The risk for otolaryngologists, head and neck, and maxillofacial surgeons
The first reported physician fatality related to COVID-19 in Wuhan, China, was that of an otolaryngology physician on January 25, 2020.8 In Wuhan epidemic statistics, health workers represented 3.8% of the infected, 14.8% had severe disease and the overall mortality rate was of 0.6%.1, 4, 9 On the other hand, in Italy, 20% of responding healthcare workers were infected, and some have died. 10 People in contact with symptomatic patients, such as health personnel, are the most susceptible to infection. The most commonly infected healthcare personnel worked in general wards.11
Human-to-human spread occurs through respiratory secretions (although fecal-oral spread has also been confirmed) so healthcare personnel that manage patients with diseases of the aerodigestive tract (dentists, otolaryngologists, head and neck surgeons, gastroenterologists, pneumonologists, respiratory therapists, speech therapists, and infectious disease physicians) or ophthalmologists are the most susceptible healthcare workers to become infected (risk ratio of 2.13).1, 12, 13 Therefore it was rapidly recognized that there is a particular need for protective measures in these professional groups.14
In cases of COVID-19 patients with known respiratory disease, protective measures are usually followed by surgeons. However, a significant number of patients do not have fever nor respiratory symptoms (13-30%), so surgeons should apply respiratory protective strategies for all patients. This is especially true in tropical countries, were symptoms can simulate other viral infectious diseases such as dengue.15  The classical symptoms of the infection are fever, dry cough and shortness of breath. The syndrome rarely resembles a classical “cold” or with a runny nose that helps distinguish it from the common viral flu. Nonetheless, precautions must be taken for all patients with flu-like symptoms.
Recent reports from sites around the world have shown that anosmia and dysgeusia are significant symptoms associated with the COVID-19 pandemic. Anosmia, in particular, has been seen in patients ultimately testing positive for the coronavirus with no other symptoms. For this reason, the American Academy of Otolaryngology (AAO-HNSF) has proposed that these symptoms be added to the list of screening tools for possible COVID-19 infection. (https://www.entnet.org/content/aao-hns-anosmia-hyposmia-and-dysgeusia-symptoms-coronavirus-disease)
All procedures that have the potential to aerosolize aerodigestive secretions, such as nasolaryngoscopy, endotracheal intubation, non-invasive ventilation, transnasal endoscopic surgery and high-speed handpieces or ultrasonic instruments, increase the risk of infection and should be avoided or employed only when mandatory.1, 16 There is no information regarding any potential risk for electrocautery smoke or transoral laser resection generated smoke but it would be reasonable to take appropriate precautions in these settings too.
Due to the characteristics of the virus, the standard protective measures of daily workflow do not prevent the infection, and specific masks (N-95 or FFP2 or higher) or powered air-purifying respirator (PAPR), other PPE and dedicated sterilization measures should be implemented to avoid the infection.17, 18  However, one case series report that none of 41 health workers that had contact with aerosolized secretions of COVID-19 positive patients and employed standard PPE, developed an infection. It suggests that the rate of infection, when standard measures are employed, is considerably lower than when they are not used or are used improperly.12, 19 One of the more important reasons to explaining healthcare workers infection may be related to the lack of PPE and education about its correct use.9 It has been suggested that standard measures properly followed are more successful than the quick implementation of complex protection strategies.12, 20
Pregnancy, age over 55 years, some chronic diseases (chronic hepatitis, renal diseases, diabetes mellitus, autoimmune diseases and cancer) represent risk factors for developing severe acute respiratory distress syndrome (ARDS); affected health workers should not take care for infected patients.21 There is no information about intrauterine or transplacental transmission to the newborn.22, 23
The disease also imposes a physical, mental and emotional burden to healthcare workers.24 Most physicians caring for infected patients and for patients considered “suspicious” for infection become more quickly exhausted. There is also a specific risk associated with “health anxiety”;  a phenomenon defined as “anxiety that occurs when perceived sensations of changes  are interpreted as symptoms of being ill .”25 This occurs commonly in daily life, but in times of infectious diseases outbreaks, this phenomenon can produce detrimental effects. Today, (accurate, but often also incorrect) information about the clinical course, rate of complications and mortality of COVID-19 is incessantly emphasized and widespread through media and social networks. This increases the frequency and severity of health anxiety, characterized by catastrophic misinterpretation of sensations, wrong beliefs about the disease’s consequences and dysfunctional coping.25, 26 As more information is received and more ensues, excess anxiety results in a loss of the ability to make rational decisions. Specifically for surgeons, this situation could have two polar effects: firstly, some people may see doctors as a source of contagion and avoid them (and thus, medical assistance); secondly, other people may see them as source of security and visit them repeatedly, putting a further burden on strained health services. Both situations increase the risk for surgeons: in the first case, they can be threatened in public areas and in the second their capacity to help may be overwhelmed. An infection-related xenophobia is also a potential risk for foreign surgeon’s practice.11, 27
Finally, the impact of financial concerns of healthcare workers on their wellbeing and performance should not be underestimated.