Airborne Aerosol Generation During Endonasal Procedures in the Era of COVID-19: Risks and Recommendations.
OBJECTIVE
In the era of SARS-CoV-2, the risk of infectious airborne aerosol generation during otolaryngologic procedures has been an area of increasing concern. The objective of this investigation was to quantify airborne aerosol production under clinical and surgical conditions and examine efficacy of mask mitigation strategies.


STUDY DESIGN
Prospective quantification of airborne aerosol generation during surgical and clinical simulation.


SETTING
Cadaver laboratory and clinical examination room.


SUBJECTS AND METHODS
Airborne aerosol quantification with an optical particle sizer was performed in real time during cadaveric simulated endoscopic surgical conditions, including hand instrumentation, microdebrider use, high-speed drilling, and cautery. Aerosol sampling was additionally performed in simulated clinical and diagnostic settings. All clinical and surgical procedures were evaluated for propensity for significant airborne aerosol generation.


RESULTS
Hand instrumentation and microdebridement did not produce detectable airborne aerosols in the range of 1 to 10 μm. Suction drilling at 12,000 rpm, high-speed drilling (4-mm diamond or cutting burs) at 70,000 rpm, and transnasal cautery generated significant airborne aerosols (P < .001). In clinical simulations, nasal endoscopy (P < .05), speech (P < .01), and sneezing (P < .01) generated 1- to 10-μm airborne aerosols. Significant aerosol escape was seen even with utilization of a standard surgical mask (P < .05). Intact and VENT-modified (valved endoscopy of the nose and throat) N95 respirator use prevented significant airborne aerosol spread.


CONCLUSION
Transnasal drill and cautery use is associated with significant airborne particulate matter production in the range of 1 to 10 μm under surgical conditions. During simulated clinical activity, airborne aerosol generation was seen during nasal endoscopy, speech, and sneezing. Intact or VENT-modified N95 respirators mitigated airborne aerosol transmission, while standard surgical masks did not.
['Workman|Alan D|AD|', 'Jafari|Aria|A|', 'Welling|D Bradley|DB|', 'Varvares|Mark A|MA|', 'Gray|Stacey T|ST|', 'Holbrook|Eric H|EH|', 'Scangas|George A|GA|', 'Xiao|Roy|R|', 'Carter|Bob S|BS|', 'Curry|William T|WT|', 'Bleier|Benjamin S|BS|']
D000336:Aerosols D000073640:Betacoronavirus D000086382:COVID-19 D002102:Cadaver D018352:Coronavirus Infections D004724:Endoscopy D006801:Humans D009666:Nose D013517:Otorhinolaryngologic Surgical Procedures D058873:Pandemics D010316:Particle Size D000067393:Personal Protective Equipment D011024:Pneumonia, Viral D011446:Prospective Studies D012307:Risk Factors D000086402:SARS-CoV-2
airborne aerosolization COVID-19 nasal endoscopy endoscopy aerosol-generating procedure aerosol-generating surgery