Endonasal drilling may be employed safely in the COVID-19 era

Adapting management strategies for sellar-suprasellar lesions during the COVID-19 pandemic: a pragmatic approach from the frontline

PURPOSE

During the ongoing COVID-19 pandemic, endonasal surgeries for sellar-suprasellar lesions were discouraged due to the risk of transmission of the disease. We reviewed the changes in our management protocol for these lesions as our disease understanding and preparedness evolved.

MATERIALS AND METHODS

This was a retrospective observational study including patients with sellar-suprasellar and clival lesions presenting to us between March and October 2020. Management protocols were divided into three phases based on the prevalence of the disease and the number of mandatory preoperative COVID-19 tests being conducted. The surgical approach used was analyzed in relation to the preferred approach during pre-COVID times, and surgical outcomes and complications were noted.

RESULTS

A total of 31 cases were operated during this period. During Phase I (low prevalence; no preoperative COVID testing) endonasal surgeries were largely abandoned in favor of transcranial approaches. In Phase II (medium prevalence; one preoperative COVID test) we gradually resumed endonasal surgeries for 'emergent' and 'essential' cases, and subsequently in Phase III (high prevalence; two preoperative COVID tests), we had no hesitation in performing 'elective' endonasal surgeries with additional barriers for prevention of aerosol transmission. No patient developed COVID-19 infection postoperatively. Eight HCWs in our department acquired the disease during this period, none of whom were directly involved in the surgeries for the above cohort of patients.

CONCLUSIONS

With a strict preoperative COVID testing protocol, adherence to proper drilling techniques and using additional barriers to prevent droplet and aerosol spread, endonasal surgeries for sellar-suprasellar lesions are safe during this COVID-19 pandemic.

A negative-pressure face-mounted system reduces aerosol spread during endonasal endoscopic surgery

Purpose: As there is a potential risk of Covid-19 transmission during endonasal surgery we studied methods to reduce droplet and aerosol generation during these procedures. Methods: Droplet spread was assessed using ultraviolet light and a camera that detected fluorescence in the operative field and surgeon’s personal protective equipment. Density of aerosols sized <10µ was measured using a photometric particle counter. We designed a face-mounted negative-pressure mask placed on the patients face during endoscopic endonasal surgery. Sixteen patients were recruited between October 2020 to March 2021 and randomly assigned to the mask and no-mask groups. We compared droplet spread and aerosols generated in both groups, with copious irrigation and continuous suction during drilling forming the mainstay of surgical technique in all cases. Results: Droplet contamination due to direct spillage of fluorescein from the syringe was noted in two patients. Aerosol density rose during sphenoid drilling in both groups, with no significant difference when continuous suction and irrigation were employed (1.27 times vs. 1.07 times the baseline, p=0.248). Aerosol density rose significantly when suction and irrigation were interrupted in the no-mask group (44.9 times vs. 1.2 times, p=0.028), which was not seen when the mask was used. Conclusions: Aerosol generation increases during drilling in endonasal procedures and is a concern during this pandemic. The use of a rigid suction close to the drill along with copious irrigation is effective in reducing aerosol spread. The use of a negative pressure mask provides additional safety when inadvertent blockage of suction and inadequate irrigation occur.

Rapidly Progressive Pituitary Apoplexy in a Patient with COVID-19 Disease Treated with Endoscopic Endonasal Surgery

This report describes a case of pituitary apoplexy with rapidly evolving hemorrhage in a 74-year-old female with coronavirus disease 2019 (COVID-19) disease. The patient presented with severe headache and mild respiratory symptoms, with laboratories concerning for pituitary hypofunction. Brain imaging demonstrated a sellar mass concerning for a pituitary adenoma with ischemic apoplexy. She subsequently developed visual deficits within 24 hours of presentation, and repeat imaging demonstrated evolving hemorrhage and new mass effect on the optic chiasm. She was successfully managed with urgent endoscopic endonasal surgery despite her COVID-19 positive status by taking special intraoperative precautions to mitigate SARS-CoV2 transmission risk. Only a handful of cases of pituitary apoplexy have been reported in association with COVID-19 disease, and even fewer reports exist of endonasal procedures in such cases. We discuss the potential implication of COVID-19 in the occurrence of pituitary apoplexy, in addition to the safety and success of endonasal surgery in this population.

Evaluation of the aerosol generating potential of endoscopic dacryocystorhinostomy

PURPOSE

The COVID-19 pandemic gave rise to renewed concerns of the transmission risks posed by surgeries on sites of high viral colonization such as the nasopharynx. Endoscopic dacryocystorhinostomy (DCR) involves the creation of a new tear duct from the lacrimal sac to the nasal cavity. The purpose of this project is to determine if endoscopic DCR is an aerosol generating procedure (AGP).

METHODS

An optical particle sizer (OPS) was used to intraoperatively quantify aerosol concentrations during four cases of endoscopic DCR. The OPS sampled the air once every 60 seconds throughout the operations. The time of important operative steps were documented and correlated with OPS readings. Particle concentrations during each major surgical step were compared to baseline readings by the Mann Whitney U Test.

RESULTS

There were statistically significant increases in median particle concentrations during laryngeal mask airway intubations for both particles 0.3 to 5.0 μm and >5.0 μm (P < .001 and P = .023, respectively). Median particle concentrations during nasolacrimal duct probing, middle meatal debridement, drilling, balloon insertion, tube insertion, and Posisef insertion were not statistically different from baseline.

CONCLUSIONS

Endoscopic DCR in itself does not appear to be an AGP. It is, however, associated with other aerosol generating events such as laryngeal mask intubation, and thus requires appropriate personal protective equipment. Cautious interpretation of the results is encouraged given the limitations of OPS.

LEVEL OF EVIDENCE

4.

Development and validation of a patient face-mounted, negative-pressure antechamber for reducing exposure of healthcare workers to aerosolized particles during endonasal surgery

OBJECTIVE

The authors developed a negative-pressure, patient face-mounted antechamber and tested its efficacy as a tool for sequestering aerated particles and improving the safety of endonasal surgical procedures.

METHODS

Antechamber prototyping was performed with 3D printing and silicone-elastomer molding. The lowest vacuum settings needed to meet specifications for class I biosafety cabinets (flow rate ≥ 0.38 m/sec) were determined using an anemometer. A cross-validation approach with two different techniques, optical particle sizing and high-speed videography/shadowgraphy, was used to identify the minimum pressures required to sequester aerosolized materials. At the minimum vacuum settings identified, physical parameters were quantified, including flow rate, antechamber pressure, and time to clearance.

RESULTS

The minimum tube pressures needed to meet specifications for class I biosafety cabinets were -1.0 and -14.5 mm Hg for the surgical chambers with ("closed face") and without ("open face") the silicone diaphragm covering the operative port, respectively. Optical particle sizing did not detect aerosol generation from surgical drilling at these vacuum settings; however, videography estimated higher thresholds required to contain aerosols, at -6 and -35 mm Hg. Simulation of surgical movement disrupted aerosol containment visualized by shadowgraphy in the open-faced but not the closed-faced version of the mask; however, the closed-face version of the mask required increased negative pressure (-15 mm Hg) to contain aerosols during surgical simulation.

CONCLUSIONS

Portable, negative-pressure surgical compartments can contain aerosols from surgical drilling with pressures attainable by standard hospital and clinic vacuums. Future studies are needed to carefully consider the reliability of different techniques for detecting aerosols.

International consensus statement on allergy and rhinology: rhinosinusitis 2021

I.

EXECUTIVE SUMMARY

BACKGROUND: The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICAR-RS) has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 as well as updates to the original 140 topics. This executive summary consolidates the evidence-based findings of the document.

METHODS

ICAR-RS presents over 180 topics in the forms of evidence-based reviews with recommendations (EBRRs), evidence-based reviews, and literature reviews. The highest grade structured recommendations of the EBRR sections are summarized in this executive summary.

RESULTS

ICAR-RS-2021 covers 22 topics regarding the medical management of RS, which are grade A/B and are presented in the executive summary. Additionally, 4 topics regarding the surgical management of RS are grade A/B and are presented in the executive summary. Finally, a comprehensive evidence-based management algorithm is provided.

CONCLUSION

This ICAR-RS-2021 executive summary provides a compilation of the evidence-based recommendations for medical and surgical treatment of the most common forms of RS.

Coronavirus Disease-19 and Rhinology/Facial Plastics

This review summarizes the challenges and adaptations that have taken place in rhinology and facial plastics in response to the ongoing coronavirus disease-19 pandemic. In particular, the prolonged exposure and manipulation of the nasal and oral cavities portend a high risk of viral transmission. We discuss evidence-based recommendations to mitigate the risk of viral transmission through novel techniques and device implementation as well as increasing conservative management of certain pathologies.

Communication Chaos from Discrepancies in Personal Protective Equipment and Preoperative Guidelines

OBJECTIVES/HYPOTHESIS

To compare personal protective equipment (PPE) guidelines, specifically respirator use, among international public health agencies, academic hospitals, and otolaryngology-head and neck surgery (OHNS) departments in the United States for the care of coronavirus-19 (COVID-19) patients.

STUDY DESIGN

Cross sectional survey.

METHODS

Review of publicly available public health and academic hospitals guidelines along with review of communication among otolaryngology departments.

RESULTS

Among 114 academic institutions affiliated with OHNS residencies, 20 (17.5%) institutions provided public access to some form of guidance on PPE and 73 (64%) provided information on screening or diagnostic testing. PPE guidelines were uniquely described based on several variables: location of care, COVID-19 status, involvement of aerosol generating or high-risk procedures, and physical distance from the patient. Six hospital guidelines were highlighted. Across these six institutions, there was agreement that N95 respirators were needed for high-risk patients undergoing high-risk procedures. Variations existed among institutions for scenarios with low-risk patients. Definitions of the low-risk patient and high-risk procedures were inconsistent among institutions. Three of the highlighted institutions had OHNS departments recommending higher level of airway protection than the institution.

CONCLUSIONS

OHNS departments typically had more stringent PPE guidance than their institution. Discrepancies in communicating PPE use were frequent and provide inconsistent information on how healthcare workers should protect themselves in the COVID-19 pandemic. Identification of these inconsistencies serves as an opportunity to standardize communication and develop evidence-based guidelines.

LEVEL OF EVIDENCE

V Laryngoscope, 131:E746-E754, 2021.

Mitigation of Aerosols Generated During Rhinologic Surgery: A Pandemic-Era Cadaveric Simulation

OBJECTIVE

After significant restrictions initially due to the COVID-19 pandemic, otolaryngologists have begun resuming normal clinical practice. However, the risk of SARS-CoV-2 transmission to health care workers through aerosolization and airborne transmission during rhinologic surgery remains incompletely characterized. The objective of this study was to quantify the number concentrations of aerosols generated during rhinologic surgery with and without interventions involving 3 passive suction devices.

STUDY DESIGN

Cadaver simulation.

SETTING

Dedicated surgical laboratory.

SUBJECTS AND METHODS

In a simulation of rhinologic procedures with and without different passive suction interventions, the concentrations of generated aerosols in the particle size range of 0.30 to 10.0 µm were quantified with an optical particle sizer.

RESULTS

Functional endoscopic sinus surgery with and without microdebrider, high-speed powered drilling, use of an ultrasonic aspirator, and electrocautery all produced statistically significant increases in concentrations of aerosols of various sizes (P < .05). Powered drilling, ultrasonic aspirator, and electrocautery generated the highest concentration of aerosols, predominantly submicroparticles <1 µm. All interventions with a suction device were effective in reducing aerosols, though the surgical smoke evacuation system was the most effective passive suction method in 2 of the 5 surgical conditions with statistical significance (P < .05).

CONCLUSION

Significant aerosol concentrations were produced in the range of 0.30 to 10.0 µm during all rhinologic procedures in this cadaver simulation. Rhinologic surgery with a passive suction device results in significant mitigation of generated aerosols.