A Cost-Effective Solution to Limit Aerosol Transmission of Infectious

Letters

A Cost-effective Solution to Limit Aerosol ering the challenges of performing mastoidectomy in the coro- Transmission of Infectious Agents navirus disease 2019 era. Mastoidectomy is an aerosol- During Mastoid Drilling generating procedure (AGP) owing to the use of drills and To the Editor We read with interest the research letter pub- presence of potentially virus-containing respiratory mucosa lin- lished online on April 28, 2020, titled “ASimple Technique for ing the mastoid air cells.2 The recommended personal protec- Droplet Control During Mastoid Surgery.”1 Mastoid bone drill- tive equipment for AGPs is a FFP3 mask and a face visor to pre- ing is an aerosol-generating procedure with the potential to vent aerosolized particles coming into contact with mucosal transmit infectious agents from the upper aerodigestive tract surfaces of the face, including the nose, mouth, and eyes.3 As via the eustachian tube and middle ear. Although there are no the authors point out “using a microscope with a face shield is coronavirus disease 2019–specific data, other studies have virtually impossible.”1 Clamp and Broomfield4 quantified this, found common viruses in the middle ear and nasopharynx.2-4 demonstrating that face shields reduced the surgical view to a To continue safely with emergency mastoid surgeries and other median of 4%. Although the use of plastic drapes are 1 alterna- time-critical surgeries involving mastoid bone drilling during tive to a face shield, they are somewhat problematic.1 Instru- this period, we have also devised a cost-effective solution to ments have to be passed beneath the drapes by the scrub nurse, limit aerosol transmission to the surgeon and other person- which is slow and cumbersome.2 The seal is not airtight, and nel in the operating room. lifting drapes to change instruments releases viral particles into The microscope used during mastoid bone drilling is rou- the theater environment.3 Third, there is the contamination risk tinely covered with a sterile clear drape. Excess material is cut to the surgical team and environment when removing the drapes off from the far end of this sterile drape and then used to se- afterwards. cure to the microscope lens using clear adhesive dressing Swimming goggles provide a low-cost solution: (Tegaderm). The other end is then secured around the opera- • The surgeon can get sufficiently close enough to the micro- tive field and over the water-collection bag. A tent-like shield scope to not restrict the field of view (surgeon able to visu- is thus created. Small slits are cut on either side of this tent to alize 98% of the target visualized with no eye protection).2 accommodate the 2 hands of the surgeon. They provide an airtight and watertight seal thus prevent- Although this is not a perfect system, it manages to con- ing severe acute respiratory syndrome coronavirus 2 virus tain most, if not all, of the droplets generated during surgery. particles from coming into contact with the eye. It is readily available, simple to set up, and does not incur any • An FFP3 mask is used in addition to protect the nose and additional cost. mouth.4 Prescription contact lenses may be worn with the goggles, and prescription goggles are also available. Jiun Fong Thong, MRCS, MMED • Goggles can be kept on for the entire procedure (even when Jia Hui Ng, MRCS, MMED not using the microscope), avoiding potential contamina- Tze Kiat Ng, MBBS tion by repeated donning and doffing. • Goggles can be reused after cleaning with a suitable antivi- Author Affiliations: Department of Otolaryngology–Head and Neck surgery, ral agent, such as ethanol spray, which rapidly inactivates the Singapore General Hospital, Singapore (Thong, J. H. Ng); Department of encapsulated virus.5 Urology, Singapore General Hospital, Singapore (T. K. Ng). • Doffing the goggles requires a 2-person technique to avoid Corresponding Author: Jiun Fong Thong, MRCS, MMED, Department of Otolaryngology-Head and Neck surgery, Singapore General Hospital, Outram self-contamination. Road, Singapore 169608 ([email protected]). We demonstrate a low-cost solution for mastoid surgery Published Online: August 27, 2020. doi:10.1001/jamaoto.2020.2417 that provides an airtight seal to prevent viral particles con- Conflict of Interest Disclosures: Dr J. Ng reported grants from Singapore tacting the clinician's eyes, while allowing the surgeon to get General Hospital during the conduct of the study. No other disclosures were sufficiently close to the microscope that the view is not reported. impaired. 1. Carron JD, Buck LS, Harbarger CF, Eby TL. A simple technique for droplet control during mastoid surgery. JAMA Otolaryngol Head Neck Surg. 2020;146 (7):671-672. doi:10.1001/jamaoto.2020.1064 Elinor Warner, MBBS, MA, MRCS Kay Seymour, MA, MB, BChir 2. Heikkinen T, Thint M, Chonmaitree T. Prevalence of various respiratory viruses in the middle ear during acute otitis media. N Engl J Med. 1999;340(4): Michael John Wareing, MBBS, BSc 260-264. doi:10.1056/NEJM199901283400402 3. Wiertsema SP, Chidlow GR, Kirkham LA, et al. High detection rates of nucleic Author Affiliations: Ear, Nose & Throat Department, Royal London Hospital, acids of a wide range of respiratory viruses in the nasopharynx and the middle London, United Kingdom. ear of children with a history of recurrent acute otitis media. J Med Virol. 2011;83 Corresponding Author: Elinor Warner, MBBS, MA, MRCS, Royal London (11):2008-2017. doi:10.1002/jmv.22221 Hospital, Whitechapel Road, London E1 1FR, United Kingdom (elinor.warner@ 4. Pitkäranta A, Virolainen A, Jero J, Arruda E, Hayden FG. Detection of nhs.net). rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis Published Online: August 27, 2020. doi:10.1001/jamaoto.2020.2420 media by reverse transcriptase polymerase chain reaction. Pediatrics. 1998;102 (2):291-295. doi:10.1542/peds.102.2.291 Additional Contributions: We thank David Carrington, Virology consultant at St George’s Hospital, for his expertise and input on this letter. Conflict of Interest Disclosures: None reported. To the Editor We were interested by the recent article by 1. Carron JD, Buck LS, Harbarger CF, Eby TL. A simple technique for droplet Carron, et al “A Simple Technique for Droplet Control control during mastoid surgery. JAMA Otolaryngol Head Neck Surg. 2020;146 During Mastoid Surgery”1 because we have also been consid- (7):671-672. doi:10.1001/jamaoto.2020.1064

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2. Pitkäranta A, Virolainen A, Jero J, Arruda E, Hayden FG. Detection of infected patients, the precautions to reduce time of expo- rhinovirus, respiratory syncytial virus, and coronavirus infections in acute otitis sure to infective secretions, the establishment of experi- media by reverse transcriptase polymerase chain reaction. Pediatrics. 1998;102 (2 Pt 1):291-295. doi:10.1542/peds.102.2.291 enced teams, and the caution in postprocedure waste dis- posal were discussed and translated to the current 3. COVID-19 personal protective equipment (PPE) [Internet]. GOV.UK. https://www.gov.uk/government/publications/wuhan-novel-coronavirus- COVID-19 pandemic. infection-prevention-and-control/covid-19-personal-protective-equipment- Of note, the authors’ recommendations focused on maxi- ppe. Accessed May 28, 2020. mizing the safety of clinicians, which is undoubtedly a cru- 4. Clamp P, Broomfield S. The challenge of performing mastoidectomy using cial aspect. For example, delaying tracheostomy until com- the operating microscope with COVID-19 personal protective equipment (PPE). Authorea. Published online May 19, 2020. doi:10.22541/au.158990752.24382560 plete virus clearance has been proposed to minimize the risk of clinician infection.2 However, there is little to no consider- 5. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coronaviruses on inanimate surfaces and their inactivation with biocidal agents. JHospInfect. ation of patients’ perspective. Would patients with COVID-19 2020;104(3):246-251. doi:10.1016/j.jhin.2020.01.022 benefit from tracheostomy? This question remains unan- swered, and none of the studies presented data on tracheos- In Reply We thank Thong et al for their letter. We chose our tomy best timing in these patients. method because it allows easy setup and takedown for con- Sparse randomized clinical trials (RCTs) involving patients tinued microscope use after drilling is complete. We have taken with different underlying conditions have compared out- to using the Sterile-Z Back Table Drape because it has a perfo- comes between early vs late tracheostomy, with inconsistent re- ration down the middle to allow for easy break-away when it sults. A large Italian RCT3 reported no significant differences in is no longer needed. As stated in our original Research Letter,1 ventilator-associated pneumonia, mortality, and length of in- we expect better modifications to come about, and otolaryn- tensive care unit (ICU) stay between the early (after 6-8 days gologists will always be a creative group. from endotracheal intubation) and late (13-15 days) tracheos- We appreciate the alternative suggestion from Warner et al. tomy groups. Conversely,in an RCT including patients with neu- Contamination of the facial and/or forehead skin with drop- rological conditions in an ICU,4 early tracheostomy (≤3 days) pro- lets would still need to be carefully treated using their method, vided significantly lower intensive care unit (ICU) mortality, and those of us who wear glasses but cannot wear contact 6-month mortality, and use of sedatives. In their meta- lenses would not be able to use swim goggles. analysis comprising 222 501 adult patients with prolonged intubation, Adly et al5 showed that early tracheostomy (≤7 days) Jeffrey D. Carron, MD was significantly associated with better outcomes, including Lauren S. Buck, MD mortality rate, incidence of hospital-acquired pneumonia, du- Claude F. Harbarger, MD ration of mechanical ventilation, and length of ICU stay. Thomas L. Eby, MD Although there is general agreement that optimizing safety protocols for tracheostomy in patients with COVID-19 is of ut- Author Affiliations: Department of Otolaryngology and Communicative most importance, data on tracheostomy best timing in these Sciences, University of Mississippi Medical Center, Jackson. patients is still lacking. Would early tracheostomy in patients Corresponding Author: Jeffrey D. Carron, MD, Department of Otolaryngology with COVID-19 improve weaning, disease clinical course, and/or and Communicative Sciences, University of Mississippi Medical Center, 2500 N State St, Jackson, MS 39216 ([email protected]). reduce ICU stay? This remains nebulous, and significant vari- Published Online: August 27, 2020. doi:10.1001/jamaoto.2020.2412 ability—even regarding percutaneous vs surgical tracheos- Conflict of Interest Disclosures: Dr Carron reported grants from Med-El tomy techniques—exists in the clinical practice. outside the submitted work.No other disclosures were reported. We congratulate the authors1 on their contribution and look 1. Carron JD, Buck LS, Harbarger CF, Eby TL. A simple technique for droplet forward to further research investigating safety and potential control during mastoid surgery. JAMA Otolaryngol Head Neck Surg. 2020;146 advantages for early tracheostomy in patients with COVID-19. (7):671-672. doi:10.1001/jamaoto.2020.1064 Diego Cazzador, MD Tracheostomy During COVID-19 Pandemic— Sebastiano Franchella, MD In Search of Lost Timing Paolo Navalesi, MD To the Editor Tay et al should be complimented on their Viewpoint “Surgical Considerations for Tracheostomy Dur- Author Affiliations: Otolaryngology Unit, Department of Neuroscience, University of Padova, Padova, Italy (Cazzador); Otolaryngology Unit, ing the COVID-19 Pandemic: Lessons Learned From the Department of Women's and Children's Health, University of Padova, Padova, 1 Severe Acute Respiratory Syndrome Outbreak” highlighting Italy (Franchella); Section of Anesthesiology and Intensive Care, Department of preoperative and perioperative recommendations for tra- Medicine-DIMED, University of Padova, Padova, Italy (Navalesi). cheostomy during the coronavirus disease 2019 (COVID-19) Corresponding Author: Diego Cazzador, MD, Otolaryngology Unit, pandemic. The authors searched the literature for tracheos- Department of Neuroscience, University of Padova, Via Giustiniani 2, 35128 Padova, Italy ([email protected]). tomies performed during the previous outbreak of severe Published Online: September 3, 2020. doi:10.1001/jamaoto.2020.2627 acute respiratory syndrome (SARS), finding 3 case series and Conflict of Interest Disclosures: None reported. 2 case reports (23 procedures). Lessons learned from those experiences were summarized into 5 points. The need for 1. Tay JK, Khoo ML, Loh WS. Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory adequate personal protective equipment in performing sur- syndrome outbreak. Published online March 31, 2020. JAMA Otolaryngol Head gery, the site to perform surgery to lessen transport of Neck Surg. doi:10.1001/jamaoto.2020.0764

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