10.14639/0392-100X-suppl.1-42-2022-05
During the Coronavirus Disease 2019 (COVID-19) pandemic, otolaryngology has been shown to be a high-risk specialty due to the exposure to aerosol-generating physical exami- nations, procedures and surgical interventions on the head and neck area, both in adult and paediatric patients. This has prompted the issue of updating the guidelines by International Health Authorities in the Ear Nose and Throat (ENT) field and, at the same time, has stimu- lated engineers and healthcare professionals to develop new devices and technologies with the aim of reducing the risk of contamination for physicians, nurses and patients. Methods. A review of the literature published on PubMed, Ovid/Medline and Scopus data- bases was performed from January 01, 2020 to December 31, 2021.Results. 73 articles were eligible to be included, which were subdivided into 4 categories: (“Artificial Intelligence (AI)”; “Personal Protective Equipment (PPE)”; “Diagnostic tools”; “Surgical tools”).Conclusions. All of the innovations that have been developed during the COVID-19 pan- demic have laid the foundation for a radical technological change of society, not only in medicine but also from a social, political and economical points of view that will leave its mark in the coming decades.
text/xml
1827-675X
2109
en
Maria Luisa Fiorella
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
technology
Diagnostic and surgical innovations in otolaryngology for adult and paediatric patients during the COVID-19 era
Text.Serial.Journal
https://www.actaitalica.it/
42
Annual congress report
2022-04-26
2022-04-06
2022-04-28
2022-04-28
S46-S57
1
Maria Luisa Fiorella
2022/04/26
10.14639/0392-100X-suppl.1-42-2022-05
S46
Department of Otorhinolaryngology, Aldo Moro University, Bari, Italy
1827-675X
technology
S57
Diagnostic and surgical innovations in otolaryngology for adult and paediatric patients during the COVID-19 era
https://www.actaitalica.it/article/download/2109/770
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42(SUPPL.1):S46-S57; doi: 10.14639/0392-100X-suppl.1-42-2022-05




Diagnostic and surgical innovations in otolaryngology for
adult and paediatric patients during the COVID-19 era
Innovazioni diagnostiche e chirurgiche in otorinolaringoiatria per i pazienti adulti
e pediatrici durante l’era COVID-19
Paolo Petrone1*, Emanuela Birocchi2*, Cesare Miani3, Roberta Anzivino4, Pasqua Irene Sciancalepore5,
Antonio Di Mauro6, Paolo Dalena7, Cosimo Russo4, Vincenzo De Ceglie8, Maurizio Masciavè9, Maria Luisa Fiorella8
1
  Directorate General, ASL BA, Bari, Italy; 2 Department of Pediatrics, Aldo Moro University, Bari, Italy; 3 Department of
Otorhinolaryngology, Hospital of Tolmezzo, ASUFC Udine, Udine, Italy; 4 Department of Otorhinolaryngology, Di Venere Hospital, ASL
BA, Bari, Italy; 5 Centre of Phoniatry and Rehabilitation of Communication Disorders, Lecce, Italy: 6 National Pediatric Health Care
System, Margherita di Savoia, Italy; 7 Department of Otorhinolaryngology, University Hospital Essen, Essen, Germany; 8 Department
of Otorhinolaryngology, Aldo Moro University, Bari, Italy; 9 Department of Clinical and Experimental Medicine, University of Foggia,
Foggia, Italy
*
  P. Petrone and E. Birocchi contributed equally to this work.


SUMMARY
During the Coronavirus Disease 2019 (COVID-19) pandemic, otolaryngology has been
shown to be a high-risk specialty due to the exposure to aerosol-generating physical exami-
nations, procedures and surgical interventions on the head and neck area, both in adult and
paediatric patients. This has prompted the issue of updating the guidelines by International
Health Authorities in the Ear Nose and Throat (ENT) field and, at the same time, has stimu-
lated engineers and healthcare professionals to develop new devices and technologies with
the aim of reducing the risk of contamination for physicians, nurses and patients.
Methods. A review of the literature published on PubMed, Ovid/Medline and Scopus data-
bases was performed from January 01, 2020 to December 31, 2021.
Results. 73 articles were eligible to be included, which were subdivided into 4 categories:
(“Artificial Intelligence (AI)”; “Personal Protective Equipment (PPE)”; “Diagnostic tools”;
“Surgical tools”).
Conclusions. All of the innovations that have been developed during the COVID-19 pan-                       Received: January 28, 2022
demic have laid the foundation for a radical technological change of society, not only in                   Accepted: February 17, 2022
medicine but also from a social, political and economical points of view that will leave its
mark in the coming decades.                                                                                 Correspondence
                                                                                                            Paolo Petrone
KEY WORDS: COVID-19, SARS-CoV-2, otolaryngology, adult, pediatric, technology                               Directorate General, ASL BA.
                                                                                                            lungomare Starita 1, 70132 Bari, Italy
                                                                                                            Tel. + 39 080 5842484
RIASSUNTO
                                                                                                            E-mail: paolo.petrone@asl.bari.it
Durante la pandemia da COVID-19, l’otorinolaringoiatria ha dimostrato di essere una delle
specialità a più alto rischio di contatto con le malattie virali a trasmissione aerea, a causa
dell’esposizione a procedure generanti aerosol sul distretto testa-collo, sia sul paziente adulto             How to cite this article: Petrone P, Birocchi E,
che pediatrico. Questo ha rappresentato il punto di partenza non solo per l’emanazione di                     Miani C, et al. Diagnostic and surgical innovations
                                                                                                              in otolaryngology for adult and paediatric patients
nuove linee guida da parte delle Società scientifiche internazionali, ma ha anche stimolato                   during the COVID-19 era. Acta Otorhinolaryngol
l’inventiva di tecnici e operatori sanitari nello sviluppare nuovi dispositivi e tecnologie per               Ital 2022;42(SUPPL.1):S46-S57. https://doi.
ridurre il rischio di contaminazione per gli operatori sanitari e per il paziente.                            org/10.14639/0392-100X-suppl.1-42-2022-05
Metodi. È stata eseguita una revisione della letteratura dal giorno 1 gennaio 2020 al 31
dicembre 2021 utilizzando i database di PubMed, Ovid/Medline e Scopus.                                      © Società Italiana di Otorinolaringoiatria
Risultati. Sono stati selezionati 73 articoli e raccolti in 4 categorie differenti (“Intelligenza Artifi-   e Chirurgia Cervico-Facciale
ciale”; “Dispositivi di Protezione Individuale”; “Strumenti diagnostici”; “Strumenti chirurgici”).
Conclusioni. Le innovazioni sviluppate durante la pandemia da COVID-19 hanno posto le basi                                 OPEN ACCESS

per una trasformazione in ambito tecnologico di tutta la società, non solo da un punto di vista             This is an open access article distributed in accordance with
medico ma anche da un punto di vista sociale, politico, ed economico, riflettendosi in una tra-             the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                            Commercial-NoDerivatives 4.0 International) license. The
sformazione che segnerà la mentalità dell’intera popolazione mondiale per i prossimi decenni.               article can be used by giving appropriate credit and mentio-
                                                                                                            ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: COVID-19, SARS-CoV-2, otorinolaringoiatria, adulto, pediatria,                               only in the original version. For further information: https://
tecnologia                                                                                                  creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                    Innovations in otolaryngology during the COVID-19 era




Introduction                                                    ter narrowing the search according to our topic of interest,
                                                                73 articles were eligible to be included in our review.
Amongst all healthcare specialists, otorhinolaryngologists
                                                                These articles were subsequently divided into 4 categories:
are especially increased risk of COVID-19 infection 1 due
                                                                4 papers were included in “Artificial Intelligence (AI)”;
to their exposure to aerosol-generating physical examina-
                                                                26 papers were included in “Personal Protective Equipment
tions, procedures and surgical interventions on the head
                                                                (PPE)”; 11 papers were included in “Diagnostic tools”;
and neck area, in both adult and paediatric patients. In ad-
                                                                33 papers were included in “Surgical tools”. One article
dition, while the adult patient is more manageable because
                                                                was cited twice because it contained some innovations that
of his vaccinated status and general compliance, paediatric
                                                                we selected to be included both in “Personal Protective
patients are even more hazardous to the healthcare worker
                                                                Equipment (PPE)” plus “Diagnostic tools”.
because they are less compliant and more inclined to cry
and cough, and because they may not be wearing face
masks 2.                                                        Discussion
Therefore, in order to minimise the spread of SARS-CoV-2        Artificial Intelligence (AI)
spread during everyday practice, several protective meas-       During the COVID-19 pandemic, we have witnessed sig-
ures have recently been developed. We conducted a re-           nificant development and diffusion of innovative tools –
view of the literature with the aim of describing the strate-
                                                                already available to the general population – which have
gies – especially technological innovations – that have been
                                                                played a positive role in health communication by raising
adopted to mitigate viral trasmission during the COVID-19
                                                                awareness of health status and safety of the healthcare
pandemic in ENT clinical practice.
                                                                provider and patient. They substantially contributed to be-
                                                                havioural changes, i.e. increasing cognition of seriousness,
Methods                                                         susceptibility, action clue and self-efficacy. All of this was
We reviewed the literature to identify innovations that         achieved through the use of social media and videogame
have been developed for the management of the ENT               platforms.
patient during the COVID-19 pandemic era. English-lan-          Jiang 4 conducted a study on college students using “Plague
guage papers and abstracts published on PubMed, Ovid/           Inc.®”, an infectious disease-themed, simulation game de-
Medline and Scopus databases were examined from Janu-           veloped in 2012 by Ndemic Creations® for Iphone Operat-
ary 01, 2020 to December 31, 2021, according to the Pre-        ing Systems and Android Systems, based on Centers for
ferred Reporting Items for Systematic Reviews and Me-           Disease Control and Prevention algorithms. He success-
ta-Analyses (PRISMA) guidelines (Fig. 1) 3. Our search          fully demonstrated how a videogame can help gain deeper
was based on the following key-words: “innovations,             understanding of factors influencing infectious disease out-
COVID-19, otolaryngology”; “innovations, COVID-19,
ENT”; “COVID-19; otolaryngology”; “COVID-19,
ENT”; “COVID-19 pediatric ENT surgery”; “COVID-19,
masks”; “otolaryngology, masks”. The latest interven-
tions, techniques, diagnostic and surgical solutions were
evaluated according to the Oxford Center for Evidence
Based Medicine (EBM) criteria.

Results
The search performed on PubMed, Ovid/Medline and Sco-
pus databases has yielded 1483 English-language abstracts
and papers. Based on the titles and abstracts, we selected
innovations about: upper airways’ Personal Protective
Equipment (PPE); diagnostic and surgical devices in laryn-
gology and head and neck surgery, rhinology and skull base
surgery, audiology and ear surgery; Artificial Intelligence
(AI) related devices employed during the COVID-19 pan-
demic in the ENT specialty. Therefore, we excluded papers
whose title and abstract were unrelated to these topics. Af-    Figure 1. PRISMA diagram (from Liberati et al., 2009 3, mod.).



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P. Petrone et al.




breaks, improve knowledge and educate both healthcare                              A survey on performing in-office otolaryngology
personnels and the general population.                                             procedures during COVID-19 pandemic 8 showed gloves
Murri et al. 5 have shown that, as the COVID-19                                    and masks are the most commonly used types of PPE
pandemic unfolded, health professionals turned to rapid                            by ENT specialists. Another international survey noted
communication media (i.e. Facebook groups, Whatsapp                                a significantly higher use of powered air-purifying
and Telegram chats, Twitter feeds) more than to official                           respirators (PAPRs) in high-risk aerosol.generating
academic sources in an attempt to seek information and                             medical paediatric procedures 9. In fact, health authorities
update their scientific knowledge. This has the potential to                       recommend that every diagnostic procedure needs to be
spread misinformation and distrust towards public health                           performed on patients who are possibily or certainly
authorities.                                                                       infected with COVID-19 should take place in Negative
At the same time, during the pandemic, machine learning                            Pressure Rooms (NPRs) wearing full PPE. However,
and deep learning-based AI technology have improved                                PAPRs and NPRs may not always readily available in
medical equipment and workflow to minimise contacts                                healthcare facilities.
with patients 6, enabling healthcare workers to make more                          To overcome this limitation, Sayin et al. 10 presented
efficient and safer clinical decisions. This was implemented                       a closed chamber unit for ENT examination during
thanks to: wearable devices with patients’ GPS data on Wi-                         aerosol-generating endoscopic examinations, allowing for
Fi, 5G and Bluetooth technologies (cardiac and respiratory                         communication between the examiner and patient to take
wearable sensors); Internet of Things systems-based remote                         place thanks to a Bluetooth speaker in the room, with the
screening (color-coded patient severity identification,                            negative pressure blocking aerosol dissemination. Other
facial recognition, smartphone applications for screening);                        authors 11 have modified a liftable, protective methacrylate
intelligent diagnostic systems for neural networks and                             shield to enclose the whole ENT examination chair, with
digital image processing technology (chest X-rays and                              holes placed in the front, allowing the ENT specialist to
CT images); remote intensive care to reduce unnecessary                            introduce his hands and equipment.
patient-doctor contacts.                                                           A smaller airway-isolating system, called COVID-19
Furthermore, Wang has proposed the use of a remotely-                              Airway Management Isolation Chamber (CAMIC) 12
controlled, low-cost microrobot for nasopharyngeal swab                            covering the patient’s head and chest area, aims at creating
sample collection 7, replacing medical staff and therefore                         an internal negative pressure generated by an aspiration
limiting aerosol and droplet contamination for healthcare                          mechanism. This device consists of a polyvinyl chloride
workers.                                                                           hollow frame with fenestrations, with a suction vacuum
All of these technologies can help solve not only staff                            line and a contralateral air supply line (Fig. 2). Its strong
shortage, but also limit healthcare-related rising costs and                       barrier allows the creation of a safer environment for
waste, reaching a safety level that may go beyond Personal                         noninvasive upper airway management. A negative-
Protective Equipment (PPE), since they are able to inimize                         pressure plastic cover with a smoke evacuator and high-
contact with the infected patient (Tab. I).                                        efficiency particulate air (HEPA) filtration unit 13 was tested
                                                                                   for patients needing tracheostomy. For the same purpose,
Personal Protective Equipment (PPE)                                                other authors have developed an external fixator equipment
This is the richest chapter of innovations that has been                           made up of a metal frame wrapped with a sterile plastic
proposed during lockdown and, more extensively, during                             cover 14.
these two years of the COVID-19 pandemic; it also plays a                          For the paediatric patient, protective acrylic boxes have
fundamental role against future airborne infectious disease                        been developed to perform microlaryngoscopy and
outbreaks in the field of otolaryngology.                                          bronchoscopy, containing aerosolised respiratory secretions


Table I. Artificial Intelligence’s core elements.
 Artificial Intelligence (AI)
 Innovations        Simulation games
                    Social media
                    Wearable devices
                    Internet of Things
                    Intelligent diagnostic systems
 Key point          Platforms and technological devices are able to promote a rapid – often real-time – spread of relevant information and minimize interhuman
                    contacts, thus reducing the contamination risk related to airborne infections during the present and future public-health crises




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                                                                                                Innovations in otolaryngology during the COVID-19 era




Figure 2. CAMIC polyvinyl chloride hollow frame: (A) CAMIC architecture; (B) CAMIC assembled frame; (C) CAMIC on the surgical bed, viewed from above;
(D) CAMIC on the surgical bed, viewed from below (from Blood et al., 2021 12).


with a 3-open-sided suspension covered with a transparent                   demonstrated that the addition of either safety goggles or
plastic sheet 15.                                                           glasses to an upward-facing face shield are able to decrease
HEPA filters, PAPRs, N95s and other PPEs used to                            the risk of eye contamination during cough 18.
protect team members during aerosol-generating medical                      More importantly, enhanced PPE devices can successfully
procedures can negatively affect communication,                             be integrated to everyday ENT practice tools, such as
increasing noise levels and listening effort in ENT                         headlights. Namely, standard headlights were modified so
operative rooms. Therefore, either repurposing operative                    as to provide better protection for the healthcare provider.
room team members’ headsets and cellphones towards a                        Some authors have succeeded in doing so 19 by using a
conference call or using an in-ear communication device                     3D-printed adaptor that is able to generate a protective
has been shown to be an effective strategy to facilitate                    barrier through a transparent sheet. Another headlight-
communication 16,17.                                                        related innovation is represented by a custom-made
For in-office examinations, given the potential for airborne                clear laminated shield that should be directly fixed to the
conjunctival transmission, wearing enhanced PPE plays a                     headlight, functioning as a barrier between the examining
pivotal role in ensuring physicians’ individual safety during               ENT specialist and the patient 11.
the COVID-19 pandemic. Notwithstanding, eye protection                      Despite being less comfortable to wear, face masks remain
may often be neglected by ENT specialists. It has been                      the first-line defense device for every airborne infection, as



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P. Petrone et al.




they are able to guarantee safety of healthcare personnel                       masks were tested by Vicini et al. during ENT surgical
and the general population even when facing potential                           procedures 23.
COVID-19 future variants of concern. Convissar et al. 20                        On the other hand, a cheaper, cost-effective innovation,
assembled a reusable makeshift filter mask, called Modified                     is represented by a reusable half-face respirator, the
Airway from VentilatoR Circuit (MAVerIC), starting from                         Sundstrom SR 100 respirator, routinely used in industrial
an adult anaesthesia breathing circuit with HEPA filters, a                     settings to filter gas and vapour particulates 24.
facemask and a rubber head strap, with or without an eye                        The COVID-19 pandemic has marked the rise of 3D-printing
protection. MAVerIC is able to filter 99.7% of particles                        technology, especially for endoscopy masks, thus allowing
≥ 0.3 microns.                                                                  ENT specialists to use rigid and flexible endoscopes
3D-printed adaptors have represented another great                              during in-office evaluations. Davies et al. 25 studied a
innovation for PPEs, whose potential has been exploited                         stereolithographic 3D-printed nasal endoscopy mask with
both on their own, as an interface between elastomeric                          a side port for connection to supplemental oxygen or inline
respirators and anaesthesia circuit filters 21 or together                      ventilation filter. Two types of endoscopy masks have been
with masks. One of the most affordable examples is                              tested, both reusable and disposable, which were effective
represented by the use of snorkerling masks (Fig. 3).                           in preventing diffusion of large droplets after a simulated
Thierry et al. tested the EasyBreath snorkeling mask                            cough.
with an upper adaptor connected to a filter, which                              Another 3D-printed mask was tested – first on mannequins
greatly increased surgeons’ visual comfort and safety 22.                       and then on human volunteers – by Ference et al. 26,27
Different models of modified full-face snorkeling                               (Fig. 4). It is an Aerosol Containment Mask with an




Figure 3. A modified snorkeling mask: (A) EasyBreath® mask with an adaptor and a filter; (B) EasyBreath® mask with dive lights and lower adaptor (from Therry
et al., 2020 22).



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Figure 4. An aerosol containment mask for endoscopy: (A) mask architecture; (B) mask on patient; (C) patient undergoing endoscopy (from Ference et al.,
2021 27).


N-95 respirator filter and two frontal ports to support the                       also be considered to cover the nose and the mouth during
passage of a rigid or flexible endoscope or suction. Other                        the endoscopy depending on the age and compliance of the
authors have developed a modified ENVO® mask by                                   patient 33 (Tab. II).
SleepNet, which uses suction to create a negative-pressure
environment in the nasal and oral cavity of the patient                           Diagnostic tools
during laryngoscopy 28.                                                           During lockdowns, some healthcare workers asked parents
Hoffman et al. 29 proposed a new model for a negative-                            to monitor their children’s throat using smartphone
pressure face shield with controlled access to the nose                           cameras 34. These digital tools have also been successfully
and mouth. Alternatively, a standard endoscopy face                               used on adults and were deemed to be convenient by patients
mask has been altered to allow the passage of a flexible                          and reliable by doctors 35. However, to avoid difficulties in
laryngoscope by fashioning a 3-mm slit with a scalpel 30.                         evaluation and diagnostic errors, digital photo shooting
For flexible endoscopy, other authors 31 developed patient-                       must follow strict rules, i.e: the patient needs to position
worn enhanced protection face shields. The fibreoptic                             himself in front of the mirror with optimal room lighting
endoscope was inserted into stellate openings, obtaining                          and setting flash to forced mode; 16:9 image ratio and
a barrier against aerosolised particles. To limit airborne                        highest resolution; horizontal format to cut all unnecessary
contamination, Curran et al. 32 proposed the use of a low-                        facial features (nose, eyes, forehead, etc.); use of the back
cost device made up of an anaesthetic closed facemask,                            camera without digital zoom and audible indicator when
anaesthetic filter, and DAR (Covidien) connector with a                           shooting 36.
reusable harness attachment for CPAP.                                             It may be something of an understatement, but whenever
Lastly, the idea of making a hole in a surgical mask worn                         in-office fibrolaryngoscopic examination is required, it
by the patient must be limited to children, since according                       should be performed not by using the endoscope lens, but
to some authors the use of a pre-prepared modified mask                           with a camera and monitor so as to maximise the distance
for the paediatric patient with a hole for the scope should                       between the patient and examining physician 33. This holds


Table II. Personal Protective Equipment’s core elements.
 Personal Protective Equipment (PPE)
 Innovations      Environmental isolation (powered-air purifying respirators, negative pressure rooms, closed chamber examination unit, chair shields)
                  Patient isolation (head and chest shields, face shields, plastic covers and protective boxes with HEPA filters, endoscopy masks)
                  Healthcare personnel isolation (N95 masks, eye protection, headlight shields, filter masks, snorkeling masks)
 Key point        Isolation methods play a fundamental role in the reduction of contamination related to airborne infections




                                                                                                                                                         S51
P. Petrone et al.




especially true for paediatric patients, given their higher                          and healthcare professionals. The common ground to all
propensity to cough and cry along with less compliance.                              guidelines, both for adult and paediatric patients 44, is to
As an alternative to the traditional approach, the so-                               defer to a later date every procedure, except those that are
called “back approach to the patient” 37, where during the                           deemed to be emergent and/or whose management and
endoscopic examination the specialist positions himself                              prognosis is time-sensitive, i.e: urgent/emergent cases that
behind the patient facing the monitor, may represent                                 could require surgery; surgery for acute airway obstruction;
a simple yet effective solution to decrease healthcare                               prompt diagnosis of suspected cancer; surgical intervention
professionals’ exposure to viral particles.                                          for sepsis following initial first-line medical management.
Sciancalepore et al. 38 have tested the accuracy of                                  Other recommendations include the suggestion of letting
transcutaneous laryngeal ultrasonography (TLUSG) for                                 procedures to be done by the most skilled surgeons and the
vocal fold mobility assessment, which was a noninvasive                              use of open approaches rather than endoscopic ones, with
alternative to fibrolaryngoscopy during COVID-19                                     the aim of reducing time of exposure both for patients and
pandemic given its ability to screen for vocal fold paralysis                        clinicians 45.
without aerosol-generating procedures, especially in                                 As far as pre-surgical anaesthesia is concerned, general
patients undergoing thyroidectomy. A further step to this                            anaesthetic procedures should preferably be switched to
approach may be telerobotic ultrasound examination 39                                local ones. However, when intubation is necessary, short-
which, despite being more time-consuming, is safer for                               ening peri-procedural aerosolisation and pausing to allow
healthcare professionals and a valid alternative to diagnose                         for aerosol dispersion may be useful 45. In addition, as just
patients who cannot go to the hospital.                                              the act of intubating COVID-19 positive patients is consid-
Lockdowns have marked the rise of digital USB-otoscopes                              ered to be at high risk of viral transmission; we witnessed
(DUO), of which different models – even unexpensive                                  the development of innovative devices to protect healthcare
ones – have been developed by companies all over the                                 professionals from particle aerosolisation.
world. They can be connected to smartphones to visualise                             A tracheostomy should be performed on a careful case-by-
the auditory canal and tympanic membrane, thus allowing                              case indication, and key technical modifications become
self-monitoring 40, even on children 41. Even though more                            necessary. In particular, the use of myorelaxants helps to
professional otoscopes have been developed, such as                                  reduce the risk of cough-generated particle diffusion 46.
Smartphone-Enabled Wireless Otoscope (SEWO) 42 to                                    Due to the high viral aerosolisation risk, other devices have
be employed during telehealth consultations, and many                                been developed and can be adapted to the neck and chest
patients have found these devices ready and easy-to-use,                             of the patient through a plastic envelopment, with holes al-
physicians reported that they would not feel comfortable                             lowing the specialist to manouver surgical tools 47-49. Other
using the images for diagnosis or to defer an in-person                              authors 50 have tested a negative airway pressure respira-
examination 43 (Tab. III).                                                           tor (NAPR) system to protect health care workers. When
                                                                                     suction was applied to the NAPR, no particle escape was
Surgical tools                                                                       noted. Another study tested a specific protocol to avoid
During the COVID-19 pandemic, rather than tool-related                               droplet contamination during unsecured airway procedures
surgical innovations, we witnessed a rethinking of surgical                          independently from COVID-19 test results, consisting in
approaches and choices of techniques and instruments,                                the use of a surgical tent surrounding the patient. An ul-
with the purpose of minimising the risk of contamination.                            trafiltration smoke evacuator is secured to the drape on the
Indeed, health authorities in the ENT field have tried to                            patient’s chest 51. Continuous suction should be placed near
face the evolving viral outbreak by rapidly developing                               the operating field 52.
specific guidelines to ensure the safety of both patients                            To reduce the risk of viral transmission, it is advisable to


Table III. Diagnostic tools’ core elements.
 Diagnostic tools
 Innovations        Smartphone cameras
                    USB otoscopes
                    New endoscopic approaches to the patient
                    Transcutaneous laryngeal ultrasonography
 Key point          The use of modern video tools with diagnostic purposes and the adaptation of alternative approaches and diagnostic tools significantly
                    contributes to reduce contact between the healthcare worker and the patient, proving to be effective in minimizing airborne contamination risk




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                                                                                      Innovations in otolaryngology during the COVID-19 era




employ viricidal substances perioperatively; in particular,      tested the efficacy of SPIWay® Endonasal sheaths to
pre-operative hypertonic solution (< 5% NaCl) irrigations        reduce particle dispersion caused by nasal drilling. When
have been shown to improve mucociliary clearance 53.             a flexible suction was inserted together with the SPIWays,
Alternatively, 0.23-7% povidone iodine – whose efficacy          no aerosols were spread during drilling. Others 74 have
had already been reported for Severe Acute Respiratory           introduced the Negative-pressure Otolaryngology Viral
Syndrome Coronavirus 1 (SARS-CoV-1) and Middle East              Isolation Drape (NOVID) system to reduce the risk of
Respiratory Syndrome Coronavirus Infection (MERS-                aerosolisation; it consists of a plastic drape suspended
CoV) 54 – was confirmed to be an optimal choice during           above the patient’s head and surgical field with a smoke
SARS-CoV-2, even in paediatric patients 55. The use of           evacuator suction (Fig. 5). In another study, a low-cost,
these substances as nasal and oropharyngeal washings both        modifiable and easily producible negative pressure face-
for the patient and for healthcare professionals has been        mounted antechamber was developed utilising 3D printing
suggested before and after surgical interventions performed      and silicone moulding to effectively reduce aerosolisation
on subjects on patients who are possibily or certainly in-       from endoscopic drilling without disturbing the flow of
fected with COVID-19 56. Povidone iodine irrigations have        the operation 75.
also been suggested for every procedure where drilling is        Lastly, in ear surgery, a COVID-19 Airway Management
involved, such as mastoidectomies 57.                            Isolation Chamber (CAMIC) Ear system was tested by
During surgery, the employment of adhesive dressings on          using a schedule of Poly-Vinyl Chloride pipes with holes
nasal and oral cavities is recommended to reduce particle        in order to create a hollow frame with fenestrations to
diffusion 58,59. The same has also been demonstrated for         facilitate vacuum suction 76 (Fig. 6, Tab. IV).
ear surgery: the use of a barrier drape (so-called OtoTent)
significantly reduced particulate dispersion 60.                 Conclusions
International guidelines also recommend to mini-
mise – whenever possible – the use of surgical electrical        In conclusion, the COVID-19 era has significantly
instruments, such as drills, electrical and diathermic de-       strengthened the application of many innovations that were
vices, in order to avoid biological particle aerosolisation.     considered routine in our everyday life, even in the non-
The risk of viral spread following drilling 61-63 or CO2 laser   medical field. Moreover, it has contributed to empower
ablation-derived smoke is well estabilished in every ENT
surgical subspecialty, i.e. head and neck surgery, nose and
skull base surgery and ear surgery 64-69. Therefore, during
the COVID-19 pandemic, the use of coarse or cutting burs,
irrigation, handheld suction, or additional suction becomes
of crucial importance 59.
Among the few truly innovative devices that were con-
ceived during the lockdown, Hoffman et al. tested laser
plume containment for diagnostic and operative transnasal
potassium-titanyl-phosphate laryngoscopy for biopsy in lo-
cal anaesthesia 70. The device – developed by the Univer-
sity of Iowa – consists of a negative-pressure face shield
installed on a camera stand with two frontal access ports
and a lateral suction port. The suction system was a stand-
ard wall suction for all the diagnostic laryngoscopies and a
portable one for laser and biopsy procedures.
As far as nasal and skull base surgery is concerned, other
authors have created a modified Vent Mask, using a sur-
gical mask with the finger of a non-latex glove, to allow
passage of an endoscope, with significant reduction of
aerosolisation. This solution was only tested on a cadaver
model 71. In another cadaver model, the authors tested a         Figure 5. The Negative-pressure Otolaryngology Viral Isolation Drape
suction mitigation system of airborne particulate generat-       (NOVID): (A) a holder (arrow) with star ring retractor (arrow-head); (B) HEPA
                                                                 filter (arrow) with suction; (C) endoscope insertion; (D) fluorescein-laden drop-
ed during sinonasal drilling and cautery, with a rigid suc-      lets: patient’s nose (arrow), opening of the suction device (square), gauze out-
tion placed in the contralateral nostril 72. Another study 73    side the operating field (circle) (from David et al., 2020 74).



                                                                                                                                            S53
P. Petrone et al.




                                                                             challenges in every field of medicine. Consequently, a
                                                                             radical mindset and changes in approach has affected every
                                                                             specialty, and especially in otolaryngology. The pandemic
                                                                             has influenced the development of artificial intelligence-
                                                                             based tools available to the general population, becoming
                                                                             a powerful surge of social, political and administrative
                                                                             change. These are able to influence medicine behind the
                                                                             scenes, while supporting its growth in the coming decades.

                                                                             Conflict of interest statement
                                                                             The authors declare no conflict of interest.

                                                                             Funding
                                                                             This research did not receive any specific grant from fund-
                                                                             ing agencies in the public, commercial, or not-for-profit
                                                                             sectors.

                                                                             Authors’ contributions
                                                                             PP, EB, CM and MLF: design of the work, data collection,
                                                                             data analysis and interpretation; drafting the article; critical
                                                                             revision of the article, final approval of the version to
                                                                             be published; RA, PIS, ADM, PD, CR, VDC and MM:
Figure 6. CAMIC-Ear system on the microscope drape; microscope hand-         acquisition of data, analysis and interpretation of data,
pieces with sterile covers (yellow stars) (from Tolisano et al., 2020 76).   critical revision of the article.

                                                                             Ethical consideration
Table IV. Surgical tools’ core elements.                                     Ethical review and approval was not required for the study.
 Surgical tools                                                              All review procedures have been performed in accordance
 Innovations        Employing surgical tents and drapes                      with the requirements of the World Medical Association’s
                    Using pre-operative viricidal solutions
                    Favouring local instead of general anesthesia
                                                                             Declaration of Helsinki.
                    Shortening intubation-related aerosolization
                    Anaesthetic drug choice                                  Availability of data and materials
                    Avoiding eletrical instruments                           The datasets used and/or analysed during the current study
                    Suctioning near the operating field
                                                                             are available from the corresponding author on reasonable
 Key point          Rethinking of surgical approaches, choices of            request.
                    techniques and instruments can effectively reduce the
                    risk of contamination
                                                                             References
                                                                             1
                                                                                 Mannelli G, Ralli M, Bonali M, et al. Impact of COVID-19 pan-
both patients and healthcare workers on the relevance and                        demic on Italian Otolaryngology Units: a nationwide study.
correct use of PPEs to such an extent that it represents                         Acta     Otorhinolaryngol      Ital    2020;40:325-331.    https://doi.
                                                                                 org/10.14639/0392-100X-N0832
the most important chapter of the innovations that were                      2
                                                                                 Cho RHW, Yeung ZWC, Ho OYM, et al. Pearls of experience for safe
developed during these past two years.                                           and efficient hospital practices in otorhinolaryngology-head and neck
Rethinking customary diagnostic and surgical approaches                          surgery in Hong Kong during the 2019 novel coronavirus disease
can minimise the risks related to airborne viral transmission.                   (COVID-19) pandemic. J Otolaryngol Head Neck Surg 2020;49:30.
                                                                                 https://doi.org/10.1186/s40463-020-00427-4
However, these novelties in the diagnosis of upper airway                    3
                                                                                 Liberati A, Altman DG, Tetzlaff J. et al. The PRISMA statement for re-
diseases – by reducing interhuman contact – may affect the                       porting systematic reviews and meta-analyses of studies that evaluate
human dimension of care in the doctor-patient relationship.                      health care interventions: explanation and elaboration. J Clin Epide-
All these innovations developed during the COVID-19                              miol 2009;62:E1-E34. https://doi.org/10.1016/j.jclinepi.2009.06.006
pandemic represent a true revolution, triggered by the fast-
                                                                             4
                                                                                 Jiang R, Shao B, Si S, et al. Health Communication in games at
                                                                                 the early stage of COVID-19 epidemic: a grounded theory study
paced evolution of biomedical technology, in an attempt                          based on Plague, Inc. Games Health J 2021;10:408-419. https://doi.
to create something that is able to face the multifaceted                        org/10.1089/g4h.2020.0135




S54
                                                                                                     Innovations in otolaryngology during the COVID-19 era




5
     Murri R, Segala FV, Del Vecchio P, et al. Social media as a tool for       21
                                                                                     Liu DCY, Koo TH, Wong JKK, et al. Adapting re-usable elastomeric
     scientific updating at the time of COVID pandemic: results from a               respirators to utilise anaesthesia circuit filters using a 3D-printed
     national survey in Italy. PLoS One 2020;15:e0238414. https://doi.               adaptor – a potential alternative to address N95 shortages during the
     org/10.1371/journal.pone.0238414                                                COVID-19 pandemic. Anaesthesia 2020;75:1022-1027. https://doi.
6
     Chen SW, Gu XW, Wang JJ, et al. AIoT used for COVID-19 pan-                     org/10.1111/anae.15108
     demic prevention and control. Contrast Media Mol Imaging                   22
                                                                                     Thierry B, Célérier C, Simon F, et al. How and why use the Eas-
     2021;2021:3257035. https://doi.org/10.1155/2021/3257035                         yBreath® surface snorkeling mask as a personal protective equip-
7
     Wang S, Wang K, Tang T, et al. Design of a low-cost miniature robot             ment during the COVID-19 pandemic? Eur Ann Otorhinolaryn-
     to assist the COVID-19 nasopharyngeal swab sampling. IEEE Trans-                gol Head Neck Dis 2020;137:329-331. https://doi.org/10.1016/j.
     actions on Medical Robotics and Bionics 2021;3:289-293. https://doi.            anorl.2020.05.006
     org/10.1109/TMRB.2020.3036461                                              23
                                                                                     Vicini C, Cammaroto G, Meccariello G, et al. Overview of differ-
8
     Calcagno H, Anthony BP, Halum SL, et al. Safety practices for in-               ent modified full-face snorkelling masks for intraoperative pro-
     office laryngology procedures during clinical reintroduction amidst             tection. Acta Otorhinolaryngol Ital 2020;40:317-324. https://doi.
     COVID-19. Laryngoscope Investig Otolaryngol 2021;6:780-785.                     org/10.14639/0392-100X-N0841
     https://doi.org/10.1002/lio2.591                                           24
                                                                                     Patel B, Hardman JC, Yang W, et al. Reusable respirators as per-
9
     Kim DH, Chadha NK, Nguyen LH, et al. Personal protective equip-                 sonal protective equipment during ENT surgery. J Laryngol Otol
     ment availability and usage amongst pediatric otorhinolaryngolo-                2020;134:732-734. https://doi.org/10.1017/S0022215120001346
     gists during the COVID-19 pandemic: an international survey. Int J         25
                                                                                     Davies JC, Chan HHL, Gilbert RW, et al. Nasal endoscopy during
     Pediatr Otorhinolaryngol 2020;138:110349. https://doi.org/10.1016/j.            the COVID-19 pandemic: mitigating risk with 3D printed masks. La-
     ijporl.2020.110349                                                              ryngoscope 2020;130:2561-2563. https://doi.org/10.1002/lary.29004
10
     Sayin İ, Devecioğlu İ, Yazıcı ZM. A Closed chamber ENT examina-            26
                                                                                     Ference EH, Kim W, Oghalai JS, et al. COVID-19 in the clinic: aerosol
     tion unit for aerosol-generating endoscopic examinations of COV-                containment mask for endoscopic otolaryngologic clinic procedures.
     ID-19 patients. Ear Nose Throat J 2020;99:594-596. https://doi.                 Otolaryngol Head Neck Surg 2021 Jun 22:1945998211024944.
     org/10.1177/0145561320931216                                                    https://doi.org/10.1177/01945998211024944. Epub ahead of print.
11
     Farneti P, Sorace F, Tasca I. Personal protective equipment for ENT        27
                                                                                     Ference EH, Kim W, Oghalai JS, et al. COVID-19 in the clinic: human
     activity during COVID-19 pandemic. Eur Arch Otorhinolaryngol                    testing of an aerosol containment mask for endoscopic clinic procedures.
     2020;277:2933-2935. https://doi.org/10.1007/s00405-020-06177-3                  Otolaryngol Head Neck Surg 2021 Jun 27:1945998211029184.
12
     Blood TC Jr, Perkins JN, Wistermayer PR, et al. COVID-19 air-                   https://doi.org/10.1177/01945998211029184. Epub ahead of print.
     way management isolation chamber. Otolaryngol Head Neck Surg               28
                                                                                     McCarty EB, Soldatova L, Brant JA, et al. Innovations in
     2021;164:74-81. https://doi.org/10.1177/0194599820942500                        otorhinolaryngology in the age of COVID-19: a systematic literature
13
     Bertroche JT, Pipkorn P, Zolkind P, et al. Negative-pressure aerosol            review. World J Otorhinolaryngol Head Neck Surg 2021 Jan 22.
     cover for COVID-19 tracheostomy. JAMA Otolaryngol Head Neck                     https://doi.org/10.1016/j.wjorl.2021.01.001. Epub ahead of print.
     Surg 2020;146:672-674. https://doi.org/10.1001/jamaoto.2020.1081.          29
                                                                                     Hoffman HT, Miller RM, Walsh JE, et al. Negative pressure face
     Erratum in: JAMA Otolaryngol Head Neck Surg 2020;146:678. htt-                  shield for flexible laryngoscopy in the COVID-19 era. Laryngo-
     ps://doi.org/10.1001/jamaoto.2020.1370                                          scope Investig Otolaryngol 2020;5:718-726. https://doi.org/10.1002/
14
     Cordier PY, De La Villeon B, Martin E, et al. Health workers’ safety            lio2.437
     during tracheostomy in COVID-19 patients: homemade protective              30
                                                                                     Narwani V, Kohli N, Lerner MZ. Application of a modified endos-
     screen. Head Neck 2020;42:1361-1362. https://doi.org/10.1002/                   copy face mask for flexible laryngoscopy during the COVID-19 pan-
     hed.26222                                                                       demic. Otolaryngol Head Neck Surg 2020;163:107-109. https://doi.
15
     Pollaers K, Herbert H, Vijayasekaran S. Pediatric microlaryngo-                 org/10.1177/0194599820928977
     scopy and bronchoscopy in the COVID-19 era. JAMA Otolaryn-                 31
                                                                                     Anon JB, Denne C, Rees D. Patient-worn enhanced protection
     gol Head Neck Surg 2020;146:608-612. https://doi.org/10.1001/                   face shield for flexible endoscopy. Otolaryngol Head Neck Surg
     jamaoto.2020.1191                                                               2020;163:280-283. https://doi.org/10.1177/0194599820934777
16
     Levin M, Zhou K, Sommer EC, et al. Ambient noise levels and wire-          32
                                                                                     Curran J, Calder N, Yaneza M, et al. Reducing potential aerosol gen-
     less headsets for communication in aerosolizing otolaryngology sur-             eration in flexible nasolaryngoscopy: a novel method. J Laryngol Otol
     gery during COVID-19. Otolaryngol Head Neck Surg 2021;165:528-                  2020;134:744-746. https://doi.org/10.1017/S0022215120001413
     531. https://doi.org/10.1177/0194599820986584                              33
                                                                                     Leitmeyer K, Felton M, Chadha NK. Strategies for restarting pedi-
17
     Nguyen DL, Kay-Rivest E, Tewfik MA, et al. Association of in-ear                atric otolaryngology outpatient clinics after a pandemic-related
     device use with communication quality among individuals wear-                   shutdown such as from COVID-19. Int J Pediatr Otorhinolaryngol
     ing personal protective equipment in a simulated operating room.                2020;139:110414. https://doi.org/10.1016/j.ijporl.2020.110414
     JAMA Netw Open 2021;4:e216857. https://doi.org/10.1001/                    34
                                                                                     Maurrasse SE, Rastatter JC, Hoff SR, et al. Telemedicine dur-
     jamanetworkopen.2021.6857                                                       ing the COVID-19 pandemic: a pediatric otolaryngology perspec-
18
     Ng JH, Daniel D, Sadovoy A, et al. Eye protection in ENT practice during        tive. Otolaryngol Head Neck Surg 2020;163:480-481. https://doi.
     the COVID-19 pandemic. OTO Open 2021;5:2473974X211010408.                       org/10.1177/0194599820931827
     https://doi.org/10.1177/2473974X211010408                                  35
                                                                                     Cai Y, Zheng YJ, Gulati A, et al. Patient use of low-cost digital
19
     Viera-Artiles J, Valdiande JJ. 3D-printable headlight face shield adapt-        videoscopes and smartphones for remote ear and oropharyngeal
     er. Personal protective equipment in the COVID-19 era. Am J Otolar-             examinations. JAMA Otolaryngol Head Neck Surg 2021;147:336-
     yngol 2020;41:102576. https://doi.org/10.1016/j.amjoto.2020.102576              342. https://doi.org/10.1001/jamaoto.2020.5223
20
     Convissar D, Berra L, Chang MG, et al. Personal protective equip-          36
                                                                                     Maret D, Peters OA, Auria JP, et al. Smartphone oral self-
     ment N95 facemask shortage quick fix: the modified airway from                  photography in teledentistry: recommendations for the patient. J
     VEntilatoR Circuit (MAVerIC). Cureus 2020;12:e7914. https://doi.                Telemed Telecare 2021 Jun 23:1357633X211028513. https://doi.
     org/10.7759/cureus.7914                                                         org/10.1177/1357633X211028513. Epub ahead of print.




                                                                                                                                                       S55
P. Petrone et al.




37
     Di Maio P, Traverso D, Iocca O, et al. Endoscopic nasopharyngoscopy        52
                                                                                     Leboulanger N, Sagardoy T, Akkari M, et al. COVID-19 and ENT
     and ENT specialist safety in the COVID 19 era: the back endoscopy               pediatric otolaryngology during the COVID-19 pandemic. Guide-
     approach to the patient. Eur Arch Otorhinolaryngol 2020;277:2647-               lines of the French Association of Pediatric Otorhinolaryngology
     2648. https://doi.org/10.1007/s00405-020-06093-6                                (AFOP) and French Society of Otorhinolaryngology (SFORL). Eur
38
     Sciancalepore PI, Anzivino R, Petrone P, et al. Transcutaneous                  Ann Otorhinolaryngol Head Neck Dis 2020;137:177-181. https://doi.
     laryngeal ultrasonography: a promising tool for otolaryngologists               org/10.1016/j.anorl.2020.04.010
     during COVID-19. Am J Otolaryngol 2021;42:102772. https://doi.             53
                                                                                     Farrell NF, Klatt-Cromwell C, Schneider JS. Benefits and safety of
     org/10.1016/j.amjoto.2020.102772                                                nasal saline irrigations in a pandemic-washing COVID-19 away.
39
     Ganesh D, Seshadri G, Sokkanarayanan S, et al. AutoImpilo:                      JAMA Otolaryngol Head Neck Surg 2020;146:787-788. https://doi.
     smart automated health machine using IoT to improve telemedi-                   org/10.1001/jamaoto.2020.1622
     cine and telehealth. In: 2020 International Conference on Smart            54
                                                                                     Parhar HS, Tasche K, Brody RM, et al. Topical preparations to reduce
     Technologies in Computing, Electrical and Electronics (IC-                      SARS-CoV-2 aerosolization in head and neck mucosal surgery. Head
     STCEE).       Bengaloru      2020:487-493.      https://doi.org/10.1109/        Neck 2020;42:1268-1272. https://doi.org/10.1002/hed.26200
     ICSTCEE49637.2020.9277223                                                  55
                                                                                     Chorney SR, Rizzi MD, Dedhia K. Considerations for povidone-io-
40
     Bayoumy AB, Veugen CCAFM, van Rijssen LB, et al. Self-monitor-                  dine antisepsis in pediatric nasal and pharyngeal surgery during the
     ing of the tympanic membrane: an opportunity for telemedicine dur-              COVID-19 pandemic. Am J Otolaryngol 2020;41:102737. https://doi.
     ing times of COVID-19 and beyond. J Otol 2021;16:120-122. https://              org/10.1016/j.amjoto.2020.102737
     doi.org/10.1016/j.joto.2020.12.003                                         56
                                                                                     Mady LJ, Kubik MW, Baddour K, et. Consideration of povidone-
41
     Jayawardena ADL, Mankarious LA, Keamy DG Jr, et al. Pediatric,                  iodine as a public health intervention for COVID-19: utiliza-
     family-centered, “At-Home” otologic physical examination in the                 tion as “Personal Protective Equipment” for frontline provid-
     COVID-19 era. Otolaryngol Head Neck Surg 2020;163:1061-1063.                    ers exposed in high-risk head and neck and skull base oncol-
     https://doi.org/10.1177/0194599820934776                                        ogy care. Oral Oncol 2020;105:104724. https://doi.org/10.1016/j.
42
     Meng X, Dai Z, Hang C, et al. Smartphone-enabled wireless                       oraloncology.2020.104724
     otoscope-assisted online telemedicine during the COVID-19 out-             57
                                                                                     Khan MM, Parab SR. 0.5% povidone iodine irrigation in otorhinolar-
     break. Am J Otolaryngol 2020;4:102476. https://doi.org/10.1016/j.               yngology surgical practice during COVID 19 pandemic. Am J Otolar-
     amjoto.2020.102476                                                              yngol 2020;41:102687. https://doi.org/10.1016/j.amjoto.2020.102687
43
     Ronner EA, Stenerson ME, Goldschmidt NH, et al. Otoendoscopes              58
                                                                                     Lagos AE, Ramos PH, Andrade T. Protection for
     to enhance telemedicine during the COVID-19 pandemic. Ann                       otolaryngologic surgery in the COVID-19 pandemic.
     Otol Rhinol Laryngol 2021 Nov 2:34894211051810. https://doi.                    OTO         Open        2020;4:2473974X20934734.          https://doi.
     org/10.1177/00034894211051810. Epub ahead of print.                             org/10.1177/2473974X20934734
44
     Din T, Abdalla T, Chiesa-Estomba C, et al. YO-IFOS Guidelines for          59
                                                                                     Freiser ME, Dharmarajan H, Sri Kavya Boorgu DS, et al. Droplet and
     pediatric ENT surgery during COVID-19: an overview of recommen-                 aerosol generation with mastoidectomy during the COVID-19 pan-
     dations. Laryngoscope 2021;131:1876-1883. https://doi.org/10.1002/              demic: assessment of baseline risk and mitigation measures with a
     lary.29335                                                                      high-performance cascade impactor. Otol Neurotol 2021;42:614-622.
                                                                                     https://doi.org/10.1097/MAO.0000000000002987
45
     Elliott D, Ochieng C, Jepson M, et al. ‘Overnight, things changed.
     Suddenly, we were in it’: a qualitative study exploring how surgical       60
                                                                                     Chen JX, Workman AD, Chari DA, et al. Demonstration and mitiga-
     teams mitigated risks of COVID-19. BMJ Open 2021;1:E046662.                     tion of aerosol and particle dispersion during mastoidectomy relevant
     https://doi.org/10.1136/bmjopen-2020-046662                                     to the COVID-19 era. Otol Neurotol 2020;41:1230-1239. https://doi.
                                                                                     org/10.1097/MAO.0000000000002765
46
     Xu K, Lai X, Liu Z. Suggestions on the prevention of COVID-19 for
     health care workers in department of otorhinolaryngology head and
                                                                                61
                                                                                     Thamboo A, Lea J, Sommer DD, et al. Clinical evidence based re-
     neck surgery. World J Otorhinolaryngol Head Neck Surg 2020;6(Sup-               view and recommendations of aerosol generating medical procedures
     pl 1):S2-S5. https://doi.org/10.1016/j.wjorl.2020.03.002                        in otolaryngology - head and neck surgery during the COVID-19
                                                                                     pandemic. J Otolaryngol Head Neck Surg 2020;49:28. https://doi.
47
     Canelli R, Connor CW, Gonzalez M, et al. Barrier enclosure during
                                                                                     org/10.1186/s40463-020-00425-6
     endotracheal intubation. N Engl J Med 2020;382:1957-1958. https://
     doi.org/10.1056/NEJMc2007589
                                                                                62
                                                                                     Hilal A, Walshe P, Gendy S, et al. Mastoidectomy and trans-corneal
                                                                                     viral transmission. Laryngoscope 2005;115:1873-1876. https://doi.
48
     Kearsley R. Intubation boxes for managing the airway in patients
                                                                                     org/10.1097/01.mlg.0000177459.80574.2d
     with COVID-19. Anaesthesia 2020;75:969. https://doi.org/10.1111/
     anae.15081
                                                                                63
                                                                                     Norris BK, Goodier AP, Eby TL. Assessment of air quality during
                                                                                     mastoidectomy. Otolaryngol Head Neck Surg 2011;144:408-411.
49
     Begley JL, Lavery KE, Nickson CP, et al. The aerosol box for intuba-
                                                                                     https://doi.org/10.1177/0194599810394967
     tion in coronavirus disease 2019 patients: an in-situ simulation cross-
     over study. Anaesthesia 2020;75:1014-1021. https://doi.org/10.1111/
                                                                                64
                                                                                     In SM, Park DY, Sohn IK, et al. Experimental study of the poten-
     anae.15115                                                                      tial hazards of surgical smoke from powered instruments. Br J Surg
                                                                                     2015;102:1581-1586. https://doi.org/10.1002/bjs.9910
50
     Khoury T, Lavergne P, Chitguppi C, et al. Aerosolized particle re-
     duction: a novel cadaveric model and a negative airway pressure
                                                                                65
                                                                                     Carr MM, Patel VA, Soo JC, et al. Effect of electrocautery settings
     respirator (NAPR) system to protect health care workers from COV-               on particulate concentrations in surgical plume during tonsillec-
     ID-19. Otolaryngol Head Neck Surg 2020;163:151-155. https://doi.                tomy. Otolaryngol Head Neck Surg 2020;162:867-872. https://doi.
     org/10.1177/0194599820929275                                                    org/10.1177/0194599820914275
51
     Francom CR, Javia LR, Wolter NE, et al. Pediatric laryngoscopy and
                                                                                66
                                                                                     Baggish MS, Poiesz BJ, Joret D, et al. Presence of human immuno-
     bronchoscopy during the COVID-19 pandemic: a four-center col-                   deficiency virus DNA in laser smoke. Lasers Surg Med 1991;11:197-
     laborative protocol to improve safety with perioperative management             203. https://doi.org/10.1002/lsm.1900110302
     strategies and creation of a surgical tent with disposable drapes. Int J   67
                                                                                     Subbarayan RS, Shew M, Enders J, et al. Occupational exposure of
     Pediatr Otorhinolaryngol 2020;134:110059. https://doi.org/10.1016/j.            oropharyngeal human papillomavirus amongst otolaryngologists. La-
     ijporl.2020.110059                                                              ryngoscope 2020;130:2366-2371. https://doi.org/10.1002/lary.28383




S56
                                                                                                   Innovations in otolaryngology during the COVID-19 era




68
     Johnson GK, Robinson WS. Human immunodeficiency virus-1                   73
                                                                                    Dharmarajan H, Freiser ME, Sim E, et al. Droplet and aerosol gen-
     (HIV-1) in the vapors of surgical power instruments. J Med Virol               eration with endonasal surgery: methods to mitigate risk during the
     1991;33:47-50. https://doi.org/10.1002/jmv.1890330110                          COVID-19 pandemic. Otolaryngol Head Neck Surg 2021;164:285-
69
     Patel ZM, Fernandez-Miranda J, Hwang PH, et al. Letter: precautions for        293. https://doi.org/10.1177/0194599820949802
     endoscopic transnasal skull base surgery during the COVID-19 pandemic.    74
                                                                                    David AP, Jiam NT, Reither JM, et al. Endoscopic skull base and
     Neurosurgery 2020;87:E66-E67. https://doi.org/10.1093/neuros/nyaa125           transoral surgery during COVID-19 pandemic: minimizing drop-
70
     Hoffman HT, Walsh JE, Pratt A, et al. Laser plume containment dur-             let spread with negative-pressure otolaryngology viral isolation
     ing flexible transnasal laryngoscopy. Laryngoscope Investig Otolar-            drape. Head Neck 2020;42:1577-1582. https://doi.org/10.1002/
     yngol 2021;6:234-243. https://doi.org/10.1002/lio2.526                         hed.26239
71
     Workman AD, Welling DB, Carter BS, et al. Endonasal instrumenta-          75
                                                                                    Kim M, Lee M, Schwarz J, et al. A novel negative pressure, face-
     tion and aerosolization risk in the era of COVID-19: simulation, lit-          mounted antechamber to minimize aerosolization of particles dur-
     erature review, and proposed mitigation strategies. Int Forum Allergy          ing endoscopic skull base surgery. Oper Neurosurg (Hagerstown)
     Rhinol 2020;10:798-805. https://doi.org/10.1002/alr.22577                      2021;21:131-136. https://doi.org/10.1093/ons/opab173
72
     Workman AD, Xiao R, Feng A, et al. Suction mitigation of airborne         76
                                                                                    Tolisano AM, Blood TC Jr, Riley CA, et al. The COVID-19 airway
     particulate generated during sinonasal drilling and cautery. Int Forum         management isolation chamber (CAMIC) for ears. Laryngoscope
     Allergy Rhinol 2020;10:1136-1140. https://doi.org/10.1002/alr.22644            2020;130:2690-2692. https://doi.org/10.1002/lary.28942




                                                                                                                                                  S57
