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Id Subject Object Predicate Lexical cue
T1 0-88 Sentence denotes The nose lid for the endoscopic endonasal procedures during COVID-19 era: technical note
T2 90-98 Sentence denotes Abstract
T3 99-109 Sentence denotes Background
T4 110-178 Sentence denotes COVID-19 pandemic has disrupted the global health systems worldwide.
T5 179-341 Sentence denotes According to the tremendous rate of interhuman transmission via aerosols and respiratory droplets, severe measures have been required to contain contagion spread.
T6 342-569 Sentence denotes Accordingly, medical and surgical maneuvers involving the respiratory mucosa and, among them, transnasal transsphenoidal surgery have been charged of maximum risk of spread and contagion, above all for healthcare professionals.
T7 571-577 Sentence denotes Method
T8 578-941 Sentence denotes Our department, according to the actual COVID-19 protocol national guidelines, has suspended elective procedures and, in the last month, only three patients underwent to endoscopic endonasal procedures, due to urgent conditions (a pituitary apoplexy, a chondrosarcoma causing cavernous sinus syndrome, and a pituitary macroadenoma determining chiasm compression).
T9 942-1191 Sentence denotes We describe peculiar surgical technique modifications and the use of an endonasal face mask, i.e., the nose lid, to be applied to the patient during transnasal procedures for skull base pathologies as a further possible COVID-19 mitigation strategy.
T10 1193-1200 Sentence denotes Results
T11 1201-1493 Sentence denotes The nose lid is cheap, promptly available, and can be easily assembled with the use of few tools available in the OR; this mask allows to both operating surgeon and his assistant to perform wider surgical maneuvers throughout the slits, without ripping it, while limiting the nostril airflow.
T12 1495-1506 Sentence denotes Conclusions
T13 1507-1754 Sentence denotes Transnasal surgery, transgressing respiratory mucosa, can definitely increase the risk of virus transmission: we find that adopting further precautions, above all limiting high-speed drill can help preventing or at least reducing aerosol/droplets.
T14 1755-1983 Sentence denotes The creation of a non-rigid face mask, i.e., the nose lid, allows the comfortable introduction of instruments through one or both nostrils and, at the same time, minimizes the release of droplets from the patient’s nasal cavity.
T15 1985-1997 Sentence denotes Introduction
T16 1998-2129 Sentence denotes COVID-19 resulting from the new coronavirus strain (SARS-CoV-2) represents an unprecedented challenge for the global health system.
T17 2130-2313 Sentence denotes Since its appearance in Wuhan, China, in December 2019, it has rapidly spread worldwide up to be classified as a pandemic by the World Health Organization (WHO) on March 12, 2020 [3].
T18 2314-2692 Sentence denotes The interhuman transmission is the result of droplets’ projection toward another host or via human contact (e.g., handshaking) or through an inert surface [25]: the estimated half-life of SARS-CoV-2 in the droplets has been estimated to range between 1.1 to 1.2 h and it should be minded that the use of a common N95 mask does not get the risk of contagion down to zero [4, 13].
T19 2693-2804 Sentence denotes All over the world, ‘lock down’ and ‘social distancing’ have been key strategies to control infection outbreak.
T20 2805-3105 Sentence denotes A great amount of information concerning the circulation of the infection among healthcare professionals has pointed out equal volume of issues within the scientific community, in particular regarding the best strategies to contain the transmission of the virus in the intrahospital environment [19].
T21 3106-3339 Sentence denotes Due to alarming increase of cases affected by this contagious disease, many hospitals have decreased or stopped elective interventions and moved their effort and personnel to admit and take care of patients affected by COVID-19 [12].
T22 3340-3649 Sentence denotes In particular, many questions have arisen about the safety of performing medical and surgical maneuvers involving the respiratory mucosa and, in the field of neurosurgery, transnasal transsphenoidal surgery has been charged of maximum risk of spread and contagion, above all for healthcare professionals. [24]
T23 3650-3882 Sentence denotes However, patients’ needs cannot remain unfulfilled, so that we had to embrace the great challenge of continuing assistance at least for urgent and non-deferrable cases, while reducing the risks of this tremendous infectious disease.
T24 3883-4159 Sentence denotes Transnasal pituitary and skull base surgery is performed in a narrow longitudinal canal: the possibility that aerosols and droplets from the nostrils escape aspiration is described and the evidence that, subsequently, they could be inhaled by surgeons has been described [22].
T25 4160-4367 Sentence denotes The adoption of correct strategies to obtain a reduction of human contacts between medical personnel and patients along with the use of adequate PPE for both parties is crucial to keep the practice safe [1].
T26 4368-4558 Sentence denotes Accordingly, several groups developed a cogent and “maximally safe” protocol to give most appropriate treatment to the patients, while minimizing the risks of COVID-19 diffusion [7, 17, 19].
T27 4559-4727 Sentence denotes Herein, we report further tailored preventive measures we adopted during non-deferrable endoscopic endonasal surgery in order to reduce the possibility of transmission.
T28 4729-4750 Sentence denotes Materials and methods
T29 4752-4769 Sentence denotes Patient selection
T30 4770-4932 Sentence denotes Our department, according to the actual COVID-19 protocol national guidelines, has suspended elective procedures and reviewed our criteria of prioritization [21].
T31 4933-5103 Sentence denotes Accordingly, we retain that a pituitary/skull base procedure can be considered non-deferrable upon the presence ofpituitary apoplexy associated with neurological defects;
T32 5104-5262 Sentence denotes tumors with massive suprasellar and/or supradiaphragmatic component with CSF circulation obstacle and/or hydrocephalus and/or intracranial hypertension signs;
T33 5263-5343 Sentence denotes At admission, patients are screened via interview and temperature is registered.
T34 5344-5554 Sentence denotes Upon any suspicion of COVID-19, the infectivologist will be consulted in order to rule out the workflow; in any case, whether delaying surgery increases risks, precautions as for positive patients are required.
T35 5555-5778 Sentence denotes However, it should be minded that the certainty of COVID-19 negativity status is somehow difficult to assess: many COVID-19 cases are asymptomatic, and the reliability of screening tests is often limited and eventually low.
T36 5779-6300 Sentence denotes As general rule though, basic precautions, i.e., accurate and frequent hand washing, wearing a surgical mask and social distancing should be taken regardless of the patient Covid-19 status [10]; further peculiar precautions should be adopted in addition during critic procedures involving the respiratory mucosa, such as oro-tracheal aspiration, intubation, extubation, and/or when performing transnasal, transoral surgery, being essential to distinguish COVID-19-positive patients from the negative ones [6, 10, 11, 19].
T37 6301-6541 Sentence denotes Hence, in the last month, only three patients required urgent treatment, respectively, for the treatment of a pituitary apoplexy, a chondrosarcoma causing cavernous sinus syndrome and a pituitary macroadenoma determining chiasm compression.
T38 6542-6696 Sentence denotes Once we cleared COVID-19 status (telephone interview and serological exam were run), we decided to adopt endoscopic endonasal approach in all these cases.
T39 6698-6720 Sentence denotes Measures inside the OR
T40 6721-6970 Sentence denotes Only surgeons and nurses directly involved in the procedures have been admitted to the theater; it was mandatory for each of them to wear maximum level PPE [6, 11, 20, 21]: FFP2 mask, covered by surgical mask, disposable gowns and caps, face screen.
T41 6972-6995 Sentence denotes Technical consideration
T42 6996-7167 Sentence denotes Considering all the above, we retained useful to adopt peculiar surgical technique modifications, in order to further limit the spread of droplets and aerosols [3, 11, 24]
T43 7168-7332 Sentence denotes Before starting, cottonoid pledgets soaked with diluted iodopovidone are placed and left in place for at least 5 min to rinse off mucosa from any contamination [5];
T44 7333-7679 Sentence denotes After usual nasal pyramid sterile draping, an endonasal surgery facial mask, namely a nose lid, is assembled: a sterile non-latex glove layer is used to cover nostril and fixed with adhesive protection film over the nasal bridge; initially, two and then three narrow slit cut are placed over the nares to let instruments enter the nostrils (Figs.
T45 7680-7693 Sentence denotes 1, 2, and 3).
T46 7694-7812 Sentence denotes Fig. 1 Pictures showing the layer of sterile non-latex glove with a two and b three slit cuts, being used as nose lid.
T47 7813-7873 Sentence denotes Without any instrument that pierces it, the cuts are minimal
T48 7874-7924 Sentence denotes Fig. 2 Picture showing the intraoperative setting.
T49 7925-8372 Sentence denotes The nose lid is fixed with adhesive protection film over the nasal bridge and instruments can slide through the slit cuts the lid adheres to their outer diameter. a The endoscope is inserted through one nostril, i.e., the right. b Three-four hands technique: the endoscope is held by assistant at the most superior aspect of the left nostril and the surgeon holds the instruments inside the right nostril and the suction tube beneath the endoscope
T50 8373-8865 Sentence denotes Fig. 3 Picture showing the details of intraoperative setting demonstrating that air flow through the nose can be limited by the use of the nose lid. a The microdrill is inserted through the left nostril and the nose lid adheres to its outer diameter. b The endoscope and suction tube are inserted through one nostril, i.e., the right, in two different slit cuts. c The endoscope is inserted through the right nostril while the microdrill in the left one, each of them in the relative slit cut
T51 8866-8989 Sentence denotes The slit cuts permit to limit the empty space of the nares allowing the entrance and exit only of the surgical instruments.
T52 8990-9103 Sentence denotes The procedure then has been run as usual throughout into 3 steps: the nasal, the sphenoid, and the sellar phases.
T53 9104-9266 Sentence denotes A corridor between middle turbinates and the nasal septum is created and thereafter the nasal septum is detached from the sphenoid rostrum with blunt instruments.
T54 9267-9306 Sentence denotes Cautery is limited as much as possible.
T55 9307-9639 Sentence denotes The anterior wall of the sphenoid sinus is widely opened with osteotomes and rongeurs preferably and opening of the sellar floor is performed using chisel and hammer; microdrill with continuous irrigation, to reduce as much as possible the spreading of aerosol and bone dust, is used only to refine skull base opening upon the need.
T56 9641-9651 Sentence denotes Discussion
T57 9652-9913 Sentence denotes COVID-19 requires meticulous precautions in order of limiting person-to-person spread, being respiratory droplets deposited on the mucous membranes of mouth, nose, and eyes of nearby people and by close personal contact, the main routes of diffusion [2, 8, 18].
T58 9914-10053 Sentence denotes Accordingly, medical and surgical maneuvers involving the respiratory mucosa were immediately considered high-risk procedures [11, 16, 24].
T59 10054-10150 Sentence denotes It should be remembered that an otorhinolaryngologist was the first doctor to die from COVID-19.
T60 10151-10360 Sentence denotes Patients with symptomatic COVID-19 should be treated for neurosurgical disease only when surgery is not deferrable, namely when delaying it, the patient is exposed to concrete risks quoad vitam et valetudinem.
T61 10361-10580 Sentence denotes Patients harboring COVID-19 represent the main source of viral transmission and therefore must be treated in an adequate in hospital setting with personnel being provided of adequate personal protective equipment (PPE).
T62 10581-10702 Sentence denotes Additionally, a quite vast number of patients be carrier of SARS-CoV-2 and can be responsible for infection transmission.
T63 10703-10850 Sentence denotes Considering the above, caseload reduced, and routine activities have been cancelled and/or postponed if possible, to limit the spread of SARS-CoV2.
T64 10851-11137 Sentence denotes Neurosurgical scientific societies identified the transnasal skull base surgery, transoral and transfacial corridors, as the most riskful for diffusion of COVID-19 and also recommended to spare the opening of paranasal cavities and mastoids during transcranial corridors [7, 19–21, 23].
T65 11138-11398 Sentence denotes To our knowledge, “maximally safe” protocols for performing neurosurgical procedures, while minimizing the risks of COVID-19 diffusion, include the use of adequate PPE, OR settings, and the advice of reducing aerosol/droplets generating maneuvers [15, 19, 21].
T66 11399-11465 Sentence denotes Our study reports the use of a face mask, namely a nose lid (Figs.
T67 11466-11611 Sentence denotes 1 and 2), to be applied to the patient during endonasal procedures for skull base pathologies as a further possible COVID-19 mitigation strategy.
T68 11612-11800 Sentence denotes Numerous models of face masks have been proposed and tested by individual users, researchers, doctors, and commercial entities with varying degrees of success in other disciplines [9, 14].
T69 11801-11899 Sentence denotes At the moment, in our field, there are no models of face masks to contain the spread of the virus.
T70 11900-12067 Sentence denotes In our case, the mask, i.e. the nose lid, it is cheap, promptly available and can be easily assembled with the use of a few tools that we all have available in the OR.
T71 12068-12146 Sentence denotes The necessary materials include a non-latex glove and sterile protective film.
T72 12147-12321 Sentence denotes This mask allows to both operating surgeon and his assistant to perform wider surgical maneuvers throughout the slits, without ripping it, while limiting the nostril airflow.
T73 12323-12334 Sentence denotes Conclusions
T74 12335-12520 Sentence denotes Transnasal surgery, transgressing respiratory mucosa, can definitely increase the risk of virus transmission: therefore, more stringent protective and preventive measures are mandatory.
T75 12521-12689 Sentence denotes Endonasal endoscopic surgical interventions can be safely performed, if necessary, only respecting correct protocols and wearing adequate personal protective equipment.
T76 12690-12828 Sentence denotes We find that adopting further precautions, above all limiting high-speed drill, can help preventing or at least reducing aerosol/droplets.
T77 12829-13066 Sentence denotes Besides, the creation of a non-rigid face mask, i.e., the nose lid, allows the comfortable introduction of instruments through one or both nostrils and, at the same time, minimizes the release of droplets from the patient’s nasal cavity.
T78 13067-13251 Sentence denotes Nonetheless, it remains advisable to strictly adhere to COVID-19 protocols and carefully evaluate patients and procedures, in order to ensure safety and eventually limit the contagion.
T79 13253-13337 Sentence denotes This article is part of the Topical Collection on Neurosurgical technique evaluation
T80 13338-13354 Sentence denotes Publisher’s note
T81 13355-13473 Sentence denotes Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
T82 13475-13494 Sentence denotes Funding information
T83 13495-13537 Sentence denotes No funding was received for this research.
T84 13539-13572 Sentence denotes Compliance with ethical standards
T85 13574-13590 Sentence denotes Ethical approval
T86 13591-13792 Sentence denotes All procedures performed in studies involving human participants were in accordance with the ethical standards of the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
T87 13794-13810 Sentence denotes Informed consent
T88 13811-13866 Sentence denotes For this type of study, formal consent is not required.
T89 13867-13965 Sentence denotes This article does not contain any studies with human participants performed by any of the authors.
T90 13967-13987 Sentence denotes Conflict of interest
T91 13988-14507 Sentence denotes All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.