Introduction
COVID 19 in particular affects the lungs causing an ARDS type picture
resulting in an atypical form of ARDS whereby there is
disproportionately poor oxygenation despite reasonably preserved lung
compliance in the early stages 1. Experience from
Italy and China suggests that nursing the patient in a prone position is
potentially beneficial and can improve outcomes when carried out in the
early stages of the disease1,2. This has resulted in
its inclusion in several international guidelines and adoption around
the world as a valid intervention for COVID 19
patients3
Proning is not a new phenomenon and has been used as a treatment option
for ARDS for over 20 years. It is not without complications and as well
as the displacement of tubes and lines, the exacerbation of existing
traumas or dehiscence of surgical wounds there are also reports of
pressure necrosis secondary to prone positioning particularly of the
face and nose4A cochrane review in 2015 concluded that
prone ventilation was directly responsible for an increased risk of
pressure sores5There is some suggestion that the
pressure damage caused by proning occurs regardless of preventative
measures put in place (such as foam supports and measures to relieve
pressure)4But it also seems that this pressure damage
is often mild and self resolving6. Regular
repositioning of the head may also reduce pressure damage accordingly7
Given that larger numbers of patients are likely to be proned and that
proning is directly linked to pressure damage to the face and nose it
would seem logical that this would represent an increase in referrals to
ENT to assess this. Anecdotally this is the case in our department where
we have received several such calls having never previously encountered
this complication in routine practice. Although patients should be
proned with the head turned to one side to avoid such pressure
damage8 due to the highly unstable nature of COVID 19
patients and in some cases limited cervical spine rotation inevitably
some patients will end up in positions where there nose is at risk. We
present our approach to the management of these injuries borrowing from
theory and practice used to manage patients having undergone
rhinological procedures.