Tracheostomy procedures have a high risk of aerosol generation. Airway providers have reflected on ways to mitigate the SARS-CoV-2 transmission risks when approaching a surgical airway. To standardize institutional safety measures with tracheostomy, we advocate using a dedicated tracheostomy time-out applicable to all patients including those suspected of having COVID-19. The aim of the tracheostomy time-out is to reduce preventable errors that may increase the risk of transmission of SARS-CoV-2.
Coronavirus disease 2019 has undoubtedly impacted the healthcare system while causing lasting and profound implications for medical education. Senior medical students seeking exposure to the field of otolaryngology now find themselves in the challenging position of obtaining the experiences to make an informed decision on a future specialty. Virtual electives using comprehensive online material, discussion, and videos as well as the advent of telemedicine may be potential solutions to increase exposure to otolaryngology. While incorporating opportunities for authentic patient interactions is still a challenge, it is crucial that the academic otolaryngology community prioritize seeking solutions for interested medical students
Gupta, Anand1,#; Arora, Vipin2; Nair, Deepa3; Agrawal,Nishant4; Su, Yu-xiong5; Holsinger, Christopher F. 6; Chan, Jason7,#1 Department of Dentistry (Oral and Maxillofacial Surgery), Government Medical College & Hospital, Chandigarh, India. 2 Department of ENT and Head Neck Surgery, University College of Medical Sciences and GTB Hospital, Delhi, India.3 Department Head and Neck Surgical Oncology, Tata Memorial Centre, HBNI University, Mumbai, India.4 Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medicine, Chicago, IL, United States.5 Division of Oral and Maxillofacial Surgery, Faculty of Dentistry,The University of Hong Kong, Hong Kong SAR.6 Division of Head and Neck Surgery, Stanford University, Palo Alto, CA, USA.7 Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong. Keywords: Strategies for management; head and neck cancer; COVID-19; pandemic; Indian Scenario.Disclosure: Nothing to disclose.Funding: No funding received. Corresponding Authors:Anand GuptaAssistant ProfessorDepartment of Dentistry (Oral and Maxillofacial Surgery), Government Medical College and Hospital (GMCH)Sector 32 B, Chandigarh, INDIA Pin code- 160030Telephone no. +91-9810720642E mail- email@example.com Jason YK ChanAssistant ProfessorDepartment of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Hong Kong.Pin code-Telephone no. +85-235053288Email :firstname.lastname@example.org
Background: The COVID-19 pandemic has raised concern of transmission of infectious organisms through aerosols formation in endonasal and transoral surgery.Methods: Retrospective review. We introduce the Negative-Pressure Otolaryngology Viral Isolation Drape (NOVID) system to reduce the risk of aerosol. NOVID consists of a plastic drape suspended above the patient’s head and surgical field with a smoke evacuator suction placed inside the chamber.Results: Four patients underwent endonasal (4) and endo-oral surgery (1). Fluorescein was applied to the surgical field. Black light examination of fluorescein treated operative fields revealed minimal contamination distant to the surgical field. In two prolonged cases with high-speed drilling, droplets were identified under the barrier and on the tip of the smoke evacuator. Instruments and cottonoids appeared to be a greater contributor to field contamination.Conclusions: Negative-pressure aspiration of air under a chamber barrier which appears to successfully keep aerosol and droplet contamination to a minimum.
Background: Otolaryngologists represent a subset of healthcare workers uniquely vulnerable to COVID-19 transmission. Given the segmentation of extant guidelines concerning precautions and protective equipment for SARS-CoV2, we aimed to provide consolidated recommendations regarding appropriate personal protective equipment (PPE) in head neck surgery during the COVID-19 era.Methods: Guidelines published by international and United States governing bodies were reviewed in conjunction with published literature concerning COVID-19 transmission risk, testing, and PPE, to compile situation-specific recommendations for head and neck providers managing COVID-19 patients.Results: High-quality data regarding the aerosolization potential of head and neck instrumentation and appropriate PPE during head and neck surgeries are lacking. However, extrapolation of recommendations by governing bodies suggest strongly that head and neck mucosal instrumentation warrants strict adherence to airborne-level precautions.Conclusion: We present a series of situation-specific recommendations for PPE use and other procedural precautions for otolaryngology providers to consider in the COVID-19 era.
Background: The United States now has the highest death toll due to COVID-19. Many otolaryngology procedures, including laryngoscopy, bronchoscopy, and esophagoscopy, place otolaryngologists at increased risk of coronavirus transmission due to close contact with respiratory droplets and aerosolization from the procedure. The aim of this paper is to provide an overview of guidelines on how to perform these procedures during the coronavirus pandemic. Methods: Literature review was performed. Articles citing laryngoscopy, bronchoscopy, esophagoscopy use in regards to COVID-19 were included.Results: Laryngoscopy, bronchoscopy, and esophagoscopy are all used in both emergent and elective situations. Understanding the risk stratification of cases and the varied necessity of personal protective equipment is important in protecting patients and healthcare workers. Conclusions: Summary guidelines based on the literature available at this time is presented in order to decrease transmission of the virus and protect those involved.
With the arrival of the coronavirus disease (SARS-CoV-2) in the U.S., care practice paradigms have drastically changed. Data from China suggests the new virus poses additional risks as case fatality of patients with cancer was higher at 5.6% compared to 2.3% of the general population. There are three proposed major strategies to address care for patients with cancer in this SARS-CoV-2 pandemic with postponing treatment for those with stable cancer, increasing personal protection provisions for cancer patients, and increasing monitoring if a patient becomes infected with SARS-CoV-2. In this present commentary, we discuss the unique mental health challenges and burdens of head and neck cancer (HNC) patients in the times of the SARS-CoV-2 pandemic and approaches to mitigate these stressors through telemedicine to reduce future burdens to the patient and the health care system.
Background: The COVID-19 pandemic has significantly impacted medical training. Here we assess its effect on head and neck surgical education. Methods: Surveys were sent to current accredited program directors and trainees to assess the impact of COVID-19 on the fellow’s experience and employment search. Current fellows’ operative logs were compared with those of the 2018-2019 graduates. Results: Despite reduction in operative volume, 82% of current AHNS fellows have reached the number of major surgical operations to support certification. When surveyed, 86% of program directors deemed their fellow ready to enter practice. The majority of fellows felt prepared to practice ablative (96%), and microvascular surgery (73%), and 57% have secured employment to follow graduation. Five (10%) had a pending job position put on hold due to the pandemic. Conclusions: Despite the impact of the COVID-19 pandemic, current accredited trainees remain well positioned to obtain proficiency and enter the work-force.
Amy Y. Chen, MD, MPHEmory Universityachen@emory.eduMaisie Shindo, MDOregon Health Sciences Universityshindom@ohsu.eduCorresponding author:Amy Y. Chen, MD, MPHEmory Department of Otolaryngology Head and Neck Surgery550 Peachtree St. MOT 1135Atlanta, GA email@example.comShort title: Ethics Endocrine Surgery COVID 19Ethical Framework for Head and Neck Endocrine Surgery in the COVID 19 pandemicThe COVID-19 pandemic has halted all elective surgeries, allowing only emergent surgeries, and in some hospitals time-sensitive urgent surgeries to proceed. “Mr. X, This is Dr. I’m calling to discuss with you your previously planned surgery. “ I’ve been having many conversations like this with my patients over the past weeks. Surgeries may be delayed or the patient and his/ her family may need to make a heart wrenching decision whether to proceed with surgery in a hospital filling with COVID patients, risking infection themselves, and without any visitors. Endocrine surgery falls into this valley where it is neither life threatening nor totally benign either. The American Association of Endocrine Surgeons1 as well as the endocrine section of the American Head and Neck Surgery2 have put forth recommendations for thyroid and parathyroid conditions that would be considered urgent time-sensitive surgery. These include 1) high risk thyroid cancers such as those with bulky central and lateral neck disease, concern for tracheal or esophageal involvement, or short doubling time 2) Graves’ disease with thyrotoxicosis that cannot be controlled with anti-thyroid medications, 3) compressive large goiters with dyspnea or significant symptomatic vascular compression, 4) Primary hyperparathyroidism with life-threatening hypercalcemia that cannot be managed medically, 5) endocrine disorders in pregnant patient that are dangerous to the health of the mother or fetus that cannot be controlled medically.Certainly, there has been an international push to observe more well differentiated thyroid cancer; however, what about those “smallish” cancers that are near the isthmus, near the trachea/ esophagus, or with extracapsular extension? Despite their small size, these can become invasive to the degree that could result in the need to perform a more morbid procedure if surgery is delayed, and thus should be considered in the category of “time-sensitive surgery”. What about indeterminate thyroid nodules with adverse molecular markers? If such nodules present with ultrasound findings that are concerning for local invasion, even though the cytologic diagnosis is not “malignant”, such lesions should be treated as high risk cancer, and surgery should not be delayed.If proceeding with surgery, the surgeon has an ethical responsibility to discuss with the patient the potential risk of COVID-19 infection. We as surgeons have a responsibility to reduce risk of infection not only to the patient but the healthcare team who will be caring for the patient. At the minimum COVID-19 testing should be performed preoperatively within 2 days of surgery, and the patient should be educated on the importance of self-isolation and necessary precautions.If potential difficult airway is anticipated communication and planning with anesthesia pre-procedure is important. Despite that fact that the patient may test negative for COVID-19, the false negative rate is not zero, and as such, precautions need to be taken to minimize exposure. A difficult airway may result in manipulation of the airway that could potentially be aerosolizing. Having the appropriate protective gear and all necessary difficult airway equipment is essential in such a situation. If the patient needs fiberoptic laryngoscopy or tracheoscopy, nasal pledgets should be used in lieu of sprays. Surgery should certainly be postponed in Covid-19 positive patients.Scarcity of resources, surge planning, and public health mitigation efforts have all combined in a perfect storm to delay and in some situations, to deny treatment to head and neck surgery patients. Whereas some of our patients may afford a delay in their treatment, others do not have that luxury. It is incumbent upon us, as their clinicians, to integrate competing priorities into an acceptable plan.Justice, or to be just/ fair, must include a lens towards equity. One way to honor this ethical principle is to incorporate both clinical and non-clinical factors in risk assessment. Many papers have reported on the profound effect of sociodemographic factors on patient outcomes. An intersection between higher comorbidity burden and lower socioeconomic status can worsen disparities of who gets treatment. For example, algorithms that incorporate comorbidity are necessary so that resources can be allocated for the “greater good;” however, these guidelines risk heightening disparities and health inequity. Strategies to ameliorate these disparities include flexibility of treatment options, creative discharge planning, and thorough pre-operative conditioning. Flexibility of treatment options include consideration of definitive chemoradiation, induction chemotherapy prior to surgery (to buy time), and resection with delayed reconstruction.Beneficence, or to do good, is a guiding principle of ethics. With limited resources, the “good” of society supersedes the “good’ of the individual. Hence, the cancellation of elective, non-emergent cases is instituted. So is the prioritization of surgical cases that are not likely to need ICU care, blood products, extended inpatient stay, and extensive ancillary laboratory/ radiology testing.However, these cancellations/ delays in treatment/ changes in treatment can cause anxiety for both the clinician and his/ her patient. Many of our patients have been waiting for several weeks for their treatment to start, only to have it be delayed or altered. How do we reassure the patient that the new plan is the best plan, given the restrictions that the COVID 19 pandemic places on systems? How do we, as clinicians, resolve our inner turmoil in delaying/ denying/ altering treatment.Early data already demonstrate that COVID 19 is affecting vulnerable racial minorities at a higher disproportionate rate. To compound the adverse effects, this cohort has more access issues due to transportation, hourly job limitations, and lack of stable insurance. The delay in surgery may result in the patient’s loss of insurance status due to loss of income and/ or being furloughed. As we move into the next phase of easing up restrictions, such factors need to be taken into consideration in prioritizing whom we select for surgery.1. https://www.endocrinesurgery.org/assets/COVID-19/AAES-Elective-Endocrine-Surgery.pdf2. https://www.ahns.info/wp-content/uploads/2020/03/Endocrine-Surgery-during-the-Covid.pdf
The novel coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and was declared a pandemic in March 2020. A plethora of respiratory sampling methods for SARS-CoV-2 viral detection has been used and in the current evolving situation, there is no international consensus on the recommended method of respiratory sampling for diagnosis. Otolaryngologists deal intimately with the upper respiratory tract and a clear understanding of the respiratory sampling methods is of paramount importance. This article aims to provide an overview of the various methods and their evidence till date.
Background. Chemosensitive disorders are very frequent in the early stages of COVID-19 and in paucisymptomatic cases. These patients are typically placed in home quarantine. This study has the aim of validating a new olfactory and gustatory objective evaluation test in these patients.Methods. Thirty-three home-quarantined COVID-19 patients have undergone a self-administered chemosensitive test the day before the control swab. On this occasion, the patients underwent operator-administered already validated tests. The results were finally compared.Results. The differences between the results of the two tests were not significant for both the olfaction (P = 0.201) and the taste (P = 0.180).Conclusion. The olfactory and gustatory evaluation by self-administered test can be considered a valid tool, fundamental for obtaining objective qualitative and quantitative data on the extent of chemosensitive disorders in home-quarantined COVID-19 patients.
Introduction: The COVID-19 pandemic has raised controversies regarding safe and effective care of head and neck cancer patients. It is unknown how much the pandemic has changed surgeon practice. Methods: A questionnaire was distributed to head and neck surgeons assessing opinions related to treatment and concerns for the safety of patients, self, family, and staff. Results: A total of 67 head and neck surgeons responded during the study period. Surgeons continued to recommend primary surgical treatment for oral cavity cancers. Respondents were more likely to consider non-surgical therapy for patients with early glottic cancers and HPV-mediated oropharynx cancer. Surgeons were least likely to be concerned for their own health and safety and had the greatest concern for their resident trainees. Conclusions: This study highlights differences in the willingness of head and neck surgeons to delay surgery or alter plans during times when hospital resources are scarce and risk is high.
BACKGROUNDCoronavirus has serially overtaken our metropolitan hospitals. At peak, patients with acute respiratory distress syndrome may outnumber mechanical ventilators. In our Miami hospital system COVID-19 cases have multiplied for 4 weeks and elective surgery has been suspended.METHODSAn otolaryngologic triage committee was created to appropriately allocate resources to patients. Hospital ethicists provided support. Our tumor conference screened patients for non-surgical options. Patients were tested twice for Sars-CoV-2 before performing urgent contaminated operations. N95 masks and protective equipment were conserved when possible. Patients with low-grade cancers were advised to delay surgery, and other difficult decisions were made.RESULTSHundreds of surgeries were cancelled. Sixty-five cases supervised over three weeks are tabulated. Physicians and patients expressed discomfort regarding perceived deviations from standards, but risk of Covid-19 exposure tempered these discussions.CONCLUSIONSWe describe the use of actively managed surgical triage to fairly balance our patient’s health with public health concerns.
Background This study describes a novel approach in reducing SARS-CoV-2 transmission during tracheostomy. Methods Five patients underwent tracheostomy between 01 April 2020 and 17 April 2020. A clear and sterile plastic drape was used as an additional physical barrier against droplets and aerosols. Operative diagnosis; droplet count and distribution on plastic sheet and face shields were documented. Results Tracheostomy was performed for patients with carcinoma of tonsil (n=2) and nasopharynx (n=1), and aspiration pneumonia (n=2). Droplet contamination was noted on all plastic sheets (n=5). Droplet contamination was most severe over the central surface at 91.5% (86.7%-100.0%) followed by the left and right lateral surfaces at 5.2% (6.7%-10.0%) and 3.3% (6.7%-10.0%) respectively. No droplet contamination was noted on all face shields. Conclusion Plastic drapes can help reduce viral transmission to health care providers during tracheostomy. Face shields may be spared which in turn helps to conserve resources during the COVID-19 pandemic.
IntroductionThe rapid spread of coronavirus disease 2019 (COVID-19) worldwide raised concerns about its heavy impact on the health care delivery system and forced significant changes in the realities of the clinical practice we are accustomed to. With these changes comes a need for a different approach to outpatient evaluation of common otolaryngology complaints in patients with new symptoms.Recently published set of guidelines for evaluation of head and neck during the COVID-19 pandemic recommended to postpone the management of benign disease including benign salivary or thyroid gland disease.1 In order to limit the chance of COVID-19 infection among patients or health care workers, surveying patients via telephone or telemedicine visit was advised, reserving in-person evaluation for the patients at risk for significant negative outcomes. The challenge is that these measures can only be applied in clear-cut clinical scenarios, when the disease process is most likely benign and the care delivery can be postponed.In cases with a high degree of uncertainty based on available clinical information, many physicians will have to decide how to proceed after initial telemedicine encounter. Clinicians will have to consider how to balance a potential delay in diagnosis, including cancer diagnosis, against the risk of COVID-19 exposure, and may need to exercise their best judgement knowing that for head and neck cancer the risk of progression with cancer care delay is high.2 In this communication, we present our approach to triaging and evaluation of patients with complaints concerning for salivary gland disease.
As this ever-evolving pandemic lays itself, more of its impact is being understood. Until recently, most guidelines were reported to aid in managing and treating suspected or confirmed cases. Research institutions around the world are responding with a sense of confusion. Some are continuing routinely, especially those who are overseeing clinical trials that could offer life-saving therapies, particularly against the novel coronavirus. Since research must continue even in the face of a shutdown, we aim to collate the currently available recommendations from various organizations and provide guidance to head and neck researchers across the world during these trying times.
The 2019 novel coronavirus disease (COVID-19) pandemic has been spreading worldwide at an alarming rate. Healthcare workers have been confronted with the challenge of not only treating patients with the virus, but also managing the disruption of healthcare services caused by COVID-19. In anticipation of outbreak, clinic sessions and operation theatre lists have been actively cut back since February 2020 to reduce hospital admissions and clinic attendances. This has severely disrupted healthcare services, leading to accumulating clinic caseload and substantial delays for operations. The head and neck cancer service has been faced with the difficult task of managing the balance between infection risk to healthcare providers and the risk of disease progression from prolonged waiting times. We share our experience in Hong Kong on the mitigation of head and neck cancer service disruption through telehealth and multi-institution collaboration.
BackgroundOutpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation.MethodsFor suspected cancer referrals, we adapted the Head and Neck Cancer Risk Calculator (HaNC-RC)-V.2, generated from 10,244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value and area under the curve of 0.89. For follow up patients, a symptom inventory generated from 5,123 follow-up consultations was used. A customised Excel Data Tool was created, trialled across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol and registration link for the project. Stakeholder support was obtained from national bodies.ResultsNo remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centres show that 77.1% of patients were discharged directly or have had their appointments deferred.DiscussionSignificant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC-RC V.2 is feasible and the authors welcome international collaboration.