several weeks due to the pandemic, and the
reconstructive plastic surgery team had to reschedule other surgeries to
accommodate the new schedule. Over the next three weeks she developed no
symptoms of any type, and repeat CT chest was normal.

\emph{Patient \#4 -- Early April:} 20-year-old male with bilateral
pansinusitis complicated by unilateral orbital abscess and progressive
vision impairment with diffusely restricted extraocular movements and an
intraocular pressure of 41 mmHg. He was transferred from an outside
hospital without any testing or chest radiographs. On the day of
arrival, hospital day 1, RT-PCR was performed and was negative.
Intravenous antibiotics were instituted, and surgery was planned for
hospital day 4 to allow for preoperative COVID-19 testing. Since sinus
surgery was considered a high-risk procedure for SARS-CoV-2
transmission, a second RT-PCR was performed according to protocol and
unfortunately was positive. The patient remained asymptomatic other than
symptoms attributed to sinusitis and orbital abscess. Due to the
positive finding, surgery was delayed for further testing, and he was
transferred to a designated COVID-19 ward. Patient was uneasy about
being on this ward, and subsequently left against medical advice without
surgery on hospital day 5, refusing further workup. In telemedicine
follow-up three weeks later, he reported never having
coronavirus-associated symptoms; however, without additional workup his
true disease status is unknown. He has therefore been excluded from
statistical calculations related to the test. The patient reported that
his infection improved on oral antibiotics, and visual changes
normalized.

\emph{DISCUSSION}

Discrepancies in preoperative reverse transcriptase polymerase chain
reaction (RT-PCR) screening for SARS-CoV-2 can create major concerns
with regards to proceeding with otolaryngologic surgeries that are
medically urgent yet risky for SARS-CoV-2 transmission. Justified fear
for the safety of the patient and the healthcare providers involved in
the patient's care can cause significant changes to the course of care.
Lei et al. (2020) have reported that operating during the prodrome of
COVID-19 can lead to life-threatening complications. False negative
results are widely known to occur and are well-documented in the medical
literature, however nothing has been published about false positive
results.\textsuperscript{21} Therefore, when faced with patients with
suspected false positive results, our department and institution as a
whole were left with little guidance on how to proceed in these
circumstances. It would have been dangerous to providers to simply
assume the single positive result was spurious; likewise, delaying
urgent surgery for three weeks for what might be a spurious positive
result carried significant implications for the patient.

We turned to the expertise of several colleagues, including pathology,
radiology, and infectious disease, as well as internal departmental
experts who were part of the Surgical Review Committee. It seemed
reasonable that if repeat testing, multiple times in some instances, was
negative, we could declare patients as falsely positive and safely
proceed with surgery. Chest imaging, particularly computed tomography,
and subsequent clinical course also supported the determination that
these were false positives. These false positives tests were seen in a
clinically significant 7.1\% of our patients. As part of the decision
process, pathologists were able to re-review tests to report the titer
levels. Rather than accepting the results reported simply as
``detected'' or ``not detected'' in the electronic medical record, we
discussed suspicious cases to determine if titers were borderline
positive or strongly positive. We sparked conversation with infectious
disease physicians, pulmonologists, and particularly infectious disease
specialists who were now specializing in the care of COVID-19 positive
patients to seek expert opinions.

To our knowledge, there are no papers reporting false positive
SARS-CoV-2 RT-PCR tests. Tahamtan and Ardebili (2020) discuss possible
factors causing false negative results of SARS-CoV-2 RT-PCR, namely
mismatches between the testing primers and viral genome or low viral
loads in samples due to timing of disease or location of
collection.\textsuperscript{22} False positive RT-PCR for the diagnosis
of norovirus and dengue virus have been discussed, and indicate higher
rates of false positives for certain viral
targets.\textsuperscript{23-25} This supports repeat testing of patients
using a different testing platform with a different viral target for
more accurate testing when the result is questioned.

We hypothesize that mechanisms for generation of false positive results
for SARS-CoV-2 may include the following:

1) pure technical artifacts where fluorescence signal is generated due
to non-specific nuclease degradation of the probe probably associated
with off-target probe binding.~In short, a technical artifact.~This is
most likely associated with a weak positive signal.

2) detection of another non-SARS-CoV-2 virus/microorganism that has not
yet been accounted for in the global databases used to design the
primers/probes in these assays.~Recall that all of these assays are new.

3) technical cross-contamination at any point along the sample chain of
testing. If a manual pipetting step is involved, it could a technologist
who accidentally made an error.~In some instrument configurations, it
could be a sample carryover contamination event.~We tend to trust robots
and instruments, but they are not infallible.

Otolaryngology patients are unique in that the patient often has disease
involving the mucosa in the upper aerodigestive where the SARS-CoV-2
virus resides, and from which our nasopharyngeal swabs are obtained.
Changing the location in which the sample is obtained could be
considered. One of our patients, who was heavily irradiated in the area
swabbed, had a tracheostomy, and thus, a bronchioalveolar lavage would
have been easy to obtain. However, this was not performed. There has
been no previous discussion in the literature regarding whether local
mucosal cancer, infection, or inflammation can affect RT-PCR testing for
this disease. Individual history of radiation to the head and neck can
affect saliva production which may theoretically alter the ability of
nasopharyngeal swab to collect specimen. While there was no difference
seen in our groups regarding mucosal pathology, cancer diagnosis, or
history of radiation, our sample size is quite small and further
investigation is warranted. In any case, it would seem logical that
mucosal abnormalities would lead to false negatives more often than
false positives due to inadequate sampling.

Chest computed tomography (CT) has never been described as a tool for
screening asymptomatic preoperative patients with no history of COVID-19
exposure. It has, however, been discussed for its utility as both a sole
diagnostic test and as an adjunct along with RT-PCR. Findings of
COVID-19 have been reported as ground-glass opacities with segmental
consolidations; these overlap with many other pulmonary disease and
therefore on meta-analysis, pooled specificity and positive-predictive
value is low, 37\% and 1.5-30.7\%
respectively.\textsuperscript{26,27}Sensitivity of CT chest alone is
94-97\%, with a negative predictive value of 95.4 to 99.8\% in reports
out of China with high prevalance.\textsuperscript{26,28} Ai et al.
(2020) showed 75\% of patients with symptoms concerning for COVID-19 and
a negative RT-PCR but positive CT chest later converted to positive
RT-PCR.\textsuperscript{28} Individual case reports have similarly shown
the utility of chest CT as adjunct with RT-PCR to diagnose COVID-19 in
patients with negative RT-PCR.\textsuperscript{27,29}

There are reports of asymptomatic positive patients with classic CT
chest findings for COVID-19, however these patients were known to have
exposure to SARS-CoV-2.\textsuperscript{30,31} Between 70-100\% of
patients were found to have CT findings consistent with COVID-19, and
between one-fifth and one-fourth of patients later developed symptoms of
the disease. Our preoperative patients were asymptomatic with no known
history of direct COVID-19 exposure; their only risk factor was living
in a city during the ascending portion of the COVID-19 pandemic.
Regardless, these reports provide evidence for CT chest changes in
pre-symptomatic patients. It therefore seems reasonable that CT chest
can serve as an adjunct test to help providers determine if subclinical
infection could be present. This may assist with determining which of
the two results is false. A negative CT chest can help reassure
providers that the positive RT-PCR test is spurious and allow the
surgery to proceed as scheduled.

Among our four patients with discrepant results: five additional RT-PCR
tests were performed, two patients had surgery delayed 3 or 4 days each,
two patients were sent to COVID-19 designated units, and one patient
left against medical advice without surgery for an orbital abscess. As
the weeks progressed, we became familiar with the possibility of false
positive findings and had raised suspicions for when positive results
might indeed reflect false positives. In the most recent patient with
positive preoperative testing without symptoms (Patient \#3),
pathologists recommended immediate re-testing based on the borderline
titers in her test results rather than delaying surgery for weeks for a
potential COVID-19 infection. We were therefore able to move swiftly and
continue with the surgery, rather than delay for weeks anticipating a
clinical COVID-19 infection, which a more strongly positive test might
have required.

Prolonged inpatient stays pose risks for all patients at all times;
however, in the midst of the pandemic there are heightened risks.
Particularly for Patient \#2, who falls into a highly at-risk group due
both to age and underlying pulmonary disease, the importance of a
prolonged stay should not be minimized. Fortunately, we were familiar
with the possibility of false positives by the time that this patient's
positive test occurred, and we were able to keep her out of the COVID
unit until additional testing was performed and negative on three
further repeat tests. Placement in COVID-19 designated units, as seen
with the earlier cases of Patient \#1 and \#4, creates safety concerns
for both patients and providers. While COVID-specific units are
appropriate and necessary for the safe treatment of COVID-positive
patients, the misplacement of false positive patients in these units
exposes the patients to SARS-CoV-2 at an unnecessarily high rate.
Providers from the surgical team, who in ordinary circumstances would
not be in these high-risk units, are also placed in an environment with
increased risk of disease contraction for themselves and risk of
transmission to other patients. Moreover, our young and healthy patient
was so concerned about his placement in this high-risk ward that he left
against medical advice despite the risk of progressive vision loss. The
psychological effects of these wards on our surgical patients should not
be dismissed.

At this point in time, there is no ``gold standard'' test to which the
results of the RT-PCR can be compared, which limits the statistical
validity in the reporting a specificity. We therefore favor reporting a
probable false positive rate of 7.1\% in lieu of specificity, until such
a time that a more accurate test is available. However, if we are to use
chest imaging, close clinical follow up, and expert opinion as a gold
standard in the absence of a true gold standard, the specificity would
be 0.97. Classic statistical teaching is that a positive result in a
highly specific test, such as in this case, should rule in the disease.
However, we believe these test results must be considered as part of the
broader clinical picture.

Little data exists about the use of RT-PCR tests to screen preoperative
patients without symptoms of COVID-19. In the preoperative setting, the
use of a screening test such as RT-PCR for SARS-CoV-2 is faulty in that
screening tests have a higher accepted false positive rate, and the
pre-test probability of a positive test in these patients is already
low. Ideally there should be a confirmation test for positive results
with higher accuracy, and perhaps, once validated, testing for
immunoglobulins against SARS-CoV-2 can fill this role in the future. As
the prevalence of the disease continues to increase, concern over false
positives will increase as many providers become hesitant to consider a
test falsely positive. Unlike false positive tests in the general
population for whom this result would cause self-quarantine, unrealized
false positive tests in preoperative patients can have significant
clinical implications and interfere with urgent cancer surgery or other
emergency surgery.

\emph{CONCLUSION}

Recent experiences at our hospitals suggest that despite high
specificity of RT-PCR for SARS-CoV-2, positive screening tests in the
absence of other symptoms or classic findings of the disease should be
rigorously verified before urgent care is delayed. It is a disservice to
our patients not to remain vigilant to possible false positive tests as
the resultant clinical implications can jeopardize the safety of our
patients. We recommend a multidisciplinary approach for investigation,
including re-evaluation of RT-PCR titers by pathologists, repeating
RT-PCR on a different testing platform, and obtaining a CT of the chest,
particularly for patients who do not have other chest pathology. Testing
for immunoglobulins specific for SARS-CoV-2 antigens was not yet widely
available at the time of these interventions, but this may prove useful
as it becomes more readily available.

\emph{REFERENCES}

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\end{enumerate}

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\textbf{Hosted file}

\verb`Table_1_Targets.docx`  available at \url{https://authorea.com/users/312328/articles/452508-false-positive-rt-pcr-screening-for-sars-cov-2-in-the-setting-of-urgent-head-and-neck-surgery-and-otolaryngologic-emergencies-during-the-pandemic-clinical-implications}



\textbf{Hosted file}

\verb`Table_2_RTPCR.docx`  available at \url{https://authorea.com/users/312328/articles/452508-false-positive-rt-pcr-screening-for-sars-cov-2-in-the-setting-of-urgent-head-and-neck-surgery-and-otolaryngologic-emergencies-during-the-pandemic-clinical-implications}



\textbf{Hosted file}

\verb`Table_3_RTPCR.docx`  available at \url{https://authorea.com/users/312328/articles/452508-false-positive-rt-pcr-screening-for-sars-cov-2-in-the-setting-of-urgent-head-and-neck-surgery-and-otolaryngologic-emergencies-during-the-pandemic-clinical-implications}

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