key: cord-336373-xb3jrg75
authors: Vivas, Esther X.
title: COVID19 and Otology/Neurotology
date: 2020-08-22
journal: Otolaryngol Clin North Am
DOI: 10.1016/j.otc.2020.08.003
sha: 
doc_id: 336373
cord_uid: xb3jrg75

The severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), responsible for the worldwide COVID-19 pandemic, has caused unprecedented changes to society as we know it. The effects have been particularly palpable in the practice of medicine. The medical community now has to re-evaluate everything we do on a daily basis, practices once deemed routine are now scrutinized. The field of otolaryngology has not been spared. We’ve had to significantly alter the way we provide care to patients, changes that are likely to become a new norm for the foreseeable future. This chapter will highlight some of the changes as they apply to otology/neurotology. Although this is written from the perspective of an academic physician, it is also applicable to private practice colleagues.

4. Alterations to standard microscope draping to mitigate spread of pulverized bone splatter during mastoid drilling should be considered given the unknown risk posed by aerosolized particles from the middle ear and mastoid. 5 . Telehealth is an option for otologic and neurotologic patients. Examples are cochlear implant patients, tinnitus/hyperacusis management as well as atypical migraine and some vestibular patients. Neurotologic consultations are also feasible, such as treatment planning and surveillance of vestibular schwannoma.

The severe acute respiratory syndrome corona virus 2 (SARS-CoV-2), responsible for the worldwide COVID-19 pandemic, has caused unprecedented changes to society as we know it.

The effects have been particularly palpable in the practice of medicine. The medical community now has to re-evaluate everything we do on a daily basis, practices once deemed routine are now scrutinized. The field of otolaryngology has not been spared. We've had to significantly alter the way we provide care to patients, changes that are likely to become a new norm for the foreseeable future. This chapter will highlight some of the changes as they apply to otology/neurotology. Although this is written from the perspective of an academic physician, it is also applicable to private practice colleagues.

The field of otolaryngology has been at the forefront in creating novel ways to deliver care due to our command of the upper aerodigestive tract. Scientific endeavors were jump started by discovery of high viral loads in the nasopharynx 1,2 . We've had to alter how to examine patients, from deciphering what's adequate PPE, to the way rooms are ventilated and equipment disinfected, to how we manage patient workflow in order to provide proper screening and implement social distancing parameters within the clinics. We've also had to develop new preand intra-operative protocols, including alterations to well established OR set ups. The changes have been topics of much discussion and approached differently depending on the nature of the facility, each taking into account the availability of reliable COVID-19 PCR testing, adequate PPE and staff resources. Not surprisingly, these factors can be vastly different when considering for example, a large tertiary medical center vs small independent outpatient surgical facility. The wide spectrum thus prompts protocols that reflect internal resources unique to each facility.

Although those who routinely manage the upper digestive tract endured the most drastic changes to their practice, otologists and neurotologists have not been spared. At the height of the pandemic, when much was unknown and reliable viral testing was unavailable and PPE sparse, we faced a startling stop in outpatient and surgical care. What was deemed "elective" was suspended, and only urgent and essential care provided. Many dove into telehealth visits, albeit knowing that lack of an adequate microscopic exam or audiometric and vestibular testing limited diagnosis and treatment options. As time passed however, we faced the uncharted territory of triaging patient care. When would it be safe to offer stapedectomies? Tympanoplasties or cochlear implants? Could that draining chronic ear wait a few weeks, or a month or two? What about vestibular schwannoma surgery or repair of CSF leaks? We flocked to online professional J o u r n a l P r e -p r o o f forums and sought guidance from national societies and international colleagues, many with weeks or months of experience behind them, all with the intent to gather a collective voice.

Patients were understandably conflicted as well, anxious at the thought of going into facilities with COVID-19 positive inpatients. The elderly and those with comorbid conditions were in a precarious situation, left weighing the benefit of getting a much-awaited cochlear implant for example with the risk of nosocomial infection. It wasn't until there was reliable testing for SARS-CoV-2, a steady supply of PPE and predictable inpatient hospital resource capacity that we phased back into the OR and clinics.

During this time, we saw a surge of society consensus statements and recommendations or guidelines that were difficult to implement because of the variability in loco-regional virus burden and health care capacity between states and even counties. Ultimately, many of those statements or recommendations found themselves quickly outdated as information about the virus evolved. Given the rapid evolution of the pandemic, at the time of this entry the published data was too scarce to implement robust evidence-based protocols. This is particularly true for the otology/neurotology practice. In the following text I will review some of the changes to the practice of otology and neurotology in the US, in the context of the COVID-19 pandemic. Similarly, with CSF leaks, some present with a chronic history of relatively asymptomatic CSF otorrhea, while others are acutely ill with meningitis. Some conditions clearly need to be managed urgently, because the risk of delaying care outweighs the COVID-19 exposure risk, while others can be delayed without affecting the overall prognosis.

There are many considerations when counseling the surgical patient, but the reality is many of the procedures we routinely provide can be postponed for weeks and even months. While we can't postpone a large CPA tumor with obstructive hydrocephalus or a coalescent mastoiditis with extratemporal extension, we can certainly delay an adult cochlear implant or stapedectomy.

The same wide spectrum that makes the subspecialty interesting, challenges us when prioritizing care, particularly when presented with months' worth of surgical backlog, restricted OR availability and limited hospital resources. Each practitioner therefore has to juggle unique challenges. What may be a barrier to someone practicing in South Dakota, may not be problematic in California because of the loco-regional variability in case density and healthcare resources. Similar hurdles can be experienced by private practice colleagues that cannot access J o u r n a l P r e -p r o o f resources available to their academic counterparts in the same city. As a result, it would be inappropriate to provide detailed or blanket statements on how the practice has changed collectively, but change has occurred in some way for all. In addition to this, the peer reviewed literature is nearly non-existent as it relates to our subspecialty. With that in mind, the following discussion is largely based on exchanges with colleagues via professional forums and communications from national and international societies.

Early reports of heightened infection risk to healthcare workers from aerosolization of viral particles produced by high speed drills, most notably during endonasal sinus or skull base surgery, raised the question of whether similar phenomenon was applicable to middle ear and mastoid surgery. 3 Although there have been reports of corona viruses found in middle ear specimens, there has been no data specific to SARS-CoV-2 thus far 4, 5 . Given the lack of data for SARS-CoV-2, many opted for precaution and instituted alterations to the clinic and OR setup to minimize spread of aerosolized middle ear and mastoid contents. Examples of changes include the integration of filters into clinic suctions, improved ventilation in clinic rooms and novel draping in the OR, such as the use of tent-like coverage over microscopes in order to capture or limit droplet splatter during mastoid drilling (Figure 1 ). Special anesthesia protocols for intubation were procured and the use of intra-operative respirators implemented. N95 masks with or without face shields and eye protection became the most common PPE used. Other respirators were either in scarce availability or were too cumbersome to use under a microscope, most notably as experienced with CAPR and PAPRs. Ultimately the specifics of PPE is usually left up to the surgeon and surgical team, a decision influenced by the facility's resources, surgeon's J o u r n a l P r e -p r o o f preference, nature of surgical intervention and the COVID status of the patient 6 . In general, it is safe to say that while N95s have been used extensively, the role of CAPR and PAPR is limited for routine otologic and neurotologic procedures, but may be necessary on COVID-19 positive patients.

Another change to standard operating procedures has been the implementation of pre-operative COVID-19 testing for all patients undergoing surgery. The most common screening method is PCR testing from nasopharyngeal swab. The results help guide PPE requirements and also enables the surgeon to postpone procedures when possible for those found to be COVID-19 positive. A decision guided by published reports of poor perioperative prognosis in infected patients 7, 8 .

Another change has been the implementation of face masks for all patient encounters. We have learned that consistent mask use, whether it be in the workplace or beyond, is critical in containing the spread of disease. This necessary practice has proven quite problematic by restricting ease of communication for the hard of hearing because it eliminates the ability to lip read 9 . Due to the large volume of hard of hearing and deaf patients in an otolaryngology practice, the use of face masks with transparent windows are optimal. Although this may be a necessity for the otolaryngology or audiology provider, it is unlikely to be implemented by the rest of the medical community as it is difficult to procure such masks.

Finally, the use of telehealth underwent significant expansion during the pandemic, particularly when shelter-in-place orders went into effect. Some institutions have been more aggressive than J o u r n a l P r e -p r o o f others with implementing these services, and although it may not be a viable option for all otologic or neurotologic patients, it has proven beneficial in specific circumstances. Examples of good telehealth candidates include cochlear implant follow ups, tinnitus or hyperacusis counseling and vestibular patients, such as those with established Meniere's disease and lack of middle ear pathology. Telehealth neurotologic consultations for management of CPA lesions, already implemented pre-COVID by several institutions, is another example of a suitable telehealth candidate.

The COVID-19 pandemic has required otologists and neurotologists to implement several changes into our practice. Due to the unforeseeable timeline in controlling the global pandemic, most of those changes are bound to be left in place for the foreseeable future. As more information on SARS-CovV-2 becomes available, we will need to continuously evaluate current practices in order to keep up with the changing face of this pandemic.

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