CSF Rhinorrhea After Endonasal Intervention to the Skull Base (CRANIAL) — Part 2: Impact of COVID-19

Abstract

Background During the coronavirus disease 2019 (COVID-19) pandemic, concerns have been raised regarding the increased risk of perioperative mortality for patients with COVID-19, and the transmission risk to healthcare workers, especially during endonasal neurosurgical operations. The Pituitary Society has produced recommendations to guide management during this era. We sought to assess contemporary neurosurgical practice and the effects of COVID-19. Methods A multicenter prospective observational cohort study was conducted at 12 tertiary neurosurgical units (United Kingdom and Ireland). Data were collected from March 23 to July 31, 2020, inclusive. The data points collected included patient demographics, preoperative COVID-19 test results, operative modifications, and 30-day COVID-19 infection rates. Results A total of 124 patients were included. Of the 124 patients, 116 (94%) had undergone COVID-19 testing preoperatively (transsphenoidal approach, 97 of 105 [92%]; expanded endoscopic endonasal approach, 19 of 19 [100%]). One patient (1 of 116 [0.9%]) had tested positive for COVID-19 preoperatively, requiring a delay in surgery until the infection had been confirmed as resolved. Other than transient diabetes insipidus, no other complications were reported for this patient. All operating room staff had worn at least level 2 personal protective equipment. Adaptations to surgical techniques included minimizing drilling, draping modifications, and the use of a nasal iodine wash. At 30 days postoperatively, no evidence of COVID-19 infection (symptoms or positive formal testing results) were found in our cohort and no mortality had occurred. Conclusions Preoperative screening protocols and operative modifications have facilitated endonasal neurosurgery during the COVID-19 pandemic, with the Pituitary Society guidelines followed for most of these operations. We found no evidence of COVID-19 infection in our cohort and no mortality, supporting the use of risk mitigation strategies to continue endonasal neurosurgery in subsequent pandemic waves.

One year into the COVID‐19 pandemic: What do we know so far from studies assessing risk and mitigation of droplet aerosolisation during endonasal surgery? A systematic review

“…Nineteen studies considered techniques to mitigate this risk and they will be considered in terms of those which employ ‘standard’ precautions, those which investigate the role of suction on aerosolisation and those which report novel adjunctive techniques. 12 , 14 , 15 , 16 , 18 , 20 , 21 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 …”

“…Four studies report their experience of endonasal surgery during COVID‐19 with cumulative patient number of 305. 12 , 25 , 26 , 27 Risk is mitigated through a combination of pre‐operative patient testing (with or without detail of subsequent self‐isolation for patients) and staff PPE use in the operating theatre, with no added precautions unique to endonasal surgery. Though there were subtle differences between each, all can be considered to reflect variation in the standard operating procedure between institutions.…”

“…None make specific measurements as to aerosolisation but patient and/or staff infection levels are reported as an outcome of risk mitigation. Naik et al 25 and the work from the CRANIAL Consortium 26 report no symptomatic COVID‐19 infections in patients at 14 and 30 days postoperatively, though no formal testing was performed. Penner et al 12 and Taha et al 27 tested staff and found no evidence of COVID‐19 infection during their case series.…”

“…Though risk of transmission will be dependent on factors such as local infection rate, testing and vaccination status, it has been demonstrated that close adherence to PPE use, particularly with use of FFP3 level masks, is effective at preventing COVID‐19 infection for healthcare professionals involved in endonasal rhinological and skull base surgery. 12 , 25 , 26 , 27 …”

“… 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 While several studies suggest this can be mitigated to a degree, primarily through use of suction, 14 , 15 , 20 , 21 , 24 it is challenging to recommend specific mitigation strategies that will eliminate risk completely, particularly with use of the high‐speed drill. Studies do indicate that close adherence to standard operating procedures, 12 , 25 , 26 , 27 concerning both pre‐operative patient testing and intraoperative PPE use for staff, can be effective at preventing spread of COVID‐19 during rhinological surgery.…”