COVID-19 for neurosurgeons

COVID-19 for neurosurgeons

In every country, all surgical plans have been modified. In Wuhan, the staff was enrolled in COVID-units. In New York, the Mount Sinai Hospital Health System was in lockdown mode. In South Korea, sterilizing chambers have been placed. In Italy, some Departments were reorganized in a Hub and Spoke fashion. In the Latin American region, they adopted special measures for every case. In the UK a conference center has been used to accommodate intensive care unit (ICU) beds. The third part was about neurosurgical practice during the COVID-19 pandemic. In Wuhan, the main hospital was used for urgent non-COVID patients. In New York, the neurosurgeon staff works in ICU as an advanced practitioner (APP). In South Korea, every patient is screened. In Italy, the on-duty Hub neurosurgeons have been doubled. In the Latin American region recommendations have been developed by some neurosurgical societies. In the UK local non-specialists and rheumatologists, neurosurgical experts are collaborating in terms of best practice. The final part touched upon how to perform safe surgery and re-start after the pandemic. In China, elective surgical procedures are performed very carefully. In New York, surgery planning will be based on the patient’s viral load. In South Korea and in Italy disinfection plans and negative-pressure O.R. were created. In the Latin American region, the aim is to have a rapid testing system. In the UK they have developed flowcharts to guide trauma patient management.

In general, the pandemic scenario was presented as a thought-provoking challenge in all countries which requires tireless efforts for both maintaining emergency and elective neurosurgical procedures 1).

Role

see Role of Neurosurgeons in the COVID-19 Pandemic.

While neurosurgeons are not on the frontline of COVID-19 management and treatment, they commonly care for critically ill patients who will continue to present with subarachnoid hemorrhages, subdural hematomas, brain tumors, traumatic brain injuries, spinal cord injuries, and compressive myelopathies while the pandemic occurs. While public health measures such as quarantine and social distancing are proving effective at slowing the spread, 2) 3) surgeons remain in direct contact with their patients throughout their operations. Protecting the surgical team from contracting COVID-19 is of utmost importance as they are both a potential vector for patient contamination and a scarce resource that cannot be easily replaced.


COVID-19 appears to be principally spread, either directly or via fomites, through droplets from respiratory epithelium— especially the upper respiratory tract. Blood is not at this point a recognized vehicle; if the significant virus were present in the blood, we would be able to do a blood test for the disease. Similarly, it does not seem to concentrate on the cerebrospinal fluid. Thus, most neurosurgical procedures to the spine and head should be safe with routine face and eye protection if Personal protection equipment is unavailable.

Recommendations

COVID-19 recommendations for neurosurgeons.

COVID-19 in chronic subdural hematoma

COVID-19 in chronic subdural hematoma.

Pituitary Surgery During Covid-19

Pituitary Surgery During Covid-19

New York City

In an Invited Commentary, Ammar et al. describe their experiences and share lessons learned regarding triage of patients, staff safety, workforce management, and the psychological impact as they have adapted to a new reality in the Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City. Department of Neurosurgery at Montefiore Medical Center, a COVID-19 hotspot in New York City 4).

Italy

see COVID-19 in Italy.

Switzerland

Switzerland neurosurgery is doing, where urgent or elective cases are performed in a separate location, and providers and patients require negative COVID-19 tests and chest radiographs prior to entry. Furthermore, there would be greater demand for rapid data analysis and iterative systems research to ensure the best neurosurgical practices 5).

COVID-19 and central nervous system

COVID-19 and central nervous system.

Emotional impact

The emotional impact of COVID-19: from medical staff to common people was published by Montemurro from the Department of Neurosurgery, Azienda Ospedaliera Universitaria Pisana (AOUP), Pisa, Italy 6).

Neurosurgery in an infant with COVID-19

Administering general aneasthesia to infants with respiratory infections is a challenge because aneasthetic drugs suppress immunity and can thus contribute to intubation-related mechanical stress and inflammation. Neurosurgery in infants with coronavirus disease 2019 (COVID-19) therefore poses a dilemma because the infection is associated with relative immune suppression and a dysregulated inflammatory response, which act as drivers of the disease 7).

From Milan, Italy, we report the case of an 8-month-old male patient with a complex hydrocephalus who had a shunt malfunction during the COVID-19 pandemic. The infant presented with a mild temperature, a dry cough, and an occipital cerebrospinal fluid collection, suggestive for shunt malfunctioning. Neurological examination was negative, but the infant deteriorated and vomited repeatedly. The head CT scan indicated a shunt disconnection. A chest x-ray was negative for overt interstitial pneumonia and the nasopharyngeal swab tested positive for severe acute respiratory syndrome coronavirus 8)

While the baby showed upper respiratory symptoms due to COVID-19, concerns emerged regarding the need for general anaesthesia for shunt revision. To our knowledge, no reports exist regarding the risk of general anaesthesia in infants with COVID-19. Nevertheless, considering the certainty of progressive neurological deterioration if no intervention was taken, the neurosurgical intervention was arranged.

According to the available protocols for patients with COVID-19, 9)

a negative pressure operating room was set up. The staff were provided with full-head hoods, eye protection, filtering facepiece 3 masks, fluid-resistant gowns, double long-sleeved gloves, and impermeable disposable shoe covers. Surgeons and scrubbing nurses had additional sterile surgical suits and an additional pair of long-sleeved gloves. The patient was transferred from a ward dedicated to patients with COVID-19 to the surgical theatre through an isolated and restricted area by trained personnel wearing protective gear 10) Surgery lasted approximately 1 h, and the infant recovered from general anaesthesia promptly. 4 days after surgery, vomiting had worsened and a second neurosurgical revision of the shunt was done. Again, the baby underwent surgery under general anaesthesia without respiratory complications. The baby was promptly extubated, and the neurosurgical course was favourable. To the best of our knowledge, this is the first reported case of an infant with COVID-19 undergoing neurosurgical operations under general anaesthesia. This case might reflect a general observation of relative resistance of babies and children to COVID-19, 11) suggesting the possibility that paucisymptomatic infants with COVID-19 can undergo major surgical procedures without additional morbidity. This early case report needs confirmation and extension and might have broader implications for other surgical procedures addressing potentially life-threatening conditions in infants 12).

References

1)

Fontanella MM, Saraceno G, Lei T, Bederson JB, You N, Rubiano AM, Hutchinson P, Wiemeijer-Timmer F, Servadei F. Neurosurgical activity during COVID-19 pandemic: an expert opinion from China, South Korea, Italy, United Stated of America, Colombia and United Kingdom. J Neurosurg Sci. 2020 Apr 29. doi: 10.23736/S0390-5616.20.04994-2. [Epub ahead of print] PubMed PMID: 32347685.
2)

Chinazzi M, Davis JT, Ajelli M, et al. The effect of travel restrictions on the spread of the 2019 novel coronavirus (COVID-19) outbreak. Science. published online: March 6, 2020 (doi:10.1126/science.aba9757).
3)

Wilder-Smith A, Chiew CJ, Lee VJ. Can we contain the COVID-19 outbreak with the same measures as for SARS? Lancet Infect Dis. published online: March 5, 2020 (doi:10.1016/S1473-3099(20)30129-8).
4)

Ammar A, Stock AD, Holland R, Gelfand Y, Altschul D. Managing a Specialty Service During the COVID-19 Crisis: Lessons From a New York City Health System. Acad Med. 2020 Apr 17. doi: 10.1097/ACM.0000000000003440. [Epub ahead of print] PubMed PMID: 32304386.
5)

Robertson FC, Lippa L, Broekman MLD. Editorial. Task shifting and task sharing for neurosurgeons amidst the COVID-19 pandemic. J Neurosurg. 2020 Apr 17:1-3. doi: 10.3171/2020.4.JNS201056. [Epub ahead of print] PubMed PMID: 32302998; PubMed Central PMCID: PMC7164328.
6)

Montemurro N. The emotional impact of COVID-19: from medical staff to common people. Brain Behav Immun. 2020 Mar 30. pii: S0889-1591(20)30411-6. doi: 10.1016/j.bbi.2020.03.032. [Epub ahead of print] PubMed PMID: 32240766.
7)

Lu X Zhang L Du H et al. SARS-CoV-2 infection in children. N Engl J Med. 2020; (published online March 18.) DOI:10.1056/NEJMc2005073
8) , 9)

Wax RS Christian MD Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anesth. 2020; (published online February 12.) DOI:10.1007/s12630-020-01591-x
10)

Tien HC Chughtai T Jogeklar A Cooper AB Brenneman F Elective and emergency surgery in patients with severe acute respiratory syndrome (SARS). Can J Surg. 2005; 48: 71-74
11)

Li G Fan Y Lai Y et al. Coronavirus infections and immune responses. J Med Virol. 2020; 92: 424-432
12)

Carrabba G, Tariciotti L, Guez S, Calderini E, Locatelli M. Neurosurgery in an infant with COVID-19. Lancet. 2020 Apr 22. pii: S0140-6736(20)30927-2. doi: 10.1016/S0140-6736(20)30927-2. [Epub ahead of print] PubMed PMID: 32333840.

COVID-19

COVID-19

On 30 December 2019, a report of a cluster of pneumonia of unknown aetiology was published on ProMED-mail, possibly related to contact with a seafood market in Wuhan, China.

Hospitals in the region held an emergency symposium, and support from federal agencies is reportedly helping to determine the source of infection and causative organism. The seafood market has since been closed, but purportedly sold a variety of live animal species. On 5 January 2019, the World Health Organization (WHO) published a document outlining their request for more information from Chinese public health authorities, and detailed 44 patients had ‘pneumonia of unknown aetiology’, with 121 close contacts under surveillance (www.who.int/csr/don/05-january-2020-pneumonia-of-unkown-cause-china/en/). The WHO reported that 11 patients were severely ill, and many affected individuals had contact with the Huanan Seafood market. Some patients were reported to have fever, dyspnea and pulmonary infiltrates on chest radiography 1).


It was declared a public health emergency of international concern on Jan 30, 2020, by WHO 2).

By early January, terms like “the new coronavirus” and “Wuhan coronavirus” were in common use. On February 11, 2020, a taxonomic designation “severe acute respiratory syndrome coronavirus 2” (SARS-CoV-2) became the official means to refer to the virus strain, that was previously termed as 2019-nCoV and Wuhan coronavirus. Within a few hours on the same day, the WHO officially renamed the disease as COVID-19.

COVID-19 has high homology to other pathogenic coronaviruses, such as those originating from bat-related zoonosis (SARS-CoV), which caused approximately 646 deaths in China at the start of the decade.

Epidemiology

COVID-19 Epidemiology

Etiology

The genome of 2019-nCoV partially resembled SARS-CoV and MERS-CoV, and indicating a bat origin. The COVID-19 generally had a high reproductive number, a long incubation period, a short serial interval and a low case fatality rate (much higher in patients with comorbidities) than SARS and MERS. Clinical presentation and pathology of COVID-19 greatly resembled SARS and MERS, with less upper respiratory and gastrointestinal symptoms, and more exudative lesions in post-mortems. Potential treatments included remdesivir, chloroquine, tocilizumab, convalescent plasma and vaccine immunization (when possible) 3).

Transmission

Probable aircraft transmission of Covid-19 in-flight from the Central African Republic to France 4).


Estimates of case counts in Wuhan based on assumptions of 100% detection in travellers could have been underestimated by several fold. Furthermore, severity estimates will be inflated several fold since they also rely on case count estimates. Finally, our model supports evidence that underdetected cases of COVID-19 have probably spread in most locations around the world, with greatest risk in locations of low detection capacity and high connectivity to the epicentre of the outbreak 5).

COVID-19 virus genome

The complete genome of SARS-CoV-2 from Wuhan, China was submitted on January 17, 2020 in the National Center for Biotechnology 6) (NCBI) database, with ID NC_045512. The genome of SARS-CoV-2 is a 29,903 bp single-stranded RNA (ss-RNA) coronavirus. It has now been shown that the virus causing COVID-19 is a SARS-like coronavirus that had previously been reported in bats in China.

COVID-19 and central nervous system

COVID-19 and central nervous system.

Essential care of critical illness

Essential care of critical illness must not be forgotten in the COVID-19 pandemic 7).

COVID-19 for neurologists

COVID-19 for neurologists

COVID-19 for Neurosurgeons

see COVID-19 for neurosurgeons.

COVID-19 for Vascular surgeons

see COVID-19 for Vascular surgeons.

COVID-19 for Dermatologists

COVID-19 for Dermatologists

COVID-19 for Gastroenterologists

COVID-19 for Gastroenterologists

COVID-19 for Pediatricians

COVID-19 for Pediatricians

COVID-19 for Psychiatrists

COVID-19 for Psychiatrists.

COVID-19 for Oncologists

COVID-19 for Oncologists.

COVID-19 for Otolaryngologists

COVID-19 for Otolaryngologists.

COVID-19 for Cardiologists

COVID-19 for Cardiologists.

COVID-19 for Gynecologists

COVID-19 for Gynecologists.

Diagnosis

COVID-19 Diagnosis.

Treatment

COVID-19 Treatment.

Palliative Care

COVID-19 Palliative Care.

Prevention

COVID-19 Prevention.

Operating room preparation for COVID-19

see Operating room preparation for COVID-19.

Telemedicine in the COVID-19 era

see Telemedicine in the COVID-19 era.

Outcome

The mortality rate for COVID-19 is not as high (approximately 2-3%), but its rapid propagation has resulted in the activation of protocols to stop its spread. This pathogen has the potential to become a pandemic. It is therefore vital to follow the personal care recommendations issued by the World Health Organization 8).

Diabetes is a risk factor for the progression and prognosis of COVID-19

A total of 174 consecutive patients confirmed with COVID-19 were studied. Demographic data, medical history, symptoms and signs, laboratory findings, chest computed tomography (CT) as well we treatment measures were collected and analyzed.

Guo et al. found that COVID-19 patients without other comorbidities but with diabetes (n=24) were at higher risk of severe pneumonia, the release of tissue injury-related enzymes, excessive uncontrolled inflammation responses and hypercoagulable state associated with dysregulation of glucose metabolism. Furthermore, serum levels of inflammation-related biomarkers such as IL-6, C-reactive protein, serum ferritin, and coagulation index, D-dimer, were significantly higher (p< 0.01) in diabetic patients compared with those without, suggesting that patients with diabetes are more susceptible to an inflammatory storm eventually leading to rapid deterioration of COVID-19.

Data support the notion that diabetes should be considered as a risk factor for a rapid progression and bad prognosis of COVID-19. More intensive attention should be paid to patients with diabetes, in case of rapid deterioration 9).


Racism and discrimination in COVID-19 responses 10)

Case reports

2019 novel coronavirus infection in a three-month-old baby 11).


3 cases of SARS-CoV-2 infected children diagnosed from February 3 to February 17, 2020 in Tianjin, China. All of these three cases experienced mild illness and recovered soon after treatment, with the nucleic acid of throat swab turning negative within 14, 11, 7 days after diagnosis respectively. However, after been discharged, all the three cases were tested SARS-CoV-2 positive in the stool samples within 10 days, in spite of their remained negative nucleic acid in throat swab specimens. Therefore, it is necessary to be aware of the possibility of fecal-oral transmission of SARS-CoV-2 infection, especially for children cases 12).


Lv et al. reported the dynamic change process of target genes by RT-PCR testing of SARS-Cov-2 during the course of a COVID-19 patient: from successive negative results to successive single positive nucleocapsid gene, to two positive target genes (orf1ab and nucleocapsid) by RT-PCR testing of SARS-Cov-2, and describe the diagnosis, clinical course, and management of the case. In this case, negative results of RT-PCR testing was not excluded to diagnose a suspected COVID-19 patient, clinical signs and symptoms, other laboratory findings, and chest CT images should be taken into account for the absence of enough positive evidence. This case highlights the importance of successive sampling and testing SARS-Cov-2 by RT-PCR as well as the increased value of single positive target gene from pending to positive in two specimens to diagnose laboratory-confirmed COVID-19 13).

Literature

see COVID-19 Literature

References

1)

Bogoch II, Watts A, Thomas-Bachli A, Huber C, Kraemer MUG, Khan K. Pneumonia of unknown aetiology in Wuhan, China: potential for international spread via commercial air travel. J Travel Med. 2020 Mar 13;27(2). pii: taaa008. doi: 10.1093/jtm/taaa008. PubMed PMID: 31943059; PubMed Central PMCID: PMC7107534.
2)

WHO. Statement on the second meeting of the International Health Regulations (2005) Emergency Committee regarding the outbreak of novel coronavirus (2019-nCoV). Jan 30, 2020. https://www.who.int/newsroom/detail/30-01-2020-statement-on-thesecond-meeting-of-the-international-healthregulations-(2005)-emergency-committeeregarding-the-outbreak-of-novel-coronavirus- (2019-ncov) (accessed Feb 1, 2020).
3)

Xie M, Chen Q. Insight into 2019 novel coronavirus – an updated intrim review and lessons from SARS-CoV and MERS-CoV. Int J Infect Dis. 2020 Apr 1. pii: S1201-9712(20)30204-6. doi: 10.1016/j.ijid.2020.03.071. [Epub ahead of print] Review. PubMed PMID: 32247050.
4)

Eldin C, Lagier JC, Mailhe M, Gautret P. Probable aircraft transmission of Covid-19 in-flight from the Central African Republic to France. Travel Med Infect Dis. 2020 Apr 1:101643. doi: 10.1016/j.tmaid.2020.101643. [Epub ahead of print] PubMed PMID: 32247016.
5)

Niehus R, De Salazar PM, Taylor AR, Lipsitch M. Using observational data to quantify bias of traveller-derived COVID-19 prevalence estimates in Wuhan, China. Lancet Infect Dis. 2020 Apr 1. pii: S1473-3099(20)30229-2. doi: 10.1016/S1473-3099(20)30229-2. [Epub ahead of print] PubMed PMID: 32246905.
6)

Wuhan seafood market pneumonia virus isolate Wuhan-Hu-1, complete genome. Nucleotide, National Center for Biotechnology Information (NCBI), National Library of Medicine (US), National Center for Biotechnology Information, Bethesda, MD, https://www. ncbi.nlm.nih.gov/nuccore/1798174254 (accessed on 2020-02-28).
7)

Baker T, Schell CO, Petersen DB, Sawe H, Khalid K, Mndolo S, Rylance J, McAuley DF, Roy N, Marshall J, Wallis L, Molyneux E. Essential care of critical illness must not be forgotten in the COVID-19 pandemic. Lancet. 2020 Apr 1. pii: S0140-6736(20)30793-5. doi: 10.1016/S0140-6736(20)30793-5. [Epub ahead of print] PubMed PMID: 32246914.
8)

Palacios Cruz M, Santos E, Velázquez Cervantes MA, León Juárez M. COVID-19, a worldwide public health emergency. Rev Clin Esp. 2020 Mar 20. pii: S0014-2565(20)30092-8. doi: 10.1016/j.rce.2020.03.001. [Epub ahead of print] Review. English, Spanish. PubMed PMID: 32204922.
9)

Guo W, Li M, Dong Y, Zhou H, Zhang Z, Tian C, Qin R, Wang H, Shen Y, Du K, Zhao L, Fan H, Luo S, Hu D. Diabetes is a risk factor for the progression and prognosis of COVID-19. Diabetes Metab Res Rev. 2020 Mar 31:e3319. doi: 10.1002/dmrr.3319. [Epub ahead of print] PubMed PMID: 32233013.
10)

Devakumar D, Shannon G, Bhopal SS, Abubakar I. Racism and discrimination in COVID-19 responses. Lancet. 2020 Apr 1. pii: S0140-6736(20)30792-3. doi: 10.1016/S0140-6736(20)30792-3. [Epub ahead of print] PubMed PMID: 32246915.
11)

Zhang YH, Lin DJ, Xiao MF, Wang JC, Wei Y, Lei ZX, Zeng ZQ, Li L, Li HA, Xiang W. [2019 novel coronavirus infection in a three-month-old baby]. Zhonghua Er Ke Za Zhi. 2020 Mar 2;58(3):182-184. doi: 10.3760/cma.j.issn.0578-1310.2020.03.004. Chinese. PubMed PMID: 32135587.
12)

Zhang T, Cui X, Zhao X, Wang J, Zheng J, Zheng G, Guo W, Cai C, He S, Xu Y. Detectable SARS-CoV-2 Viral RNA in Feces of Three Children during Recovery Period of COVID-19 Pneumonia. J Med Virol. 2020 Mar 29. doi: 10.1002/jmv.25795. [Epub ahead of print] PubMed PMID: 32222992.
13)

Lv DF, Ying QM, Weng YS, Shen CB, Chu JG, Kong JP, Sun DH, Gao X, Weng XB, Chen XQ. Dynamic change process of target genes by RT-PCR testing of SARS-Cov-2 during the course of a Coronavirus Disease 2019 patient. Clin Chim Acta. 2020 Mar 27. pii: S0009-8981(20)30134-0. doi: 10.1016/j.cca.2020.03.032. [Epub ahead of print] PubMed PMID: 32229107.

Precautions for endoscopic transnasal skull base surgery during the COVID-19 pandemic

PRECAUTIONS FOR ENDOSCOPIC TRANSNASAL SKULL BASE SURGERY DURING THE COVID-19 PANDEMIC

Key Words: COVID-19, coronavirus, transmission, endoscopic surgery, extended endoscopic skull base surgery, personal protective equipment (PPE), Powered Air Purifying Respirators (PAPR)

Zara M. Patel, MD; Juan Fernandez-Miranda, MD; Peter H. Hwang, MD; Jayakar V. Nayak, MD, PhD; Robert Dodd, MD, PhD; Hamed Sajjadi, MD; Robert K. Jackler, MD

Stanford University School of Medicine
Departments of Otolaryngology-Head & Neck Surgery and Neurosurgery

On March 12, 2020 the World Health Organization (WHO) officially announced the COVID-19 outbreak a pandemic, where to date there have been over 381,000 cases resulting in over 16,500

1

The compilation of information below is anecdotal, based primarily on personal communication with international colleagues reporting their individual experiences, and more data is needed before strict policies are set. There is no scientific evidence in this report. However, based on the preliminary observations summarized below and the fast course of events, it would be prudent to exercise an abundance of caution as more data accumulates. Our goal with this preliminary, rapid article is to alert surgeons of the need to temporarily alter their practices to avoid repeating the unfortunate experience of the early period of the epidemic.

Personal communication with colleagues deployed in Wuhan, China to combat the COVID-19 outbreak, have warned us about the potential risks of endonasal endoscopic surgery in COVID – 19 symptomatic patients. From their reports, a patient with mild flu-like symptoms underwent transphenoidal pituitary surgery in early January 2020, before the severity of this pandemic was well established. Multiple members (>14 by report) of the patient care team, both within and outside of the operating room, became infected from what became recognized as human-to-

2

deaths worldwide.
information that we can gain from our international colleagues who have already experienced this, or are currently going through it, should be utilized to protect our patients, our hospital teams and ourselves.

The COVID-19 pandemic is accelerating within the United States, and any

human transmission of COVID-19.
second case of intraoperative transmission of COVID-19 occurred later on January 2020, at the peak of the pandemic in Wuhan province. A young patient with a known pituitary adenoma developed fever and acute vision changes and was diagnosed with pituitary apoplexy and suspected viral pneumonia based on imaging studies. The surgical team was aware of the potential risks of infection, but given the acuity of symptoms proceeded with transphenoidal surgery using personal protective equipment (PPE). The neurosurgeon and two OR nurses employed N95 masks and the anesthesiologist reportedly used a “home-made” positive pressure helmet. The operation was completed successfully without incident and the surgical team was quarantined after surgery. Within 3-4 days, all of them developed fever and respiratory

Testing for COVID-19 prior to that time was scarce. A

symptoms compatible with pneumonia, except the anesthesiologist. Fortunately, all recovered with no sequelae. The patient, however, required prolonged intubation, but finally recovered.

A significant number of doctors who became infected and even died in Wuhan, China were anesthesiologists/critical care doctors, ophthalmologists, and otolaryngologists, possibly due to

3

From our colleagues in Iran, Dr. Ebrahim Razmpa, Professor of Otolaryngology at Tehran University Medical Sciences, Dr. Saee Atighechi, Associate Professor of Otolaryngology at Yazd University School of Medicine, and Dr. Mohammed Hossein Baradanfar, Professor and Chairman of Otolaryngology Yazd University School of Medicine, we have additionally heard that at least 20 otolaryngologists in Iran are currently hospitalized with COVID-19, with 20 more in isolation at home. They are testing only people who have been admitted to the hospital,

so those twenty at home are not confirmed, but have classic symptoms. A previously healthy 60 year old facial plastic surgeon died from COVID-19 three days ago. A young, otherwise healthy otolaryngology chief resident had a short prodrome, rapidly decompensated and died from what was found to be acute myocarditis and cardiac arrest. It was recently confirmed from these colleagues that he did also test positive for COVID-19.

The British Association of Otorhinolaryngology has now also stated two of its consultants are on

8

Our colleague Dr. Puya Deghani-Mobaraki, in Italy, also reports otolaryngologists being affected adversely, but his information is about the possible loss of smell and taste that this virus brings. They are not only seeing it in their patients, but they have noticed it within their own ranks, in otherwise healthy asymptomatic doctors, at rates far above what could be considered normal. This observation has also been reported in the media regarding patients, as an under-reported

9,10

quarantine or to come in and be tested, depending on individual evaluation.

Based on this information, and until we know more, we are performing only urgent/emergent surgery at Stanford University at this time. Due to this apparent high risk with endoscopic transnasal surgery on COVID-19 symptomatic patients, in spite of current limitations in testing capacity, our institution has approved testing for COVID-19 in pre-operative patients needing this type of procedure urgently or emergently. This is true even for asymptomatic patients (ie. no cough and/or fever), although the true risk in this cohort of patients is still unknown. If the test is negative and the patient is asymptomatic, we may proceed using normal levels of protective gear; however, the rate of false negative tests is still to be determined, and until this is known , the use of additional levels of PPE, such as N95 and face shields can be considered. If the test is

the high viral shedding from the nasal and oropharyngeal cavity.
high risk of infection when taking care of COVID-19 patients without PPE. High risk procedures include intubation and procedures involving the upper respiratory tract and gastrointestinal tract with risk for aerosolization, such as endoscopy, bronchoscopy, and laryngoscopy.

7
Hospital “Hippocrates” are quarantined, as a doctor at the Otolaryngology Clinic reportedly

ventilators and being treated for COVID-19.

In Athens, 21 staff members of the Athens General

tested positive for COVID-19.

aspect of this disease process.
France in association with COVID-19 that the government has issued an official statement instructing citizens with this symptom to contact their physicians, who may advise self-

11

In fact, this symptom has been seen now so commonly in

Healthcare providers are at

positive, we defer surgery if at all possible until the infection is cleared, verified by repeat testing. When endonasal surgery cannot be postponed in a COVID-19 positive patient, based on guidelines now being used in China, we have recommended to our institutional officials that we utilize full PAPR (an enclosed powered system with HEPA filter), acknowledging that they have challenging decisions surrounding allocation of limited resources that are urgently needed by our

12

The question of whether two separate negative tests are needed before surgery, or if one is sufficient, is under active discussion. The test that we are using, developed at Stanford, is an in- house assay that uses a real time RT-PCR for SARS-CoV-2. This first screens for the presence of virus envelope protein, and if positive then evaluates for the presence of the RNA-dependent RNA polymerase gene for confirmation (Developed by Benjamin Pinsky MD, Stanford University). Positive results from this test have been demonstrated to be very sensitive and very specific and have been given early approval by the FDA. The Chinese CDC test uses different gene targets and primers and thus may, or may not, have a different accuracy profile. Conservation of precious testing and PPE resources is another reason to limit these operations to the bare minimum at this time. We also recommend use of as minimal an OR team as necessary and that no trainees or observers be allowed in the room both for reasons of safety and to preserve PPE.

In the clinic setting, we have similarly restricted visits to only urgent/emergent patients and have ceased the use of spray anesthetic/decongestants, opting instead for nasal pledgets as needed, but preferably avoiding endoscopy whenever possible. We are using N95 masks, face shields and gowns for all outpatient nasal endoscopies.

Please keep in mind that from the time of this submission, the situation may have evolved, and our policies may have changed. We hope that more hard data becomes available soon upon which to base these important decisions. We follow with tempered optimism the evolution of this pandemic in China, where at this point no new local cases have been reported for several days now, with gradual return to normal surgical activities, including endoscopic endonasal surgery.

We thank our international colleagues who have given us this important information, and we extend wishes of safety and health to all our otolaryngology, neurosurgery, and critical care/anesthesia colleagues at this challenging time.

John’s Hopkins Coronovirus Center. https://coronavirus.jhu.edu/map.html Accessed March 21, 2020

2China Newsweek. View.inews.qq.com/a/20200125A07TT200?uid=&devid=BDFE70CD-5BF1-4702-91B7- 329F20A6E839&qimei=bdfe70cd-5bf1-4702-91b7-329f20a6e839

3https://www.bloomberg.com/news/articles/2020-03-17/europe-s-doctors-getting-sick-like-in-wuhan-chinese- doctors-say?fbclid=IwAR2ds9OWRxQuMHAuy5Gb7ltqUGMZNSojVNtFmq3zzcSLb_bO9aGYr7URxaI

critical care teams taking care COVID-19 patients.
should be considered whenever possible. Because endonasal surgery creates clouds of droplets and aerosols which may permeate the operating environment, anyone in the operating theater requires the same protection when operating on known COVID-19 positives.

Alternatively, a transcranial approach

3van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med. 2020 Mar 17. doi: 10.1056/NEJMc2004973. [Epub ahead of print]

55Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med. 2020 Mar 19;382(12):1177-1179. doi: 10.1056/NEJMc2001737. Epub 2020 Feb 19.

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6Xu K , Lai XQ , Liu Z . Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2020 Feb 2;55(0):E001. doi:

10.3760/cma.j.issn.1673-0860.2020.0001. [Epub ahead of print] [Suggestions for prevention of 2019 novel coronavirus infection in otolaryngology head and neck surgery medical staff].
[Article in Chinese (translated via Google translator); Abstract available in Chinese from the publisher]

7 https://news.sky.com/story/coronavirus-experts-say-new-symptoms-could-be-loss-taste-or-smell-11961439 8 8https://www.euractiv.com/section/politics/news/cracks-appear-in-nordic-response-to-covid-19-crisis/

9 9https://en.radiofarda.com/a/loss-of-sense-of-smell-among-iranians-coinciding-with-coronavirus- epidemic/30478044.html

10 https://www.forbes.com/sites/judystone/2020/03/20/theres-an-unexpected-loss-of-smell-and-taste-in-coronavirus- patients/#48e2a8c85101

11https://www.sortiraparis.com/news/coronavirus/articles/210162-coronavirus-update-on-the-situation-in-paris-and- ile-de-france-controls-reinforc/lang/en

12 Lian, Tingbo (Editor). Handbook of COVID-19 Prevention and Treatment. The First Affiliated Hospital. Zhejiang University School of Medicine. Compiled according to Clinical Experience.

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