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July 30, 2020

Risk of SARS-CoV-2 Transmission During Flexible Laryngoscopy: A Systematic Review

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Tulane University, New Orleans, Louisiana
  • 2Tulane University School of Medicine, New Orleans, Louisiana
  • 3Health Sciences Center, Department of Otolaryngology–Head and Neck Surgery, Louisiana State University, New Orleans
JAMA Otolaryngol Head Neck Surg. Published online July 30, 2020. doi:10.1001/jamaoto.2020.1973
Key Points

Question  What is the evidence for minimizing the use of flexible laryngoscopy during the coronavirus disease 2019 pandemic?

Findings  This systematic review found a paucity of data regarding the risks of severe acute respiratory syndrome coronavirus 2 aerosolization and transmission during endoscopic procedures of the aerodigestive tract. Aggregate data suggested a decreased risk in endoscopic procedures compared with other aerosol-generating procedures such as intubation; use of proper personal protective equipment also diminished the risk for nosocomial transmission during upper airway procedures.

Meaning  Although more clinical and basic science research is needed to formalize conclusions, flexible laryngoscopy can likely be performed safely during the coronavirus disease 2019 pandemic with appropriate precautionary measures.


Importance  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reportedly infected otolaryngologists disproportionately in the early parts of the coronavirus disease 2019 pandemic. Recommendations from national and international health organizations suggest minimizing the use of flexible laryngoscopy as a result.

Objective  To review evidence on the risks of aerosolization and transmission of SARS-CoV-2 from patients to health care personnel during endoscopy of the upper aerodigestive tract.

Evidence Review  A comprehensive review of literature was performed on April 19, 2020, using the PubMed/MEDLINE (1966-April 2020), Embase (1975-April 2020), and Web of Science (1900-April 2020) databases. All English-language primary research studies were included if they assessed the transmission of SARS-CoV-2 or SARS-CoV-1 during procedures in the upper aerodigestive tract. The primary outcome measure was disease transmission among health care workers. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used for accuracy of reporting.

Findings  The queries for SARS-CoV-2 and SARS-CoV-1 identified 6 articles for systematic review. No studies included in this review provided data for SARS-CoV-2 transmission during flexible laryngoscopy. A total of 204 of 1264 health care workers (16.1%) had procedure-specific infections of SARS-CoV-1 or SARS-CoV-2. Among those, 53 of 221 (24.0%) were exposed during intubation, 1 of 15 (6.7%) during bronchoscopy, and 1 of 1 (100%) during endoscopy-assisted intubation.

Conclusions and Relevance  A substantial lack of research precludes formal conclusions about the safety of flexible laryngoscopy and transmission of SARS-CoV-2 from patients to health care workers. The use of appropriate precautionary measures and personal protective equipment appears to reduce the risk of transmission. Given the uncertainty in transmission and the known benefits of safety precautions, upper airway endoscopy may be reasonable to perform if precautionary steps are taken.

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