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.

Experience with 2D Exoscope System for Bilateral Simultaneous Cochlear Implant Surgery in the Era of the COVID-19 Pandemic.

We report the first case series utilizing the exoscope exclusively for bilateral simultaneous cochlear implant surgery and discuss the advantages, disadvantages, as well as surgical outcomes in the Covid-19 era. The VITOM® 2D is compatible with enhanced PPE and draping techniques which can improve safety while providing comparable surgical outcomes.

Patient-Related long-term outcome measures after mastoid surgery at a tertiary care center of North India: A retrospective analysis

Background: Long-term postsurgical follow-up in chronic otitis media (COM) is crucial in otologic practice for outcome assessment. Validated questionnaires for the same are robust alternatives when physical visits are not feasible such as the current COVID-19 pandemic and we present our findings of outcome assessment using COM outcome test (COMOT)-15 questionnaire through nonphysical mode. Material(s) and Method(s): A retrospective analysis of a cohort of 112 patients of COM who underwent surgery by the single senior otology surgeon between 2009 and 2019 was done using COMOT 15 questionnaire through telephonic methods to circumvent the need of office visits. Result(s): Fifty out of 112 patients could be contacted and consented for the assessment and their COMOT-15 scores were obtained. The numbers of patients with any otologic symptoms and their need for consultations, except hearing loss were significantly less. One-third of the patients had mild to moderate residual hearing loss and its quality of life impacts, although the same neither was statistically significant nor required increased numbers of consultations. Conclusion(s): Bothering symptoms and the need for a frequent visit to the doctor is significantly less with adequate clearance of disease and mastoid obliteration in cases of canal wall down procedures. The residual mild-to-moderate hearing loss are not significant and manageable with day-to-day activities. Successful outcome of COM surgery needs long-term follow-up and evaluation by all practicing otologic departments and surgeons which can well be done through nonphysical modes in unprecedented situations like the current times. Copyright © 2022 Indian Journal of Otology Published by Wolters Kluwer-Medknow.

COVID-19 and otologic surgery.

In this article, we aim to summarize the impacts of COVID-19 on the practice of otologic surgery. Cadaveric studies have indicated COVID-19 viral particles are present in the middle ear mucosa of infected hosts. Otologic procedures can generate significant amounts of droplets due to reliance on high-speed drills. Multiple guidelines have been developed to improve patient and provider safety peri-operatively. Particle dispersion can be mitigated during microscopic mastoidectomy by utilizing barrier drape techniques. The barrier drape may similarly be applied to the surgical exoscope. Endoscopic techniques have theoretical improved safety benefits by minimizing the need for drilling. The discoveries and innovations borne of the COVID-19 pandemic will lay the groundwork for the practice of otology amidst future pandemics.

eP455: Fetal ultrasound presentation and neonatal diagnosis of Freeman-Sheldon syndrome in son of previously undiagnosed adult male

Background: Freeman-Sheldon syndrome [distal arthrogryposis type 2A (OMIM #193700), DA2A, Freeman-Burian syndrome] is a rare autosomal dominant multiple pterygium syndrome caused by alterations in MYH3. The phenotypic features, particularly of the face, are distinct and easily recognizable, and the diagnosis can be confirmed with molecular gene analysis. Fetal ultrasound imaging may provide important diagnostic clues to facilitate the diagnostic process. Informed consent and parental permission were provided by the parents. Case presentation: The infant’s mother presented for a Maternal Fetal Medicine genetic counseling telehealth appointment (due to COVID-19 pandemic restrictions) as a G7P2132, 32-year old female who had insulin-dependent diabetes and thrombocytosis. Her partner was a 24-year old male with a history of hearing loss, a V-shaped palate, and a lower lip cleft. Gestational age was 14 4/7 weeks and the indications were: increased nuchal translucency, paternal complex medical history, maternal G6PD heterozygote, and recurrent pregnancy loss. During the genetic counseling session, the following were addressed: 1) Maternal heterozygote status for G6PD indicated that if the fetus was male, there was a 50% chance he would be affected with G6PD-deficiency;2) Increased nuchal translucency on fetal ultrasound (US) with measurement at 98th percentile is associated with an increased risk of chromosomal abnormalities, microdeletion/duplications, and Noonan syndrome. The patient reportedly had low risk cell-free DNA but results were not available to the counselor at the time of consult. The option for additional genetic screening and diagnostic testing was declined;3) Three first trimester pregnancy losses with the father of this baby (FOB) were addressed, and parents deferred chromosome analyses at the time;4) Mother shared FOB’s complex history of bilateral sensorineural hearing loss, V-shaped cleft palate, lower lip cleft, and micrognathia. However, father was not present during the telehealth encounter. Mother was counseled regarding the possibility of an autosomal dominant condition with the potential risk to the pregnancy of up to 50%. It was recommended that the FOB have a clinical genetics evaluation, which could potentially provide a specific diagnosis and inform recurrence risk and management guidance. Follow-up MFM genetic counseling telephone visit occurred with the mother at 31 6/7 weeks gestation due to multiple congenital anomalies evident on fetal ultrasound. A 25 week fetal ultrasound revealed hypotelorism and a thickened nuchal translucency. A repeat study at 29 weeks revealed a V-shaped palate with a possible cleft, micrognathia, and midline mandibular cleft. FOB’s history was revisited. It was determined that he had 3 previous “no shows” to Genetics clinic appointments and did not pursue evaluation after the last counseling appointment. Again, it was emphasized that in order to best make a diagnosis for the family, an affected person would need to undergo a thorough evaluation, including medical and family history review, physical examination, and any indicated genetic testing. The parents were comfortable with the likelihood that the baby had the same condition as the father, but variable expressivity and broad range pf phenotypic presentation were explained. Recommendations for postnatal evaluation of the infant and pertinent genetic testing were provided. Consultative Genetics evaluation of the infant at 2 days of age revealed a short, broad forehead with supraorbital fullness leading to a horizontal brow indentation;mask-like facial appearance;hypotelorism;very deep set eyes with blepharophimosis;deep, creased nasal bridge;small, upturned nose with hypoplastic alae and narrow nares;microstomia with pursed lips;glossoptosis;micrognathia;2 deep vertical chin creases;short neck with excess nuchal skin;inverted and wide spaced nipples;clenched hands with 5th digits overlying 4th and 2nd overlying 3rd, bilaterally;bilateral vertical talus;2nd toes longer and overlying rd toes;clinodactyly of 4th and 5th toes bilaterally;and deep gluteal crease with no visible sinus. There were no evident contractures. The father has a complex history with no medical assessments prior to age 18. He reported that he did “not look like anyone else” in his family. He has a diagnosis of autistic spectrum disorder, a submucous cleft, vision issues, hearing loss necessitating a hearing aid on the left, and a history of cholesteatomas and of mastoidectomy. On brief examination, he had a mask-like face, blepharophimosis, left microphthalmia, left esotropia, narrowing of his midface, deep vertical crease on the mandibular region, microstomia, broad great toes, single flexor creases on the thumbs, and contracture of right thumb. Maxillofacial CT of the infant revealed hypoplastic mandibular body, ramus, and condyles bilaterally with micrognathia and retrognathia;hypoplastic maxilla bilaterally;and enophthalmos with retracted appearance of globes in the bony orbits bilaterally. Multiple facial bone abnormalities were seen, including microsomia, micrognathia, retrognathia, orbital hypotelorism and enophthalmos Genetic testing was performed via a custom Whole Exome Slice at GeneDx laboratories and included the MYH3 and TNNI2 genes. Results revealed a heterozygous pathogenic change in MYH3 (c.2015 G>A;p. R6724) consistent with the diagnosis of Freeman-Sheldon syndrome. Conclusion: The presentation of “midline mandibular cleft” on fetal ultrasound was the most specific prenatal finding. This is a very rare fetal finding. Thus, it should prompt further evaluation to assess for true clefting versus ridging or creasing. Additionally, targeted assessment for other findings or clinical clues for Freeman-Sheldon syndrome, such as contractures, “windmill vane” hand, and mouth size, could aid in the differential diagnosis considerations and the diagnostic process. Admittedly, these are position and quality dependent, and are challenging to assess even in ideal situations. The phenotype of the father was immediately recognizable. However, due to COVID-19 pandemic restrictions, prior to the infant’s birth, only telehealth visits were conducted and the father’s participation was by telephone. This limited the ability to narrow the differential diagnosis without visualization of his distinct phenotypic features. Finally, missed opportunities to diagnose the father prior to this pregnancy occurred. Many clinics send “no show” letters to referring providers and patients, as we do. Emphasizing the importance of diagnosis prior to pregnancy for individuals concerned about having a genetic disorder should be considered as part of the information shared in these letters.

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.

Aerosol generation during cadaveric simulation of otologic surgery and live cochlear implantation.

OBJECTIVE: The risk of SARS-CoV-2 transmission to healthcare workers through airborne aerosolization during otologic surgery has not been characterized. The objective of this study was to describe and quantify the aerosol generation during common otologic procedures in both cadaveric surgical simulation and live patient surgery. METHODS: The number concentrations of generated aerosols in the particle size range of 0.30 to 10.0 µm were quantified using an optical particle sizer during both a cadaveric simulation of routine otologic procedures as well as cochlear implant surgery on live patients in the operating room. RESULTS: In the cadaveric simulation, temporalis fascia graft harvest using cold techniques (without electrocautery) (n = 4) did not generate aerosols above baseline concentrations. Tympanoplasty (n = 3) and mastoidectomy (n = 3) both produced statistically significant increases in concentrations of aerosols (P < 0.05), predominantly submicron particles (< 1.0 µm). High-speed, powered drilling of the temporal bone during mastoidectomy with a Multi Flute cutting burr resulted in higher peak concentrations and greater number of spikes in aerosols than with a diamond burr. In the operating room, spikes in aerosols occurred during both cochlear implant surgeries. CONCLUSION: In the cadaveric simulation, temporalis fascia graft harvest without electrocautery did not generate aerosol levels above baseline, while significant aerosol levels were generated during mastoidectomy and to a much less degree during tympanoplasty. Aerosol spikes were appreciated during cochlear implantation surgery in live patients. LEVEL OF EVIDENCE: 2.

Heads-up Surgery: Endoscopes and Exoscopes for Otology and Neurotology in the Era of the COVID-19 Pandemic.

A new era of surgical visualization and magnification is poised to disrupt the field of otology and neurotology. The once revolutionary benefits of the binocular microscope now are shared with rigid endoscopes and exoscopes. These 2 modalities are complementary. The endoscope improves visualization of the hidden recesses through the external auditory canal or canal-up mastoidectomy. The exoscope provides an immersive visual experience and superior ergonomics compared with binocular microscopy. Endoscopes and exoscopes are poised to disrupt the standard of care for surgical visualization and magnification in otology and neurotology.

Barrier for Particle Dispersion Control During Mastoidectomy.

Introduction The China Health Authority alerted the World Health Organization (WHO) of several cases of pneumonia, and the WHO has declared the novel coronavirus (COVID-19) a global pandemic. Mastoidectomy is a high-risk aerosol generating procedure with the potential to expose the surgeon to infectious particles. Objective Aim to develop a low-cost prototype for a barrier device that can be used during mastoidectomy. Methods Describe the steps involved during otological emergency, requiring immediate surgical procedure, in untested patients. The Otorhinolaryngology Surgical Team of Walter Cantídio Hospital developed the barrier for particle dispersion presented here. Results During surgery, the prototype did not compromise visualization of the surgical field and instrumentation. Microscope repositioning was not compromised or limited by tent Instrumentation and instrument pouch under the Microscope-Tent (MT) performed surgery. After surgery, the plastic sheet was removed simply, without requiring strength. Bone dust and irrigation droplets were collected on the tent. Conclusion Our team developed and practiced, in an otologic emergency, a low-cost and reproducible barrier device that can be used in mastoidectomy in COVID-19 patients. Further tests on efficacy may be necessary.

Droplet and bone dust contamination from high-speed drilling during mastoidectomy.

OBJECTIVES: The aim of this study was to examine contamination from otolaryngologic procedures involving high-speed drilling, specifically mastoid surgery, and to assess the adequacy of PPE in such procedures. DESIGN AND SETTING: Mastoid surgery was simulated in a dry laboratory using a plastic temporal bone, microscope and handheld drill with irrigation and suction. Comparisons of distance of droplet and bone dust contamination and surgeon contamination were made under differing conditions. Irrigation speed, use of microscope and drill burr size and type were compared. MAIN OUTCOME MEASURES: Measurement of the distance of field contamination while performing simulated mastoidectomy and location of surgeon contamination. RESULTS: There was a greater distance field contamination and surgeon contamination without the use of the microscope. Contamination was reduced by using a smaller drill burr and by using a diamond burr when compared to a cutting burr. The use of goggles and a face mask provided good protection for the surgeon. However, the microscope alone may provide sufficient protection to negate the need for goggles. CONCLUSIONS: While the risks of performing mastoid surgery during the coronavirus pandemic cannot be completely removed, they can be mitigated. Such factors include using the microscope for all drilling, using smaller size drill burrs and creating a safe zone around the operating table.

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.

Quantification and Comparison of Droplet Formation During Endoscopic and Microscopic Ear Surgery: A Cadaveric Model.

OBJECTIVES: The COVID-19 pandemic and the disproportional spread of the disease among otorhinolaryngologists raised concerns regarding the safety of health care staff. Therefore, a quantitative risk assessment for otologic surgery would be desirable. This study aims to quantitatively compare the risk of perioperative droplet formation between microscopic and endoscopic approaches. STUDY DESIGN: Experimental research. SETTING: Temporal bone laboratory. METHODS: The middle ear of whole head specimens was injected with fluorescein (0.2 mg/10 mL) before endoscopic and microscopic epitympanectomy and mastoidectomy. Fluorescent droplet deposition on the surgical table was recorded under ultraviolet light, quantified, and compared among the interventions. Drilling time, droplet proportion, fluorescein intensity, and droplet size were assessed for every procedure. RESULTS: A total of 12 procedures were performed: 4 endoscopic epitympanectomies, 4 microscopic epitympanectomies, and 4 mastoidectomies. The mean (SD) proportion of fluorescein droplets was 0.14‰ (0.10‰) for endoscopic epitympanectomy and 0.64‰ (0.31‰) for microscopic epitympanectomy. During mastoidectomy, the deposition of droplets was 8.77‰ (6.71‰). Statistical comparison based on a mixed effects model revealed a significant increase (0.50‰) in droplet deposition during microscopic epitympanectomy as compared with endoscopic epitympanectomy (95% CI, 0.16‰ to 0.84‰). CONCLUSIONS: There is considerable droplet generation during otologic surgery, and this represents a risk for the spread of airborne infectious diseases. The endoscopic technique offers the lowest risk of droplet formation as compared with microscopic approaches, with a significant 4.5-fold reduction of droplets between endoscopic and microscopic epitympanectomy and a 62-fold reduction between endoscopic epitympanectomy and cortical mastoidectomy.

Coronavirus Disease-19 and Otology/Neurotology.

The severe acute respiratory syndrome corona virus 2, responsible for the worldwide COVID-19 pandemic, has caused unprecedented changes to society as we know it. The effects have been particularly palpable in the practice of medicine. The field of otolaryngology has not been spared. We have had to significantly alter the way we provide care to patients, changes that are likely to become a new norm for the foreseeable future. This article highlights some of the changes as they apply to otology/neurotology. Although this is written from the perspective of an academic physician, it is also applicable to private practice colleagues.

Awareness of an Primitive Art for Treating Otological Diseases in Present Covid-19 Scenario: Need of the Hour.

In current scenario of Covid-19 pandemic spread of virus via aerosol generating procedures has become a special concern in otorhinolaryngology community. Motive of this study is to spread awareness of an ancient forgotten method of performing mastoidectomy through which risk of virus infection can be greatly reduced among otologic surgeons. Retrospective Observational study. Three patients of chronic otitis media with complication were operatively intervened with combined approach of otorhinolaryngology and neurosurgeons. Mastoidectomies were performed without drilling. Instruments used were small, medium and large size gouge, chisel and hammer, curettes, kerrison punches and other microscopic ear instruments. All three patients recovered well without any residual disease or cavity problems. Referring ancient practices like above in this COVID era may prove an important tool in addressing surgical urgencies while combating transmission risks at the same time. One should be vigilant and versatile in surgical techniques in order to serve the needy and save the saviours simultaneously.

An operative barrier system for skull base and mastoid surgery: creating a safe operative theatre in the era of COVID-19.

Within Neurotology, special draping systems have been devised for mastoid surgery recognizing that drilling of middle ear mucosa is an aerosol generating medical procedure (AGMP) which can place surgical teams at risk of COVID-19 infection. We provide a thorough description of a barrier system utilized in our practice, along with work completed by our group to better quantify its effectiveness. Utilization of a barrier system can provide near complete bone dust and droplet containment within the surgical field and prevent contamination of other healthcare workers. As this is an early system, further adaptations and national collaborations are required to ultimately arrive at a system that seamlessly integrates into the surgical suite. While these barrier systems are new, they are timely as we face a pandemic, and can play a crucial role in safely resuming surgery.

Two-drape closed pocket technique: minimizing aerosolization in mastoid exploration during COVID-19 pandemic.

BACKGROUND: Mastoidectomy is associated with extensive bone-drilling which makes it a major aerosol generating procedure. Considering the ongoing COVID-19 global pandemic, it is essential to devise methods to minimize aerosolization and hence ensure safety of the healthcare workers during the operative procedure. METHODS: Two disposable surgical drapes are used to create a closed pocket prior to commencement of mastoid bone-drilling. This limits aerosolization of bone-dust in the external operating theatre environment. CONCLUSION: Two-drape closed pocket technique is an easy, cost-effective and safe method to limit aerosolization of tissue particles during mastoidectomy.

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

OBJECTIVES/HYPOTHESIS: The overall aim of this study was to evaluate personal protective equipment (PPE) that may facilitate the safe recommencement of cochlear implantation in the COVID-19 era, with the broader goal of minimizing the period of auditory deprivation in prelingually deaf children and reducing the risk of cochlear ossification in individuals following meningitis. METHODS: The study design comprised 1) an objective assessment of mastoid drilling-induced droplet spread conducted during simulated cochlear implant (CI) surgery and its mitigation via the use of a protective drape tent and 2) an evaluation of three PPE configurations by otologists while performing mastoid drilling on ex vivo temporal bones. The various PPE solutions were assessed in terms of their impact on communication, vital physiological parameters, visual acuity and fields, and acceptability to surgeons using a systematic risk-based approach. RESULTS: Droplet spread during simulated CI surgery extended over 2 m, a distance greater than previously reported. A drape tent significantly reduced droplet spread. The ensemble of a half-face mask and safety spoggles (foam lined safety goggles) had consistently superior performance across all aspects of clinical usability. All other PPE options were found to substantially restrict the visual field, making them unsafe for microsurgery. CONCLUSIONS: The results of this preclinical study indicate that the most viable solution to enable the safe conduct of CI and other mastoid surgery is a combination of a filtering facepiece (FFP3) mask or half-face respirator with safety spoggles as PPE. Prescription spoggles are an option for surgeons who need to wear corrective glasses to operate. A drape tent reduces droplet spread. A multicenter clinical trial to evaluate the effectiveness of PPE should be the next step toward safely performing CI surgery during the COVID-19 era. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2693-2699, 2020.

The challenge of performing mastoidectomy using the operating microscope with coronavirus disease 2019 personal protective equipment (PPE).

OBJECTIVE: Mastoidectomy is considered an aerosol-generating procedure. This study examined the effect of wearing personal protective equipment on the view achieved using the operating microscope. METHODS: ENT surgeons assessed the area of a calibrated target visible through an operating microscope whilst wearing a range of personal protective equipment, with prescription glasses when required. The distance between the surgeon's eye and the microscope was measured in each personal protective equipment condition. RESULTS: Eleven surgeons participated. The distance from the eye to the microscope inversely correlated with the diameter and area visible (p < 0.001). The median area visible while wearing the filtering facepiece code 3 mask and full-face visor was 4 per cent (range, 4-16 per cent). CONCLUSION: The full-face visor is incompatible with the operating microscope. Solutions offering adequate eye protection for aerosol-generating procedures that require the microscope, including mastoidectomy, are urgently needed. Low-profile safety goggles should have a working distance of less than 20 mm and be compatible with prescription lenses.