COVID-19 and rhinological surgery.

The Coronavirus-19 (COVID-19) pandemic has caused disruptions in the normal patient care workflow, necessitating adaptations within the healthcare profession. The objective of this article is to outline some of these adaptations and considerations necessitated by COVID-19 within the subspeciality of rhinology and endoscopic skull base surgery.

A Novel Negative Pressure, Face-Mounted Antechamber to Minimize Aerosolization of Particles During Endoscopic Skull Base Surgery.

BACKGROUND: The COVID-19 pandemic has revealed deficiencies in the adequacy of personal protective equipment (PPE) for healthcare workers. Endoscopic endonasal skull base surgery is thought to be among the highest-risk aerosol-generating procedures for surgeons and operating room personnel. OBJECTIVE: To validate the efficacy and clinical feasibility of a novel surgical device. METHODS: A low-cost, modifiable, and easily producible negative pressure, face-mounted antechamber was developed utilizing 3D printing and silicone molding. Efficacy was evaluated using an optical particle sizer to quantify aerosols generated during both cadaver and intraoperative human use with high-speed drilling. RESULTS: Particle counts in the cadaver showed that drilling led to a 2.49-fold increase in particles 0.3 to 5 µm (P = .001) and that the chamber was effective at reducing particles to levels not significantly different than baseline. In humans, drilling led to a 37-fold increase in particles 0.3 to 5 µm (P < .001), and the chamber was effective at reducing particles to a level not significantly different than baseline. Use of the antechamber in 6 complex cases did not interfere with the ability to perform surgery. Patients did not report any facial discomfort after surgery related to antechamber use. CONCLUSION: The use of a negative pressure facial antechamber can effectively reduce aerosolization from endoscopic drilling without disturbing the flow of the operation. The antechamber, in conjunction with appropriate PPE, will be useful during the COVID-19 pandemic, as well as during flu season and any future viral outbreaks.

Transnasal endoscopic skull base surgery in the COVID-19 era: Recommendations for increasing the safety of the method.

Transnasal endoscopic skull base surgery (eSBS) has been adopted in recent years, in great part to replace the extended procedures required by external approaches. Though sometimes perceived as "minimally invasive", eSBS still necessitates extensive manipulations within the nose/paranasal sinuses. Furthermore, exposure of susceptible cerebral structures to light and heat emanated by the telescope should be considered to comprehensively evaluate the safety of the method. While the number of studies specifically targeting eSBS safety still remains scarce, the problem has recently expanded with the SARS-CoV-2 pandemic, which also has implications for the safety of the surgical personnel. It must be stressed that eSBS may directly expose the surgeon to potentially high volumes of virus-contaminated aerosol. Thus, the anxiety of both the patient and the surgeon must be taken into account. Consequently, safety requirements must follow the highest standards. This paper summarizes current knowledge on SARS-CoV-2 biology and the peculiarities of human immunology in respect of the host-virus relationship, taking into account the latest information concerning the SARS-CoV-2 worrisome affinity for the nervous system. Based on this information, a workflow proposal is offered for consideration. This could be useful not only for the duration of the pandemic, but also during the unpredictable timeline involving our coexistence with the virus. Recommendations include technical modifications to the operating theatre, personal protective equipment, standards of testing for SARS-CoV-2 infection, prophylactic pretreatment with interferon, anti-IL6 treatment and, last but not least, psychological support for the patient.

Nasoseptal Flap Necrosis After Endoscopic Skull Base Surgery in the Setting of COVID-19 Pandemic.

BACKGROUND: A novel viral strain known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has created a worldwide pandemic known as coronavirus 2019 (COVID-19). Early reports from China have highlighted the risks associated with performing endoscopic endonasal skull base surgery in patients with SARS-CoV-2. We present a rare complication of nasoseptal flap (NSF) necrosis associated with COVID-19, further emphasizing the challenges of performing these procedures in this era. CASE DESCRIPTION: A 78-year-old man underwent an extended endoscopic endonasal transplanum resection of a pituitary macroadenoma for decompression of the optic chiasm. The resulting skull base defect was repaired using a pedicled NSF. The patient developed meningitis and cerebrospinal fluid (CSF) leak on postoperative day 13, requiring revision repair of the defect. Twelve days later, he developed persistent fever and rhinorrhea. The patient was reexplored endoscopically, and the NSF was noted to be necrotic and devitalized with evident CSF leakage. At that time, the patient tested positive for SARS-CoV-2. Postoperatively, he developed acute respiratory distress syndrome complicated by hypoxic respiratory failure and death. CONCLUSIONS: To our knowledge, this is the first reported case of NSF necrosis in a patient with COVID-19. We postulate that the thrombotic complications of COVID-19 may have contributed to vascular pedicle thrombosis and NSF necrosis. Although the pathophysiology of SARS-CoV-2 and its effect on the nasal tissues is still being elucidated, this case highlights some challenges of performing endoscopic skull base surgery in the era of COVID-19.

Ventilated Upper Airway Endoscopic Endonasal Procedure Mask: Surgical Safety in the COVID-19 Era.

BACKGROUND: COVID-19 poses a risk to the endoscopic skull base surgeon. Significant efforts to improving safety have been employed, including the use of personal protective equipment, preoperative COVID-19 testing, and recently the use of a modified surgical mask barrier. OBJECTIVE: To reduce the risks of pathogen transmission during endoscopic skull base surgery. METHODS: This study was exempt from Institutional Review Board approval. Our study utilizes a 3-dimensional (3D)-printed mask with an anterior aperture fitted with a surgical glove with ports designed to allow for surgical instrumentation and side ports to accommodate suction ventilation and an endotracheal tube. As an alternative, a modified laparoscopic surgery trocar served as a port for instruments, and, on the contralateral side, rubber tubing was used over the endoscrub endosheath to create an airtight seal. Surgical freedom and aerosolization were tested in both modalities. RESULTS: The ventilated mask allowed for excellent surgical maneuverability and freedom. The trocar system was effective for posterior surgical procedures, allowing access to critical paramedian structures, and afforded a superior surgical seal, but was limited in terms of visualization and maneuverability during anterior approaches. Aerosolization was reduced using both the mask and nasal trocar. CONCLUSION: The ventilated upper airway endoscopic procedure mask allows for a sealed surgical barrier during endoscopic skull base surgery and may play a critical role in advancing skull base surgery in the COVID-19 era. The nasal trocar may be a useful alternative in instances where 3D printing is not available. Additional studies are needed to validate these preliminary findings.

Skull-base surgery during the COVID-19 pandemic: the Italian Skull Base Society recommendations.

Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), is highly contagious with devastating impacts for healthcare systems worldwide. Medical staff are at high risk of viral contamination and it is imperative to know what personal protective equipment (PPE) is appropriate for each situation. Furthermore, elective clinics and operations have been reduced in order to mobilize manpower to the acute specialties combating the outbreak; appropriate differentiation between patients who require immediate care and those who can receive telephone consultation or whose treatment might viably be postponed is therefore crucial. Italy was 1 of the earliest and hardest-hit European countries and therefore the Italian Skull Base Society board has promulgated specific recommendations based on consensus best practices and the literature, where available. Only urgent surgical operations are recommended and all patients should be tested at least twice (on days 4 and 2 prior to surgery). For positive patients, procedures should be postponed until after swab test negativization. If the procedure is vital to the survival of the patient, filtering facepiece 3 (FFP3) and/or powered air purifying respirator (PAPR) devices, goggles, full-face visor, double gloves, water-resistant gowns, and protective caps are mandatory. For negative patients, use of at least an FFP2 mask is recommended. In all cases the use of drills, which promote the aerosolization of potentially infected mucous particles, should be avoided. Given the potential neurotropism of SARS-CoV-2, dura handling should be minimized. It is only through widely-agreed protocols and teamwork that we will be able to deal with the evolving and complex implications of this new pandemic.