Ear Procedures Guidelines During Covid

Following are the EAR PROCEDURES GUIDELINES DURING COVID Pandemic.

Mastoid surgery

1. Significant aerosolisation of bone and other tissues occurs during mastoid drilling¹. Whilst the main route of transmission of the COVID-19 virus is through the respiratory system, there is some evidence of blood-borne transmission, although this risk is likely to be low^2,3. Similarly, there is evidence that corona viruses are present in the epithelium of the middle ear during upper respiratory tract infections, although there is no specific evidence, to date, in COVID-19 specifically^4,5. As a result, there may be a significant risk of viral transmission when undertaking this type of surgery in patients infected with COVID-19 virus. It is not possible to prevent drill-induced aerosolisation and although FFP3 masks prevent inhalation of particles, standard eye protection may not adequately prevent ocular exposure. Mastoid surgery should therefore be avoided unless there is a life-threatening urgency to proceed.
2. Urgent indications may include:
   • acute mastoiditis
   • otogenic intracranial sepsis
   • operable temporal bone malignancy.
3. Vestibular schwannoma surgery should not be regarded as urgent unless there is life-threatening brainstem compression. A retrosigmoid, rather than translabyrinthine approach, should be used to minimise drill time, and exposure to middle ear mucosa.
4. The duration of the COVID-19 pandemic period is unclear but, assuming a 3-month period before normal practice can resume, cholesteatoma surgery and auditory implantation, including in children, should not be regarded as urgent. Further guidance will be offered in the event that ongoing precautions will be required beyond 3 months.
5. Testing for COVID-19 is unlikely to be helpful as sensitivity of throat/nose swabs has been reported to be as low as 32%. In addition, long turnaround times make testing impractical. All patients should therefore be presumed to be positive.
6. If mastoid drilling is unavoidable, drilling should be kept to a minimum and PPE including FFP3 mask, close fitting eye protection (glasses are preferable to a visor), waterproof gown and gloves should be used as a minimum whilst not using the microscope (subsequently referred to as full PPE).
7. Use of the microscope may offer some degree of eye protection during drilling but drilling should still be kept to a minimum. If possible, the surgeon should continue to wear eye protection.
8. Some clinicians may feel more comfortable using a hazmat suit with external filtration if undertaking mastoid surgery, particularly if the patient is confirmed as COVID-19 positive. The decision to use this level of protection lies with the clinician.
9. A rigid otoscope with camera may be used instead of the microscope, accepting the limitations of single-handed surgery if the PPE equipment makes use of the microscope difficult.
10. All unnecessary staff should leave theatre and those that remain should wear PPE as above.
11. For acute mastoiditis, curettage should be carried out rather than mastoid drilling, if possible.
12. If drilling is required, slowing drill speed, reducing irrigation volume and using effective suction may reduce aerosolisation.
13. Good hypotension will minimise bleeding and may also reduce aerosolisation.
14. Surgery should be carried out by the most experienced otological surgeon available.

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