Letter to the Editor. The COVID-19 pandemic in Singapore

View More View Less
  • Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
Free access

If the inline PDF is not rendering correctly, you can download the PDF file here.

TO THE EDITOR: We read with great interest the article by Lo et al.1 (Lo YT, Teo NWY, Ang BT. Editorial. Endonasal neurosurgery during the COVID-19 pandemic: the Singapore perspective. J Neurosurg. 2020;133[1]:26–28) where the authors, in line with a current diffused thinking about the high viral load found in the nasopharynx,2 shared the local advisories in terms of preoperative COVID-19 screening and healthcare worker protection during undeferrable transnasal (TN) surgeries.

In our country, the Italian Skull Base Society recently suggested that all patients who are candidates for surgery be tested for COVID-19 with at least 2 swab tests repeated at an interval of 2–4 days, to minimize false-negative results.3 To further decrease the risk of SARS-CoV-2 positivity, we require a strict 2-week period of self-isolation before hospital admission to our institution. Nevertheless, the risk of infection due to possible false-negative swab tests, eventual infection development after surgery, or a longer period of incubation (around 1% of patients after 14 days)4 remains.

In this context, patient safety appears to be under-stressed, which deserves to be protected along with the safety of healthcare workers. In fact, the decision to perform TN skull base surgery could preclude the eventual use of continuous positive airway pressure (CPAP) for COVID-19 treatment, if needed, due to the risk of pneumocephalus correlated to high intranasal pressures.5,6 As a matter of fact, when respiratory insufficiency due to SARS-CoV-2 is refractory to simple O2 administration and requires pulmonary assistance, the first step is represented by CPAP use, followed by endotracheal intubation.7 In this emergency period, characterized by wide diffusion of the virus, hospitals are at risk of running out of ventilators, as has occurred in Lombardy, Italy. As a consequence, in the postoperative period, endotracheal intubation may be the best available option for these patients developing pulmonary insufficiency, given that CPAP carries an increased risk of pneumocephalus with possible brain injury, CSF leak, and infection. In particular, the association between CPAP and pneumocephalus has been studied in obstructive sleep apnea syndrome (OSAS) patients affected by pituitary tumors (prevalence up to 46% in individuals with acromegaly).6 Although treatment of OSAS is based on positive airway pressure, there is no consensus on how and when reintroduce positive pressure therapy after TN surgery.8

Furthermore, preliminary work confirms the tropism of SARS-CoV-2 for the nervous system,9 but the question of whether a skull base bone defect with or without a dura mater defect and its eventual dimension may facilitate local viral neuroinvasion remains without answer.

Hence, we strongly suggest suspending all deferrable transnasal surgeries, at the moment. Regarding this aspect, in cases that cannot be deferred, some authors have suggested considering the alternatives to purely endonasal transmucosal surgeries, such as craniotomies and microscope-based submucosal approaches with entry to the sella through nondrilling techniques.10

For example, the decision-making process for the treatment of a common pituitary macroadenoma affecting optic structures should reflect the careful balance of clinical aspects, considering those with rapid visual or campimetric deterioration as undeferrable cases, and anatomical characteristics, paying attention to prevalent tumor growth direction (e.g., intrasellar, suprasellar, infrasellar with eventual bony erosion).

In addition, in COVID-19 times we feel that the decision-making process should take into account all risk factors associated with possible CSF leak (BMI > 25 kg/m2, older age, and diabetes mellitus) that have been proven to make the local healing process longer,11,12 ruling out the possibility of using CPAP for an eventual COVID-19 treatment in the early postoperative period (and reasonably raising the risk of SARS-COV2 neuroinfection).

In conclusion, the issue of TN surgery in the COVID-19 era involves both operator and patient safety. The “do-no-harm principle” must be followed to plan the safest surgery in patients in whom CSF leak, nasal airways and brain communication, and viral recrudescence may potentially result in harm to the patient. The right balance between the advantages and disadvantages of TN approaches and craniotomies for sellar/suprasellar and parasellar lesions must be revisited in the SARS-COV2 era, keeping in mind the potential for COVID-19 related complications.

Disclosures

The authors report no conflict of interest.

References

  • 1

    Lo YT, Teo NWY, Ang BT. Editorial. Endonasal neurosurgery during the COVID-19 pandemic: the Singapore perspective. J Neurosurg. 2020;133(1):2628.

    • Search Google Scholar
    • Export Citation
  • 2

    Zou L, Ruan F, Huang M, 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
  • 3

    Castelnuovo P. Skull base surgery during COVID-19 emergency—recomendations on COVID-19 pandemic by the Italian Skull Base Society. Italian Skull Base Society. Accessed June 9, 2020. http://www.attingo-edu.it/en/recommendations-covid-19-prof-castelnuovo-sib.html

    • Export Citation
  • 4

    Lauer S, Grantz K, Bi Q, The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020;172(9):577582.

    • Search Google Scholar
    • Export Citation
  • 5

    Kopelovich JC, De La Garza GO, Greenlee JDW, Pneumocephalus with BiPAP use after transsphenoidal surgery. J Clin Anesth. 2012;24:415418.

    • Search Google Scholar
    • Export Citation
  • 6

    White-Dzuro GA, Maynard K, Zuckerman SL, Risk of post-operative pneumocephalus in patients with obstructive sleep apnea undergoing transsphenoidal surgery. J Clin Neurosci. 2016;29:2528.

    • Search Google Scholar
    • Export Citation
  • 7

    WHO. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Accessed June 9, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

    • Export Citation
  • 8

    Choi DL, Reddy K, Weitzel EK, Postoperative continuous positive airway pressure use and nasal saline rinses after endonasal endoscopic skull base surgery in patients with obstructive sleep apnea: a practice pattern survey. Am J Rhinol Allergy. 2019;33(1):5155.

    • Search Google Scholar
    • Export Citation
  • 9

    Mao L, Jin H, Wang M, Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683690.

    • Search Google Scholar
    • Export Citation
  • 10

    Jenkins A. Transmission of COVID-19 during neurosurgical procedures — some thoughts from the United Kingdom. Letter. Neurosurgery. 2020;87(1):E68.

    • Search Google Scholar
    • Export Citation
  • 11

    Fraser S, Gardner PA, Koutourousiou M, Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg. 2018;128:10661071.

    • Search Google Scholar
    • Export Citation
  • 12

    Ivan ME, Bryan Iorgulescu J, El-Sayed I, Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery. J Clin Neurosci. 2015;22(1):4854.

    • Search Google Scholar
    • Export Citation
View More View Less
  • Singapore General Hospital, Singapore
Keywords:

Response

We thank the authors of the letter for their thoughtful comments and important advice.

The primary thrust of our paper was to give some background to and recommendations for personal protective equipment (PPE) use in endonasal skull base surgery. The decision on whether to proceed with this surgery is complex and has to take into account many factors. The two main factors are the safety of the patient and safety of the medical personnel. Patient safety will entail weighing the benefits of surgery versus delaying surgery, and, if delaying surgery, defining what the possible endpoints might be, such as more ICU beds, more inpatient hospital beds, and availability of preoperative COVID-19 testing, among others, without compromising the patient’s health. If we decide to continue with surgery at this point in time, what would the appropriate level of PPE be?

The considerations will include the following:

  • 1. The local situation of COVID-19, whether it is controlled and contained, or whether it is widely prevalent. In Singapore, between February and March 2020, the situation was controlled and contained, the number of COVID-19 patients was low, and the risk assessment by the government of community prevalence, spread, and asymptomatic carriage was deemed to be low; hence, surgery was not deferred. Currently, with the explosion of numbers from foreign-worker dormitories and the presence of unlinked cases indicative of asymptomatic community spread, the risk of operating on an asymptomatic or presymptomatic COVID-19 patient is higher. In addition, hospital resources are now diverted to managing COVID-19 patients, so surgeries are still limited to emergency or semiurgent procedures only.
  • 2. The availability of COVID-19 testing. We agree with the authors’ hospital’s policy of preoperative COVID-19 testing. However, this may not be available in every country due to a shortage of tests or priority given to screening symptomatic individuals rather than preoperative testing. As such, one would have to consider how to mitigate the risk of proceeding with emergency operations if COVID-19 testing is unavailable. Locally, we are indeed working toward effecting routine testing, much like what the authors report.
  • 3. The availability of appropriate PPE. This is interlinked with preoperative COVID-19 testing and is mainly for the protection of the surgical team. However, one must be cognizant that operating on an asymptomatic or presymptomatic COVID-19 patient can place the rest of the hospital care team at risk, and not just the surgical team within the operating room.
  • 4. The risks to patients are real and need to be weighed against the benefits of proceeding with surgery at this juncture, particularly if preoperative COVID-19 testing is not performed.

We look forward to the sharing of best practice from the international neurosurgical community as the pandemic evolves.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Contributor Notes

Correspondence Francesco Restelli: francesco.restelli91@gmail.com.

INCLUDE WHEN CITING Published online July 24, 2020; DOI: 10.3171/2020.4.JNS201436.

Disclosures The authors report no conflict of interest.

  • 1

    Lo YT, Teo NWY, Ang BT. Editorial. Endonasal neurosurgery during the COVID-19 pandemic: the Singapore perspective. J Neurosurg. 2020;133(1):2628.

    • Search Google Scholar
    • Export Citation
  • 2

    Zou L, Ruan F, Huang M, 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
  • 3

    Castelnuovo P. Skull base surgery during COVID-19 emergency—recomendations on COVID-19 pandemic by the Italian Skull Base Society. Italian Skull Base Society. Accessed June 9, 2020. http://www.attingo-edu.it/en/recommendations-covid-19-prof-castelnuovo-sib.html

    • Export Citation
  • 4

    Lauer S, Grantz K, Bi Q, The incubation period of coronavirus disease 2019 (COVID-19) from publicly reported confirmed cases: estimation and application. Ann Intern Med. 2020;172(9):577582.

    • Search Google Scholar
    • Export Citation
  • 5

    Kopelovich JC, De La Garza GO, Greenlee JDW, Pneumocephalus with BiPAP use after transsphenoidal surgery. J Clin Anesth. 2012;24:415418.

    • Search Google Scholar
    • Export Citation
  • 6

    White-Dzuro GA, Maynard K, Zuckerman SL, Risk of post-operative pneumocephalus in patients with obstructive sleep apnea undergoing transsphenoidal surgery. J Clin Neurosci. 2016;29:2528.

    • Search Google Scholar
    • Export Citation
  • 7

    WHO. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Accessed June 9, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected

    • Export Citation
  • 8

    Choi DL, Reddy K, Weitzel EK, Postoperative continuous positive airway pressure use and nasal saline rinses after endonasal endoscopic skull base surgery in patients with obstructive sleep apnea: a practice pattern survey. Am J Rhinol Allergy. 2019;33(1):5155.

    • Search Google Scholar
    • Export Citation
  • 9

    Mao L, Jin H, Wang M, Neurologic manifestations of hospitalized patients with coronavirus disease 2019 in Wuhan, China. JAMA Neurol. 2020;77(6):683690.

    • Search Google Scholar
    • Export Citation
  • 10

    Jenkins A. Transmission of COVID-19 during neurosurgical procedures — some thoughts from the United Kingdom. Letter. Neurosurgery. 2020;87(1):E68.

    • Search Google Scholar
    • Export Citation
  • 11

    Fraser S, Gardner PA, Koutourousiou M, Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg. 2018;128:10661071.

    • Search Google Scholar
    • Export Citation
  • 12

    Ivan ME, Bryan Iorgulescu J, El-Sayed I, Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery. J Clin Neurosci. 2015;22(1):4854.

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 62 62 62
PDF Downloads 35 35 35
EPUB Downloads 0 0 0