Suction mitigation of airborne particulate generated during sinonasal drilling and cautery

Dispersion of droplets due to the use of air purifiers during summer: Focus on the spread of COVID-19

Coronavirus disease (COVID-19), which emerged in 2019, has induced worldwide chaos. The main cause of COVID-19 mass infection indoors is the spread of virus-containing droplets via indoor airflow, which is affected by air conditioners and purifiers. Here, ten experimental cases were established to analyze how use of air purifiers affects the spread of virus-containing droplets. The experiments were conducted in a school classroom with an air conditioner in summer. In the droplet dispersion experiment, paraffin oil was used as the droplet substance. Two main scenarios were simulated: (1) an infected student was seated in the back of the classroom; and (2) the teacher, standing in the front of the classroom, was infected. The results were expressed using two parameters: peak concentration and loss rate, which reflect the degree of direct and indirect infection (airborne infection), respectively. The air purifier induced a peak concentration decrease of 42% or an increase of 278%, depending on its location in the classroom. Conversely, when the air purifier was operated in the high mode (flow rate = 500 CMH; cubic meters per hour), the loss rate showed that the amount of droplet nuclei only decreased by 39% and the droplet amount decreased by 22%. Thus, the airborne infection degree can be significantly reduced. Finally, the use of air purifiers in the summer may be helpful in preventing group infections by reducing the loss rate and peak concentration if the air purifier is placed in a strategic location, according to the airflow of the corresponding room.

Development of protective equipment for endoscopic treatment and surgery in otorhinolaryngology

Objective

The coronavirus disease pandemic has raised concerns regarding the transmission of infections to healthcare workers. We developed a new protective device to reduce the risk of aerosol diffusion and droplet infection among healthcare workers. Here, we report the results of a theoretical evaluation of the efficacy of this device.

Methods

We used suction-capable masks with and without rubber slits, sleeves for the insertion section of endoscopes and treatment tools, and a cover for the control section of the endoscope. To simulate droplet spread from patients, we created a droplet simulation model and an aerosol simulation model. The results with and without the devices attached and with and without the suction were compared.

Results

The droplet simulation model showed a 95% reduction in droplets with masks with rubber slits; furthermore, a reduction of 100% was observed when the insertion sleeve was used. Evaluation of aerosol simulation when suction was applied revealed an aerosol reduction of 98% and >99% with the use of the mask without rubber slits and with the combined use of the mask and insertion sleeve, respectively. The elimination of droplet emission upon instrument removal confirmed that the instrument sleeve prevented the diffusion of droplets. The elimination of droplets upon repeated pressing of the suction button confirmed that the cover prevented the diffusion of droplets.

Conclusion

We developed a device for infection control, in collaboration with a gastrointestinal endoscopist and Olympus Medical Systems Corporation, that was effective in reducing droplet and aerosol diffusion in this initial theoretical assessment.

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.

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.

Safety for the Rhinologist in the Age of COVID-19: Mask Use, Nasal Corticosteroids, Saline Irrigation, and Endoscopic Procedures – Literature Review

Introduction  Coronavirus disease 2019 (COVID-19) has claimed millions of lives. Adequate protection of the professionals involved in patient care is essential in the battle against this disease. However, there is much uncertainty involving safety-relarted topics that are of particular interest to the rhinologist in the context of COVID-19.

Objective  To evaluate the current evidence regarding three safety-related topics: mask and respirator use, performance of nasal endoscopic procedures, and use of topical nasal and intranasal medications (saline irrigation and nasal corticosteroids).

Methods  A literature review was performed on the PubMed, Scopus, and Cochrane databases, with standardized search queries for each of the three topics of interest.

Results  In total, 13 articles on mask use, 6 articles on the safety of nasal corticosteroids, 6 articles on the safety of nasal endoscopic procedures, and 1 article on nasal irrigation with saline solution were included in the final analysis.

Conclusion  N95 respirators are essential for the adequate protection of otolaryngologists. If reuse is necessary, physical methods of sterilization must be employed. No evidence was found to contraindicate the use of nasal corticosteroids, whether acute (in the management of sinonasal inflammatory conditions) or continued (in patients who use them chronically). Nasal irrigation with saline solution apparently does not increase the risk in the context of COVID-19. Nasal endoscopic procedures should only be performed after testing the patient for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the surgical team must wear full personal protective equipment to prevent aerosol exposure.

Inanimate surface contamination of SARS-CoV-2 during midfacial fracture repair in asymptomatic COVID-19 patients

Purposes

To evaluate inanimate surface contamination of SARS-CoV-2 during midfacial fracture repair (MFR) and to identify relevant aggregating factors.

Methods

Using a prospective non-randomised comparative study design, we enrolled a cohort of asymptomatic COVID-19 patients undergoing MFR. The predictor variables were osteofixation system (conventional titanium plates [CTiP] vs. ultrasound-assisted resorbable plates [USaRP]). The main outcomes were the presence of SARS-CoV-2 on four different surfaces. Other study variables were categorised into demographic, anatomical, and operative. Descriptive, bi- and multivariate statistics were computed.

Results

The sample consisted of 11 patients (27.3% females, 63.6% right side, 72.7% displaced fractures) with a mean age of 52.7 ± 20.1 years (range, 19–85). Viral spread was, on average, 1.9 ± 0.4 m. from the operative field, including most oral and orbital retractors’ tips (81.8% and 72.7%) and no virus was found at 3 m from the operative field, but no significant difference was found between 2 osteofixation types. On binary adjustments, significantly broader contamination was linked to centrolateral MFR (P = 0.034; 95% confidence interval [CI], 0.05 to 1.02), and displaced MFR > 45 min (P = 0.022; 95% CI, 0.1 to 1.03).

Conclusions

USaRP, albeit presumably heavily aerosol-producing, cause similar SARS-CoV-2 distribution to CTiP. Non-surgical operating room (OR) staff should stay ≥ 3 m from the operative field, if the patient is SARS-CoV-2-positive. Enoral and orbital instruments are a potential virus source, especially during displaced MFR > 45 min and/or centrolateral MFR, emphasising an importance of appropriate patient screening and OR organisation.

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.

Are medical procedures that induce coughing or involve respiratory suctioning associated with increased generation of aerosols and risk of SARS-CoV-2 infection? A rapid systematic review

BACKGROUND

The risk of transmission of SARS-CoV-2 from aerosols generated by medical procedures is a cause for concern.

AIM

To evaluate the evidence for aerosol production and transmission of respiratory infection associated with procedures that involve airway suctioning or induce coughing/sneezing.

METHODS

The review was informed by PRISMA guidelines. Searches were conducted in PubMed for studies published between January 1st, 2003 and October 6th, 2020. Included studies examined whether nasogastric tube insertion, lung function tests, nasendoscopy, dysphagia assessment, or suctioning for airway clearance result in aerosol generation or transmission of SARS-CoV-2, SARS-CoV, MERS, or influenza. Risk of bias assessment focused on robustness of measurement, control for confounding, and applicability to clinical practice.

FINDINGS

Eighteen primary studies and two systematic reviews were included. Three epidemiological studies found no association between nasogastric tube insertion and acquisition of respiratory infections. One simulation study found low/very low production of aerosols associated with pulmonary lung function tests. Seven simulation studies of endoscopic sinus surgery suggested significant increases in aerosols but findings were inconsistent; two clinical studies found airborne particles associated with the use of microdebriders/drills. Some simulation studies did not use robust measures to detect particles and are difficult to equate to clinical conditions.

CONCLUSION

There was an absence of evidence to suggest that the procedures included in the review were associated with an increased risk of transmission of respiratory infection. In order to better target precautions to mitigate risk, more research is required to determine the characteristics of medical procedures and patients that increase the risk of transmission of SARS-CoV-2.

One year into the COVID-19 pandemic: What do we know so far from studies assessing risk and mitigation of droplet aerosolisation during endonasal surgery? A systematic review

Objectives

As we pass the anniversary of the declaration of a global pandemic by the World Health Organisation, it invites us to reflect upon the inescapable changes that coronavirus has wrought upon ENT and, in particular, rhinological practice. As it remains unclear when we will emerge from the shadow of COVID‐19, a critical analysis of the evidence base on both the assessment and mitigation of risk is vital for ENT departments worldwide. This article presents a systematic review of the literature examining articles which consider either the quantification of risk or strategies to mitigate risk specifically in the setting of rhinological surgery.

Design

Systematic literature review.

Results

The literature search yielded a total of 3406 returns with 24 articles meeting eligibility criteria. A narrative synthesis stratified results into two broad themes: (1) those which made an assessment as to the aerosolisation of droplets during sinus surgery, further sub‐divided into work which considered macroscopically visible droplets and that which considered smaller particles; (2) and those studies which examined the mitigation of this risk.

Conclusion

Studies considering the aerosolisation of both droplets and smaller particles suggest endonasal surgery carries significant risk. While results both highlight a range of innovative adjunctive strategies and support suction as an important intervention to reduce aerosolisation, appropriate use of personal protective equipment (PPE) should be considered mandatory for all healthcare professionals involved in rhinological surgery. Studies have demonstrated that close adherence to PPE use is effective in preventing COVID‐19 infection.

Aerosolisation in endonasal endoscopic pituitary surgery

PURPOSE

To determine the particle size, concentration, airborne duration and spread during endoscopic endonasal pituitary surgery in actual patients in a theatre setting.

METHODS

This observational study recruited a convenience sample of three patients. Procedures were performed in a positive pressure operating room. Particle image velocimetry and spectrometry with air sampling were used for aerosol detection.

RESULTS

Intubation and extubation generated small particles (< 5 µm) in mean concentrations 12 times greater than background noise (p < 0.001). The mean particle concentrations during endonasal access were 4.5 times greater than background (p = 0.01). Particles were typically large (> 75 µm), remained airborne for up to 10 s and travelled up to 1.1 m. Use of a microdebrider generated mean aerosol concentrations 18 times above baseline (p = 0.005). High-speed drilling did not produce aerosols greater than baseline. Pituitary tumour resection generated mean aerosol concentrations less than background (p = 0.18). Surgical drape removal generated small and large particles in mean concentrations 6.4 times greater than background (p < 0.001).

CONCLUSION

Intubation and extubation generate large amounts of small particles that remain suspended in air for long durations and disperse through theatre. Endonasal access and pituitary tumour resection generate smaller concentrations of larger particles which are airborne for shorter periods and travel shorter distances.

Aerosol Generation During Laryngology Procedures in the Operating Room

OBJECTIVE

Severe acute respiratory syndrome coronavirus-2 spreads through respiratory fluids. We aim to quantify aerosolized particles during laryngology procedures to understand their potential for transmission of infectious aerosol-based diseases.

STUDY DESIGN

Prospective quantification of aerosol generation.

METHODS

Airborne particles (0.3-25 μm in diameter) were measured during live-patient laryngology surgeries using an optical particle counter positioned 60 cm from the oral cavity to the surgeon's left. Measurements taken during the procedures were compared to baseline concentrations recorded immediately before each procedure. Procedures included direct laryngoscopy with general endotracheal anesthesia (GETA), direct laryngoscopy with jet ventilation, and carbon dioxide (CO₂ ) laser use with or without jet ventilation, all utilizing intermittent suction.

RESULTS

Greater than 99% of measured particles were 0.3 to 1.0 μm in diameter. Compared to baseline, direct laryngoscopy was associated with a significant 6.71% increase in cumulative particles, primarily 0.3 to 1.0 μm particles (P < .0001). 1.0 to 25 μm particles significantly decreased (P < .001). Jet ventilation was not associated with a significant change in cumulative particles; when analyzing differential particle sizes, only 10 to 25 μm particles exhibited a significant increase compared to baseline (+42.40%, P = .002). Significant increases in cumulative particles were recorded during CO₂ laser use (+14.70%, P < .0001), specifically in 0.3 to 2.5 μm particles. Overall, there was no difference when comparing CO₂ laser use during jet ventilation versus GETA.

CONCLUSIONS

CO₂ laser use during laryngology surgery is associated with significant increases in airborne particles. Although direct laryngoscopy with GETA is associated with slight increases in particles, jet ventilation overall does not increase particle aerosolization.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Droplet and Aerosol Generation With Mastoidectomy During the COVID-19 Pandemic: Assessment of Baseline Risk and Mitigation Measures With a High-performance Cascade Impactor

HYPOTHESIS

Aerosols are generated during mastoidectomy and mitigation strategies may effectively reduce aerosol spread.

BACKGROUND

An objective understanding of aerosol generation and the effectiveness of mitigation strategies can inform interventions to reduce aerosol risk from mastoidectomy and other open surgeries involving drilling.

METHODS

Cadaveric and fluorescent three-dimensional printed temporal bone models were drilled under variable conditions and mitigation methods. Aerosol production was measured with a cascade impactor set to detect particle sizes under 14.1 μm. Field contamination was determined with examination under UV light.

RESULTS

Drilling of cadaveric bones and three-dimensional models resulted in strongly positive aerosol production, measuring positive in all eight impactor stages for the cadaver trials. This occurred regardless of using coarse or cutting burs, irrigation, a handheld suction, or an additional parked suction. The only mitigation factor that led to a completely negative aerosol result in all eight stages was placing an additional microscope drape to surround the field. Bone dust was scattered in all directions from the drill, including on the microscope, the surgeon, and visually suspended in the air for all but the drape trial.

CONCLUSIONS

Aerosols are generated with drilling the mastoid. Using an additional microscope drape to cover the surgical field was an effective mitigation strategy to prevent fine aerosol dispersion while drilling.

Aerosol and Droplet Risk of Common Otolaryngology Clinic Procedures

OBJECTIVES

Define aerosol and droplet risks associated with routine otolaryngology clinic procedures during the COVID-19 era.

METHODS

Clinical procedures were simulated in cadaveric heads whose oral and nasal cavities were coated with fluorescent tracer (vitamin B2) and breathing was manually simulated through retrograde intubation. A cascade impactor placed adjacent to the nares collected generated particles with aerodynamic diameters ≤14.1 µm. The 3D printed models and syringes were used to simulate middle and external ear suctioning as well as open suctioning, respectively. Provider's personal protective equipment (PPE) and procedural field contamination were also recorded for all trials using vitamin B2 fluorescent tracer.

RESULTS

The positive controls of nebulized vitamin B2 produced aerosol particles ≤3.30 µm and endonasal drilling of a 3D model generated particles ≤14.1 µm. As compared with positive controls, aerosols and small droplets with aerodynamic diameter ≤14.1 µm were not detected during rigid nasal endoscopy, flexible fiberoptic laryngoscopy, and rigid nasal suction of cadavers with simulated breathing. There was minimal to no field contamination in all 3 scenarios. Middle and external ear suctioning and open container suctioning did not result in any detectable droplet contamination. The clinic suction unit contained all fluorescent material without surrounding environmental contamination.

CONCLUSION

While patients' coughing and sneezing may create a baseline risk for providers, this study demonstrates that nasal endoscopy, flexible laryngoscopy, and suctioning inherently do not pose an additional risk in terms of aerosol and small droplet generation. An overarching generalization cannot be made about endoscopy or suctioning being an aerosol generating procedure.

LEVEL OF EVIDENCE

3.

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.

Reducing the risks of endoscopic sinonasal surgery in the Covid-19 era

Objectives

Many routine sinonasal procedures utilising powered instruments are regarded as aerosol‐generating. This study aimed to assess how different instrument settings affect detectable droplet spread and patterns of aerosolised droplet spread during simulated sinonasal surgery in order to identify mitigation strategies.

Design

Simulation series using three‐dimensional (3‐D) printed sinonasal model. Fluorescein droplet spread was assessed following microdebriding and drilling of fluorescein‐soaked grapes and bones, respectively.

Setting

University dry lab.

Participants

3‐D printed sinonasal model.

Main outcome measures

Patterns of aerosolised droplet spread.

Results and Conclusion

There were no observed fluorescein droplets or splatter in the measured surgical field after microdebridement of nasal polyps at aspecific irrigation rate and suction pressure. Activation of the microdebrider in the presence of excess fluid in the nasal cavity (reduced or blocked suction pressure, excessive irrigation fluid or bleeding) resulted in detectable droplet spread. Drilling with either coarse diamond or cutting burs resulted in detectable droplets and greater spread was observed when drilling within the anterior nasal cavity. High‐speed drilling is a high‐risk AGP but the addition of suction using a third hand technique reduces detectable droplet spread outside the nasal cavity. Using the instrument outside the nasal cavity inadvertently, or when unblocking, produces greater droplet spread and requires more caution.

Aerosol generation during routine rhinologic surgeries and in-office procedures

OBJECTIVE

Cadaveric simulations have shown endonasal drilling and cautery generate aerosols, which is a significant concern for otolaryngologists during the COVID-19 era. This study quantifies aerosol generation during routine rhinologic surgeries and in-office procedures in live patients.

METHODS

Aerosols ranging from 0.30 to 10.0 μm were measured in real-time using an optical particle sizer during surgeries and in-office procedures. Various mask conditions were tested during rigid nasal endoscopy (RNE) and postoperative debridement (POD).

RESULTS

Higher aerosol concentrations (AC) ranging from 2.69 to 10.0 μm were measured during RNE (n = 9) with no mask vs two mask conditions (P = .002 and P = .017). Mean AC (0.30-10.0 μm) were significantly higher during POD (n = 9) for no mask vs a mask covering the patient's mouth condition (mean difference = 0.16 ± 0.03 particles/cm3, 95% CI 0.10-0.22, P < .001). There were no discernible spikes in aerosol levels during endoscopic septoplasty (n = 3). Aerosol spikes were measured in two of three functional endoscopic sinus surgeries (FESS) with microdebrider. Using suction mitigation, there were no discernible spikes during powered drilling in two anterior skull base surgeries (ASBS).

CONCLUSION

Use of a surgical mask over the patient's mouth during in-office procedures or a mask with a slit for an endoscope during RNE significantly diminished aerosol generation. However, whether this reduction in aerosol generation is sufficient to prevent transmission of communicable diseases via aerosols was beyond the scope of this study. There were several spikes in aerosols during FESS and ASBS, though none were associated with endonasal drilling with the use of suction mitigation.

LEVEL OF EVIDENCE

4.

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.

Aerosol and droplet generation from mandible and midface fixation: Surgical risk in the pandemic era

PURPOSE

The COVID-19 pandemic has led to concerns over transmission risk from healthcare procedures, especially when operating in the head and neck such as during surgical repair of facial fractures. This study aims to quantify aerosol and droplet generation from mandibular and midface open fixation and measure mitigation of airborne particles by a smoke evacuating electrocautery hand piece.

MATERIALS AND METHODS

The soft tissue of the bilateral mandible and midface of two fresh frozen cadaveric specimens was infiltrated using a 0.1% fluorescein solution. Surgical fixation via oral vestibular approach was performed on each of these sites. Droplet splatter on the surgeon's chest, facemask, and up to 198.12 cm (6.5 ft) away from each surgical site was measured against a blue background under ultraviolet-A (UV-A) light. Aerosol generation was measured using an optical particle sizer.

RESULTS

No visible droplet contamination was observed for any trials of mandible or midface fixation. Total aerosolized particle counts from 0.300-10.000 μm were increased compared to baseline following each use of standard electrocautery (n = 4, p < 0.001) but not with use of a suction evacuating electrocautery hand piece (n = 4, p = 0.103). Total particle counts were also increased during use of the powered drill (n = 8, p < 0.001).

CONCLUSIONS

Risk from visible droplets during mandible and midface fixation is low. However, significant increases in aerosolized particles were measured after electrocautery use and during powered drilling. Aerosol dispersion is significantly decreased with the use of a smoke evacuating electrocautery hand piece.

Diagnostic and therapeutic endonasal rhinologic procedures generating aerosol during COVID-19 pandemic: a systematized review

Introduction

Most rhinologic procedures, particularly endoscopic sinonasal procedures, are liable to produce aerosols. The severe acute respiratory syndrome coronavirus 2 (SARS-Co V-2) transmits via respiratory droplets, but the degree of its spread through airborne routes by aerosol is unclear.

Objective

The aim of this article is to counsel rhinologists on how to modify their conventional practice during the COVID-19 pandemic by prioritising the need of procedures, identifying aerosol- generating procedures and using precise personal protection equipment for various endonasal procedures.

Methods

We did a review of articles indexed for MEDLINE on PubMed, ENT Cochrane, DOAJ and Web of Science databases using the keywords nasal endoscopy, SARS‐CoV‐2, COVID‐19, aerosol generating medical procedures and rhinology to formulate guidelines for the safety of healthcare workers.

Results

The review included evidence from 28 articles from the otorhinolaryngology, surgery, infectious disease, head and neck surgery and cancer biology literature. We have provided recommendations and relevant information for rhinologists during the COVID-19 pandemic, based on the available studies and data, to warrant high-quality patient care and requisite levels of infection prevention during rhinology procedures.

Conclusion

In rhinology, marked care is advised during nasal packing, electrocauterisation and use of high-speed rotating devices in potentially infected tissue as they are considerable aerosol- producing procedures. The choice of personal protective equipment is based on the risk of exposure and possible modes of aerosol generation.