Recommendations from the CSO-HNS taskforce on performance of tracheotomy during the COVID-19 pandemic.

INTRODUCTION: The performance of tracheotomy is a common procedural request by critical care departments to the surgical services of general surgery, thoracic surgery and otolaryngology - head & neck surgery. A Canadian Society of Otolaryngology - Head & Neck Surgery (CSO-HNS) task force was convened with multi-specialty involvement from otolaryngology-head & neck surgery, general surgery, critical care and anesthesiology to develop a set of recommendations for the performance of tracheotomies during the COVID-19 pandemic. MAIN BODY: The tracheotomy procedure is highly aerosol generating and directly exposes the entire surgical team to the viral aerosol plume and secretions, thereby increasing the risk of transmission to healthcare providers. As such, we believe extended endotracheal intubation should be the standard of care for the entire duration of ventilation in the vast majority of patients. Pre-operative COVID-19 testing is highly recommended for any non-emergent procedure. CONCLUSION: The set of recommendations in this document highlight the importance of avoiding tracheotomy procedures in patients who are COVID-19 positive if at all possible. Recommendations for appropriate PPE and environment are made for COVID-19 positive, negative and unknown patients requiring consideration of tracheotomy. The safety of healthcare professionals who care for ill patients and who keep critical infrastructure operating is paramount.

Contribution of the medial orbital floor to endoscopic orbital decompression.

PROBLEM: This study explores contribution of the orbital floor to mechanical outcomes of orbital decompressions. METHOD OF STUDY: Endoscopic medial wall orbital decompressions with and without extensive medial orbital floor removal (OFR) were performed on opposite sides of ten thawed fresh-frozen cadaver heads Bone removal was compared on pre- and post-dissection CT scans and after orbital exenteration. RESULTS: Bony removal in the anterior orbital apex was significantly better after OFR (117 vs 66, p < 0.0001). An average of 10.3% (range 0 - 45.5%) of the orbital floor directly under the globe was removed with the OFR technique. The orbital floor preservation (OFP) technique resulted in average bone removal of 3.6 cm2, whereas OFR decompression resulted in average of 5.7 cm2 (p = 0.0003). Post-operative recession of the globe was significant in both arms of the study relative to the unoperated state (OFP averaged 2.99 mm decompression, p = 0.001 and OFR averaged 4.25 mm decompression, p = 0.02). CONCLUSIONS: Endoscopic removal of the medial orbital floor when performed in addition to medial wall decompression removes > 60% more orbital bone and an additional 51 of orbital apex bone. Extensive endoscopic removal of the mid-portion of the medial orbital floor results in bone loss beneath the globe itself.