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\begin{document}

\title{\textbf{Changing Paradigms in Sinus and Skull Base Surgery as the
COVID-19 Pandemic Evolves: Preliminary Experience from a Single Italian
Tertiary Care Center}}



\author[1]{Alberto D. Arosio, MD}%
\affil[1]{ASST Sette Laghi, Ospedale di Circolo}%


\vspace{-1em}



  
  \date{March 14, 2025}


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\selectlanguage{english}
\begin{abstract}
\textbf{Background}. Italy was the first European country suffering from
COVID-19. Healthcare resources were redirected to manage the pandemic.
We present our initial experience with the management of urgent and
non-deferrable surgeries for sinus and skull base diseases during the
COVID-19 pandemic.~\textbf{Methods}. A retrospective review of patients
treated in a single referral center during the first two months of the
pandemic was performed. A comparison between the last two-month period
and the same period of the previous year was carried out.
\textbf{Results}. Twenty-four patients fulfilled the inclusion criteria.
A reduction of surgical activity was observed (-60.7\%).~ A
statistically significant difference in pathologies treated was found (p
= .016), with malignancies being the most frequent indication for
surgery (45.8\%).~\textbf{Conclusions}. Although we feel optimistic for
the future, we don't feel it is already time to restart elective
surgeries. Our experience may serve for other centers who are facing the
same challenges.%
\end{abstract}%



\sloppy




\emph{Apostolos Karligkiotis}\textsuperscript{\emph{a}} \emph{MD,
Alberto D. Arosio}\textsuperscript{\emph{b}} \emph{MD,~ Paolo
Battaglia}\textsuperscript{\emph{b,c}} \emph{MD, Giorgio
Sileo}\textsuperscript{\emph{b}} \emph{MD, Camilla
Czaczkes}\textsuperscript{\emph{b}} \emph{MD, Luca
Volpi}\textsuperscript{\emph{a}} \emph{MD, PhD, Mario
Turri-Zanoni}\textsuperscript{\emph{b,c}} \emph{MD, Paolo
Castelnuovo}\textsuperscript{\emph{b,c}} \emph{MD}

\emph{~}\textsuperscript{\emph{a}} \emph{Division of
Otorhinolaryngology, Department of Surgical Specialties, ASST Sette
Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy}

\textsuperscript{\emph{b}} \emph{Division of Otorhinolaryngology,
Department of Biotechnology and Life Sciences, University of
Insubria-Varese, ASST Sette Laghi, Ospedale di Circolo e Fondazione
Macchi, Varese, Italy}

\textsuperscript{\emph{c}} \emph{Head and Neck Surgery \& Forensic
Dissection Research center (HNS\&FDRc), Department of Biotechnology and
Life Sciences, University of Insubria, Varese, Italy}

\textbf{~}

\emph{Running Title:} COVID-19 impact on Sinus and Skull Base Surgery

\emph{Keywords:} \textbf{\emph{}} COVID-19, \textbf{\emph{}} SARS-Cov-2,
\textbf{\emph{}} skull base, endoscopy, \textbf{} surgery

\textbf{~}

\textbf{Corresponding Author:}

\textbf{}Alberto D. Arosio, MD

Division of Otorhinolaryngology, - ASST Sette Laghi, Ospedale di
Circolo,

Via Guicciardini 9, 21100 Varese, Italy

Tel: +39-0332-278426

Fax: +39-0332-278945

E-mail: albertodaniele.arosio@gmail.com

\textbf{~}

\emph{No sponsorships or competing interests have been disclosed for
this article.}

\textbf{\emph{Acknowledgments}}\emph{:} MTZ is a PhD student on the
``Biotechnologies and Life Sciences'' course at Universit\selectlanguage{ngerman}à degli Studi
of Insubria, Varese, Italy.

~

\textbf{ABSTRACT}

\textbf{Background}. Italy was the first European country suffering from
COVID-19. Healthcare resources were redirected to manage the pandemic.
We present our initial experience with the management of urgent and
non-deferrable surgeries for sinus and skull base diseases during the
COVID-19 pandemic.

\textbf{Methods}. A retrospective review of patients treated in a single
referral center during the first two months of the pandemic was
performed. A comparison between the last two-month period and the same
period of the previous year was carried out.

\textbf{Results}. Twenty-four patients fulfilled the inclusion criteria.
A reduction of surgical activity was observed (-60.7\%).~ A
statistically significant difference in pathologies treated was found (p
= .016), with malignancies being the most frequent indication for
surgery (45.8\%).

\textbf{Conclusions}. Although we feel optimistic for the future, we
don't feel it is already time to restart elective surgeries. Our
experience may serve for other centers who are facing the same
challenges.

\par\null

\textbf{INTRODUCTION}

Since December 2019, the COVID-19 outbreak has spread from Wuhan to
almost 4,000,000 individuals globally infected across 215 countries,
resulting in more than 270,000 deaths.{[}1{]} The first Italian patient
affected by SARS-Cov-2 was from Codogno, Lombardy, on February
21\textsuperscript{st}, 2020. Since then, more than 218,000 COVID-19
cases have been confirmed in Italy, which is now one of the most
affected countries in the world, with more than 30,000 deaths.{[}2{]}
The majority of Italian cases occurred in Lombardy (81,225), home to a
sixth of the Italian population (10,08 million inhabitants), accounting
as of May 9\textsuperscript{th}, of 37.2\% of cases and 52.3\% of deaths
in the country.{[}2{]} The Regional Government and local health
authorities adopted strategies to contain the infection whilst trying to
protect patients and healthcare workers as much as possible. Healthcare
resources were redirected to support the management of the pandemic, to
the detriment of regular elective clinical and surgical
activities.{[}3{]} Therefore, since Monday February
24\textsuperscript{th}, 2020, all elective surgeries have been suspended
in our Hospital, too. Only emergency cases and those that could not be
postponed were eligible for hospital admission, in order to cope with
the increased needs for beds and intensive care unit (ICU) availability
for patients affected by COVID-19. Moreover, many Otolaryngology
departments throughout Lombardy ceased their activity, becoming areas
exclusively intended for COVID-19 patients care, thus increasing the
burden of patients affected by various head and neck diseases referring
to our Division.{[}4{]} Besides, considering that our tertiary care
center is a national referral center for sinus and skull base surgery,
the hospital general manager decided to allocate resources for providing
care to as many urgent and non-deferrable cases affected by sinus and
skull base diseases as possible. The critical issue was providing
logistics that were compatible with the ongoing epidemiological
emergency, which still represents today's challenge. Therefore, a task
force of experts was created to produce an institutional protocol for
hospital admission, pre-operative work-up, intra-operative precautions
and post-operative care to be followed.

The aim of the present paper is to report our preliminary experience
with the management of urgent and non-deferrable endoscopic surgeries
for sinus and skull base diseases, during the COVID-19 period,
describing the evolving recommendations which have been implemented day
by day, as new evidences emerged, until reaching the actual protocol of
precautions. Clinical and surgical data, as well as the outcomes of
patients and information about healthcare workers' exposures, are
provided. A comparison between the last two-month period and the same
period of the previous year was carried out in order to investigate the
impact of COVID-19 outbreak.

\textbf{MATERIALS AND METHODS}

Study design

A retrospective review of all patients affected by urgent or
non-deferrable sinonasal or skull base diseases who were treated at the
Division of Otorhinolaryngology of the University Hospital of Varese
(Italy) between February 24\textsuperscript{th}, 2020 and April
21\textsuperscript{st}, 2020 (PANDEMIC-Group), was carried out. All
other non-sinus and skull base urgent cases treated at our hospital have
been excluded from the present analysis. Epidemiological and clinical
data, surgical reports, complications, and follow-up information were
reviewed, as well as COVID-19 detection tests (e.g. nasopharyngeal swab
results). A retrospective analysis of all patients affected by sinonasal
or skull base diseases, surgically treated at our institution in the
same two-month period of 2019 (CONTROL-Group) was carried out.
Epidemiological, clinical, surgical and follow-up data of such patients
were retrieved as well. The PANDEMIC-Group was compared with the
CONTROL-Group in order to evaluate the changes of our surgical activity
in terms of volume cases, diseases treated, patient's geographical
origin and hospitalization time.

Patients management during COVID-19 two-months period

\emph{Indications} . The criteria for hospital admission were
established as follows{[}5{]}:

\begin{itemize}
\tightlist
\item
  urgent surgical operations such as severe trauma, bleeding,
  infections/abscesses;
\item
  sinus lesions suspected for malignancy, needing biopsy in general
  anesthesia;
\item
  non-deferrable surgical interventions, such as malignant tumors with
  critical local extension to brain, orbit and/or with borderline
  resectability, where a delay in treatment might be fatal for the
  prognosis quoad vitam et valetudinem;
\item
  pituitary tumors or skull base lesions with rapidly worsening vision
\item
  meningiomas and other skull base tumors presenting with hydrocephalus
  or brainstem compression symptoms;
\item
  rapidly evolving clinical conditions determining acute organ
  impairment (e.g. compressive optic neuropathy, intraorbital abscess)
\end{itemize}

\emph{Swab specimens} . Indications for nasopharyngeal and/or
oropharyngeal swab collection evolved during the COVID-19 two-month
period. In the early period, swab testing was performed before
hospitalization in case of body temperature more than 37.5°C and/or in
presence of at least one of the following factors: fever, cough,
dyspnoea, gastrointestinal signs/symptoms, myalgias, fatigue, headache,
pharyngodynia, rhinorrhea, active pneumonia and close contact with a
SARS-Cov-2 positive patient. Otherwise, patients were admitted without
getting tested. Given the worsening of the pandemic and the growing body
of data available, indications changed on March 23\textsuperscript{rd},
2020, when all inpatients were systematically submitted to swab specimen
collection, so that only emergencies have been performed notwithstanding
their COVID-19 status. More specifically, the execution of two swabs,
with an interval between the two tests of at least 2 days and the latest
performed within 48 hours prior to surgery, has become mandatory, in
order to minimize the possibility of false negatives.

\emph{Individual protection} . Indications for the use of personal
protective equipment (PPE) have also evolved during this period. At the
beginning, no specific protection was recommended during surgery and all
healthcare workers in the Operating Room (OR) continued to wear standard
surgical masks and gowns, leaving viral-filtering-PPE available to be
used only in case of confirmed COVID-19 patients. However, after March
23\textsuperscript{rd}, 2020, indications for PPE use changed and, since
then, surgical procedures in COVID-19 negative patients required the use
of the highest individual protection standards (at least FFP2 masks), in
consideration of the significant number of false negatives resulting
from the swab tests currently used. For positive patients, procedures
were postponed until after swab test negativization, when feasible. If
the procedure was strictly necessary for the patient's survival, surgery
was performed in a dedicated negative-pressure operating room with a
pre-established allocated run, without interfering with the
COVID-19-free areas. All medical and nursing staff in the operating room
were recommended to wear FFP3 and/or powered air-purifying respirators
(PAPR), goggles, full-face visor, double gloves, water-resistant gowns
and protective caps, not only for the entire duration of surgery but
also for the whole of the patient's stay in the operating room.{[}6{]}
If testing for COVID-19 was not available (emergency procedures such as
trauma, major bleeding, abscesses), patients were considered COVID-19
positive unless otherwise demonstrated.

\emph{Follow-up.} Postoperative management and follow-up for patients
undergoing sinus and skull base procedures followed standardized
protocols already established at our Department{[}7--9{]}. Nasal packing
are removed on the second postoperative day and following endonasal
medications are performed as needed, until hospital discharge. Then,
patients are prescribed daily nasal rinses and postoperative control in
the outpatient clinic, where further medications are performed. Even
though the SARS-Cov-2 outbreak influenced long term follow-up of
outpatients in our Clinic, post-operative medications were guaranteed in
all cases, even during the COVID-19 era, thanks to an accurate
reorganization of several aspects of the outpatient service.{[}10{]} In
order to investigate the health of the patients belonging to the
PANDEMIC-Group after their last postoperative medication, a telephone
interview was carried out retrospectively, examining the following
factors: fever, cough, dyspnoea, anosmia, dysgeusia, gastrointestinal
signs/symptoms, myalgias, fatigue, headache, pharyngodynia, rhinorrhea,
active pneumonia, need for hospitalization for any reason, potential
swab or serological tests performed and if they had been in contact with
COVID-19 positive individuals.

Medical status of healthcare providers during the COVID19 two-months
period

Healthcare workers have been monitored during the study period and
followed-up for at least 14 days after the last patient enrolled in this
study was operated, in order to rule out hospital-acquired viral
infection, since incubation time it is currently estimated to range
between 2 and 11 days, up to a maximum of 14 days.{[}11{]}

The monitoring policies of healthcare staff evolved during the pandemic,
based on new evidence gradually emerging. Between February
24\textsuperscript{th} and March 22\textsuperscript{nd}, no indications
were given to perform swab and/or serological tests for COVID-19 on the
medical staff involved in patients' care, even if they had been in
contact with a subsequently ascertained COVID-19 positive patient. In
this case, the worker, if asymptomatic, was asked to constantly wear a
surgical mask during service and notify the Occupational Medicine
Department if suspected symptoms (e.g. fever) were to develop. If
symptomatic, the worker was recommended to self-confinement and further
investigation was performed according to Regional dispositions.

Starting on March 23\textsuperscript{rd}, as for Hospital guidelines,
check-points were set up where all workers underwent body temperature
measurement every day, at the beginning of their shift, and if above
37.5°C, the worker was restricted from taking service and submitted to
SARS-Cov-2 testing and subsequent home isolation until the test's result
was available. In case of negative swab testing, self-confinement was
prolonged to one week after symptoms resolutions. In case of positivity
of the swab, home confinement was prolonged until collection of two
consecutive negative swabs, repeated 2 days apart from each other.

Nonetheless, some people among medical staff developed symptoms
compatible with the viral infection other than temperature increase,
hence they have not been tested according to Hospital provisions.
Therefore, all the medical staff who served during the COVID-19
two-months period were asked to fill out a survey, which investigated
the following items: temperature increase, development of any symptoms
compatible with SARS-Cov-2 infection, results of COVID-19 swab, rapid
qualitative test (2019-nCOC IgG/IgM rapid test, ScreenItalia, Perugia -
Italy) or quantitative serological ELISA test. Nurses, scrub staff and
anesthesiologists were excluded from the present analysis since they
have been allocated to multiple wards and operative rooms during this
two-month period and therefore they have been potentially exposed to
viral infection in other settings different from otorhinolaryngology
procedures. Conversely, all medical doctors of our Department, both
residents and seniors, were not assigned to other tasks and were
therefore suitable for assessing the impact of otorhinolaryngology
procedures on viral cross contamination.

Statistical analysis

Mean and standard deviation for age, length of stay and postoperative
days were calculated for each Group of patients. T test was performed to
investigate whether the period of treatment could influence these three
parameters. Patients' gender, provenance and pathology were compared
between the different Groups using Chi-square test. The difference in
the proportion of pathologies treated between the considered 2-months
periods was tested by means of Fisher's exact test. In all cases
a\emph{p value} \textless{} 0.05 was considered statistically
signi\selectlanguage{english}ficant. Post hoc analysis involved pairwise comparison using
multiple Fisher's exact tests (2x2) with a Bonferroni adjustment; for
this analysis the statistical significance was accepted at p \textless{}
.003. Data analysis was performed using appropriate software (IBM SPSS(r)
Statistics version 25; IBM Corporation, Armonk, New York 10504, USA).

\textbf{RESULTS}

Patient population

\emph{PANDEMIC-Group} . A total of 24 patients fulfilled the inclusion
criteria of the present study. The clinical and epidemiological data are
summarized in Table 1. There were 15 men (62.5\%) and 9 women (37.5\%)
with a male to female ratio of 1.7:1. The ages ranged from 12 to 89
years (mean, 59 +- 20 years). The first sixteen patients (66,7\%) were
not tested for COVID-19 since they didn't report any Sars-CoV-2 related
symptoms or temperature increase at the time of admission. The next
eight patients (33,3\%) were all tested for COVID-19 and only one male
patient (4,2\%) resulted positive at the time of hospital admission.
This patient was affected by squamous cell carcinoma arising in inverted
papilloma and was scheduled for surgery on March 13\textsuperscript{th}.
He underwent swab collection as he had complained of diarrhea 3 days
before. After being found positive for SARS-Cov-2, the patient was
transferred to a COVID-19 specific area, until three consecutive
nasopharyngeal swabs, performed 24 hours apart from each other, tested
negative. Notwithstanding the negative results of the swabs, the patient
was prudentially operated in the COVID-19 Operating Room, with
highest-standard PPE as indicated by the above mentioned
recommendations.{[}5{]} Among the 24 cases operated, only one
complication (4.2\%) occurred. A female patient affected by recurrent
skull base chondrosarcoma after multiple endoscopic resections and
irradiations, ended two years earlier, underwent endoscopic endonasal
debulking of the recurrence of disease and developed a temporal lobe
abscess, diagnosed on 11\textsuperscript{th} postoperative day after
hospital discharge. The patient was readmitted to the hospital for
neurosurgical intervention of stereotactic aspiration and drainage of
brain abscesses and her SARS-Cov-2 swab collection performed upon
readmission on April 7\textsuperscript{th} was negative. The culture
tests were compatible with \emph{S. marcescens} infection and the
patient was discharged after 15 days of intravenous targeted antibiotic
therapy, with MRI confirmation of resolution of the abscess. At last
follow-up, the patient was asymptomatic, she hasn't developed symptoms
compatible with COVID-19 and she is going to start adjuvant treatments
as soon as possible.

The follow-up period for the 24 patients ranges from 14 to 71 days (mean
50 days). During the postoperative follow-up, updated to May
5\textsuperscript{th}, 20 patients (83.3\%) didn't refer any symptom.
Two patients (8.3\%) referred headache and two patients (8.3\%)
complained diarrhea, in all cases with onset of symptoms occurring after
April 25\textsuperscript{th}. The two patients complaining diarrhea
performed nasopharyngeal swab, which tested negative in both of the
cases. No patients were hospitalized nor developed COVID-19 respiratory
manifestations.

\emph{CONTROL-Group.} In the same period in 2019, 61 operated patients
met the inclusion criteria. There were 29 men and 32 women, with a male
to female ratio of 0.9:1. The ages ranged from 11 to 88 years. The
distribution of the cases according to the pathology treated is provided
in Table 2.

Comparison between Groups

Table 2 provides a description of the comparison between PANDEMIC-Group
and CONTROL-Group as regards age, gender, patients' geographic origin,
mean hospitalization time and postoperative stay. No statistically
significant differences were observed when comparing the two Groups
according to these parameters.

The proportion of surgeries performed according to the pathology treated
changed during the two considered periods and a summary is provided in
Table 3. A statistically significant difference in the proportion of
pathologies treated was found between PANDEMIC-Group and CONTROL-Group
(p = .016). When pairwise comparison was performed, the proportion of
patients treated for malignancies was statistically significantly higher
than the ones treated for inflammatory diseases (p = .002). Other
pairwise comparisons between patients treated for other than tumor
pathologies with inflammatory diseases, were not statistically
significant (p \textgreater{} .003).

Healthcare providers' health status during COVID-19 two-months period

Between February 24\textsuperscript{th} and April
21\textsuperscript{st}, a total of 26 physicians (15 attending
physicians and 11 residents) were serving in the Department. A total of
11/26 medical doctors (42.3\%) referred some symptoms during this time
span. Most frequent complained symptoms were: headache (10 cases,
38.5\%), cough (6 cases, 23.1\%), fever (5 cases, 19.2\%), rhinorrhea (5
cases, 19.2\%) and diarrhea (5 cases, 19.2\%). In all cases, the onset
of the symptoms was referred before March 23\textsuperscript{rd}, 2020.
Only one physician (3.8\%) performed nasopharyngeal swab collection upon
Hospital indications, testing negative. Seven physicians (26.9\%)
performed rapid-tests, in all cases by personal decision. Only in one
case (3.8\%) the test was positive for IgG and this result was confirmed
at a following quantitative serological test performed 5 days later.

Table 4 provides a summary of the survey conducted, highlighting data
regarding exposition to COVID-19 positive patients, the use of PPE and
the diagnostic tests performed.

\textbf{DISCUSSION}

Italy has been the first European country suffering from COVID-19. The
unexpected spread of a scarcely-known virus was accompanied by initial
confusion and disorganization.{[}12{]} By recalling our memories and
reading the emails and text messages of the past two months, we
identified two different periods from different factors, setting March
22\textsuperscript{nd}, 2020 as the turning point. During the first
month (from February 24\textsuperscript{th} to March
22\textsuperscript{nd}), no protection was recommended during
examinations of apparently healthy people, thus asymptomatic carriers
were not taken into consideration as possible transmission vehicles.
However, since SARS-CoV-2 is transmitted through droplets{[}13{]},
progressive evidence that Otolaryngologists are at particularly high
risk even when performing routine clinical procedures has suggested to
use surgical masks as individual protection. At that time, surgical
procedures continued to be performed wearing standard medical masks,
leaving viral-filtering-PPE available for use only in case of confirmed
COVID-19 patients. However, around the globe the shortage of PPE, along
with the lack of clear recommendations about their correct use, have
contributed to increased infections among otorhinolaryngologists. In
fact, it is noticeable that the first physician who died of COVID-19 in
Wuhan, China, on January 25\textsuperscript{th}, 2020 was an ENT
surgeon, but the fact was only reported globally on March
20\textsuperscript{th}, 2020.{[}14{]} More or less at the same time,
Patel et al. published a letter, which was diffused through emails and
websites, about the first case of COVID-19 transmission during an
endoscopic transsphenoidal pituitary surgery in Wuhan, that resulted in
cross-contamination of 14 healthcare workers, emphasizing the high
potential for hospital-acquired viral infections.{[}6,15{]} This has
generated reluctance to perform endonasal endoscopic procedures
worldwide. Preliminary data emerging from international laboratory and
clinical experiences show that surgical procedures involving the
airways, or using them as a surgical corridor, such as transnasal skull
base surgery, must be prudentially considered high-risk procedures, at
least until further evidence becomes available.{[}6,16--18{]} The
concurrent publication of recommendations by the Italian Society of
Otorhinolaryngology{[}19{]}, the European Rhinologic Society{[}20{]} and
ENT UK{[}21{]} as well as the Italian Skull Base Society{[}5{]} led us
from March 23\textsuperscript{rd}, to elevate the standard of protection
for healthcare providers during sinus and skull base procedures.

To the best of our knowledge, this is the first paper reporting the
largest case-series of patients operated for urgent and emergent sinus
and skull base pathologies during the COVID-19 pandemic in a
tertiary-care referral center.

\textbf{Volume of surgical activity.} A considerable reduction was
observed during the COVID-19 outbreak, as high as -60.7\%. This is due
to the compliance with the Regional and Hospital provisions,
establishing elective and non-urgent surgical procedures to be
suspended. One of the aims of this paper was therefore to assess how
these provisions, together with the logistical changes imposed by the
ongoing outbreak, impacted the surgical activity of our Division.

\textbf{Pathologies treated.} A significant difference was found between
the two Groups analyzed (p = .016). Pairwise analysis was significant (p
= .002) when comparing malignancies with inflammatory diseases in the
two Groups, due to the high number of cancers treated during the
COVID-19 period. We believe that this is attributable to both a
reduction of the inflammatory cases treated due to suspension of
elective surgery, as well as to a reduction of the surgical activity in
other Italian sinus and skull base referral centers, which led to a
centralization of skull base malignancies cases towards our Division.

\textbf{Patients' geographical origin.} The percentage of extra-regional
patients was comparable between PANDEMIC and CONTROL Groups (41.7\%
versus 39.3\%, respectively) without statistically significant
differences (p = .844) (Figure 1). Our Otorhinolaryngology Division is a
well-known referral-center for skull base disease, receiving many
extra-regional patients every year. Notwithstanding this unprecedented
scenario, there were several high-priority sinonasal and skull base
diseases whose treatment could not be delayed, because of the risk for
significant worsening of the patient's quality of life and negative
impact on overall survival rates. Our preliminary results emphasize the
need for sinus and skull base referral centers able to continue
providing care even in such emergencies like the COVID-19 outbreak, in
order to manage selected critical patients at risk for a fatal course if
not treated promptly. This can be done only if the reorganization of the
referral centers, realized to face COVID-19 emergency, is able to
reserve appropriate resources for sinus and skull base surgery, namely
preserving the activity of some Departments which are essential for this
specific procedures (Neurosurgery, Interventional Radiology, Pathology,
Plastic Surgery), as well as setting up a COVID-19 free ICU for proper
postoperative monitoring.{[}22{]}

\textbf{Patients' health status.} The mean follow-up time after surgery
for the PANDEMIC- Group in our study was 50 days, with a minimum of at
least 14 days, which corresponds to the estimated time of incubation for
SARS-Cov-2. All patients have been followed in the outpatient clinic by
means of endoscopic medications accordingly. At the retrospective
telephonic survey conducted on May 5\textsuperscript{th}, a total 4
patients (16.7\%) referred symptoms (headache and diarrhea, two cases
each) after hospital discharge and only two of them underwent
nasopharyngeal swab collection, which tested negative in both of the
cases. We acknowledge that performing a single telephone interview
retrospectively to investigate the patients' state of health cannot
provide certainty about their health status, but it allowed us to easily
retrieve information while avoiding unnecessary or unauthorized
movements during the lockdown period.

\textbf{Medical staff safeguard.} Protection and health of medical staff
are a highly debated topic during the COVID-19 outbreak {[}6,18{]}. In
this regard, the initial confusion progressively faded away and the
supply of PPE became more adequate over time, so that, one month after
the beginning of the outbreak in Italy, more stringent measures for
protecting healthcare workers were adopted with widespread PPE usage and
restrictions from duty in case of suspected symptoms. Interestingly,
according to the survey performed, all symptoms referred by the
physicians serving in our Division began before the time when clear
indications were disposed by the Hospital. At present, no indication is
given to test asymptomatic medical staff for COVID-19 infection, even in
presence of epidemiologic criteria. This explains why only half of the
ENT medical staff was tested, either with a nasopharyngeal or a rapid
serological test. The latter was performed based on personal decision in
all cases. In such a critical time of resources constraints, with
stringent indications for execution of diagnostic tests, it seems
reasonable to concentrate efforts on prevention, with appropriate PPE
use and logistic re-arrangements focused on protecting the health of
both patients and healthcare workers. In this regard, our experience may
serve for the other centers who are facing sudden emergency conditions.

\textbf{Open issues.} To date, all medical and nursing staff wear
appropriate PPE, as prescribed in several guidelines.{[}5,6{]} However,
even establishing the aerosolization risk of endoscopic procedures, as
hypothesized by a preliminary study performed on cadaver with detection
of particles measuring less than 5 micron{[}17{]}, we still don't know
exactly which procedures generate aerosolization of mucus and possible
viral particles measuring less than 0.3 micron. Therefore, although the
risk for healthcare providers has been decreased by wearing proper PPE,
we still don't know the actual risk for non-suspect patients undergoing
endoscopic transnasal surgery, considering that COVID-19 remains viable
in aerosol particles up to 3 hours.{[}23{]} Moreover, the use newer
tests like the one from Abbott (Abbott Laboratories, Chicago, IL, USA),
administered shortly before entering the patient's operating room and
results ready within 15 minutes, could impact the logistics of elective
surgeries planning, especially in the next phase of the
pandemic.{[}24{]} These considerations move us to future directions
regarding the OR environment and air turnover, how long one surgery
should be distanced from the other, and if it is necessary to change OR,
always use negative pressure ORs, use specific HEPA filters for suction
or UV lights.{[}25--27{]} Finally, neurotropism of SARS-Cov-2 is under
investigation{[}28{]} and the consequences of surgically creating a
direct cerebral access route through skull base surgeries are still
unknown to date.

\par\null

\textbf{Study limitations.} As happens in all preliminary studies, there
are some limitations to our paper that deserve to be mentioned. First of
all, it is a retrospective study with confounding factors which were not
considered in the analysis (e.g. change of staff between 2019 and 2020,
pandemic versus normal conditions, sensitivity and specificity of
diagnostic tests, etc). Secondly, it was not possible to establish with
certainty the COVID-19 status of all patients and physicians due to
stringent indications to perform nasopharyngeal swabs and/or serological
tests based on current regulations. Their widespread use would certainly
strengthen the value of this study. Thirdly, the present paper analyzed
only the first two months of the COVID-19 outbreak in Italy, which
represents a reasonable time to report an initial experience but not to
draw definitive conclusions. In this regard, it is too early to infer
how the COVID-19 pandemic might influence other aspects of patients'
care, such as long-term follow-up. Taking into account the similar
situation happened in Wuhan, we can anticipate that this will be a
crucial aspect to put efforts into during the following months.{[}29{]}

\textbf{Conclusions} . Although we feel optimistic for the future, we
don't feel it is already time to restart elective surgeries, since the
pandemic, according to WHO on May 1\textsuperscript{st}, 2020, is not
over yet. We believe that only urgent and non-deferrable cases should be
treated until further evidence shows adequate safety measures for both
patients and healthcare providers. Here we share our Institution's
preliminary surgical experience aiming to facilitate the adoption of
similar measures by other referral centers. More studies and research
are necessary in order to collect data and provide more accurate
recommendations, considering that the evolution of the pandemic is
unpredictable.

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