key: cord-0726683-m3zjun4k
authors: Yan, Carol H.; Davis, Morgan E.
title: COVID19 and Rhinology/Facial Plastics
date: 2020-08-19
journal: Otolaryngol Clin North Am
DOI: 10.1016/j.otc.2020.08.002
sha: 8d7df5cee2b830c8f60b3cc30ed04a08e9262abf
doc_id: 726683
cord_uid: m3zjun4k

This review summarizes the challenges and adaptations that have taken place in the field of Rhinology and Facial plastics in response to the ongoing COVID-19 pandemic. In particular, the prolonged exposure and manipulation of the nasal and oral cavities portends high risk of viral transmission. We discuss evidence-based recommendations to mitigate the risk of viral transmission through novel techniques and device implementation as well as increasing conservative management of certain pathologies.

compared to that of throat swabs in symptomatic patients. 4 One theory explaining this heightened association is that susceptibility genes required for viral infection, including angiotensin-converting enzyme 2 (ACE2), have the highest expression in the ciliated epithelial and goblet cells of the nasal mucosa, making this anatomic region an ideal target for viral invasion and replication. 5 Viral transmission is also possible in asymptomatic patients, with some data demonstrating similar levels of viral loads among asymptomatic and symptomatic individuals, suggesting that transmission of disease is possible even early in the disease course and without clinical signs. 4 Thus, the infection route of SARS-CoV-2 poses a particular threat to the rhinologist or facial plastic surgeon whose surgical practices include diagnostic and therapeutic procedures involving the nasal airway.

The current gold standard for SARS-CoV-2 testing relies on RT-PCR via nasal, nasopharyngeal, or oropharyngeal swabs. The potential for a false negative result is not uncommon [6] [7] [8] and it has been suggested that patients with nasal pathologies including septal deviation, nasal polyps, or masses may be at higher risk for a false negative result due to inaccurate sampling. 9 Bleier and Welch reported a case of a false negative COVID-19 result during preoperative testing on a patient with chronic rhinosinusitis with nasal polyps. As the patient underwent endoscopic sinus surgery, nasal polyps were noted obstructing the nasopharynx and a repeat intraoperative SARS-CoV-2 swab of the nasopharynx was in fact positive for COVID-19. There was inadvertent exposure for multiple healthcare personnel wearing only traditional surgical masks instead of higher level PPE given the false pretense of a negative preoperative screening. 9 In response, J o u r n a l P r e -p r o o f DeConde and colleagues have suggested performing both a nasal and oropharyngeal swab on select patients at high risk for an inadequate or inaccessible nasal or nasopharyngeal sample. 10 

One of the earliest reports highlighting the high risk of rhinologic procedures were two cases of endoscopic transsphenoidal surgery performed in Wuhan, China in January 2020 that resulted in SARS-CoV-2 transmission and illness of healthcare workers thought to be acquired intraoperatively. 11 While the details and timing of the viral transmission have been debated, 12, 13 the distribution of Patel and colleagues' letter brought attention to the uniquely high risk of viral transmission from aerosolizing nasal and endoscopic skull base procedures. Research has since been aimed at determining specific risks of aerosolization of the SARS-CoV-2 virus and categorization of true aerosol generating procedures (AGPs).

While there is well established evidence supporting SARS-CoV-2 transmission via droplet and direct contact, the risk of airborne transmission through AGPs (transmission of particles <5-10µm in size) remains controversial. One study demonstrated that aerosolized SARS-CoV-2 particles of <5µm remain viable in air for at least 3 hours and on surfaces up to 72 hours depending on the surface material. 3 Simulated nasal endoscopic procedures have investigated the aerosolization risk associated with endonasal instrumentation due to concern that potential AGPs would require enhanced safety precautions. Manipulation of nasal mucosa during endoscopy was found to distribute larger droplets up to a distance of 66cm. 14 Use of high speed drills and electrocautery during endonasal surgery carried the highest risk for aerosolization of virus particles, whereas cold instruments and powered suction microdebriders were lower risk. [13] [14] J o u r n a l P r e -p r o o f Although diagnostic nasal endoscopy was initially thought to be non-aerosol-generating, a subsequent study by the same authors reported that both rigid and flexible nasal endoscopy can generate aerosols. 15 Perhaps more importantly, they found a regular surgical mask insufficient in protecting against particle transmission generated by simulated airborne aerosol conditions in contrast to an N95 mask which effectively contained aerosol spread. 15 Studies outside the otolaryngologic literature demonstrated similar findings of particle distribution with the use of drills and other high speed energy instruments including saws, cautery, laser, and ultrasonic technology. 14, [16] [17] [18] Proposed methods to mitigate potential microscopic particle contamination include judicious utilization of high powered drills with cutting burs recommended over diamond burs and use of continuous suctioning in the surgical field. 2, 19 Additional research is warranted to better understand the mechanism of SARS-CoV-2 airborne transmission and further stratify risk of aerosol generation associated with different endonasal procedures and instrumentation to guide appropriate PPE use and ensure maximum safety in non-simulated scenarios. The American Academy of Otolaryngology -Head and Neck Surgery (AAO-HNS) initially recommended in March 2020 that extreme caution should be employed during any trans-nasal or trans-oral procedure with use of standard universal precautions during any evaluation of these areas. These guidelines also favored limiting not only surgeries, but also routine clinic examinations (nasal endoscopy and flexible laryngoscopy), to those strictly deemed necessary. 22 Vukkadala and colleagues 23 at Stanford University proposed the following guidelines for management of otolaryngologic surgeries during the initial COVID-19 outbreak based on risk stratification and COVID status. 

At the onset of the COVID-19 pandemic in March 2020, health care systems were urged to delay all elective or non-urgent surgeries in accordance with the Centers for Disease Control and Prevention (CDC) recommendations. 24 Among all surgical specialties, otolaryngology and maxillofacial surgery took a particularly hard decline in surgical activity. 25 Given the higher risk associated with upper airway exposure, Radulesco et al 26 Although perhaps limited in comprehensive patient evaluation and patient-provider interaction, telemedicine can be advantageous in not only eliminating risk, but also in patient convenience, effective time management, and electronic transfer of patient files. 27 On May 12, 2020, the CDC released a general framework outlining the gradual resumption of non-urgent hospital services and expansion of elective operative care in the United States. 24 Between late May and June, elective in-person clinic visits ensued while the option of telemedicine visits remained. In order to safely carry out elective office-based practices, new clinic protocols were developed to ensure patient and healthcare worker safety and adherence to social distancing. 28 General considerations for safe re-openings of rhinologic and facial plastics surgical clinics included pre-visit patient screening and education 24-48 hours prior to scheduled appointments as well as day-of symptom screening and temperature checks. Pre-visit COVID-19 testing is also routinely used, when available, to screen asymptomatic carriers especially for new patients and those who are expected to undergo AGPs. 16 One must be mindful of select patients J o u r n a l P r e -p r o o f for which COVID-19 nasal swabs are contraindicated or of low yield due to reduced test sensitivity. This cohort includes postoperative skull base patients, patients with postoperative packing or nasal splints, and patients with unfavorable anatomy due to severely deviated septum, obstructing nasal mass, or thick mucus and polyps. 16 Patients necessitating "high risk" in-clinic procedures should be identified early on in order to facilitate appropriate scheduling and ensure availability of adequate PPE for all staff.

Full capacity clinics are difficult to implement due to enhanced sanitation measures and appropriate downtime of rooms following AGPs. While respiratory droplets dissipate after 30 minutes of generation, AGPs pose a greater danger for transmission due to the production of airborne aerosol particles that can travel 23-27 feet and remain viable in air up to 3 hours. 3, 16 In accordance with CDC guidelines, procedure rooms without negative pressure and continual HEPA filtration and air turnover should remain vacant following any AGP prior to cleaning, with timing based on a room's ability for air handling and duration of time spent in room. [30] [31] As clinical practices continue to expand and function at higher capacities despite persistent increases in the number of COVID-19 cases, an important challenge will be finding the proper Chlorhexidine has also been suggested as a possible solution to reduce viral load and transmission risk. 38 Studies have demonstrated that chlorhexidine alone is less effective than PVP-I and other standard disinfectants against a wide range of human viruses, not including SARS-CoV-2, in both in vitro experiments 39 and studies of disinfection of inanimate surfaces. 40 Studies investigating the efficacy of chlorhexidine specifically against the novel coronavirus do not yet exist and therefore no recommendation has been made regarding its routine use as a disinfectant for SARS-CoV-2.

Implementation of a nasal tent using a simple 160 x 200 cm clear plastic sheet to create a barrier between the patient and the provider has been proposed as a feasible and cost effective adjunct to limit potential viral spread during high risk nasal procedures. 41 Maharaj and colleagues describe utilizing this barrier with a low flow continuous suction circuit to filter contaminated particles as well as a setup of all necessary surgical instruments beneath the tent as to avoid passage of instruments after the start of the procedure as to minimize contamination for operating room personnel. This novel technique has the potential for more widespread application if additional studies can validate its efficacy. Nevertheless, it highlights the potential for innovation in surgical protective equipment to enhance operating room safety during the current COVID-19 pandemic and future outbreaks.

The CDC currently recommends use of negative pressure isolation rooms when performing AGPs or allowing adequate down time in procedure rooms following AGPs to allow clearance of J o u r n a l P r e -p r o o f SARS-CoV-2 by other means. 28-29 Negative pressure rooms are not readily available in the outpatient setting and long wait periods in between room use is cumbersome and not conducive to efficient workflow. As a result, use of portable air purifiers with high-efficiency particulate air (HEPA) filters have been discussed because of their theoretical ability to decontaminate airborne particles generated during in clinic AGPs. 41 The CDC supports use of HEPA filtration systems found in PAPRs effective against SARS-CoV-2 42 ; however, its broader application in portable systems for clinic and procedures rooms has not been established. Implementation of portable HEPA filters intended to decontaminate airborne SARS-CoV-2 in the clinical setting should only be used as an adjunct to other already well established measures for infection control. 41 

Irritative conditions that can trigger a sneeze or cough have the potential to distribute and transform larger respiratory droplets into airborne aerosols [14] [15] [16] indicating the potential for any routine endoscopy to unexpectedly become an AGP. Ironically, the use of common anesthetic and decongestant sprays during nasal endoscopy, which are intended to increase patient comfort and decrease airway irritability, have been discouraged due to the risk of aerosolization of viral particles with the use of nasal atomizer sprays. As alternative means of anesthesia to prevent irritation of nasal mucosa, the American Academy of Otolaryngology supports use of lidocaine and phenylephrine soaked pledgets. 22 

Use of nasal endoscopy plays a fundamental role in evaluation and diagnosis of common pathologies in otolaryngology. Workman and colleagues 14-16 developed a modified valved endoscopy of the nose and throat (VENT) mask using regular surgical masks and N-95 masks J o u r n a l P r e -p r o o f which they engineered to allow passage of an endoscope while maintaining a tight seal to prevent droplet and aerosol contamination. In contrast to standard endoscopy performed in unmasked conditions, use of modified VENT masks with surgical and N-95 masks prevented droplet and airborne particle distribution, respectively, during simulated AGPs.

Another proposed modification to standard endoscopy technique is the "back endoscopy approach" during which the endoscopist stands behind the patient and faces the monitor as to avoid standing in the direct trajectory of droplets or aerosols. 44 4. Aesthetic care procedures PPE is required for all office aesthetic treatments with surgical masks, safety glasses, gown and gloves recommended for injectables and non-invasive body contouring. Energy-based procedures of the head and neck such as those utilizing laser, light, and heat, may involve AGPs and thus maximal PPE including N-95 masks are recommended. 45 Smoke evacuator suction systems are necessary during these procedures. Cooling positive air pressure traditionally utilized for pain management during a number of laser and other energy-emitting device procedures are not recommended.

Given the aforementioned risks of viral exposure from nasal procedures and the prior temporary cessation on elective surgical procedures, one must consider how to best manage patients with 50 In a retrospective study, 64.4% of all CRS subjects treated with NSI did not require surgical management after treatment for at least 6 weeks. 51 These studies are preliminary but promising given the likely prolonged COVID-19 environment.

Given the high prevalence of chemosensory dysfunction and in particular, olfactory loss associated with COVID-19 [52] [53] [54] [55] [56] [57] [58] , it is more important than ever to recognize smell loss and taste loss and address the impact of chemosensory loss with subjects. Otolaryngologists and rhinologists need to be aware of sudden onset hyposmia /anosmia as a predictor of SARS-CoV-2 infection particularly in those who are otherwise asymptomatic, and gain familiarity with use of treatment options such as topical steroid rinses and olfactory training. [59] [60] [61] Of those who reported smell loss associated with COVID-19, an estimated 25% of the subjects may not regain their smell, although this data is still preliminary. 54 As elective and routine care resumes, medical aesthetic specialties including cosmetic facial plastics practices have identified a need in providing positive self-image and sense of well-being to patients following a lengthy and stressful period of quarantine. 45 With the increased prevalence of mask wearing during the COVID-19 pandemic, there is increased attention to the upper half of one's face. Botulinum toxin (BTX) treatment of the glabella complex has been suggested to decrease negative emotions and promote well-being for both the treated individual and others who come into contact with the individual. 63 One study found that over 40% of patients without prior facial cosmetic treatments now wished to pursue treatment after identifying concerns over their facial appearance highlighted during their initial telehealth visits. 64 These findings suggest that the increased utilization of video conferencing technology during the current pandemic may translate to increased number of patients pursuing nonsurgical and surgical facial cosmetic procedures, which may be challenging to achieve in a safe but timely manner. • Use of portable HEPA filters may be used as an adjunct for infection control but have not been tested specifically against

• Povidone-iodine rinses at 1.25% and 2.5% for intra-nasal and intra-oral use, respectively, may be safe however, in vivo efficacy against SARS-CoV2 is not well established.

• Use of topical medications on pledgets for nasal anesthesia and decongestion prior to nasal endoscopy is preferred over sprays, and may reduce irritative conditions resulting in aerosols

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