Since the first cases of Covid-19 were reported in China in December 2019, the SARS-CoV-2 virus has shown a high capacity of sustained transmission over the world (1). The high mortality rate, mainly due to the virus itself, could also, to a lesser extent, be explained by the sheer numbers of patients, overwhelming hospitals and leading to difficulty in providing optimal care (2,3). Many countries have adopted a mitigation strategy to combat the epidemic; physical distancing and mobility restrictions are the main objectives of the lock-down. The objective is to limit the spread of the virus among the population and to reduce the height of the epidemic peak by flattening the curve (2–4). This means spreading out the number of infected patients over a long period of time to prevent the virus from overwhelming our available critical care resources (3,4). Healthcare teams have had to postpone their nonemergency consultations and surgical activities to increase their medical resources that are redirected to infected patients.
The article aims to propose a strategy for organizing consultation and surgery for ear and lateral skull base diseases in the context of the current situation of active evolution of the pandemic; but also, in the future with the hope of a gradual recovery to normal practice as Covid-19 cases globally begin to plateau or decline.
BACKGROUND
The first case of pneumonia of an unknown origin was reported in Wuhan, China (5). A virus was identified in the bronchoalveolar fluids of a patient with pneumonia. This pan-Betacoronavirus, SARS-CoV-2, close to 96% identical to a bat SARS-like coronavirus of the bat, is responsible for the COVID-19 (3) (COrona, VIral Disease 2019). On March 11, 2020, the World Health Organization (WHO) declared Covid-19 an international health emergency (6) and announced a pandemic situation (7).
The main interhuman infection pathway is the projection of droplets coming from lower and upper airways (7–9). Stability of the virus coming from droplets on fomites (abiotic surfaces) has been confirmed for more than 72 hours, mainly on plastic, stainless steel, and paperboard (10).
Viral Infection Pathway and Its Application for Otolaryngologists
Early infection of healthcare workers has been reported from China and widely described in countries reporting the disease (11–15).
Otolaryngologists are particularly exposed to infection from anatomical areas where the virus is highly concentrated, mainly nasal fossa and nasopharynx (9,11,16) even from asymptomatic patients (9).
The middle ear and mastoid epithelium is similar to the respiratory epithelium of upper airways (17). Respiratory viruses have been identified by polymerase chain reaction (PCR) in middle ear effusions (18) causing acute otitis media without identified bacteria in the nasopharynx (19). Among other viruses (human rhinovirus, respiratory syncytial virus), human coronavirus RNA has been detected by RT-PCR in samples from otitis media with effusion (20,21). There has been no proof to date to show the presence of SARS-CoV-2 in the middle ear and mastoid (22). But, the coexistence of the same viral pathogens in the nasopharynx and the middle ear could raise the issue of a potential risk of viral load in the middle ear in Covid-19 positive patients (23).
Another crucial point is the ability of the virus to remain alive in the air (10,11) and to be transmitted through aerosols.
Infection through aerosols may be possible in the case of exposure to high concentrations of aerosols in a relatively closed environment (24–26).
An aerosol is a suspension of particles in a gas. A virus excreted by a patient can dissolve in an aerosol, leading to the formation of a bio-aerosol (27). Bio-aerosols measuring 1 to 5 μm constitute an airborne transmission path (11). Those of smaller size are deposited on surfaces. The persistence of SARS-CoV-2 for more than 8 hours in air samples collected 1 m away from an infected patient suggests a very high risk of airborne transmission of the virus (11,28), as well as the evidence of airborne SARS-CoV-2 particles smaller than 5 μm for at least 3 hours (10).
Droplets projected during coughing or sneezing, usually 1 to 5 mm in size, can reach 1 to 2 m. Aerosols can reach several hundred meters and have already been confirmed as a dissemination means among other viruses (H1N1, SARS, MERS) (27,29–32). A study published in the New England Journal of Medicine reports a high probability of survival and transmission of the virus as aerosols for 3 hours (10).
The size of aerosol particles is inversely proportional to the air speed. All physiological (coughing, sneezing) and mechanical (intubation, endoscopy, noninvasive ventilation) procedures produce aerosols (11). Among these mechanical procedures, high-speed drills are used for mastoidectomy. They can generate aerosols of bone, mucosa, fluids, and blood (33). Some have theorized that, if Sars-CoV-2 is present in the mastoid, mastoidectomy using a high-speed drill could be dangerous for people inside the operating room and expose health workers to viral infection (17). Transcanal endoscopic approaches could help by limiting bone drilling of the mastoid and the external ear canal (34,35).
Norris et al. have compared surgical masks and N95 masks in preventing inhalation of bone dust. The N95 surgical respirator showed statistically less particulate exposure when compared with control testing. Standard surgical masks did not display any benefit for preventing transmission of bone dust (36). N95 masks have been shown to significantly decrease particulate exposure by filtering 95% of droplets and aerosols of less than 0.3 μm (National Institute for Occupational Safety and Health (NIOSH) (11)). In Europe, masks are classified as FFP1, FFP2, and FFP3 providing filtration of 80%, 94%, and 99% respectively. The FFP2 mask corresponds to N95 (37). FFP2 are more effective than surgical masks in preventing inhalation of the virus (38) but require correct fitting and respect for wearing times (39). The N95 mask can be covered by a regular surgical mask mainly to prevent soiling of the N95. In summary, a N95/FFP2 mask may be used in the operating room and outpatient clinics in case of contact with patients without COVID-19 negative confirmed status.
The authors have previously identified coronavirus in tears (20) as well as transconjunctival spread of COVID-19 (40). This highlights the importance of wearing airproof glasses and/or a full-face shield when using an endoscope or exoscope.
A clear plastic drape could be fashioned and used over the operative field to contain all aerosolized particles as an effective barrier to prevent wide travel or dissemination of aerosolized particles throughout the operating room as well as eye projection.
Screening for Covid-19
RT-PCR test (polymerase chain reaction) sensitivity for detection of viral RNA on nasal swab samples is low (56–83%) (41,42). Identification of the virus may also be delayed (41). The median duration of viral shedding in oropharyngeal samples has been reported between 8 and 37 days (median time: 20 d) from illness onset in surviving patients, and is detectable until death in nonsurviving patients (43). Positive tests have also been reported in patients with normal chest CT-scan results (44).
Chest CT-scan imaging has high sensitivity but limited specificity in early pulmonary symptoms (45,46). However, more than 50% of patients may have normal result in the first few days after the onset of symptoms (46). A normal chest CT scan can therefore not be considered strict criterion for excluding Covid-19 infection (47,48), despite greater sensitivity than PCR tests (49). Chest CT scans should therefore be reserved for symptomatic patients, but should not be deemed sufficiently reliable in asymptomatic patients (50).
No antibody testing is considered as being reliable enough until now, regarding sensitivity and specificity (51,52). Serological tests are not recommended in the context of early diagnosis of Covid-19 (53,54).
Protective equipment (masks, glasses, and/or full-face shield) may be used in clinics and operating room. With no short-term prospect of vaccine or even of effective treatment, this should be the concern of each healthcare worker, while the virus is actively circulating. In a recent article, Topsakal and Rompaey (17) report that “after the peak of this pandemic, restrictions on daily otological practice should somehow be adjusted to allow health services closer to the standards we are used to.”
The following recommendations are proposed in the context of active circulation of the virus. They may be subject to change over time according to the evolution of the pandemic. Furthermore, these recommendations should however be adapted to locations where Covid-19 is less present, according to the number of infected patients and the number of hospitalizations especially in intensive care units (55). Considering these criteria, patient screening and effective protection of health workers should be ensured, surgical criteria (Table 1) may be softened and discussed case-by-case in areas with low circulation of the virus.
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TABLE 1: Timing of otologic/neurotologic practices during the covid-19 pandemic
Future recovery of surgical activity should be gradual and spread over time. Hospitals and clinics should keep appropriate capacities for hospitalizations and intensive cares, drugs, ventilators, PPE, and personnel (56). There should be a sustained reduction in the number of new infected patients in relevant geographic areas for at least 14 days before elective surgery is resumed (56).
STRATEGY FOR CLINICS AND OPERATING ROOMS
Most consultations and surgical procedures for ear diseases have been postponed (Table 2).
TABLE 2: Strategy for otologic/neurotologic practices during the covid-19 pandemic
Medical and paramedical workers with comorbidities (pregnancy, diabetes, uncontrolled hypertension, disease obstructive pulmonary disease, immunosuppression context), should avoid any contact with patients for whom the Covid-19 negative status is not known, especially in the operating room (57).
Outpatient Clinic
An initial triage of patients is performed during the phone appointment to limit the number of patients in outpatient clinics. The aim of this is to identify emergencies, screen for viral infection, and identify possible exposure to SARS-CoV-2. Telemedicine by phone consultation is also proposed if feasible to patients without urgent ENT symptoms.
In the waiting area, physical distancing by reducing and spacing the number of seats is crucial. Accompanying persons are not authorized except in special cases (pediatric consultation, disabled, or dependent patient).
Given the high proportion of asymptomatic but contagious patients (49,50), each patient may systematically be equipped with a surgical mask until he or she leaves the hospital or clinic.
Triage Zone
An initial orientation regarding the patient's Covid-19 status is performed by a nurse. The healthcare team may be equipped with Personal Protective Equipment (PPE) (cap, FFP2-N95 mask, glasses and full-face shield, gown, gloves, overshoes). A survey is submitted to each patient including specific questions (58,59):
- 1) Patient environment (family context, professional activity, life in an institution)
- 2) Comorbidities (cardiopulmonary, endocrine, autoimmune, immunosuppression)
- 3) Current treatments (chemotherapy, corticosteroid therapy, nonsteroidal anti-inflammatory drugs)
- 4) Context of Covid-19 infection (contact with an infected patient, history of recent screening)
- 5) Symptoms (fever, headache, cough, chest pain, dermatological signs, anosmia, ageusia, nausea, vomiting, diarrhea and dyspnea, cyanosis, consciousness disorders)
Patients identified as suspects are isolated and referred to the infectious disease team. An RT-PCR test and a chest CT are performed.
Consultation Room
The number of staff in the consultation room may be limited to the practitioner. Contact with computer devices may be avoided, possibly using an additional staff member for data entry.
Each practitioner is equipped with PPE. Double gloves enable the practitioner to change the outer pair according to the care provided and in between the patients (60).
Nasal and oral examinations may be strictly limited. A nasal and laryngeal flexible fibroscopy should be performed only if absolutely necessary, because of the high risk of aerosolization (61). A nasal local anesthesia, without spray is mandatory to prevent sneezing and coughing. Use of a video fibroscopy and endoscopes if available instead of a microscope keep the practitioner's face away from the patient.
Single-use material (otoscopes, nasal speculums, and tongue depressors) are used as much as possible.
At the end of the consultation, the gloves and gown may be placed in a specific waste receptacle within the consultation room. Protective glasses are removed outside the room (60).
Disinfection of surfaces and room ventilation may be performed between each consultation, keeping in mind that the room is potentially considered to be contaminated for 3 hours (60). This parameter should be reconsidered, however, in the absence of flexible fibroscopy and protection of the patient with a mask.
Surgical and Nonsurgical Ear Pathologies
The treatments of nonsurgical emergencies (sudden hearing loss, idiopathic facial nerve palsy, vestibular neuritis) by oral steroids should be discussed. Corticosteroids would delay clearances of the virus and increase the mortality risk (62). The decision depends on the patient's risk–benefit balance.
Complicated acute otitis media without acute mastoidis with subperiosteal abscess should be treated by antibiotics first. The use of a ventilation tube should be decided in the case of failure of the medical therapy. If possible, for adults, the ventilation tube should be inserted under local anesthesia. If not or for children, the anesthesiologist should opt for endotracheal intubation as opposed to bag mask ventilation to reduce the risk of aerosolization of the virus (23).
We propose a classification for surgical indications into levels from 1 to 3, depending on the surgical delay. The aim of this classification is to limit the number of patients in operating rooms to what is strictly necessary considering the potentially dangerous evolution of the ear disease for the patient (Table 1). Cochlear implantation for sensorineural hearing loss after meningitis would be preferentially performed within 1 month of the original infection to avoid total cochlear obliteration (63).
Considering the future very gradual recovery of surgical activities under less restrictive conditions, surgical organization (except emergencies) will depend on the evolution of the disease and impact for patients. Surgeries for temporal bone malignancy, cholesteatoma, vestibular schwannoma (after multidisciplinary discussion), as well as cochlear and hearing aid implantation to support speech and language development in children could be considered as priorities.
Operating Room
Preoperative Screening
A recent article brings to light the value of a systematic PCR test 48 hours before surgery, followed by a strict quarantine and another PCR test on the day of surgery (17). This procedure could nevertheless be discussed. As reported above, PCR-test sensitivity is low (56–83%) (41,42) and diagnoses may be delayed (41). Double-negative PCR tests from nasopharyngeal swabs have also been reported among infected patients (64). Therefore, patients should be considered as Covid-19 positive in all cases and equipped with a surgical mask until and after general anesthesia.
Operating Room
An operating room under negative pressure would constitute additional or even ideal security in the current context (65). Coupling ventilation with an air-filtering system for particles is mandatory in each operating room. The airflow inside the room may guarantee a total air renewal of at least 25 times per hour to reduce the viral load in the air (66).
Circulation of staffs from the operating room may be limited. Doors may be closed and access limited (66,67). The preparation of surgical instruments and consumables before surgery may be as exhaustive as possible and available inside the operating room. A circulating staff equipped with a trolley placed in front of the door can if necessary recover some materials and consumables (66). At the end of the procedure, any single-use material has to be placed in a specific bin.
Surgical Team
Staff numbers may be limited, with no observers or students. A senior surgeon may perform procedures to reduce operating times. The entire team may be equipped with individual protections, particularly in case of temporal bone drilling: cap, protective glasses, full-face shield, sterile, and waterproof cloth around the neck, gloves, gowns, and overshoes.
At the end of surgical procedures, every staff member in the room may remove gloves and gowns before leaving the room (60). A shower should be taken before returning to their regular duties (65).
The identity of all room staff may be recorded to ensure traceability (66). Surveillance may be conducted over a long period through identification of functional signs and repeated oximetry. A chest CT scan and repeated PCR tests on nasal samples may be performed in the event of suspicious cases in staff (66).
Postoperative Room Cleaning
Room cleaning teams may be protected by Personal Protective Equipment (PPE) (N95 mask, gloves, gown, cap, and glasses). Cleaning may cover all surfaces of the room, video column, microscope (hooded), cables, computer equipment, and anesthesia equipment. Several effective disinfection solutions have been proposed (62–71% ethanol, 0.5% hydrogen peroxide, or sodium hypochlorite 0.1% for 1 min) (67,68). This extended cleaning and room ventilation time after surgery lead to significantly increased timeframes between surgical procedures (64,66).
Preoperative Simulation
Recent studies have reported that protection procedures and donning-doffing PPE sequences are misunderstood by nearly 90% of teams, including practitioners (69,70). Organizing preoperative simulations could improve procedures and safety of staff safety in operating rooms and consultation units (71–73).
Hospitalization and Postoperative Care
Outpatient hospitalization after middle ear surgery may be encouraged.
Postoperative care can be performed by the patient's family, after demonstration and acceptance, to avoid contact with health workers. A teleconsultation can then be arranged to answer questions from the patient and to organize a consultation if necessary.
CONCLUSION
In the current Covid-19 pandemic, otolaryngologists are at high risk of infection by the SARS-CoV-2 virus. Viral load in upper airways is very high. The middle ear and mastoid could, as noted in the literature, constitute a reservoir of virus. Current knowledge indicates the possibility of viral infection through droplets, contact with fomites, and aerosolization of the virus. Consultations and surgery for ear and lateral skull base pathologies potentially expose healthcare workers to infection. All procedures may be adapted and protections may be maximized to prevent infection of healthcare workers and other patients, with the spectrum of death and infirmity. These precautions should be implemented until effective treatments and a vaccine are found.
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