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American Neurotology Society, American Otological Society, and American Academy of Otolaryngology – Head and Neck Foundation Guide to Enhance Otologic and Neurotologic Care During the COVID-19 Pandemic

Kozin, Elliott D.∗,†; Remenschneider, Aaron K.∗,†,‡; Blevins, Nikolas H.§; Jan, Taha A.§; Quesnel, Alicia M.∗,†; Chari, Divya A.∗,†; Kesser, Bradley W.||; Weinstein, Jaqueline E.; Ahsan, Syed F.#,∗∗∗∗∗; Telischi, Fred F.∗∗; Adunka, Oliver F.††; Weber, Peter‡‡; Knoll, Renata M.; Coelho, Daniel H.§§; Anne, Samantha||||; Franck, Kevin H.∗,¶¶; Marchioni, Daniele##; Barker, Frederick G. II∗∗∗; Carter, Bob S.∗∗∗; Lustig, Lawrence R.†††,‡‡‡; Bojrab, Dennis I.§§§; Bhansali, Sanjay A.||||||; Westerberg, Brian D.¶¶¶; Lundy, Larry###; Jackler, Robert K.; Roland, J. Thomas Jr.∗∗∗∗; Chandrasekhar, Sujana S.††††,‡‡‡‡,§§§§; Antonelli, Patrick J.||||||||; Carey, John P.¶¶¶¶; Welling, D. Bradley∗,†; Slattery, William H. III####; Lee, Daniel J.∗,†; members of the American Neurotology Society Council, members of the American Otological Society Council, and members of the American Academy of Otolaryngology – Head and Neck Surgery Hearing Committee and Implantable Hearing Devices Committee

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doi: 10.1097/MAO.0000000000002868
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Abstract

In 2019, a novel enveloped RNA betacoronavirus was identified in Wuhan, China, and later named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by the World Health Organization (1). The rapid global spread of coronavirus disease of 2019 (COVID-19) has been well documented in the lay press and medical literature. As of July 26, 2020, there are over 145,000 deaths attributable to COVID-19 in the United States alone (2).

Particularly troublesome about the COVID-19 pandemic is the significant risk of disease transmission to the healthcare team (3–9). There are several peer-reviewed and non-peer-reviewed reports that highlight the risk of COVID-19 transmission from direct contact, droplets, and aerosolization of viral particles from the respiratory tract mucosa (10–13). Otolaryngologists and associated health care workers (HCW) may be at high risk for COVID-19 disease transmission based on a symptom complex that may prompt an otolaryngology visit and their subsequent close contact with the upper aerodigestive tract of patients during diagnostic evaluation, and therapeutic procedures of the head and neck (14–19). In addition, there is evidence that infected individuals can be minimally symptomatic or asymptomatic and yet carry high viral loads and transmit disease to others (20–22). There is an urgent need to evaluate and mitigate the risk of COVID-19 transmission for all patients, providers, and HCW in otolaryngologic practices.

Many COVID-19-related concerns may be theoretical in nature or based on expert opinion rather than on scientific evidence. This guidance is not intended to be construed as the “standard of care,” and may be superseded, supplemented, or enhanced by guidance from local, state, and federal government agencies, local/regional hospital systems, and/or other medical societies. Further, the following recommendations are not intended to define clinical indications for diagnostic and surgical procedures across the breadth of our specialty. These have already been determined over many years and are updated regularly. We recognize that there may be local conditions related to the extent of COVID-19 infections within a community, the type of practice/hospital system, the availability of effective personal protective equipment (PPE) and other supplies, the physical configuration of workspaces, practice economics, local rules and regulations, and other constraints that may affect the ability to follow every aspect of this guidance. The intent is to consider this a living document and update it as new information becomes available and thusly the information contained herein is subject to change on an ongoing basis.

RELEVANCE OF COVID-19 TO OTOLOGY AND NEUROTOLOGY

There is a paucity of data on the risk of COVID-19 transmission during otologic and neurotologic practices and procedures (18,23–26). Consequently, data-based guidance on case selection and PPE use is lacking. Other coronaviruses have been isolated from the middle ear in patients with otitis media with effusion (27–29). Early data suggests that the middle ear and mastoid air cell system may also become infected by SARS-CoV-2 (30).

Similar to other aerosol-generating medical procedures (AGMP), such as endonasal procedures (19,31), aerosolization of bone, mucosa, and tympanic fluid has been shown to occur during mastoid and skull base drilling (32–35). Powered and heat-generating instrumentation, such as otologic drills, ultrasonic dissectors, electrocautery, and lasers, may further aerosolize infectious particles (36–43). The spread of other viruses, including Ebola, SARS-CoV, and Middle East respiratory syndrome coronavirus, has been associated with AGMPs (41,44–47). Taken together, there may be a risk of viral transmission to the health care team when performing otologic and neurotologic procedures in the clinic and operating room in patients infected with SARS-CoV-2.

COVID-19 RISK ASSESSMENT IN OTOLOGIC AND NEUROTOLOGIC PRACTICES

A multitude of factors are incorporated into the assessment of a patient's risk for being infected with SARS-CoV-2, including 1) diagnostic screening (usually reverse transcription-polymerase chain reaction (RT-PCR) testing on a nasal swab), 2) COVID-19 symptom screening (fever, cough, fatigue, shortness of breath, anosmia, etc.), 3) history of contact with COVID-19-positive patients, and 4) recent travel from high-risk locations, including certain locations in the United States. Up to date COVID-19 symptoms and risk factors are maintained on the CDC website (48).

The importance of symptoms, history of contact with COVID-19-infected individuals, and travel is controversial given significant numbers of asymptomatic COVID-positive patients and widespread community acquisition of COVID-19 (20–22). Although clinical symptoms and travel history may remain helpful to identify high-risk patients, this may not be the sole or preferred means of pretreatment screening.

Various means of testing for SARS-CoV-2 infection are becoming increasingly available. However, most institutions use a sample collected by nasopharyngeal swab for an RT-PCR test. The sensitivity of the swab is dependent on various factors including the swab collection technique, the viral load present in the patient, and the primer used for RT-PCR. The specificity may be reduced by cross-reactivity with other coronaviruses or potential lab contamination. Otolaryngologists should be aware of the limitations imposed by the sensitivity/specificity of current COVID-19 testing, especially in asymptomatic patients (49–52).

To improve posttest likelihood of disease, some US-based centers advocate for two independent rounds of nasopharyngeal swab RT-PCR testing separated by 24 hours in patients before nonemergent surgery. After negative testing, some insist the patient self-quarantine before surgery, while other centers have an “expiration date” on testing due to the fact that a patient may become infected with SARS-CoV-2 after the testing is complete and before the surgery being performed. Further, emerging studies from Europe and Asia have indicated a role for multimodality testing, such as the inclusion of chest CT imaging as part of the COVID-19 screening pathway to improve screening sensitivity (52–56).

Based on the changing landscape of COVID-19 transmission, including infectious capacity of asymptomatic patients, as well as evolving COVID-19 testing paradigms, we advocate two patient categories for the purposes of risk stratification:

  • High-risk patients
    • ∘ Positive COVID-19 test result
    • ∘ Symptomatic patients (57), including person under investigation (PUI) for COVID-19
    • ∘ Inability to test and evaluate symptoms for COVID-19
  • Intermediate-risk patients
    • ∘ Negative COVID-19 test result
    • ∘ Asymptomatic patient with no COVID-19 testing

Notably, a low-risk category is purposefully omitted given the limitations and variability of current COVID-19 viral testing in the United States, which may be in part due to multiple factors, such as testing modality, variation in swabbing technique, timing of testing, and viral load of testing location (e.g. nasopharynx vs. sputum) (51,58,59). Asymptomatic patients with a negative COVID-19 test result may ultimately fall into this category. As COVID-19 testing evolves, these categories of patients will likely change with the categorization of “low risk” patients, particularly in nonendemic areas. Next-generation COVID-19 testing (e.g. serum antibody testing, coupled with an understanding of what patterns indicate effective immunity) will hopefully guide this designation.

In high-risk patients, management of all nonemergent otologic and neurotologic conditions may be postponed until the patient has recovered as determined by time since onset of symptoms, symptom resolution, and/or testing. Even in patients with presymptomatic SARS-CoV-2 infection, surgery has been associated with an increased risk of patient morbidity and mortality (60-62) irrespective of the risk of viral infection transmission to HCW.

In intermediate-risk patients, clinicians may proceed with evaluation and treatment of patients based upon their own judgement and clinic/hospital regulations. In the case of a suspiciously symptomatic patient who tests negative for COVID-19, clinical judgment may decide whether treatment may proceed or be delayed until symptoms resolve, and/or repeat testing further confirms absence of infection.

New algorithms on how to manage patients who have “recovered” from COVID-19 may be developed, as evidence emerges to confirm or refute if postinfectious individuals are protected against subsequent COVID-19 reinfection. Furthermore, the expected window to RT-PCR test conversion (positive to negative) in postinfectious patients is highly variable and may affect resumption of care for these patients.

OTOLOGIC AND NEUROTOLOGIC OFFICE-BASED VISITS AND PROCEDURES

The risk of COVID-19 transmission in the office setting is based on several factors, including routine examination of the head and neck, instrumentation of mucosal surfaces, viral load of the upper airway in symptomatic and asymptomatic COVID-19-positive patients (10,63,64), use of PPE, and air exchange in the clinic examination room to name but a few. Careful consideration of these factors, in conjunction with local context, may be given to all visits and procedures planned.

Patient Flow and Personal Protective Equipment

All patients and their accompanying persons may be screened for COVID-19 symptoms by telephone before entering the office to prevent transmission to fellow patients, clinical office staff, and HCW. The CDC website may be referenced for current symptom and risk factor-based case definitions (48).

All patients should maintain appropriate social distancing requirements in the waiting area after patient check-in as needed to comply with CDC social distancing guidelines. Waiting room seating arrangements may be adjusted to facilitate policies related to social distancing. Alternatively, patients may wait in their car or outside the clinic until an exam room is available and which time they are notified to come into the clinic and straight into the available room. Schedulers may consider staggering appointments and avoid double-booking to minimize patient crowding. Accompanying visitors may be discouraged or limited unless necessary, as in the case of pediatric patients. Clinics may maintain standard precautions for all patients and associated visitors: depending on the status of the pandemic locally, patients may (but in some states must) cover their mouths and noses in the clinic setting, such as with a homemade or provided surgical mask (65,66).

Office Prioritization of Otologic and Neurotologic Diagnoses

The following recommendations provide guidance for diagnoses and timing considerations for in-person visits. The list is not meant to be exhaustive and the timing is not meant to be absolute. The experience and discretion of the otolaryngologist may determine reasons for such visits to be scheduled on a different timeframe. When possible, telemedicine screening of new patients or established patients with new concerning symptoms can be implemented to further determine the urgency of in-person visits.

Diagnoses Requiring an “Urgent” Clinic Visit

  • Sudden sensorineural hearing loss
  • Meniére's disease with intractable vertigo and/or drop attacks
  • Acute pediatric or adult otitis media refractory to systemic/topical antibiotics
  • Trauma to pinna with resultant auricular hematoma
  • Cerebrospinal fluid leak
  • Chronic ear disease and new onset facial nerve paralysis, intractable otalgia, or suspicion of intracranial complication (e.g. sigmoid sinus thrombosis, epidural or brain abscess)
  • Lateral skull base neoplasm (e.g. schwannoma and meningioma) with significant new growth, brainstem compression, hemorrhage, or acute neurologic deterioration
  • Acute facial paralysis
  • Otitis externa with intractable otalgia unresponsive to topical and systemic antibiotics
  • Otitis externa, progressive despite ototopical management or secondary to cerumen impaction or retained foreign-body in ear canal (e.g. button battery)
  • Otogenic skull base osteomyelitis
  • Lesion or history concerning for otologic malignancy
  • Infected or malfunctioning auditory implant
  • Essential postoperative care (e.g. packing or suture removal, if cannot be done locally)
  • New patients with concerning symptoms without a diagnosis

Protocol for In-Office Procedures in High-risk Patients

In the case of COVID-19 high-risk patients, wearing an N95 or filtering face piece 2 (FFP2) mask, face shield, gown, and gloves may be appropriate for HCW. Head and shoe covers may be considered based on risk of splashing (Table 1) (67). Occlusive goggles may be considered if face shields are incompatible with use of the binocular microscope. Powered air purifying respirator (PAPR) may also be considered if the provider has an inadequate N95 / FFP2 fit. All HCW directly involved with the patient procedural care may use similar PPE.

TABLE 1
TABLE 1:
Personal protective equipment for clinic evaluation without procedures

HCW may choose to perform otologic office procedures with as few staff as possible in the room to minimize risk of exposure. However, otolaryngologists must judge when the availability of an assistant might decrease the risk of contaminating equipment.

While the risk for aerosolization during a standard otologic exam is likely to be lower than nasal or oral cavity exams, otolaryngologists are well aware of the propensity for ear canal instrumentation to elicit coughing due to stimulation of Arnold's nerve cough reflex. This could produce an unexpected plume of potentially infectious droplets. Aerosolization may also occur through instrumentation of infected tissue, including suction of middle ear effusions. Thus, instrumentation of the ear may be considered a potential AGMP. The risk may be minimized by having the patient wear a mask.

Examination rooms with aerosols may require additional cleaning or longer “elapsed time” for clearance of aerosols depending on the room air exchange rate, which will affect PPE usage by staff and/or the timetable for cleaning the room after use. This may alter clinic patient flow and may require thoughtful consideration of space utilization and ambulatory volumes. As additional information is acquired, this need for longer elapsed time will need to be re-revaluated.

Protocol for In-Office Procedures for Intermediate-risk Patients

Clinicians should be up to date on definitions and implications of “COVID-19 negative” test status; high false-negative rates on certain types of testing have been reported (49–52). If there is any question regarding COVID-19 results, the HCW may choose to follow high-risk precautions, as described above.

In intermediate-risk patients, clinicians should use their judgement on the implementation of PPE (Table 1). At a minimum, the provider may wear exam gloves, surgical mask, and eye protection with standard hand hygiene before and after the exam. This may provide protection for the HCW if the patient had a false-negative test but will also protect the patient if the HCW is infected with SARS-CoV-2, but asymptomatic. While the HCW may choose to perform the medical interview of intermediate-risk patients while wearing a surgical mask, given the limitations of current testing, close proximity to patients during physical exams, and potential for aerosolization during in-office otologic procedures, HCW may consider “upstaging” to high-risk PPE and an N95 mask. Given known limitations in availability of PPE, clinicians may consider extended or reuse of N95 masks based on local policies, resources, and equipment. They may also protect the N95 mask from droplet contamination by wearing a second surgical mask over top of it.

Special Clinic Procedural Considerations

  • 1. Designate a single room, microscope, and audiology booth for COVID-19-positive patients and persons under investigation and use an approved cleaning protocol after each use. Minimize the amount of equipment and nonmedical objects in the room that could potentially become contaminated. A separate room may be designated for donning and/or doffing PPE.
  • 2. Mastoid debridement and cerumen removal with intact tympanic membrane are skin procedures and do not communicate with the upper aerodigestive tract. A viral filter (e.g. HEPA) may be easily placed between the suction canister and suction pump to minimize the risk of aerosolization of viral particles present in middle ear fluid into the room.
  • 3. The necessity of nasopharyngoscopy and other instrumentation of the upper airway should be carefully considered in high-risk patients as these are potentially aerosolizing procedures (10,31). Nonaerosolizing techniques for nasal decongestion and anesthesia (nasal pledgets instead of sprays) may also be considered. A video system rather than direct visualization through the endoscope will keep the examiners face further from the patient and may be considered.
  • 4. Patients and HCW may use a mask for otologic procedures to minimize possible aerosolization during coughing as a result of Arnold's nerve cough reflex.
  • 5. Masking may also be considered during Dix-Hallpike testing or canalith repositioning procedures given potential for close proximity to the patient.
  • 6. Many patients seen in the Otology Clinic suffer from significant hearing loss and rely on lip-reading to a variable degree. If a mask cannot be worn by the HCW in these circumstances, the HCW may want to keep a minimum distance of 6 feet (2 m) from the patient during the interview and use the mask during performance of the physical examination. Clear masks are available and may facilitate lipreading; however, their efficacy for droplet and aerosol protection is unknown.

Conditions That May Require Treatment With Corticosteroids

The role of corticosteroids in COVID-19 infection remains controversial at the time of writing (June 21, 2020), and interim guidelines may change as studies determine the effects of corticosteroids on different aspects of the SARS-CoV 2 infection (68,69). For idiopathic sudden sensorineural hearing loss, clinicians may consider intratympanic (IT) steroid therapy (70). Clinicians should weigh the immunosuppressive risk of systemic steroids against the repeat visits and instrumentation necessary for IT steroid injections, while considering whether or not any treatment with steroids will alter the natural course of the disease. If proceeding with IT therapy, the patient may wear a mask to minimize risk of virus dispersal during coughing.

Oral steroid treatment of Bell's Palsy (or other otologic conditions normally managed with systemic steroids) may be decided in the context of patient history, including COVID-19 status, and potential for exposures in the home or work environment.

OPERATING ROOM GUIDANCE AND PERSONAL PROTECTIVE EQUIPMENT

The decision of whether or not to proceed with surgical management of otologic and neurotologic disorders during the COVID-19 pandemic may be part of the standard informed consent discussion process between the surgeon and patient. Clinic visits and surgical prioritization may be based, in part, on acuity of illness, and the risks and benefits of withholding and providing care. However, priority of care should not just be based on disease-related factors; risk of viral transmission, local access to PPE, ventilator availability, and community COVID-19 prevalence may also be considered. Local emergency operation committees, inclusive of surgeons, may be formed to review case priorities either at a policy level, or case-by-case.

Many otologic procedures can be performed in the ambulatory care setting, keeping in mind the availability of and need for a negative pressure room for some procedures in some patients. Consequently, such procedures will not cause undue stresses on limited in-patient resources as hospitals emerge from intense periods of the COVID-19 pandemic.

The following list is intended to provide examples of diagnoses for which surgical intervention may be prioritized into tiers according to urgency. It may be necessary to re-evaluate patients in clinic before a rescheduled procedure to exclude significant disease progression that may alter an operative plan. The following list is not meant to be exhaustive, and the experience and discretion of the otolaryngologist may determine reasons for such cases to be performed within a different timeframe.

Diagnoses Necessitating “Emergent” Operative Management (Tier 1)

These diagnoses have high associated morbidity or even mortality if not addressed immediately. Surgery may be undertaken regardless of COVID-19 status, although rapid testing, if available, may inform the use of appropriate PPE. Examples include:

  • Coalescent mastoiditis with or with impending extra- or intracranial complications (sigmoid sinus thrombosis, epidural abscess, brain abscess, labyrinthitis, facial palsy)
  • Cerebellopontine angle tumor with neurological deterioration and/or threatened brainstem herniation
  • Temporal bone trauma with vascular or severe facial nerve injury

Diagnoses Necessitating “Urgent” Operative Management (Tier 2)

These are diagnoses where timely surgery is indicated but where surgery may be delayed for clarification or resolution of acute COVID-19 infection. Examples include:

  • Chronic ear disease associated with acute facial nerve paresis or paralysis
  • Temporal bone malignancy or adjacent malignancy requiring temporal bone resection
  • Impending cochlear ossification (e.g. from bacterial meningitis) requiring cochlear implant surgery due to bilateral sensorineural hearing loss
  • Postoperative infections or wound complications not responsive to conservative management
  • Infection of auditory implant not responding to conservative management and requiring explantation
  • Cerebrospinal fluid leak of the temporal bone deemed to have a high risk of meningitis
  • Idiopathic facial paralysis amenable to surgical management based on surgeon and patient preferences
  • Cholesteatoma with active infection not responding to ototopical and systemic antibiotics.

Diagnoses Necessitating Time-sensitive Operative Management (Tier 3)

These are diagnoses in COVID-19-negative or recovered patients who would indicate surgery as soon as feasible in the milieu of the practice/hospital. Examples include:

  • Pediatric and adult chronic ear disease/cholesteatoma necessitating tympanomastoidectomy (but without impending complications)
  • Pediatric and adult severe to profound hearing loss meeting criteria for cochlear implantation
  • Incapacitating vertigo amenable to surgery
  • Growing cerebellopontine angle tumors without significant brainstem compression or intracranial sequelae

Diagnoses That Warrant Routine Scheduling for Surgical Intervention (Tier 4)

These are diagnoses in COVID-19-negative or recovered patients who would typically indicate the need for nonurgent, routine scheduling. Examples include:

  • Otosclerosis warranting stapedotomy
  • Conductive hearing loss warranting ossiculoplasty or implantation of bone conduction device
  • Tympanic membrane perforation or retraction without complication
  • Chronic Eustachian tube dysfunction patient that may benefit from Eustachian tube balloon dilation

Preoperative Risk Assessment

COVID-19 screening may be part of routine preoperative planning to maximize safety to HCW and other patients. The screening process may take into account a number of factors, including the prevalence of COVID-19 at the time of surgery specific to the locale, availability of testing, and recommendations of local public health experts. Screening with a symptom questionnaire, body temperature measurement, and oximetry may be sufficient in certain settings; in other scenarios, formal laboratory-based preoperative testing for SARS-CoV-2 infection may be performed, even in asymptomatic patients to assist in stratifying risk category and use of appropriate PPE.

Surgery in patients with a peri-operative SARS-CoV-2 infection has been associated with an increased risk of morbidity and mortality in preliminary nonotology/neurotology reports out of China and Italy (60-62). These data are limited, and further studies are needed. Similar to any other comorbidity, surgeons should also be aware of how the infection with SARS-CoV-2 may influence overall surgical risk, including the risk of general anesthesia. When medical history, clinical status, and testing all suggest symptomatic or early/asymptomatic SARS-CoV-2 infection, the risks to the patient of worsening their COVID-19 infection and the risks of exposing HCW to infection must be weighed against the risks of not proceeding with surgery. Life-threatening (Tier 1) conditions may still warrant emergent operative management, unless the COVID-19 infection already places the patient in extremis. For Tier 2 conditions, the shared decision making must carefully weigh risks related both to the otologic/neurotologic disease and the COVID-19 infection, and the potential for benefit from the procedure.

As in the clinic-setting, SARS-CoV-2 infection transmission in the operating room may be associated with instrumentation of mucosal surfaces (e.g. airway during intubation and extubation; mastoid and middle ear) and the known high viral load of the upper airway (10). Powered instrumentation, such as high-speed drills, is known to result in aerosolization of particles and, potentially, virus (32,36–43). Indeed, otologic and skull base surgery may be as hazardous (or possibly more so given volume of droplets and particulate debris produced during drilling) (71) to surgical team members as other airway procedures. Thus, the appropriate level of PPE use for each case should be carefully considered.

Personal Protective Equipment for High-risk Patients in the Operating Room

Providers should be aware that bony dissection with powered instruments creates a plume of particulate that has been documented in otology and other fields, such as orthopedic surgery (32–35,72). In the case of a high-risk patient, we recommend the use of PPE that includes an N95 /FFP2 respirator with full face shield for all members of the operating room team (73) (Tables 2 and 3). Theoretically, an N95 /FFP2 with a face shield or airtight goggles should form a complete barrier to any aerosolized particles; however, protection depends upon a “perfect seal” with the N95 mask for the surgeon and associated personnel. Additional PPE consideration should include the use of waterproof gown, head cover including neck protection and double gloves (Table 2). Given the high-risk nature of otolaryngologic procedures, surgeons are encouraged to advocate for necessary equipment for all operating room staff, including the scrub technicians, nurses, and anesthesia team.

TABLE 2
TABLE 2:
Personal protective equipment for procedures in the clinic and operating room
TABLE 3
TABLE 3:
Personal protective equipment (PPE)

The use of a powered air-purifying respirator (PAPR) with N95 mask (73) may provide protection in the case of ill-fitting N95/FFP2 respirator. PAPR devices are diverse and may consist of a hood alone, a hood and upper body suit, or an entire body suit with ventilation. All PAPRs involve air filtration through the hood and are cumbersome and unfamiliar to most otolaryngologists, such that contamination can occur during doffing. Therefore, an equipment in-service covering both donning and doffing techniques is beneficial, as uninformed use alone may lead to contamination and unintended infection (74–77); this cannot be over-emphasized as it may be the most important aspect of PPE usage. An understanding of local PAPR models, coverage extent, and availability is essential. Further, the data on PAPR use in otology/neurotology is limited, especially in otology/neurotology. Previous reports have indicated potential for surgical site infections from PAPR exhaust, thus additional studies are needed (78).

Personal Protective Equipment for Intermediate Risk Patients in the Operating Room

Given the limited or unknown reliability of SARS-CoV-2 testing results, particularly in asymptomatic patients, clinicians should use their clinical judgement on the implementation of PPE for intermediate risk patients. At a minimum, the provider may wear standard surgical PPE, including surgical mask, face shield/eye protection, waterproof gown, and gloves (Table 2). Clinicians should be up to date on definitions of “COVID-19 negative” status, which are often institution/test dependent and quickly evolving. If there is any question regarding formal COVID-19 results, high-risk precautions, as described above, may be implemented.

Special Surgical Considerations in High-risk Patients Undergoing Otologic Procedures

  • 1. In high-risk scenarios, the most experienced surgeon may choose to perform the procedure to minimize operative time and mitigate risk to staff. Participation of trainees may be guided by local policies.
  • 2. Trainees, including medical students, residents, and fellows, may be incorporated into the clinic and operating room based on local policies, risk assessment, and available PPE, with safety from infection transmission being paramount. While virtual learning may be used, hands-on learning in the clinic and operating room should be a high priority.
  • 3. Surgeons may consider performing a “PPE timeout” as part of the standard preoperative checklist. There should be a discussion regarding patient SARS-CoV-2-testing status, risk of possible transmission (e.g. droplets versus aerosol generating) and availability of appropriate PPE equipment for OR staff. A “PPE timeout” may help to ensure that the entire operative team is coordinated regarding possible transmission risks and necessary precautions.
  • 4. A binocular surgical microscope may be used with PAPR or face shield and N95 mask (Fig. 1A). However, based on surgeon preference, other methods may include:
    • a. Goggles (rather than a face shield) in conjunction with an N95 during microscopic-assisted dissection. (Swim goggles may be considered if surgical goggles are not available.)
    • b. Surgical loupes for magnification under PAPR.
    • c. Rigid endoscopes may be used as an alternative to traditional microscopy during transcanal cases (79,80) for improved comfort and visualization when using a face shield or PAPR. Heads-up surgery (the surgeon's head is positioned up and looking forward) uses a Hopkins rod telescope or exoscope and high-resolution video monitor rather than the binocular microscope (81–84).
    • d. Extracorporeal digital microscope (exoscope) can be utilized as an alternative to the microscope during mastoidectomy or craniotomy approaches for heads-up dissection and improved visualization (83) when using a face shield or PAPR (Fig. 2).
  • 5. A “source control drape” or “microscope tent” may be created to encompass the surgical field. This may reduce biomaterial spray during drilling (Fig. 1, B and C) (71). There are various permutations that could be trialed that may avoid the tent being drawn into the suction (85). One may consider running a smoke evacuator or dedicated suction through the tented area that may further mitigate small droplet and airborne aerosol dispersion. At this point, the efficacy of these drapes to decrease transmission of COVID-19 is unknown. Further research is needed on source control drapes to quantify their impact on particle dispersion and disease transmission.
  • 6. Introduction of filters (e.g. HEPA) in suction machine tubing after exiting from the cannister may trap droplets that might carry viral particles, especially if the machine exhausts into the room.
  • 7. As aerosolization of viable pathogens (including virus particles) may occur during electrocautery and generation of surgical smoke, surgeons may wish to use judicious local vasoconstriction and cold techniques during soft tissue dissection. Electrocautery instruments with incorporated suction may also be used as these are now readily available (36–40).
FIG. 1
FIG. 1:
Binocular surgical microscopy with powered air-purifying respirator (PAPR) during left ear mastoid surgery. A, A binocular surgical microscope may be used with PAPR or face shield and a N95 mask. Surgeons should be aware of the increased distance to the oculars created by eye PPE such as a face shield, goggles or PAPR. B, C, A “source control drape” or “tent” incorporated with the microscope drape can be created and may reduce broad dispersion of surgical debris during drilling. (A similar approach can also be utilized with an exoscope.) Photos courtesy of Dr. Hilary Brodie, Dr. Rodney Diaz, and Dr. Doron Sagiv, University of California, Davis.
FIG. 2
FIG. 2:
Exoscope with personal protective equipment (PPE). Exoscope used with full PPE during a postauricular approach for a right ear mastoid abscess extending intracranially to the middle fossa. An exoscope (extracorporeal digital microscope) was used in place of a binocular microscope. An exoscope has a similar focal length as the microscope and enables “heads up” surgery without the limitations imposed by using a face shield or PAPR with binocular eyepieces. A, Three-dimensional (3D) 4K extracorporeal exoscope highlighted by circle and fiberoptic delivered light source is mounted to a manually operated articulating arm (arrow). Note that a separate drape was placed to partially enclose the surgical site around the exoscope to minimize aerosolization. B, Filtering face piece 2 (FFP2) mask (similar to N95) and surgical mask, full head, face, and eye protection (over eyeglasses and under shield) with additional gowning around the neck and taped to the shield. Courtesy of Professor Daniele Marchioni, MD, Verona, Italy.

CONCLUSION

Our understanding of SARS-CoV-2 transmission and the natural history of COVID-19 is evolving on a daily basis. This document seeks to use the best available data at the time of publication in the spirit of providing measured guidance for the otolaryngologist and associated staff for management of otologic and neurotologic conditions during the COVID-19 pandemic.

It is unknown the degree to which mucosa of the Eustachian tube, middle ear, and mastoid can shed viral particles in a patient infected with SARS-CoV-2; additional research on this point is critically needed. However, until these data are available, it is reasonable to proceed under the assumption that in SARS-CoV-2-infected patients, aero- sols created by manipulations of the middle ear or mastoid may present an infectious risk. Clinical and operative risk mitigation as discussed in this article may be implemented to assist in reducing COVID transmission risk. Furthermore, otologic and neurotologic conditions have a major impact on communication, daily functioning, and quality of life. Many conditions should be considered “urgent,” and few problems can be delayed indefinitely.

At the time of this writing, otologic and neurotologic care is underway in many parts of the world. This is critical to serve the needs of our patient population. Throughout what may become a waxing and waning COVID-19 pandemic, otologic and neurotologic clinic visits and operative cases should proceed on advice from clinic and hospital administration, infection prevention and control specialists, otolaryngologists, and local and state leaders. Local municipalities working with physicians are best suited to make determinations on the appropriateness and timing of work. We expect that best practices will continue to evolve as we learn more about COVID-19 and/or face new infectious adversaries in the future.

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Keywords:

Coronavirus; COVID; Neurotology; Otolaryngology; Otology; Personal Protective Equipment; aerosolization; ENT; Mastoidectomy

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