Download PDF
J Neurol Surg B Skull Base 2022; 83(02): 137-144
DOI: 10.1055/s-0040-1718768
Original Article

Aerosolization in Endoscopic Sinus Surgery and Risk Mitigation in the COVID-19 Era: A Scoping Review

Catherine F. Roy
1   Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
,
Emily Kay-Rivest
1   Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
,
Lily H.P. Nguyen
1   Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
2   Department of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada
,
Denis Sirhan
3   Department of Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montréal, Canada
,
Marc A. Tewfik
1   Department of Otolaryngology—Head and Neck Surgery, McGill University Health Centre, Montreal, Quebec, Canada
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Objective The continually evolving coronavirus disease 2019 (COVID-19) pandemic has created a dire need for rapid reorganization of health care delivery within surgical services. Ensuing initial reports of high infection rates following endoscopic sinus and skull base surgery, various expert and societal guidelines have emerged. We hereby provide a scoping review of the available literature on endoscopic sinus and skull base surgery, exploring both the risk of aerosolization and expert recommendations on surgical management during the pandemic.

Methods A literature search of the PubMed database was performed up until May 9th, 2020. Additionally, websites and published statements from otolaryngology associations were searched for recommendations. This scoping review followed the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews.

Results A total of 29 peer-reviewed publications and statements from expert recommendations or professional associations were included. Current expert guidance relies mainly on scarce, anecdotal evidence, and two cadaveric studies, which have demonstrated potential aerosolization during transnasal surgery. General consensus exists for delaying surgery when possible, ascertaining COVID-19 status preoperatively and donning of adequate personal protective equipment by all operating room staff (including at minimum an N95 mask). Cold, nonpowered surgical instruments are deemed the safest, while thermal instruments (electrocautery and laser) and high-speed drills should be minimized. Conflicting recommendations emerge for use of microdebriders.

Conclusion Endoscopic sinus and skull base surgery impart a potential risk of aerosolization. Hence, surgical indications, protective measures for health care workers, and surgical instrumentation must be adapted accordingly in the COVID-19 context.

Keywords

pituitary surgery - skull base surgery - aerosolization - endoscopic sinus surgery - COVID-19


Publication History

Received: 15 May 2020

Accepted: 03 September 2020

Article published online:
04 December 2020

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Patel ZM, Fernandez-Miranda J, Hwang PH. et al. Letter: precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic. Neurosurgery 2020; 87 (01) E66-E67
    CrossrefPubMedGoogle Scholar
  • 2 Zhu W, Huang X, Zhao H, Jiang X. A COVID-19 patient who underwent endonasal endoscopic pituitary adenoma resection: a case report. Neurosurgery 2020; 87 (02) E140-E146
    CrossrefPubMedGoogle Scholar
  • 3 Huang X, Zhu W, Zhao H, Jiang X. In reply: precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic. Neurosurgery 2020; 87 (02) E160-E161
    CrossrefPubMedGoogle Scholar
  • 4 Zou L, Ruan F, Huang M. et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020; 382 (12) 1177-1179
    CrossrefPubMedGoogle Scholar
  • 5 Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19 and the otolaryngologist: preliminary evidence-based review. Laryngoscope 2020; 130 (11) 2537-2543
    CrossrefPubMedGoogle Scholar
  • 6 van Doremalen N, Bushmaker T, Morris DH. et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med 2020; 382 (16) 1564-1567
    CrossrefPubMedGoogle Scholar
  • 7 Tricco AC, Lillie E, Zarin W. et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169 (07) 467-473
    CrossrefPubMedGoogle Scholar
  • 8 Workman AD, Welling DB, Carter BS. et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies. Int Forum Allergy Rhinol 2020; 10 (07) 798-805
    CrossrefPubMedGoogle Scholar
  • 9 Kohanski MA, Palmer JN, Cohen NA. Aerosol or droplet: critical definitions in the COVID-19 era. Int Forum Allergy Rhinol 2020; 10 (08) 968-969
    CrossrefPubMedGoogle Scholar
  • 10 Workman AD, Jafari A, Welling DB. et al. Airborne aerosol generation during endonasal procedures in the era of COVID-19: risks and recommendations. Otolaryngol Head Neck Surg 2020; 163 (03) 465-470
    CrossrefPubMedGoogle Scholar
  • 11 David AP, Jiam NT, Reither JM, Gurrola II JG, Aghi MK, El-Sayed IH. Endoscopic skull base and transoral surgery during COVID-19 pandemic: minimizing droplet spread with negative-pressure otolaryngology viral isolation drape. Head Neck 2020; 42 (07) 1577-1582
    CrossrefPubMedGoogle Scholar
  • 12 Patel ZM, Fernandez-Miranda J, Hwang PH. et al. In reply: precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic. Neurosurgery 2020; 87 (02) E162-E163
    CrossrefPubMedGoogle Scholar
  • 13 Givi B, Schiff BA, Chinn SB. et al. Safety recommendations for evaluation and surgery of the head and neck during the COVID-19 Pandemic. JAMA Otolaryngol Head Neck Surg 2020; 146 (06) 579-584
    CrossrefPubMedGoogle Scholar
  • 14 American Academy of Otolaryngology—Head and Neck Surgery. Academy Supports CMS, Offers Specific Nasal Policy. Published March 26, 2020. Accessed May 6, 2020 at: www.entnet.org/content/academy-supports-cms-offers-specific-nasal-policy
    PubMedGoogle Scholar
  • 15 Castelnuovo P, Turri-Zanoni M, Karligkiotis A. et al; Italian Skull Base Society Board, Italian Skull Base Society Board (Società Italiana Basicranio [SIB]). Skull-base surgery during the COVID-19 pandemic: the Italian Skull Base Society recommendations. Int Forum Allergy Rhinol 2020; 10 (08) 963-967
    CrossrefPubMedGoogle Scholar
  • 16 Couloigner V, Schmerber S, Nicollas R. et al; French Society of Otorhinolaryngology, Head, Neck Surgery (SFORL), French College of Otorhinolaryngology, Head, Neck Surgery, French Syndicate of ENT Specialists (SNORL). COVID-19 and ENT surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137 (03) 161-166
    CrossrefPubMedGoogle Scholar
  • 17 Mitchell RA, King JAJ, Goldschlager T, Wang YY. Impact of COVID-19 on pituitary surgery. ANZ J Surg 2020; 90 (06) 963-964
    CrossrefPubMedGoogle Scholar
  • 18 Van Gerven L, Hellings PW, Cox T. et al. Personal protection and delivery of rhinologic and endoscopic skull base procedures during the COVID-19 outbreak. Rhinology 2020; 58 (03) 289-294
    CrossrefPubMedGoogle Scholar
  • 19 Canadian Society of Otolaryngology Head and Neck Surgery Executive Committee. Guidance for Health Care Workers Performing Aerosol Generating Medical Procedures during the COVID-19 Pandemic. Published March 26, 2020. Accessed May 6, 2020 at: www.entcanada.org/wp-content/uploads/Protocol-for-COVID-and-AGMP-3-iw-mailer.pdf
    PubMedGoogle Scholar
  • 20 Fleseriu M, Dekkers OM, Karavitaki N. Endocrinology in the time of COVID-19: management of pituitary tumours. Eur J Endocrinol 2020; 183 (01) G17-G23
    CrossrefPubMedGoogle Scholar
  • 21 Daci R, Natarajan SK, Johnson MD. Letter: safety considerations for neurosurgical procedures during the COVID-19 pandemic. Neurosurgery 2020; 87 (02) E239-E240
    CrossrefPubMedGoogle Scholar
  • 22 Zacharia BE, Eichberg DG, Ivan ME. et al. Letter: surgical management of brain tumor patients in the COVID-19 era. Neurosurgery 2020; 87 (02) E197-E200
    CrossrefPubMedGoogle Scholar
  • 23 Frauenfelder C, Butler C, Hartley B. et al. Practical insights for paediatric otolaryngology surgical cases and performing microlaryngobronchoscopy during the COVID-19 pandemic. Int J Pediatr Otorhinolaryngol 2020; 134: 110030
    CrossrefPubMedGoogle Scholar
  • 24 Radulesco T, Verillaud B, Béquignon E. et al; French Association of Rhinology (AFR), French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL). COVID-19 and rhinology, from the consultation room to the operating theatre. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137 (04) 309-314
    CrossrefPubMedGoogle Scholar
  • 25 Ramakrishna R, Zadeh G, Sheehan JP, Aghi MK. Inpatient and outpatient case prioritization for patients with neuro-oncologic disease amid the COVID-19 pandemic: general guidance for neuro-oncology practitioners from the AANS/CNS Tumor Section and Society for Neuro-Oncology. J Neurooncol 2020; 147 (03) 525-529
    CrossrefPubMedGoogle Scholar
  • 26 Kolias A, Tysome J, Donnelly N. et al. A safe approach to surgery for pituitary and skull base lesions during the COVID-19 pandemic. Acta Neurochir (Wien) 2020; 162 (07) 1509-1511
    CrossrefPubMedGoogle Scholar
  • 27 Bann DV, Patel VA, Saadi R. et al. Best practice recommendations for pediatric otolaryngology during the COVID-19 pandemic. Otolaryngol Head Neck Surg 2020; 162 (06) 783-794
    CrossrefPubMedGoogle Scholar
  • 28 Fang Y, Zhang H, Xie J. et al. Sensitivity of chest CT for COVID-19: comparison to RT-PCR. Radiology 2020; 296 (02) E115-E117
    CrossrefPubMedGoogle Scholar
  • 29 Patel ZM. Reflections and new developments within the COVID-19 pandemic. Int Forum Allergy Rhinol 2020; 10 (05) 587-588
    CrossrefPubMedGoogle Scholar
  • 30 Mady LJ, Kubik MW, Baddour K, Snyderman CH, Rowan NR. Consideration of povidone-iodine as a public health intervention for COVID-19: utilization as “personal protective equipment” for frontline providers exposed in high-risk head and neck and skull base oncology care. Oral Oncol 2020; 105: 104724
    CrossrefPubMedGoogle Scholar
  • 31 Centers for Disease Control and Prevention. Summary of changes to the guidance. Published April 13, 2020. Accessed May 7, 2020 at: www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html
    PubMedGoogle Scholar
  • 32 ENT UK. Guidelines for changes in ENT during COVID-19 pandemic. Published March 20, 2020. Accessed May 7, 2020 at: www.entuk.org/entuk-guidelines-changes-ent-during-covid-19-pandemic
    PubMedGoogle Scholar
  • 33 Kessler RA, Zimering J, Gilligan J. et al. Neurosurgical management of brain and spine tumors in the COVID-19 era: an institutional experience from the epicenter of the pandemic. J Neurooncol 2020; 148 (02) 211-219
    CrossrefPubMedGoogle Scholar
  • 34 Pierce JS, Lacey SE, Lippert JF, Lopez R, Franke JE. Laser-generated air contaminants from medical laser applications: a state-of-the-science review of exposure characterization, health effects, and control. J Occup Environ Hyg 2011; 8 (07) 447-466
    CrossrefPubMedGoogle Scholar
  • 35 Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? a systematic review. Surg Endosc 2013; 27 (09) 3100-3107
    CrossrefPubMedGoogle Scholar
  • 36 Thamboo A, Lea J, Sommer DD. et al. Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology—head and neck surgery during the COVID-19 pandemic. J Otolaryngol Head Neck Surg 2020; 49 (01) 28
    CrossrefPubMedGoogle Scholar
  • 37 Nogler M, Lass-Flörl C, Wimmer C, Bach C, Kaufmann C, Ogon M. Aerosols produced by high-speed cutters in cervical spine surgery: extent of environmental contamination. Eur Spine J 2001; 10 (04) 274-277
    CrossrefPubMedGoogle Scholar
  • 38 Setzen M, Svider PF, Pollock K. COVID-19 and rhinology: a look at the future. Am J Otolaryngol 2020; 41 (03) 102491
    CrossrefPubMedGoogle Scholar
  • 39 Lancaster EM, Sosa JA, Sammann A. et al. Rapid response of an academic surgical department to the COVID-19 pandemic: implications for patients, surgeons, and the community. J Am Coll Surg 2020; 230 (06) 1064-1073
    CrossrefPubMedGoogle Scholar
  • 40 UNESCO World Commission on the Ethics of Scientific Knowledge and Technology (COMEST). The Precautionary Principle. Published March 2005. Accessed May 7, 2020 at: https://unesdoc.unesco.org/ark:/48223/pf0000139578
    PubMedGoogle Scholar
  • 41 Bertroche JT, Pipkorn P, Zolkind P, Buchman CA, Zevallos JP. Negative-pressure aerosol cover for COVID-19 tracheostomy. JAMA Otolaryngol Head Neck Surg 2020; 146 (07) 672-674
    CrossrefPubMedGoogle Scholar
  • 42 Matava CT, Yu J, Denning S. Clear plastic drapes may be effective at limiting aerosolization and droplet spray during extubation: implications for COVID-19. Can J Anaesth 2020; 67 (07) 902-904
    CrossrefPubMedGoogle Scholar
  • 43 Canelli R, Connor CW, Gonzalez M, Nozari A, Ortega R. Barrier enclosure during endotracheal intubation. N Engl J Med 2020; 382 (20) 1957-1958
    CrossrefPubMedGoogle Scholar