[Endoscopic endonasal surgery during COVID-19 pandemic: Management guideline]. / Cirugía endoscópica endonasal durante la pandemia COVID-19: protocolo de actuación.

Current SARS-CoV-2 coronavirus pandemic is challenging medical and surgical activities. Specifically, within neurosurgery, endoscopic endonasal approaches pose a high risk of contagion for healthcare personnel involved in it. Initially, the recommendation was to avoid such surgeries. However, the pandemic has dragged on and new solutions must be proposed to continue carrying out these approaches safely. Given the lack of established protocols, we propose the following one, which concisely establishes the measures to be taken in both urgent and scheduled surgery. In addition, a new protection-aspiration device (Maskpirator) is described.

Droplet and Aerosol Generation With Endonasal Surgery: Methods to Mitigate Risk During the COVID-19 Pandemic.

OBJECTIVE: To define the aerosol and droplet risks associated with endonasal drilling and to identify mitigation strategies. STUDY DESIGN: Simulation series with fluorescent 3-dimensional (3D) printed sinonasal models and deidentified cadaveric heads. SETTINGS: Dedicated surgical laboratory. SUBJECTS AND METHODS: Cadaveric specimens irrigated with fluorescent tracer and fluorescent 3D-printed models were drilled. A cascade impactor was used to collect aerosols and small droplets of various aerodynamic diameters under 15 µm. Large droplet generation was measured by evaluating the field for fluorescent debris. Aerosol plumes through the nares were generated via nebulizer, and mitigation measures, including suction and SPIWay devices, nasal sheaths, were evaluated regarding reduction of aerosol escape from the nose. RESULTS: The drilling of cadaveric specimens without flexible suction generated aerosols ≤3.30 µm, and drilling of 3D sinonasal models consistently produced aerosols ≤14.1 µm. Mitigation with SPIWay or diameter-restricted SPIWay produced same results. There was minimal field contamination in the cadaveric models, 0% to 2.77% field tarp area, regardless of drill burr type or drilling location; cutting burr drilling without suction in the 3D model yielded the worst contamination field (36.1%), followed by coarse diamond drilling without suction (19.4%). The simple placement of a flexible suction instrument in the nasal cavity or nasopharynx led to complete elimination of all aerosols ≤14.1 µm, as evaluated by a cascade impactor positioned immediately at the nares. CONCLUSION: Given the findings regarding aerosol risk reduction, we strongly recommend that physicians use a suction instrument in the nasal cavity or nasopharynx during endonasal surgery in the COVID-19 era.

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.

Minimizing Contagion Risks of COVID-19 During Transoral Robotic Surgery.

In this communication, we would like to share our experience in managing TORS patients during COVID-19 pandemic. Laryngoscope, 130:2593-2594, 2020.