CORRESPONDENCE

In Reply: Precautions for Endoscopic
Transnasal Skull Base Surgery During theCOVID-19 Pandemic
To the Editor:
COVID-19 has been spreading all over the world over the past
2 mo.1 Owing to the striking increase of COVID-19 cases, thesafety of medical workers is a concern.2 Because the virus exists
in all parts of the respiratory tract, there is a heated discussion on
the timing of surgical treatment of respiratory diseases, especiallythe safety assessment of endoscopic transsphenoidal surgery in thedepartment of neurosurgery.
Recently, Patel et al3 submitted an article titled “Precautions for Endoscopic Transnasal Skull Base Surgery During
the COVID-19 Pandemic” to remind the neurosurgeon andotolaryngologist to pay attention to the extended endoscopic
skull base surgery of patients with COVID-19. In the article,
Patel et al3 cited the co-occurrence of 14 COVID-19 infected
medical workers and a COVID-19 affected patient with pituitaryadenoma who underwent endoscopic transsphenoidal surgery
in our department, and stated the safety issue about thetranssphenoidal surgery in this emerging COVID-19 situation.
However, what was described does not accord with thefacts.
The first argument is about the sentence “multiple members(>14 by report) of the patient care team, both within and outsideof the operating room, became infected from what became recognized as human-to-human transmission of COVID-19”. It is notaccurate. At the early stage of the COVID-19 outbreak, we had
1 patient who underwent endoscopic transsphenoidal surgery on
January 6, 2020 and was diagnosed with COVID-19 13 d later.
Among the infected medical workers, 10 nurses and 4 neurosurgeons were diagnosed and only 4 nurses contacted the COVID-19
patient directly.
The second problem is that the authors3 believed that all themedical workers who participated in the surgery were infected,
especially from the experience of the second case that the author
cited, for which we have no exact information in Wuhan neurosurgery medical system. However, according to our retrospective
survey on our case, none of medical staff who participated insurgery were diagnosed with COVID-19 until March 31, 2020.
Today, all the infected medical staff have recovered. More importantly, the medical workers diagnosed with COVID-19 in ourdepartment later were the staff who were outside the operationroom. As for the infected neurosurgeon in our department, it’sconceivable to be deemed as postoperative transmission rather
than intraoperative transmission.
Finally, the opinion that the authors3 delivered should
be carefully assessed. The reason why the neurosurgeon andotolaryngologist were infected needs more data to illustrate.
According to the whole infection event that we experienced,

NEUROSURGERY

we have some facts and experiences to share with the medicalcommunity.
The reason why the infection event happened in ourdepartment at the early stage is due to little knowledge
about COVID-19 and insufficient protective measures. Besides,
the frequently interaction between medical workers in ourdepartment promoted transmission. Thus, accumulating information about the COVID-19 should be elucidated and reducing
contact between people is a necessary means to prevent the spreadof the virus.
In this infection event, more nurses were infected thansurgeons, because nurses and patients are in direct contact, suchas in daily medical care. So, compared to droplet transmission,contact transmission may be an important factor of transmission
in medical workers which more likely we ignored at the early stage.
Therefore, it is very important to wash hands and clean the surfaceof objects in wards and living areas. What’s more, it is vital to makesure that once COVID-19 patients are confirmed, strict isolation
measures must be taken as soon as possible.
As for the transsphenoidal surgery, Patel et al3 believe thataerosol droplets coming from the endonasal surgery will increase
the possibility of infection of medical staff in operating room.
However, from our case, we have learned that intraoperative
aspirator, protective clothing, N95 mask, and face shield canprovide sufficient protection to our medical staff in the surgery
room. What Patel et al3 claimed in their work might provoke
unnecessary anxiety toward endonasal endoscopic procedures
based on an anecdotal statement.
In sum, as for medical staff, proper protective measures
including N95 masks, face shield, protective clothing, andreduced contact with infected patients are necessary. No
convincing evidence exists to show that there is an increased
possibility of infection from the endoscopic transsphenoidal
surgery under the above protective measures. At this emerging
COVID-19 situation and for patients’ safety, our advice is toavoid selective endoscopic transsphenoidal surgery unless in an
emergency case, in which situation level-3 protection is definitely
needed and a negative pressure operating room is recommended.
Disclosures
The retrospective survey in the letter was supported by the National Natural
Science Foundation of China (grant 81272778 and 81974390 to Dr X. Jiang)
and the Fundamental Research Funds for the Central Universities (grant2020kfyXGYJ010 to Dr X. Jiang). The authors have no personal, financial, orinstitutional interest in any of the drugs, materials, or devices described in thisarticle.

Xing Huang, MD
Wende Zhu, MD
Hongyang Zhao, MD
Xiaobing Jiang, MD

VOLUME 0 | NUMBER 0 | 2020 | 1

CORRESPONDENCE

Department of Neurosurgery
Union Hospital
Tongji Medical College
Huazhong University of Science and Technology
Wuhan, China

REFERENCES
1. Fisher D, Wilder-Smith A. The global community needs to swiftly ramp up theresponse to contain COVID-19. Lancet (London, England). 2020;95(10230):11091110.

2 | VOLUME 0 | NUMBER 0 | 2020

2. Lancet T. COVID-19: protecting health-care workers. Lancet (London, England).
2020;395(10228):922.
3. Patel ZM, Fernandez-Miranda J, Hwang PH, et al. Letter: precautions forendoscopic transnasal skull base surgery during the COVID-19 pandemic. Neurosurgery. published online: 2020 (doi:10.1093/neuros/nyaa125).

C 2020 by the Congress of Neurological Surgeons
Copyright 10.1093/neuros/nyaa145

www.neurosurgery-online.com