Using a 4K three-dimensional exoscope system (Vitom 3D) for mastoid surgery during the coronavirus disease 2019 pandemic.

OBJECTIVE: Microscopic surgery is currently considered the 'gold standard' for middle-ear, mastoid and lateral skull base surgery. The coronavirus disease 2019 pandemic has made microscopic surgery more challenging to perform. This work aimed to demonstrate the feasibility of the Vitom 3D system, which integrates a high-definition (4K) view and three-dimensional technology for ear surgery, within the context of the pandemic. METHOD: Combined approach tympanoplasty and ossiculoplasty were performed for cholesteatoma using the Vitom 3D system exclusively. RESULTS: Surgery was performed successfully. The patient made a good recovery, with no evidence of residual disease at follow up. The compact system has excellent depth of field, magnification and colour. It enables ergonomic work, improved work flow, and is ideal for teaching and training. CONCLUSION: The Vitom 3D system is considered a revolutionary alternative to microscope-assisted surgery, particularly in light of coronavirus disease 2019. It allows delivery of safe otological surgery, which may aid in continuing elective surgery.

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.

Middle Ear Viral Load Considerations in the COVID-19 Era: A Systematic Review.

OBJECTIVE: To systematically review the available medical literature to investigate the viral load in the middle ear and mastoid cavity and the potential risk of exposure to airborne viruses during otologic surgery. DATA SOURCES: PubMed, MEDLINE, and Cochrane databases. STUDY SELECTION: This review was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Protocol. DATA EXTRACTION: Using the Boolean method and relevant search term combinations for terms "mastoid," "middle ear," "virus," "exposure" "COVID-19" "SARS-CoV-2." PubMed, MEDLINE, and Cochrane databases were queried. A total of 57 abstracts were identified and screened by two independent reviewers. Following inclusion and exclusion criteria, 18 studies were selected for the final analysis. DATA SYNTHESIS: Due to the heterogeneity of clinical data, a meta-analysis was not feasible. RESULTS: Rhinovirus, followed by respiratory syncytial virus are reported to be the most prevalent viruses in MEF samples but formal statistical analysis is precluded by the heterogeneity of the studies. Drilling was identified to have the highest risk for aerosol generation and therefore viral exposure during otologic Surgery. CONCLUSIONS: The medical literature has consistently demonstrated the presence of nucleic acids of respiratory viruses involving the middle ear, including SARS-CoV2 in a recent postmortem study. Although no in vivo studies have been conducted, due to the likely risk of transmission, middle ear and mastoid procedures, particularly involving the use of a drill should be deferred, if possible, during the pandemic and enhanced personal protective equipment (PPE) used if surgery is necessary.

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.

Covid-19 and Otologic/Neurotologic Practices: Suggestions to Improve the Safety of Surgery and Consultations.

: Since the beginning of 2020, the world has been confronted by the Covid-19 pandemic. The lock-down aims to limit the circulation of the virus and thus avoid overwhelming healthcare systems. Healthcare workers have had to adapt by postponing consultation and surgical activities. Otolaryngologists are particularly exposed to infection from the upper airway where the virus is highly concentrated. Literature has previously reported other human coronaviruses in the middle ear and mastoid, suggesting a risk of infection to staff during ear surgery where aerosolizing procedures are usually used. The aim of this article is to propose a strategy for planning consultations and surgeries for ear and lateral skull base diseases, in the context of the current active evolution of the pandemic and of the future gradual recovery to normal practice.

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.

Aerosol Dispersion During Mastoidectomy and Custom Mitigation Strategies for Otologic Surgery in the COVID-19 Era.

OBJECTIVE: To investigate small-particle aerosolization from mastoidectomy relevant to potential viral transmission and to test source-control mitigation strategies. STUDY DESIGN: Cadaveric simulation. SETTING: Surgical simulation laboratory. METHODS: An optical particle size spectrometer was used to quantify 1- to 10-µm aerosols 30 cm from mastoid cortex drilling. Two barrier drapes were evaluated: OtoTent1, a drape sheet affixed to the microscope; OtoTent2, a custom-structured drape that enclosed the surgical field with specialized ports. RESULTS: Mastoid drilling without a barrier drape, with or without an aerosol-scavenging second suction, generated large amounts of 1- to 10-µm particulate. Drilling under OtoTent1 generated a high density of particles when compared with baseline environmental levels (P < .001, U = 107). By contrast, when drilling was conducted under OtoTent2, mean particle density remained at baseline. Adding a second suction inside OtoTent1 or OtoTent2 kept particle density at baseline levels. Significant aerosols were released upon removal of OtoTent1 or OtoTent2 despite a 60-second pause before drape removal after drilling (P < .001, U = 0, n = 10, 12; P < .001, U = 2, n = 12, 12, respectively). However, particle density did not increase above baseline when a second suction and a pause before removal were both employed. CONCLUSIONS: Mastoidectomy without a barrier, even when a second suction was added, generated substantial 1- to 10-µm aerosols. During drilling, large amounts of aerosols above baseline levels were detected with OtoTent1 but not OtoTent2. For both drapes, a second suction was an effective mitigation strategy during drilling. Last, the combination of a second suction and a pause before removal prevented aerosol escape during the removal of either drape.

Demonstration and Mitigation of Aerosol and Particle Dispersion During Mastoidectomy Relevant to the COVID-19 Era.

BACKGROUND: COVID-19 has become a global pandemic with a dramatic impact on healthcare systems. Concern for viral transmission necessitates the investigation of otologic procedures that use high-speed drilling instruments, including mastoidectomy, which we hypothesized to be an aerosol-generating procedure. METHODS: Mastoidectomy with a high-speed drill was simulated using fresh-frozen cadaveric heads with fluorescein solution injected into the mastoid air cells. Specimens were drilled for 1-minute durations in test conditions with and without a microscope. A barrier drape was fashioned from a commercially available drape (the OtoTent). Dispersed particulate matter was quantified in segments of an octagonal test grid measuring 60 cm in radius. RESULTS: Drilling without a microscope dispersed fluorescent particles 360 degrees, with the areas of highest density in quadrants near the surgeon and close to the surgical site. Using a microscope or varying irrigation rates did not significantly reduce particle density or percent surface area with particulate. Using the OtoTent significantly reduced particle density and percent surface area with particulate across the segments of the test grid beyond 30 cm (which marked the boundary of the OtoTent) compared with the microscope only and no microscope test conditions (Kruskall-Wallis test, p = 0.0066). CONCLUSIONS: Mastoidectomy with a high-speed drill is an aerosol-generating procedure, a designation that connotes the potential high risk of viral transmission and need for higher levels of personal protective equipment. A simple barrier drape significantly reduced particulate dispersion in this study and could be an effective mitigation strategy in addition to appropriate personal protective equipment.