Aerosolization risk during endoscopic transnasal surgery: a prospective qualitative and quantitative microscopic analysis of particles spreading in the operating room

View More View Less
  • 1 Division of Otorhinolaryngology, Department of Surgical Specialties, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy;
  • | 2 Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy;
  • | 3 Division of Pathology, Department of Medicine and Surgery, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy; and
  • | 4 Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic represents the greatest public health emergency of this century. The primary mode of viral transmission is droplet transmission through direct contact with large droplets generated during breathing, talking, coughing, and sneezing. However, the virus can also demonstrate airborne transmission through smaller droplets (< 5 μm in diameter) generated during various medical procedures, collectively termed aerosol-generating procedures. The aim of this study was to analyze droplet contamination of healthcare workers and splatter patterns in the operating theater that resulted from endoscopic transnasal procedures in noninfected patients.

METHODS

A prospective nonrandomized microscopic evaluation of contaminants generated during 10 endoscopic transnasal procedures performed from May 14 to June 11, 2020, in the same operating theater was carried out. A dilution of monosodium fluorescein, repeatedly instilled through nasal irrigation, was used as a marker of contaminants generated during surgical procedures. Contaminants were collected on detectors worn by healthcare workers and placed in standard points in the operating theater. Analysis of number, dimensions, and characteristics of contaminants was carried out with fluorescence microscopy.

RESULTS

A total of 70 samples collected from 10 surgical procedures were analyzed. Liquid droplets and solid-tissue fragments were identified as contaminants on all detectors analyzed. All healthcare workers appeared to have been exposed to a significant number of contaminants. A significant degree of contamination was observed in every site of the operating room. The mean (range) diameter of liquid droplets was 4.1 (1.0–26.6) μm and that of solid fragments was 23.6 (3.5–263.3) μm.

CONCLUSIONS

Endoscopic endonasal surgery is associated with the generation of large amounts of contaminants, some of which measure less than 5 μm. All healthcare workers in the surgical room are exposed to a significant and similar risk of contamination; therefore, adequate personal protective equipment should be employed when performing endoscopic endonasal surgical procedures.

ABBREVIATIONS

AGP = aerosol-generating procedure; CI = contamination index; COVID-19 = coronavirus disease 2019; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Chen X, Yu B. First two months of the 2019 Coronavirus Disease (COVID-19) epidemic in China: real-time surveillance and evaluation with a second derivative model. Glob Health Res Policy. 2020;5:7.

    • Search Google Scholar
    • Export Citation
  • 2

    Castelnuovo P, Turri-Zanoni M, Karligkiotis A, et al. Skull-base surgery during the COVID-19 pandemic: the Italian Skull Base Society recommendations. Int Forum Allergy Rhinol. 2020;10(8):963967.

    • Search Google Scholar
    • Export Citation
  • 3

    De Bernardi F, Turri-Zanoni M, Battaglia P, Castelnuovo P. How to reorganize an ear, nose, and throat outpatient service during the COVID-19 outbreak: report from Northern Italy. Laryngoscope. 2020;130(11):25442545.

    • Search Google Scholar
    • Export Citation
  • 4

    Karligkiotis A, Arosio AD, Battaglia P, et al. Changing paradigms in sinus and skull base surgery as the COVID-19 pandemic evolves: preliminary experience from a single Italian tertiary care center. Head Neck. 2020;42(7):16101620.

    • Search Google Scholar
    • Export Citation
  • 5

    Lu D, Wang H, Yu R, et al. Integrated infection control strategy to minimize nosocomial infection of coronavirus disease 2019 among ENT healthcare workers. J Hosp Infect. 2020;104(4):454455.

    • Search Google Scholar
    • Export Citation
  • 6

    Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med. 2020;382(12):11771179.

    • Search Google Scholar
    • Export Citation
  • 7

    Couloigner V, Schmerber S, Nicollas R, et al. COVID-19 and ENT surgery. Eur Ann Otorhinolaryngol Head Neck Dis. 2020;137(3):161166.

  • 8

    Fehr AR, Perlman S. Coronaviruses: an overview of their replication and pathogenesis. Methods Mol Biol. 2015;1282:123.

  • 9

    Meselson M. Droplets and aerosols in the transmission of SARS-CoV-2. N Engl J Med. 2020;382(21):2063.

  • 10

    Thamboo A, Lea J, Sommer DD, et al. Clinical evidence based review and recommendations of aerosol generating medical procedures in otolaryngology - head and neck surgery during the COVID-19 pandemic. J Otolaryngol Head Neck Surg. 2020;49(1):28.

    • Search Google Scholar
    • Export Citation
  • 11

    van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl J Med. 2020;382(16):15641567.

    • Search Google Scholar
    • Export Citation
  • 12

    Mowbray N, Ansell J, Warren N, et al. Is surgical smoke harmful to theater staff? A systematic review. Surg Endosc. 2013;27(9):31003107.

  • 13

    Workman AD, Welling DB, Carter BS, et al. Endonasal instrumentation and aerosolization risk in the era of COVID-19: simulation, literature review, and proposed mitigation strategies. Int Forum Allergy Rhinol. 2020;10(7):798805.

    • Search Google Scholar
    • Export Citation
  • 14

    Azzi L, Carcano G, Gianfagna F, et al. Saliva is a reliable tool to detect SARS-CoV-2. J Infect. 2020;81(1):e45e50.

  • 15

    David AP, Jiam NT, Reither JM, et al. Endoscopic skull base and transoral surgery during COVID-19 pandemic: Minimizing droplet spread with negative-pressure otolaryngology viral isolation drape. Head Neck. 2020;42(7):15771582.

    • Search Google Scholar
    • Export Citation
  • 16

    Murr A, Lenze NR, Brown WC, et al. Quantification of aerosol particle concentrations during endoscopic sinonasal surgery in the operating room. Am J Rhinol Allergy. Published online October 4, 2020.doi: 1945892420962335

    • Search Google Scholar
    • Export Citation
  • 17

    Murr AT, Lenze NR, Gelpi MW, et al. Quantification of aerosol concentrations during endonasal instrumentation in the clinic setting. Laryngoscope. 2021;131(5):E1415E1421.

    • Search Google Scholar
    • Export Citation
  • 18

    Sharma D, Rubel KE, Ye MJ, et al. Cadaveric simulation of endoscopic endonasal procedures: analysis of droplet splatter patterns during the COVID-19 pandemic. Otolaryngol Head Neck Surg. 2020;163(1):145150.

    • Search Google Scholar
    • Export Citation
  • 19

    Workman AD, Jafari A, Welling DB, et al. Airborne aerosol generation during endonasal procedures in the era of COVID-19: risks and recommendations. Otolaryngol Head Neck Surg. 2020;163(3):465470.

    • Search Google Scholar
    • Export Citation
  • 20

    Guderian DB, Loth AG, Weiß R, et al. In vitro comparison of surgical techniques in times of the SARS-CoV-2 pandemic: electrocautery generates more droplets and aerosol than laser surgery or drilling. Eur Arch Otorhinolaryngol. 2021;278(4):12371245.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 464 464 258
Full Text Views 32 32 8
PDF Downloads 35 35 9
EPUB Downloads 0 0 0