Protection for Otolaryngologic Surgery in the COVID-19 Pandemic

Aerosol generation during coughing: an observational study

OBJECTIVE

Coronavirus disease 2019 has highlighted the lack of knowledge on aerosol exposure during respiratory activity and aerosol-generating procedures. This study sought to determine the aerosol concentrations generated by coughing to better understand, and to set a standard for studying, aerosols generated in medical procedures.

METHODS

Aerosol exposure during coughing was measured in 37 healthy volunteers in the operating theatre with an optical particle sizer, from 40 cm, 70 cm and 100 cm distances.

RESULTS

Altogether, 306 volitional and 15 involuntary coughs were measured. No differences between groups were observed.

CONCLUSION

Many medical procedures are expected to generate aerosols; it is unclear whether they are higher risk than normal respiratory activity. The measured aerosol exposure can be used to determine the risk for significant aerosol generation during medical procedures. Considerable variation of aerosol generation during cough was observed between individuals, but whether cough was volitional or involuntary made no difference to aerosol production.

Diagnostic and surgical innovations in otolaryngology for adult and paediatric patients during the COVID-19 era

During the Coronavirus Disease 2019 (COVID-19) pandemic, otolaryngology has been shown to be a high-risk specialty due to the exposure to aerosol-generating physical examinations, procedures and surgical interventions on the head and neck area, both in adult and paediatric patients. This has prompted the issue of updating the guidelines by International Health Authorities in the Ear Nose and Throat (ENT) field and, at the same time, has stimulated engineers and healthcare professionals to develop new devices and technologies with the aim of reducing the risk of contamination for physicians, nurses and patients.

Methods

A review of the literature published on PubMed, Ovid/Medline and Scopus databases was performed from January 01, 2020 to December 31, 2021.

Results

73 articles were eligible to be included, which were subdivided into 4 categories: ("Artificial Intelligence (AI)"; "Personal Protective Equipment (PPE)"; "Diagnostic tools"; "Surgical tools").

Conclusions

All of the innovations that have been developed during the COVID-19 pandemic have laid the foundation for a radical technological change of society, not only in medicine but also from a social, political and economical points of view that will leave its mark in the coming decades.

Microdebrider is less aerosol-generating than CO2 laser and cold instruments in microlaryngoscopy

Objective

COVID-19 spreads through aerosols produced in coughing, talking, exhalation, and also in some surgical procedures. Use of CO₂ laser in laryngeal surgery has been observed to generate aerosols, however, other techniques, such cold dissection and microdebrider, have not been sufficiently investigated. We aimed to assess whether aerosol generation occurs during laryngeal operations and the effect of different instruments on aerosol production.

Methods

We measured particle concentration generated during surgeries with an Optical Particle Sizer. Cough data collected from volunteers and aerosol concentration of an empty operating room served as references. Aerosol concentrations when using different techniques and equipment were compared with references as well as with each other.

Results

Thirteen laryngological surgeries were evaluated. The highest total aerosol concentrations were observed when using CO₂ laser and these were significantly higher than the concentrations when using microdebrider or cold dissection (p < 0.0001, p < 0.0001) or in the background or during coughing (p < 0.0001, p < 0.0001). In contrast, neither microdebrider nor cold dissection produced significant concentrations of aerosol compared with coughing (p = 0.146, p = 0.753). In comparing all three techniques, microdebrider produced the least aerosol particles.

Conclusions

Microdebrider and cold dissection can be regarded as aerosol-generating relative to background reference concentrations, but they should not be considered as high-risk aerosol-generating procedures, as the concentrations are low and do not exceed those of coughing. A step-down algorithm from CO₂ laser to cold instruments and microdebrider is recommended to lower the risk of airborne infections among medical staff.

International Survey of Operative Practices for Otologists and Neurotologists During the COVID-19 Crisis

OBJECTIVE

To investigate the influence of the COVID-19 pandemic on operative practices of otology and neurotology providers internationally.

STUDY DESIGN

Cross-sectional survey.

METHODS

A 78-question survey was distributed to otologists and neurotologists between May 12, 2020 and June 8, 2020 to assess the impact of the pandemic on surgical practices. Sections within the survey delineated time periods: prior to the crisis, onset of the crisis, during the crisis, postcrisis transition.

RESULTS

Of 396 survey respondents, 284 participants from 38 countries met inclusion criteria.Respondents were 16.9% female and 82.4% male, with a most common age range of 40 to 49 years (36.3%). 69.8% of participants had been in practice for over 10 years and most respondents worked in an academic medical center (79.2%). The average operative weekly caseload was 5.3 (SD 3.9) per surgeon prior to the crisis, 0.7 (SD 1.2) during the COVID-19 crisis, and 3.5 (SD 3.3) for those who had begun a postcrisis transition at the time of survey administration (p < 0.001). 71.5% of providers did not perform an elective otologic or neurotologic operative procedure during the initial crisis period. 49.8% reported modifying their surgical technique due to the COVID-19 pandemic. Use of powered air-purifying respirators and filtering facepiece 2 or 3 (FFP2/FFP3) respirators were in minimal supply for 66.9% and 62.3% of respondents, respectively.

CONCLUSION

The COVID-19 pandemic impacted the otology and neurotology community globally, resulting in significant changes in operative volume and case selection. Modification of surgical technique and shortages of personal protective equipment were frequently reported.

Evidence, not eminence, for surgical management during COVID-19: a multifaceted systematic review and a model for rapid clinical change

BACKGROUND

Coronavirus (COVID-19) forced surgical evolution worldwide. The extent to which national evidence-based recommendations, produced by the current authors early in 2020, remain valid, is unclear. To inform global surgical management and a model for rapid clinical change, this study aimed to characterize surgical evolution following COVID-19 through a multifaceted systematic review.

METHODS

Rapid reviews were conducted targeting intraoperative safety, personal protective equipment and triage, alongside a conventional systematic review identifying evidence-based guidance for surgical management. Targeted searches of PubMed and Embase from 31 December 2019 were repeated weekly until 7 August 2020, and systematic searches repeated monthly until 30 June 2020. Literature was stratified using Evans' hierarchy of evidence. Narrative data were analysed for consistency with earlier recommendations. The systematic review rated quality using the AGREE II and AMSTAR tools, was registered with PROSPERO, CRD42020205845. Meta-analysis was not conducted.

RESULTS

From 174 targeted searches and six systematic searches, 1256 studies were identified for the rapid reviews and 21 for the conventional systematic review. Of studies within the rapid reviews, 903 (71.9 per cent) had lower-quality design, with 402 (32.0 per cent) being opinion-based. Quality of studies in the systematic review ranged from low to moderate. Consistency with recommendations made previously by the present authors was observed despite 1017 relevant subsequent publications.

CONCLUSION

The evidence-based recommendations produced early in 2020 remained valid despite many subsequent publications. Weaker studies predominated and few guidelines were evidence-based. Extracted clinical solutions were globally implementable. An evidence-based model for rapid clinical change is provided that may benefit surgical management during this pandemic and future times of urgency.

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.

Experience of comprehensive interventions in reducing occupational exposure to COVID-19

Importance

The infection of medical personnel with COVID-19 was a disaster for both patients and doctors. However, some effective measures can prevent medical staff from becoming infected. This article introduces those measures and thus provides a reference for other hospitals.

Objective

In order to reduce the risk of occupational exposure and of the infection of medical staff, this article analyzed the factors, causes and experience of medical personnel on their occupational exposure to COVID-19. Some effective and targeted intervention measures can be implemented in order to avoid the occupational exposure of medical staff to COVID-19.

Evidence review

In this single-center case series involving 196 medical personnel, occupational exposure to COVID-19 was present. Nursing staff accounted for 67.35% of those cases. The relationships with an exposure source were found to be as follows: doctors and patients (87.24%), colleagues (10.20%), and roommates (2.55%). Occupational exposure was found to be present in the clinical department, radiology department, central sterile supply department, as well as in the outpatient clinics and operating rooms. The non-surgical departments accounted for 72.96% and direct contact accounted for 84.69% while failure to wear surgical masks (84.18%) and operating on the patient without wearing goggles/face shield (8.16%) were the main causes of occupational exposure. The occurrence of occupational exposure to COVID-19 declined to 0.19% after an extensive and comprehensive intervention program.

Conclusions and relevance

Some effective measures such as hand hygiene, wearing surgical masks in and around the hospital, reasonable use of goggles/face screens, raising awareness of protective measures, minimizing the number of elective operations, strengthening training as well as many other control measures were instrumental in reducing occupational exposure. For any medical institution there is room for improvement in terms of personal protection to reduce occupational exposure.