Copyright © 2020 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Overview of Upper Airway Management During COVID-19 Outbreak: Head and Neck Surgeon’s Perspective Ahmad Al Omari, MD, FACS,  Ra’ed Al-Ashqar, MD,  Amjad Nuseir, MD,  Hassan AL Balas, MD, y Hadeel Allan, MD, z Yazan Kanaan, MD,  and Firas Alzoubi, MD  Abstract: At the end of December, 2019, a new virus was named severe acute respiratory syndrome coronavirus 2 appeared in Wuhan, China, and the disease caused is called as coronavirus disease 2019 (COVID-19) by World Health Organization, which to date having infected more than 3,588,773 people worldwide, as well as causing 247,503 deaths. A human to human transmission is thought to be predominantly by droplet spread, and direct contact with the patient or contaminated surfaces. This study aims to provide a comprehensive overview as well as to highlight essential evidence-based guidelines for how head and neck surgeon and healthcare providers need to take into consideration during their management of the upper airway during the COVID-19 pandemic safely and effectively to avoid the spread of the virus to the health provider. Key Words: Airway, coronavirus disease 2019, laryngoscopy, overview, pandemic, severe acute respiratory syndrome coronavirus 2, tracheostomy T he novel coronavirus disease 2019 (also known as COVID-19) pandemic has spread with remarkable speed, thus posing sig- nificant challenges for healthcare systems and healthcare workers around the world. 1 To date, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission is thought to be through respiratory droplets, direct contact with infected patients or sur- faces, or aerosol transmission. 2,3 Although there are many mani- festations of COVID-19, commonly including symptoms such as cough, sore throat, dyspnea, anosmia, and nasal congestion, it primarily presents as a (viral pneumonia), with patients frequently requiring urgent upper airway management. Thus, COVID-19 poses a unique challenge to the head and neck surgeons worldwide, as the basis of the head and neck surgeon’s job involves performing examination and procedures on the upper airway in close contact with the patient, exposing them to infected droplets and aerosols, and posing a significant threat to the operator. As such, head and neck surgeons require in depth knowledge about COVID-19 and SARS-CoV-2, as well as clear guidelines for how to manage upper airway disease during the SARS-CoV-2 pandemic, to minimize iatrogenic transmission of the disease and personal risk. This comprehensive overview will explore and highlight evidence based guidelines for how head and neck surgeon should manage the upper airway during the COVID-19 pandemic, from nasal and throat examination, fiberoptic laryngoscopy, diffi- cult intubation, and tracheostomies. TRANSMISSION The main route of transmission of SARS-CoV-2 from person to person is through respiratory droplets, released when an infected patient coughs or sneezes, or through close contact with respiratory secretions such as during ENT examination. 2 There is also evidence of environmental contamination by SARS-CoV-2, with the viable virus being detected in aerosols up to 3 hours after aerosolization, 4 hours on copper, 24 hours on cardboard, and 2 to 3 days on plastic and stainless steel, 2–4 as well as contamination of personal protec- tive equipment, 4 thus providing a source of infection through contact with contaminated surfaces followed by direct contact with the nasal cavity or oral cavity. While the average incubation period of the virus is around 4 to 5 days, 5,6 it is thought to reach up to 14 days. 6 As such, presymptomatic transmission of the virus poses a major challenge in controlling its spread, as presymptomatic patients may be infectious. 7 CLINICAL PRESENTATION The COVID-19 presents with a wide range of clinical manifesta- tions, the majority of which are ear, nose, and throat manifestations, as reported in numerous studies. Thus, head and neck surgeon need to be well informed on the possible head- and neck-related man- ifestations of COVID-19, and how to minimize the risk to them- selves when performing procedures on COVID-19 patients. Fever appears to be the most prevalent initial symptom of COVID- 19, followed by dry cough, fatigue and myalgia. 5,8–20 Less com- monly, patients may present with sputum production, hemoptysis, headache, diarrhea, dyspnea, sore throat, rhinorrhea, nasal conges- tion, 5,8–20 and even dizziness, 10 with cough being the most prevalent ear nose and throat (ENT) manifestation of COVID-19. 5,8–20 Multiple reports have also shown that hyposmia/anosmia and dysgeusia are common symptoms of COVID-19, be it in association with other symptoms, or with patients presenting with isolated anosmia and dysgeusia in the absence of other symptoms of the disease. 21–25 Reports from South Korea show that up to 30% of COVID-19 patients had anosmia as a major presenting symptom. In Germany, almost 2 in 3 confirmed patients have anosmia. 21 Other reports claim that between 20% and 60% of COVID-19 patients have some degree of loss of smell or taste. 23 CLINICAL DIAGNOSIS In the presence of clinical suspicion of SARS-CoV-2 infection (presence of common symptoms, recent travel or exposure to known COVID-19 patients), an accurate diagnosis of COVID-19 is critical to control the spread of the disease. Currently, the most commonly used test to diagnose SARS-CoV-2 is the real time reverse transcriptase polymerase chain reaction (RT-PCR) test. 2,26–34 Samples are most commonly taken using nasopharyngeal swabs, 2,26–28,30–34 although sputum, endotracheal aspirate, oropharyngeal swabs, and bronchoal- veolar lavage may be used as well. 27,30,31 While RT-PCR is thought to be highly specific for SARS-CoV-2, its sensitivity is under question, with some studies showing it to range from 60% to 70%. 28 Thus, to rule out SARS-CoV-2 infection, we should obtain at least 2 negative RT-PCR tests from the patient. From the  Otolaryngology Department, Faculty of Medicine, Jordan University of Science and Technology; y Faculty of Medicine, Yarmouk University; and z Family Medicine Department, Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan. Received May 12, 2020. Accepted for publication May 27, 2020. Address correspondence and reprint requests to Ahmad Al Omari, MD, FACS, Department of Special Surgery, Jordan University of Science and Technology, PO Box 3030, Irbid 22110,Jordan; E-mail: ahmedjoo79@gmail.com; aialomari@just.edu.jo The authors report no conflicts of interest. Copyright # 2020 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000006798 EDUCATIONAL SUPPLEMENT The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2020 1