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DOI:
ORIGINALRESEARCH
Safetypracticesforin-officelaryngologyproceduresduring
clinicalreintroductionamidstCOVID-19
HaleyCalcagnoMD1|||
,2
1TheIndianaUniversitySchoolofMedicineandtheDepartmentofOtolaryngology-HeadandNeckSurgery,IndianaUniversity,Indianapolis,Indiana,USA
2TheDepartmentofSpeechandHearingSciences,IndianaUniversity,Bloomington,Indiana,USA
Correspondence
,DepartmentofAbstract
Otolaryngology-HeadandNeckSurgery,Objective:Describesafetypracticesforperformingin-officelaryngologyprocedures
FeslerHall,.,Suite
400,Indianapolis,IN46202,-introductionamidstthecoronavirusdisease2019(COVID-19)
Email:******@.
Methods:AnanonymoussurveyinQualtricswascreatedtoevaluatedemographics,
preproceduretesting,practicesettings,anesthesia,andpersonalprotectiveequip-
ment(PPE)useforfiveprocedurecategories(non-mucosal-traversinginjections,
mucosal-traversinginjections,endoscopywithoutsuction,endoscopywithsuction/
mucosalinterventionviaworkingchannel,andlaserviaworkingchannel).Thesurvey
wasemailedtotheFallVoiceCommunityonDocMatterandtomembersofthe
AmericanBroncho-EsophagologicalAssociation(ABEA)fromMaytoJune2020.
Results:Eighty-tworespondentswereanalyzed(responserate:10%).Respondents
representeddiverselocations,(71%)
orprivatepractices(16%),laryngologyfellowshiptraining(76%),andasignificant
practicedevotiontolaryngologyandbroncho--
introduction,-
ferredtotheORsettingformost,though36%preferredtheORforlaserprocedures.
TherewasapreferenceforpreproceduralSARS-Cov2testingforproceduresinvolv-
ingaworkingchannel(>67%),andtheseprocedureshadthehighestproportionof
respondentsdiscontinuingtheprocedureduetoCOVID-
anesthesiawerereported,
ofpersonalprotectiveequipmentutilizedweregloves(>95%)andN95masks(>67%).
Powered-airpurifyingrespiratorsandgeneralsurgicalmaskswereusedinfrequently.
Conclusions:Duringtheearlyre-introduction,respondentsreportedgenerallycon-
tinuingtoperformofficelaryngologyprocedures,whilegreatermucosalmanipulation
affecteddecisionstostopproceduresduetoCOVID-19,performpreprocedural
ThisisanopenaccessarticleunderthetermsoftheCreativeCommonsAttribution-NonCommercial-NoDerivsLicense,whichpermitsuseanddistributioninany
medium,providedtheoriginalworkisproperlycited,theuseisnon-commercialandnomodificationsoradaptationsaremade.
©.
;1–
2CALCAGNOETAL.
SARS-Cov2testing,
predominatePPE.
LevelofEvidence:N/A.
KEYWORDS
coronavirus,COVID-19,laryngoscopy,otolaryngology,personalprotectiveequipment
1|INTRODUCTION(3)endoscopywithoutsuction(ENDOSCOPY-ALONE),(4)endoscopy
withsuctionand/ornon-laserinterventionviaaworkingchannelflex-
ThediseaseprocessescausedbySARSCov-2(COVID-19)requirediblelaryngoscope(NON-LASER),and(5)laserviaaworkingchannel
practicegroupsandhospitalsystemstomakeprofoundchangestoflexiblelaryngoscope(LASER).SeeAppendixS1formoredetails.
safetypracticesinanefforttoreducehealthcareproviderandpatientQuestionsaskedforeachprocedurecategoryincludedpreferences
-headforSARS-Cov-2testingbeforeprocedures,settingforprocedures,
andnecksurgeons,particularlylaryngologyprocedures,wereafocusmethodoflocalanesthesiaforprocedures,andpreferredpersonal
ofconcerngiventheaerosolizingnatureoftheseproceduresandprotectiveequipmentduringprocedures.
-
motereasonablesafetypracticesearlyintheCOVID-19pandemic,wasthroughDocMatter(DocMatterInc.,SanFrancisco,California),a
includingguidelines2andpositionstatements3fromtheAmericanweb-basedprofessionalsocialmediasiteforhealthcareproviders.
AcademyofOtolaryngology-HeadandNeckSurgery(AAO-HNS),asThesurveywaspostedMay2020tothe“FallVoice:EBTEvent
,4-6Additionally,AnnouncementSubgroup,”thensentdirectlytootolaryngology-head
inApril2020,theAAO-HNSpublishedvirtualwebinardataregardingandnecksurgeryprovidersthataremembersofthe“FallVoice
patientselection,personalprotectiveequipment(PPE)andendo-Community:Eat,Breathe,Talk”
scopicreprocessingconsensusdatafrom300providersfromthelar-wasinitiatedJune2020viaemailtothemembersoftheAmerican
,providersfacedBroncho-EsophagolocicalAssociation(ABEA).Toavoidduplicate
unprecedentedchallengesintheearlyphaseofclinicalre-introductionresponsesformembersofbothdistributionlists,theABEAdistribu-
aftertheshutdownofin-
specifically,in-
.
otolaryngology-headandnecksurgeonsprovidingin-officelaryngol-CollecteddatawasdownloadedfromQualtricsinMicrosoftExceland
addtothenecessaryframeworkfromwhichfuturesafetyprotocolswereperformedwithFisher'sexacttestanalysesinMicrosoftExcel.
knowledge,thisistheearliestcohortofaggregated,anonymousdata
reportedbyotolaryngology-headandnecksurgeonsregardingtheir3|RESULTS
safetypracticesforavarietyofin-officelaryngologyprocedures.
|Demographics
2|MATERIALSANDMETHODSFifty-sixof343providerscompletedthesurveyviaDocMatter
(responserate:56/343(16%)),and33of563providerscompletedthe
A30-pointanonymoussurveywasdeveloped,anddatawascollectedsurveyviatheABEA(responserate:33/563[6%]).Thecumulative
anonymouslythroughQualtrics(QualtricsSoftwareCompany,Provo,responseratewas10%.Sevenrespondentsindicatedtheyhadalready
UT).Asthesurveywasanonymouswithoutidentifiableinformation,completedthesurveyand4wereincomplete,sowereexcluded
ourinstitutiondidnotrequireaformalInstitutionalReviewBoard(n=82fordataanalysis).
,-
setting,anddetailedquestionsregardingsafetypracticesfor5groupsticesettingswereacademic(58/82)orprivatepracticewithoutan
oflaryngologyprocedures,whichwerecategorizedasfollows:academicaffiliation(13/82).Laryngologyandbroncho-esophagoscopy
(1)non-mucosaltraversinginjectionswithoutplacementofascopecomprisedmorethan50%oftheclinicalpracticeof78%ofrespon-
forvisualization(NON-MUCOSAL-INJECTIONS),(2)mucosal--ninerespondents(96%)werefromtheUnitedStates,
traversinginjectionswithoutascope(MUCOSAL-INJECTIONS),while3wereinternational(Israel,India,andBrazil,respectively).
TABLE1Demographicsofsurveyrespondents(N=,95%-).NON-LASERprocedureswithendos-
count)copywerenolongerperformedduetoCOVID-19atasignificantly
N%higherratecomparedtoENDOSCOPYALONE(10/64vs1/82,respec-
Timeinpracticetively;,95%-).Allproceduresinvolvingmanipu-
lationofthemucosa(MUCOSALINJECTIONSwithoutendoscopy,
0-
NON-LASERprocedures,andLASERprocedures)resultedinhigher
6-
numbersofrespondentshaltingtheprocedureorrequiringpreprocedure
10-
-Cov2testingwashighestforNON-LASER
20+
(36/54)andLASER(33/41)
Practicesetting
twocategoriesalsohadthehighestproportionofrespondentschoosing
-19(10/82foreach).
-Cov2testingforallproceduretypes
,
,%to
%ofrespondents.
Fellowshiptraining
|Setting
Themajorityofrespondentscontinuedtoperformprocedurecatego-
-INJECTIONSwithoutendoscopy
trendedtowardsahigherpreferencefortheregularpressureoperat-
Facialplastics&
ingroomsettingvsNON-MUCOSAL-INJECTIONS,butthisdidnot
Otology/
reachstatisticalsignificance(3/40vs0/64;,95%CI
-).Proceduresinvolvingmanipulationofthemucosa
(MUCOSALINJECTIONSwithoutendoscopy,NON-LASERproce-
Percentpracticedevotedtolaryngologyand/orbronchoesophagologydures,andLASERprocedures)hadmorerespondentsreporting
0%-25%-
26%-50%,including10/41preferring
51%-75%-pressurerooms.
>75%
|Personalprotectiveequipment
RespondentsfromtheUnitedStateswerefromatotalof24States,
includingWestern(n=4states),Midwestern(n=6states),
(n=10states),andNortheastern(n=4states)statesasdefinedbymostcommonformsofPPEutilizedweregloves(>95%forallproce-
)andeyeprotection(>84%forallprocedures).N95maskuse
CaliforniaandOhiohadthehighestnumberofrespondents(8each),increasedsignificantlywithMUCOSAL-INJECTIONSwithoutendos-
-MUCOSAL-INJECTIONS(%%;
,95%-).N95maskswerepreferredacross
allprocedures,and88%ofrespondentsreporteduseforallproce-
|ProcedurepracticesduresexcludingNON-MUCOSAL-INJECTIONSwithoutendoscopy.
Standardfacemaskuseforallotherproceduretypeswaslessthan
|StoppingproceduresduetoCOVID-19and35%.Powered-airpurifyingrespirators(PAPRs)andgeneralsurgical
preproceduralSARS-Cov2testingmaskswereusedinfrequentlyforallproceduretypes.
-INJECTIONSwithout
endoscopywerehaltedduetoCOVID-|Typeoflocalanesthesia
comparedtoNON-MUCOSALINJECTIONSwithoutendoscopy(7/47
vs1/65,respectively;,95%-).Ofthoseper-Mostrespondentsreportedutilizinganon-mucosaltraversingsubcutane-
formingtheMUCOSAL-INJECTIONSwithoutendoscopy,significantlyousinjectionoflocalanesthetic(45/64)forNON-MUCOSAL-INJECTIONS
morerequirednegativeSARS-Cov2testingpriortotheprocedurecom-%ofrespondentsutilizedasubcutaneous
paredtoNON-MUCOSALINJECTIONS(15/40vs9/64,respectively;andtrans-cutaneoustopicalinjectionoflocalanestheticforMUCOSAL-
4CALCAGNOETAL.
TABLE2Reportedsafetypracticesbyproceduretype(N=numbercount)
Non-mucosalEndoscopy
traversingMucosal-withsuction/
injections,traversingnon-laser
withoutscopeinjections,Endoscopy,interventionLaservia
(NON-withoutscopewithoutsuctionviaworkingworking
MUCOSAL(MUCOSAL(ENDOSCOPYchannelchannel
INJECTIONS)INJECTIONS)ALONE)(NON-LASER)(LASER)
N%N%N%N%N%
Performingprocedure?
No,stoppedduetoCOVID-
No,unrelatedtoCOVID-
Preproceduretesting?
Yes,
No,
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