First reported in Wuhan, China, on 31 December 2019, the outbreak of coronavirus 2019 constitutes the greatest public health emergency of this century. The international spread of the epidemic, mainly due to the extremely contagions nature of the SARS-CoV-2 virus, made it inevitable that the virus would actively circulate throughout France and put unprecedented pressure on health organizations. In common with many countries, one of the national health priorities has been to minimize person-to-person transmission, including among healthcare workers.
In the ENT field, clinical examination and invasive procedures on the respiratory tract and on airway-connected cavities (paranasal sinuses, middle ear) expose people to direct transmission of SARS-CoV-2 by inhalation of contaminated droplets or ocular projection, or to indirect transmission by contact with contaminated hands, surfaces or objects. Medical and surgical procedures are therefore considered to put practitioners and nursing staff at high risk when they come into contact with patients either confirmed or suspected to have Covid-19 [1] . In countries already affected by the pandemic, preparing for the epidemic wave or living with the virus, specific recommendations have been necessary to adapt ENT indications and medical-surgical procedures to the pandemic. In France, estimating an R0 of Covid-19 at around 3 justified postponing non-urgent face-to-face consultations and expanding the use of teleconsultation in order to limit the risks of SARS-CoV-2 infection of patients or health workers and comply with the lockdown. In response to Early Warning and Response System (EWRS) Messages from the This article proposes guidelines that will need to be adapted according to the region and preexisting arrangements. ENT specialists, in collaboration with the operational hygiene teams and all other specialties involved, should circulate these guidelines as appropriate for their organizations (dedicated treatment routes for Covid-positive patients, establishment of non-COVID-19 areas of the hospital) and adapt them as appropriate.
Faced with the outbreak of SARS-CoV-2 (pandemic phase of Covid-19), a recommendation was made in March 2020 to cancel all non-urgent surgical or medical ENT activity where this did not involve a loss of chance for the patient [2]. The purpose of this cancellation was to significantly increase critical care capacity, prioritize the reception of patients with Covid-19, prioritize the allocation of staff and provision of the equipment necessary for their medical or surgical management, and contribute to the smooth running of downstream critical care within their establishment or support for establishments mobilized by their territorial hospital groups (GHT) to respond to Covid-19. Another goal was to reduce the risks of patient and healthcare workers being contaminated within healthcare facilities.
These facilities are organized so that they can offer dedicated treatment routes for Covidpositive patients and have established non-COVID-19 areas of the hospital. In April 2020, the healthcare organization at the French Directorate-General for Health announced that it would be relying on pathways and cooperation between existing structures (GHT, public-private J o u r n a l P r e -p r o o f partnerships, etc.) or that need to be set up (surgical team from one establishment working in another establishment) in order to [3] :
 Mobilize surgical teams, both in hospitals and private practice  Organize access to fully-equipped operating theaters and post-anesthesia care units  Reserve post-surgical or post-anaesthetic beds, and if necessary medical beds, but also continuous monitoring, intensive care and critical care beds, follow-up and rehabilitative care or home care spaces, as appropriate depending on whether the patient's status is Covid-negative or Covid-positive.
Depending on the local context, treatment procedures adapted to available resources define the methods for conducting and returning PCR tests on patients suspected be infected [3] .
We recommend continuing to hold multidisciplinary consultation meetings for ENT oncology virtually (video or teleconference) to avoid delays in treating patients and prevent participants being exposed to the risk of infection [4] .
We recommend that minutes are written after a discussion with colleagues or multidisciplinary ethics committee meeting, should postponements pose complex clinical ethical questions [5] .
The French National Professional ENT Council (CNPORL) intends to answer questions from healthcare teams while helping to organize consultation meetings by digital means along with its ethics committee (ceorl@sforl.org).
At this stage where we are living with SARS-Cov-2, every precaution is taken so that patients not infected with the virus are received in the best possible conditions and the risk of contamination is avoided. There must be no withdrawal of essential care and the ENT specialist should resume contact with the most vulnerable patients to ensure they continue to be monitored and detect any risk of worsening of their illness (contact with the patient by video [4] [5] [6] , otologic and otoneurologic surgery [7] and paediatric surgery [8] .
Without claiming to be exhaustive, tables 1, 2 and 3 give examples of best practice advice in relation to which specific surgical activities should go ahead or be postponed during the pandemic. In addition, the indications for tonsillectomies which should not be postponed are listed in the paragraph below. Finally, it should be remembered that depending on what occurs during the teleconsultation, clinical examinations in the surgery or paraclinical examinations, the ENT specialist is still the one to decide whether hospitalization is required for medical or surgical treatment that has not been postponed.
In this ever-changing context of the Covid-19 pandemic where it is particularly difficult to take medical decisions, recommendations concerning treatments that should be continued or postponed have been published [6] or posted on the SFORL website regarding ENT cancer treatment [7, 8] , otologic and otoneurologic surgery [9] and paediatric surgery [10] . This advice applies to all surgical activity that is usually scheduled. Without exhaustively covering all 
It is advisable to check the COVID status of the patient shortly before surgery if he has signs suggestive of this infection (fever, cough, headache, myalgia, anosmia without nasal obstruction, dysgeusia, digestive disorders) or in case of ENT operations relating to the airway or its connected cavities (middle ear, paranasal sinuses), in particular endoscopies and oral, pharyngeal, laryngotracheal, endonasal, otological and otoneurological surgical procedures.
Indeed, these interventions are at high risk of contamination because they promote the aerosolization of SARS-CoV-2 [11, 12] . In the current pandemic context, untested patients should be considered infected, even in the absence of symptoms.
We recommend setting up an organization that will marshal a limited number of health professionals to deal with patients suspected to be infected, both possible and confirmed, to minimize exposure and use of personal protection equipment (PPE).
We recommend wearing PPE whenever entering the operating theatre. Health professionals in direct contact with patients should receive local training or a refresher course in techniques for putting on and removing their PPE given by the operational hygiene team [2]. Ideally, access should be restricted to the most experienced practitioners, with minimal access by health professionals still undergoing training and medical students [2].
All surfaces of the furniture in the operating theatre should be cleaned using bleach (ready-touse or dilutable) or using virucidal detergent/disinfectant products (standard EN 14476), to minimize virus transmission on people's hands [13] .
We recommend that healthcare workers treating patients who are possibly or certainly infected with SARS-Cov-2 take additional "air" and "contact" precautions (enhanced epidemic and biological risk (EBR) precautions), as outlined below [14, 15] : In addition to the mask and protective goggles, the local operational hygiene teams can provide face shields (helmets with transparent visors) to protect wearers from droplets and aerosols produced by the patient. These shields have the advantage of being able to be removed with minimal risk of touching the face. Both sides should therefore be cleaned regularly and staff should avoid bringing their hands to their face under the visor [16] .
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We recommend teamwork between anesthesiologists and surgeons to optimize the effectiveness of the precautions taken during airway procedures (intubation, extubation, ventilation,…) [12] .
ENT surgical procedures on the airway and on its connected cavities (middle ear, paranasal sinuses) involve a high risk of contamination because they encourage aerosolization of SARS-CoV-2 [11, 12] . This applies particularly to endoscopies and oral, pharyngeal, laryngotracheal, endonasal, otological and otoneurological surgical procedures.
We recommend that positive-pressure ventilation and filtration in operating theatres is maintained [13] .
The PPE should include: FFP2 (N95) mask, cap, eye protection (goggles and possibly helmet with transparent visor), long-sleeved impervious gown, gloves [14] .
Other specific surgical facilities (suspension of a transparent surgical drape above the patient) can be discussed with the local operational hygiene team to minimize aerosolization of contaminated tissue micro-fragments. Until we have more specific knowledge of the risks associated with SARS-Cov-2, use of electrosurgery (monopolar, bipolar, radiofrequency, coblation) and laser surgery should be treated with caution. The aerosolization of viral particles in the smoke plume generated by these technologies has indeed already been demonstrated [17, 18] .
• Adjust the mask with both hands to minimize leaks during periods of manual ventilation [19] • Avoid using high-flow nasal oxygen and high frequency jet ventilation Endonasal surgery [20] • Use instruments that minimize the risk of aerosolization or spray from tissue microfragments contaminated by the virus. Drilling and microdebriders should be avoided.
• Prioritize alternatives to the endonasal approach if they allow drilling or the use of the microdebrider to be avoided: external paracanthal paralateronasal or sublabial routes.
Otologic surgery [9] • Avoid drilling as much as possible since this might elicit aerosolization or spray from tissue micro-fragments that have been contaminated by SARS-Cov-2 [21, 22] Tonsillectomy and adenoidectomy (T & A) [10] • The indications to carry out T & A without delay in the current context of pandemic are enlarged tonsils and adenoids with severe obstructive sleep apnoea syndrome (OSAS).
In children, an additional argument to maintain the scheduling of this operation is the existence of comorbidities such as sickle cell anaemia where there is a risk of vasoocclusive crisis aggravated by OSAS [23] . In adults, tonsillectomy for severe OSAS can J o u r n a l P r e -p r o o f still go ahead, without prior sleep endoscopy, where there is a high probability of therapeutic success. This situation corresponds to Stage I of the Friedman classification which combines Grade 3/4 enlarged tonsils with a Grade ½ Mallampati score, without associated hypertrophy of the base of the tongue [24] . In this specific case, surgery would be preferable to starting continuous positive airway pressure (CPAP) treatment as the latter involves a risk of spreading the virus into the surrounding air [25] .
• No data is currently available concerning tropism of SARS-Cov-2 for the tonsils, nor on specific contamination risks linked to the various techniques (partial or total tonsillectomy) or instruments (electrocoagulation, radiofrequency, coblation, etc.) that might be used in a tonsillectomy. We do not therefore recommend altering the usual technique for this surgery, apart from the microdebrider whose use should be avoided in line with similar recommendations for endonasal surgery.
Key points of the organization of ENT surgical activity during the Covid-19 pandemic are summarized in box 1.
The proposals in this notice, resulting from collaboration between SFORL, SNORL and the College are based on currently available knowledge and are likely to be amended as scientific knowledge evolves concerning spread of the COVID-19 pandemic.
The authors declare that they have no competing interest.
The 10 key points of ENT surgical activity during the Covid-19 pandemic 1. Categorize procedures according to their degree of urgency 2. Assess the risks and benefits of all ENT surgical procedures according to the prevalence of COVID-19 and regional health conditions with regard to the pandemic 3. Defer any ENT surgical procedure whose postponement does not result in a loss of chance for the patient 4. In cases where the decision to postpone surgery is particularly tough, this decision should ideally be made after discussion with colleagues and notified with a written report. Multidisciplinary consultation meetings to discuss cancer management should be held virtually Table 1 . ENT cancer surgery: best practice advice in relation to the COVID-19 pandemic (adapted to take account of [7, 8] 