Recommended Personal Protective Equipment for Cochlear Implant and Other Mastoid Surgery During the COVID-19 Era

A multicenter study to investigate the positive rate of SARS-CoV-2 in middle ear and mastoid specimens from otologic surgery patients

OBJECTIVE

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), a novel coronavirus, causes coronavirus disease 2019 (COVID-19). Otologic surgeries with drilling by powered instruments induce significant aerosols, which may induce SARS-CoV-2 transmission to medical staff if SARS-CoV-2 exists in the middle ear and mastoid cavity. During a COVID-19 pandemic, therefore, confirming a negative COVID-19 test prior to otologic surgery is recommended. However, previous coronavirus studies demonstrated that coronavirus was detected in the middle ear in some patients even though the polymerase chain reaction (PCR) test using their nasopharyngeal swab was negative. This study aimed to elucidate the probability of a positive SARS-CoV-2 PCR test in the middle ear or mastoid specimens from otologic surgery patients in whom SARS-CoV-2 was not detected by preoperative PCR test using a nasopharyngeal swab.

METHODS

We conducted a prospective, multicenter clinical study. Between April 2020 and December 2021, during the COVID-19 pandemic, 251 ears of the 228 participants who underwent otologic surgery were included in this study. All participants had no symptoms suggesting COVID-19 or close contact with a confirmed COVID-19 patient two weeks prior to the surgery. They were also negative in the SARS-CoV-2 PCR tests using a nasopharyngeal swab before surgery. We collected mucosa, granulation, bone dust with mucosa or fluid from the middle ear or mastoid for the SARS-CoV-2 PCR tests during each otologic surgery.

RESULTS

The median age of the participants at surgery was 31.5 years old. Mastoidectomy using a powered instrument was conducted in 180 of 251 otologic surgeries (71.8%). According to intraoperative findings, active inflammation in the middle ear or mastoid cavities was evident in 20 otologic surgeries (8.0%), while minor inflammation was observed in 77 (30.7%). All SARS-CoV-2 PCR tests of otologic specimens showed a negative result. No patient suffered from COVID-19 within two months after otologic surgery. Furthermore, no hospital-acquired infections associated with otologic surgery occurred in our institutions CONCLUSIONS: Our results showed that PCR testing did not detect SARS-CoV-2 in middle ear and mastoid specimens, suggesting that the risk of transmission of SARS-CoV-2 is not high in otologic surgeries even using powered instruments when both clinical and laboratory tests are confirmed to be negative for COVID-19.

Otitis Media Practice During the COVID-19 Pandemic

The global coronavirus disease-2019 (COVID-19) pandemic has changed the prevalence and management of many pediatric infectious diseases, including acute otitis media (AOM). Coronaviruses are a group of RNA viruses that cause respiratory tract infections in humans. Before the COVID-19 pandemic, coronavirus serotypes OC43, 229E, HKU1, and NL63 were infrequently detected in middle ear fluid (MEF) specimens and nasopharyngeal aspirates in children with AOM during the 1990s and 2000s and were associated with a mild course of the disease. At times when CoV was detected in OM cases, the overall viral load was relatively low. The new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is the causative pathogen responsible for the eruption of the COVID-19 global pandemic. Following the pandemic declaration in many countries and by the World Health Organization in March 2020, preventive proactive measures were imposed to limit COVID-19. These included social distancing; lockdowns; closure of workplaces; kindergartens and schools; increased hygiene; use of antiseptics and alcohol-based gels; frequent temperature measurements and wearing masks. These measures were not the only ones taken, as hospitals and clinics tried to minimize treating non-urgent medical referrals such as OM, and elective surgical procedures were canceled, such as ventilating tube insertion (VTI). These changes and regulations altered the way OM is practiced during the COVID-19 pandemic. Advents in technology allowed a vast use of telemedicine technologies for OM, however, the accuracy of AOM diagnosis in those encounters was in doubt, and antibiotic prescription rates were still reported to be high. There was an overall decrease in AOM episodes and admissions rates and with high spontaneous resolution rates of MEF in children, and a reduction in VTI surgeries. Despite an initial fear regarding viral shedding during myringotomy, the procedure was shown to be safe. Special draping techniques for otologic surgery were suggested. Other aspects of OM practice included the presentation of adult patients with AOM who tested positive for SARS-2-CoV and its detection in MEF samples in living patients and in the mucosa of the middle ear and mastoid in post-mortem specimens.

Mitigation of Particle Spread During Mastoidectomy: A Systematic Review

Our objective is to analyze the risk of particle spread through mastoidectomy during the COVID-19 pandemic with an aim to assess the tools used to mitigate the spread. A systematic review was conducted using PRISMA guidelines. Our search terms included: MASTOIDECTOMY + COVID-19 or MASTOIDECTOMY + SAR- CoV-2 or MASTOIDECTOMY + CORONAVIRUS. Studies consistent with the inclusion and exclusion criteria were included in the review. Of the 20 articles identified in the initial search, six met the inclusion criteria. The included articles were all experimental studies, with five studies using cadaver subjects and one study using live human subjects. Three studies measured droplet spread and three studies measured aerosolized particle spread. The maximum distance of particle spread ranged from 30 cm to 208 cm. Four studies assessed the use of a barrier system, with two using the OtoTent and two using a barrier drape. Two studies defined the microscope alone as a possible mitigatory tool. One study compared burr type and size to determine the effects on particle spread. During the coronavirus disease 2019 (COVID-19) pandemic, evaluation of tools to mitigate particle spread is imperative for the safety of the surgical team and the healthcare system at large. Barrier drapes, OtoTents and microscopes all have proven to mitigate particle spread; however, further research needs to be performed to compare their efficacy and develop a standard of safety.

Overview of the User Experience for Snorkeling Mask Designs during the COVID-19 Pandemic

During the first wave of the COVID-19 pandemic, industries and academic institutes have collaborated to resolve the worldwide medical supply shortage issues. Innovative designs of 3D-printed items were proposed and developed by the maker community as a temporary solution to address the lack of personal protective equipment. An overview of global ongoing and past initiatives during the COVID-19 pandemic along with their challenges on retrofitting full-face snorkeling masks for healthcare applications such as splash-proof face shields, respirator masks and non-invasive ventilation systems are reported in this contribution. This study reviews these global initiatives and challenges. From our analysis, the present situation highlights the need to build solid networks between healthcare institutes and the different rapid prototyping initiatives. A clear feedback system needs to be implemented to facilitate effective collaboration between engineering (maker) and healthcare teams, to optimize the available human resources, and to achieve adequate product developments responding to the needs of healthcare workers.

Innovations in otorhinolaryngology in the age of COVID-19: a systematic literature review

OBJECTIVE

Otolaryngologists are at increased occupational risk of Coronavirus Disease 2019 (COVID-19) infection due to exposure from respiratory droplets and aerosols generated during otologic, nasal, and oropharyngeal examinations and procedures. There have been a variety of guidelines and precautions developed to help mitigate this risk. While many reviews have focused on the personal protective equipment (PPE) and preparation guidelines for surgery in the COVID-19 era, none have focused on the more creative and unusual solutions designed to limit viral transmission. This review aims to fill that need.

DATA SOURCES

PubMed, Ovid/Medline, and Scopus.

METHODS

A comprehensive review of literature was performed on September 28, 2020 using PubMed, Ovid/Medline, and Scopus databases. All English-language studies were included if they proposed or assessed novel interventions developed for Otolaryngology practice during the COVID-19 pandemic. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

RESULTS

A total of 41 papers met inclusion criteria and were organized into 5 categories ('General Recommendations for Otolaryngologic Surgery', 'Equipment Shortage Solutions', 'Airway Procedures', 'Nasal Endoscopy and Skull Base Procedures', and 'Otologic Procedures'). Articles were summarized, highlighting the innovations created and evaluated during the COVID-19 pandemic. Creative solutions such as application of topical viricidal agents, make-shift mask filters, three-dimensional (3-D) printable adapters for headlights, aerosol containing separation boxes, and a variety of new draping techniques have been developed to limit the risk of COVID-19 transmission.

CONCLUSIONS

Persistent risk of COVID-19 exposure remains high. Thus, there is an increased need for solutions that mitigate the risk of viral transmission during office procedures and surgeries, especially given that most COVID-19 positive patients present asymptomatically. This review examines and organizes creative solutions that have been proposed and utilized in the otolaryngology. These solutions have a potential to minimize the risk of viral transmission in the current clinical environment and to create safer outpatient and operating room conditions for patients and healthcare staff.

Use of a novel drape 'tent' as an infection prevention control measure for mastoid surgery

BACKGROUND

Mastoid surgery is an aerosol-generating procedure that involves the use of a high-speed drill, which produces a mixture of water, bone, blood and tissue that may contain the viable coronavirus disease 2019 pathogen. This potentially puts the surgeon and other operating theatre personnel at risk of acquiring the severe acute respiratory syndrome coronavirus-2 from contact with droplets or aerosols. The use of an additional drape designed to limit the spread of droplets and aerosols has been described; such drapes include the 'Southampton Tent' and 'OtoTent'.

OBJECTIVES

To evaluate the use of a novel drape 'tent' that has advantages over established 'tent' designs in terms of having: (1) a CE marking; (2) no requirement for modification during assembly; and (3) no obstruction to the surgical visual field.

RESULTS AND CONCLUSION

During mastoid surgery, the dispersion of macroscopic droplets and other particulate matter was confined within the novel drape 'tent'. Use of this drape 'tent' had no adverse effects upon the surgeon's manual dexterity or efficiency, the view of the surgical field, or the sterility. Hence, our findings support its use during mastoid surgery in the coronavirus disease 2019 era.