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Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 36-39

Low-cost modified face shield for safe outpatient fiberoptic laryngoscopy amid COVID-19 pandemic: An innovation

Department of Otolaryngology, Head and Neck Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission14-Oct-2020
Date of Acceptance18-Nov-2020
Date of Web Publication18-Feb-2021

Correspondence Address:
Neemu Hage
Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jlv.jlv_15_20

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Healthcare professionals globally are facing challenges with the on-going COVID-19 pandemic. Otolaryngologists are at a higher risk of exposure to aerosols from potential sources. Innovations to mitigate aerosols and deliver optimum patient care are the need of the hour. We aim to highlight a modified face shield that can be safely used for outpatient fiberoptic laryngoscopy.

Keywords: COVID-19, face shield, fiberoptic laryngoscopy, personal protective equipment

How to cite this article:
Ramavat AS, Hage N, Muraleedharan M, Panda NK. Low-cost modified face shield for safe outpatient fiberoptic laryngoscopy amid COVID-19 pandemic: An innovation. J Laryngol Voice 2020;10:36-9

How to cite this URL:
Ramavat AS, Hage N, Muraleedharan M, Panda NK. Low-cost modified face shield for safe outpatient fiberoptic laryngoscopy amid COVID-19 pandemic: An innovation. J Laryngol Voice [serial online] 2020 [cited 2023 Jan 31];10:36-9. Available from: https://www.laryngologyandvoice.org/text.asp?2020/10/2/36/309674

   Introduction Top

In the present COVID-19 pandemic, all healthcare professionals (HCPs) are facing an unprecedented challenge of providing safe, effective, and uninterrupted services to the patients while taking care of their own safety. The pandemic has affected the normal functioning of outpatient department, and endoscopies have been brought to minimum. Reports suggest up to 91% decrease in the outpatient endoscopic procedures.[1] The highest viral load has been shown to be harbored by the upper respiratory tract.[2] Even though otolaryngological endoscopies are not aerosol-generating procedures themselves, they can induce sneezing, coughing, gagging, and possible aerosolization.[3] Still, nose is considered to be a safer route of introduction of endoscope rather than oral cavity, in view of reduced gag and option of keeping the facial mask on.[1] This also makes flexible scopes a better option than the rigid ones.

Preventive measures taken during this period are broadly centered on the use of personal protective equipment (PPE). A face shield is one such PPE that provides barrier protection to the facial area and related mucous membranes (eyes, nose, and lips).[4] Coupling it with a surgical or N95 mask, along with goggles, provides sufficient protection to carry out outpatient procedures such as fiberoptic laryngoscopy (FOL). We have come up with an innovative technique of performing safe FOL using a novel modified face shield (MFS). It is an inexpensive construct, which is simple to assemble and reusable after appropriate disinfection.

We employed the procedure only on patients requiring urgent intervention such as detection of possible malignancy in high-risk patients and to diagnose upper airway obstruction secondary to a benign or malignant laryngeal pathology.[5]

   Methods Top

Materials required

  1. A standard plastic face shield
  2. Tracheostomy tube sized 5–6 mm ID (depending on the model of the fibreoptic rhinolaryngoscope used)
  3. Surgical blade No. 11
  4. A pair of scissors
  5. Gentian violet paint or India ink
  6. Quick-drying cyanoacrylate glue.


  1. The shaft of the tracheostomy tube is sharply divided from the flange/connector unit using a surgical blade [Figure 1]
  2. A circle is marked at the center of the plastic face shield using the connector end of the tube, dipped in colored dye, as a template
  3. A circular piece is then cut out, using a blade and a pair of scissors
  4. The connector of the tracheostomy tube is introduced through the hole created in the face shield and the flange secured on the inner side of the face shield with quick glue. This provides the inlet for the flexible endoscope [Figure 2]
  5. The face shield is then made to rest till the glue sets.
Figure 1: Illustration of the flange/connector unit of the tracheostomy tube

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Figure 2: Illustration of the face shield with cut out centre to accommodate the connector of the tracheostomy tube

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  1. To prevent aerosolization of virus particles, nasal pledgets and lignocaine viscous are to be used instead of sprays for the nasal cavity and pharynx, respectively[6]
  2. The patient will be wearing a surgical mask with the nose exposed.[5] This will prevent dispersion of large droplets from the oral cavity in the event of a cough or sneeze during the procedure.
  3. The MFS will be worn by the patient and adjusted by the examiner to ensure the level of the connector on the face shield close to the nares of the patient [Figure 3]
  4. Three levels of protection are recommended for the examiner – coverall gown with gloves, N95 masks, face shields, and goggles[3],[5]
  5. The procedure will be carried out with the patient in supine or sitting position based on the examiner's preference [Figure 4]
  6. After the procedure, the flexible laryngoscope will be withdrawn out carefully to avoid spillage of secretions
  7. With gloved hands, the face shield will be removed by undoing the head band from behind and touching the front of the face shield to be avoided.
Figure 3: Use of FOL using MFS on a mannequin

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Figure 4: Use of FOL using MFS on a patient

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  1. The face shield can be reused after sterilization by immersing it into a container with 1% hypochlorite solution for 30 min and rinsing with normal saline
  2. Sterilization of the room has to be done with thorough cleaning of all exposed surfaces with 75% alcohol and the flooring with 1% hypochlorite solution.[5]

   Discussion Top

With over 19 million cases to date and the curve still ascending, the novel COVID-19 is inferred to further propagate in many countries. Developing countries, such as India, are not well equipped to contend with the overwhelming figures that have emerged out of this pandemic.

Studies have revealed that 81% of infected individuals are asymptomatic or manifest with very mild symptoms and can be sources of occult transmission.[7] We must employ safety precautions while dealing with all patients alike, irrespective of their physical status.

sIn a recent article, Narwani et al. devised a modified endoscopy face mask using an adult endoscopy face mask with an attached heat moisture exchanger with viral filter.[8] The endoscopy face mask provides an airtight seal, giving it an additional barrier. The authors, however, did not comment upon the reusability of the device or the sterilization technique used. Di Maio et al. took to addressing the procedure from a different perspective.[1] They suggested a “back approach” to the patient to carry out endoscopic nasopharyngoscopy. Although simple to execute, it does not assure the prevention of contamination of the equipment and the endoscopy room.

Anon et al. described a modification of the face shield, similar to that of ours.[9] They additionally created a lower shelf in a standard face shield to contain the spread of aerosol inferiorly. A mucosal atomization device used to study the fluorescein dye splatter pattern revealed dye splatter contained within the confines of the closed space around the participant's face. This study did not employ a surgical mask (worn by the patient) as we recommend, which would significantly reduce the aerosol generation in the event of a sneeze or cough during the procedure.

The MFS is an inexpensive PPE costing approximately 1000 INR (10 GBP), whereas commercially available boxes with a port for bronchoscopes cost approximately 5000 INR (50 GBP). It can be made using readily available components and requires no special skills for its assembly. They are also reusable after appropriate sterilization.


The splatter pattern of aerosol after using the MFS has not been studied yet.

   Conclusion Top

This article highlights the use of a specially designed modified, inexpensive, reusable face shield that can be worn by the patient to avoid splatter and hence reduce exposure to aerosols to health personnel. FOL can be comfortably performed by the clinician without undue anxiety of risk of exposure and will ensure effective healthcare service delivery. We also recommend postponing endoscopies for all nonemergent indications, and it should be mandatory to get a COVID-19 test done before planning an endoscopy.

  1. Endoscopies should be done only in emergency cases in view of the COVID-19 pandemic
  2. Endoscopies by themselves are not aerosol-generating procedures but are dangerous as they can induce cough or sneeze
  3. Otolaryngologists performing endoscopies should wear three layers of protection – coverall gowns, N95 masks, goggles, and face shields
  4. Nasal route is preferred for endoscopies in comparison with oral route
  5. MFS, prepared from plastic face masks and flange of 6 mm tracheostomy tube, along with surgical mask over mouth, can protect the examiner from aerosols generated due to handling of pharynx and larynx
  6. MFSs are useful in resource-strapped conditions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Di Maio P, Traverso D, Iocca O, De Virgilio A, Spriano G, Giudice M. Endoscopic nasopharyngoscopy and ENT specialist safety in the COVID 19 era: The back endoscopy approach to the patient. Eur Arch Otorhinolaryngol 2020;277:2647-8.  Back to cited text no. 1
Zou L, Ruan F, Huang M, Liang L, Huang H, Hong Z, et al. SARS-CoV-2 viral load in upper respiratory specimens of infected patients. N Engl J Med 2020;382:1177-9.  Back to cited text no. 2
Iii JC, Dubin MG, Ishman SL, Kuppersmith RB, Smith RV. Guidance for Return to Practice for Otolaryngology-Head and Neck Surgery Part One; 2020. Available from: https://www.entnet.org/sites/default/files/uploads/guidance_for_return_to_practice_part_one_update_070120.pdf. [Last accessed on 2020 Nov 15].  Back to cited text no. 3
Roberge RJ. Face shields for infection control: A review. J Occup Environ Hyg 2016;13:235-42.  Back to cited text no. 4
Rameau A, Young VN, Amin MR, Sulica L. Flexible laryngoscopy and COVID-19. Otolaryngol Head Neck Surg 2020;162:813-5.  Back to cited text no. 5
Setzen M, Svider PF, Pollock K. COVID-19 and rhinology: A look at the future. Am J Otolaryngol 2020;41:102491.  Back to cited text no. 6
Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention. JAMA 2020;323:1239-42.  Back to cited text no. 7
Narwani V, Kohli N, Lerner MZ. Application of a modified endoscopy face mask for flexible laryngoscopy during the COVID-19 pandemic. Otolaryngol Head Neck Surg 2020;163:107-9.  Back to cited text no. 8
Anon JB, Denne C, Rees D. Patient-worn enhanced protection face shield for flexible endoscopy. Otolaryngol Head Neck Surg 2020;163:280-3.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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