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This is a very interesting and informative multinational European guide to the treatment of rhinology patients during the current pandemic, describing the safe delivery of a rhinological service to patients. Much of this has become well understood and standard practice already. Transmission is by viral droplet spread; patients are most contagious in the 72 hours after symptom onset, with higher viral loads in the nose compared to the throat. Asymptomatic patients can still have a high viral load. Virus can become aerosolised and stay in the air for three hours. Based on this, anterior rhinoscopy and nasal endoscopy should be considered high risk and therefore limited to patients with an urgent need to be examined. Urgent cases would include recurrent or severe epistaxis, complicated sinusitis, sinonasal neoplasm or CSF leak. Post-op care such as removal of packing, stents or silastic sheets needs to be considered. Before clinical examination, patients should be questioned about contacts, anosmia, respiratory symptoms and fever. Social distancing rules should be applied in the waiting room. During endoscopy, distance between patient and clinician can be maximised by using a tower with camera, screen and light source instead of using an eyepiece. Manipulation should be limited, with inspection instead of debridement by suction or forceps. Usually COVID-19 status is unknown in the clinic and risk of transmission is high, therefore PPE is mandatory: a hat, nitrile gloves, impermeable gown, FFP2 mask and goggles/visor for the clinician examining the patient. A separate room for the donning, doffing and storage of necessary equipment is useful and the examination room should be considered contaminated for three hours. This should be indicated on the door and PPE provided for cleaning staff. High level disinfection is required for rigid and flexible endoscopes. The recommendation in this paper is for two clinicians: a more senior examiner and an assistant who remains a 1.5m distance away from the patient and examiner and is responsible for computer entry, scripts and documentation. Less PPE is used this way since only the gloves need to be changed between patient unless there is visible soiling. Exposure is likely to be due to errors during doffing and donning, therefore extra awareness and training is advisable, used gowns and gloves doffed inside the consultation room, goggles and mask outside. Since all elective surgery has been postponed, surgery is limited to oncology and emergencies. For semi urgent cases, the COVID-19 status of the patient should be determined to allow for the correct use of PPE. In an emergency, patients are considered COVID-19 positive. Cases such as sphenopalatine artery ligation for epistaxis could be delayed until status is known. Testing is highly variable, and status can be based on clinical presentation with real time PCR from nasopharyngeal swab and/or chest CT. Surgical team members should be restricted, and trainees, observers or students should not be present. In endoscopic procedures, use of the drill and microdebrider should be avoided due to increased risk of aerosolising the virus. Transcranial approaches to the skull base may be safer than an endonasal approach. When there is an absolute need for an endonasal operation in a COVID-19-positive patient then the theatre should be prepared and adapted accordingly. Ventilation and pressure in the theatre should be lowered or at least equalised with the corridor, to prevent spread of the virus into the corridor and unprotected staff. Entry doors should clearly warn of the patients’ COVID-19 status and show correct donning and doffing techniques to avoid accidental, unprotected entry. The anaesthetist should be protected with an FFP3 mask and goggles. The recommendations for PPE in endoscopic endonasal procedures for COVID-19-positive patients and emergencies, patients with unknown or doubtful status are classical surgical outfit, an impermeable gown, a protective mask with powered, air-purifying respirator (PAPR) and sterile gloves. The mask should be an enclosed powered system with HEPA filter for endoscopic sinus surgery and skull base surgery. It is important that the PAPR is switched on before entering theatre. For proven COVID-19-negative patients no special PPE is warranted.

Personal protection and delivery of rhinologic and endoscopic skull base procedures during the COVID-19 outbreak.
Van Gerven L , Hellings PW, Cox T, et al.
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Suki Ahluwalia

Cairns Hospital / James Cook University, Queensland, Australia.

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