The global pandemic of 2019 Novel Coronavirus Disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the healthcare system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than SARS in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and healthcare personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the non-instrumental swallowing evaluation, appropriate use of PPE, and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.
Background The global COVID-19 pandemic brings new challenges to otolaryngology resident education. Surgical volume and clinic visits are curtailed, personal protective equipment for operating room participation is restricted, and the risk of COVID-19 disease transmission during heretofore routine patient care is the new norm. Methods We describe a small-team “cohorting” protocol including guidelines for faculty and resident in common clinical scenarios with attention paid to the risk of common otolaryngologic procedures. Results A rotating small-team approach was implemented at each clinical site, limiting interaction between Department members but providing comprehensive coverage. Faculty were involved at the earliest phase of clinical interactions. Guidelines delineated faculty and resident roles based on risk stratification by patient COVID status and anticipated procedures. Special consideration was given to high-risk procedures such as endoscopy and tracheotomy. Conclusions A small-team based approach with guidelines for faculty/resident roles may mitigate risk while optimizing patient care and maximizing education.
As an aerosol and droplets generating procedure, tracheostomy increases contamination risks for health workers in the coronavirus disease context. To preserve the health care system capacity and to limit virus cross-transmission, protecting caregivers against coronavirus infection is of critical importance. We report the use of external fixator equipment to set up a physical interface between the patient’s neck and the caregiver performing a tracheostomy in COVID-19 patients. Once the metal frame set in place, it is wrapped with a single-use clear and sterile cover for surgical C-arm. This installation is simple, easy and fast to achieve and can be carried out with inexpensive material available in every hospital. This physical interface is an additional safety measure that prevents the direct projection of secretions or droplets. It should, of course, only be considered as a complement to strict compliance with barrier precautions and personal protective equipment.
BackgroundThe coronavirus infection is rapidly spreading putting a strain on healthcare services across the globe. Oral cancer patients are susceptible often immunosuppressed due to the disease and/or the treatment received.MethodsWe performed a simulationof the currently available data using a multi state and hazards model to provide an objective model for counseling and decision making for healthcare workers.ResultsStage IV oral cancer patients that did not receive treatment had progression of disease and an increased mortality rate than patients that receive treatment but did not contract COVID-19. The patients that received treatment and got affected with COVID-19 had a far worse impact and higher mortality rate than all other groups.ConclusionIsolation and deferring treatment for stage IV oral cancer patients, so as to avoid hospital visits and contration of COVID-19, is an advisable strategy based on this model.
Background Telehealth post-operative visits are an attractive strategy to minimize exposure, especially during the SARS-CoV-2 (COVID-19) pandemic. The use of a surgical drain often prevents this minimal-exposure approach in that patients return to the outpatient clinic for drain removal. Methods and Results Following unilateral neck dissection, the customary closed-suction drain was replaced with a self-removing, passive drain dressing to facilitate same-day discharge and telehealth post-operative follow-up. The patient removed the dressing and drain at home during a telehealth visit on post-operative day four and she healed favorably without signs of infection or seroma. Conclusions When thoughtfully applied in the appropriate clinical context, small practice adaptations like this can facilitate telehealth solutions that diminish unnecessary exposure for patients, their caregivers, and healthcare staff.
Brett A. Miles DDS MD1, Bradley Schiff MD2, Ian Ganly MD MS PhD3, Thomas Ow MD MS2, Erik Cohen MD5, Eric Genden MD MPH1, Bruce Culliney MD1, Bhoomi Mehrotra MD6, Steven Savona MD6, Richard J. Wong MD3, Missak Haigentz MD5, Salvatore Caruana MD7, Babak Givi MD8, Kepal Patel MD8, Kenneth Hu MD81Icahn School of Medicine at Mount Sinai, New York, NY2Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY3Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York,4Cancer Institute at St. Francis Hospital, New York, NY5Morristown Medical Center, Leonard B. Kahn Head and Neck Cancer Institute, Morristown, NJ6Northwell Cancer Institute, Monter Cancer Center, Lake Success, NY7Columbia University, New York, NY8NYU Langone Health, New York, NY
Background. The firsts European case series are detecting a very high frequency of chemosensitive disorders in COVID-19 patients, ranging between 19.4% and 88%.Methods. Olfactory and gustatory function was objectively tested in 72 COVID-19 patients treated at University Hospital of Sassari.Results Overall, 73.6% of the patients reported having or having had chemosensitive disorders. Olfactory assessment showed variable degree hyposmia in 60 cases and anosmia in 2 patients. Gustatory assessment revealed hypogeusia in 33 cases and complete ageusia in 1 patient. Statistically significant differences in chemosensitive recovery were detected based on age and distance from the onset of clinical manifestations.Conclusion. Olfactory and gustatory dysfunctions represent common clinical findings in COVID-19 patients. Otolaryngologists and head-neck surgeons must by now keep this diagnostic option in mind when evaluating cases of ageusia and nonspecific anosmia that arose suddenly and are not associated with rhinitis symptoms
The 2019 novel coronavirus (COVID-19) pandemic has created significant challenges to the delivery of care for patients with advanced head and neck cancer requiring multimodality therapy. Performing major head and neck ablative surgery and reconstruction is a particular concern given the extended duration and aerosolizing nature of these cases. In this manuscript, we describe our surgical approach to provide timely reconstructive care and minimize infectious risk to both the providers, patients, and families.
Health crises have become a popular topic of discussion. In the wave of the ongoing pandemic, experts have suggested the role of vaping and other tobacco product use exemplifying the vulnerability of the population to contract the COVID-19. We discuss some of the events that led up to these conclusions and also offer a unique insight into another form of tobacco use that is potentially propagating its spread especially in the South Asian region – chewed tobacco. Both of these have been a perennial issue that head and neck cancer surgeons have been dealing with. Governments and Head and Neck cancer care providers now have an opportunity to deal with a common enemy in the midst of this pandemic.
Background: Pulmonary complications and infections frequently affect patients with head and neck squamous cell carcinoma (HNSCC). Common characteristics can predispose these patients to the development of severe respiratory illness, which may be particularly relevant during the 2019 coronavirus disease (COVID-19) pandemic. Methods: A scoping review was performed to assess the impact of pulmonary comorbidities and adverse respiratory outcomes in HNSCC patients. Results: Advanced age, history of tobacco and alcohol abuse, and cardiopulmonary comorbidities are significant risk factors for the development of adverse respiratory outcomes. Treatment toxicities from radiation or chemoradiation therapy significantly increase these risks. Conclusion: Respiratory complications are a frequent cause of morbidity and mortality among HNSCC patients, and the COVID-19 pandemic may disproportionately affect this population. Interventions designed to decrease smoking and alcohol use, improve oral hygiene, and aggressively manage medical comorbidities are important to the long-term management and health of these patients.
The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our healthcare system by the Coronavirus Disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.
Background: COVID-19 pandemic has strained human and material resources around the world. Practices in surgical oncology had to change in response to these resource limitations, triaging based on acuity, expected oncologic outcomes, availability of supportive resources, and safety of healthcare personnel. Methods: The MD Anderson Head and Neck Surgery Treatment Guidelines Consortium devised the following to provide guidance on triaging Head and Neck cancer (HNC) surgeries based on multidisciplinary consensus. HNC subsites considered included aerodigestive tract mucosa, sinonasal, salivary, endocrine, cutaneous, and ocular. Recommendations: Each subsite is presented separately with disease-specific recommendations. Options for alternative treatment modalities are provided if surgical treatment needs to be deferred. Conclusion: These guidelines are intended to help clinicians caring for HNC patients appropriately allocate resources during a healthcare crisis, such as the COVID-19 pandemic. We continue to advocate for individual consideration of cases in a multidisciplinary fashion based on individual patient circumstances and resource availability.
AUTHORSVelda Ling Yu Chow MD, MS, Jimmy Yu Wai Chan MD, MS, PhD, Valerie Wai Yee Ho MD, George Chung Ching Lee MD, BDS, Melody Man Kuen Wong MD, Stanley Thian Sze Wong BSc, PhD, Wei Gao, BSc, MSc, PhDCORRESPONDING AUTHORVelda Ling Yu Chow MD, MSDivision of Head and Neck SurgeryDepartment of SurgeryUniversity of Hong Kong Li Ka Shing Faculty of MedicineQueen Mary HospitalADDRESS FOR CORRESPONDANCE AND REPRINTDivision of Head and Neck SurgeryDepartment of SurgeryUniversity of Hong Kong Li Ka Shing Faculty of MedicineQueen Mary Hospital102 Pokfulam Road,Hong Kong SAR, ChinaTelephone: +852 2255 2208Fax: +852 2819 3780E-mail: firstname.lastname@example.org
Kimberley L Kiong MBBS 1 , Theresa Guo MD 1 , Christopher MKL Yao MD 1 , Neil D Gross MD 1 , Matthew M Hanasono MD 2 , Renata Ferrarotto, MD 3 , David I Rosenthal MD 4 , Jeffrey N Myers MD 1 , Ehab Y Hanna MD1, Stephen Y Lai MD 1 1 Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 2 Department of Plastics and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 3Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States. 4Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States Corresponding author: Stephen Y Lai, MD PhD Professor Patient Safety Quality Officer The University of Texas MD Anderson Cancer Center Department of Head and Neck Surgery Division of Surgery 1515 Holcombe Blvd, Unit 1445 Houston, TX 77030 email@example.com This work did not receive any grant support and has not been presented at any meeting Running title: Changing Head & Neck surgical practice during COVID-19 Keywords : Otolaryngology, Oncology, SARS-CoV2 Abstract: Background: The COVID-19 pandemic has changed healthcare, challenged by resource constraints and fears of transmission. We report the surgical practice pattern changes in a Head and Neck Surgery department of a tertiary cancer care center and discuss the issues surrounding multidisciplinary care during the pandemic. Methods: We report data regarding outpatient visits, multidisciplinary treatment planning conference, surgical caseload, and modifications of oncologic therapy during this pandemic and compared this data to the same interval last year. Results: We found a 46.7% decrease in outpatient visits and a 46.8% decrease in surgical caseload, compared to 2019. We discuss the factors involved in the decision-making process and perioperative considerations. Conclusions: Surgical practice patterns in head and neck oncologic surgery will continue to change with the evolving pandemic. Despite constraints, we strive to prioritize and balance the oncologic and safety needs of patients with head and neck cancer in the face of COVID-19. IntroductionThe rapid spread of the novel coronavirus 2019 (COVID-19) has disrupted healthcare systems globally. Some of the biggest challenges include shortage of hospital beds, healthcare workers and personal protective equipment (PPE). Given these constraints, there has been a simultaneous push for a reduction in elective clinical practice, to further reduce transmission and conserve resources 1.Cancer care is generally not considered elective and decision making about when to initiate or delay treatment during the pandemic has raised complex ethical and resource utilization issues. Yet amidst the pandemic, patients continue to develop and seek treatment for cancer. Head and neck cancers (HNC) can challenge essential functions such as eating, speaking and breathing. Tumor doubling time ranges between 15 to 99 days 2,3 and delaying treatment decreases survival and contributes to adverse outcomes 4,5. As such, there are recommendations for prompt initiation of treatment of HNC after diagnosis and to reduce the total treatment package time6,7. In an effort to limit the potential adverse effects of delaying cancer treatment during this pandemic, an increasing number of oncology guidelines have been developed, both general and specific to HNC 8,9.At the University of Texas MD Anderson Cancer Center (MDACC), our Head and Neck surgical practice has gradually changed as a result of evolving internal and external guidelines (Table 1). Harris County, Texas reported its first COVID-19 case on March 5th, 2020. Since then, the number of cases has been steadily rising with the current incidence at 35 per 100,000 residents in Texas 10. At the institutional level, MDACC has taken many pre-emptive actions and policy changes in response to the growing pandemic (Table 1).The institutional policies described have served to limit hospital attendances in anticipation of a surge in COVID-19 cases in the region. The number of new patients visits to the institution have decreased from 782/week in the first week of March to 207/week in the last week of March (-73.5%) while systemic treatment appointments, indicative of patients already in the process of treatment, have remained fairly stable (3864 to 3288 visits, -14.9%). As a downstream effect, the number of diagnostic imaging visits has decreased from 9616 to 3971 (first and last weeks of March respectively, -58.7%). Surgeries within the institution have shown a more drastic decrease, from 463 to 149 cases per week (-67.8%). Current institutional census at the time of writing (April 7th, 2020) shows 55% general bed occupancy and 35% ICU occupancy. The numbers will continue to change in response to the development of COVID-19 within the region, as we have not yet reached the peak of infection. Predictive models have suggested that the peak in COVID-19 cases will occur at the end of April11 and there are institutional plans on standby to repurpose physical facilities and the workforce to shift focus from oncology care to COVID-19 treatment if needed.In the context of the developing pandemic and tightening institutional guidelines, we seek to understand the early impact of the COVID-19 pandemic on head & neck oncologic surgery practices. We performed a review of outpatient clinic and surgical caseload within the MDACC Head and Neck Surgery department during the pandemic and compared this to the same time period in the preceding year, along with the deviations in management of patients due to COVID-19.
Flora Yan, BA1; Shaun A. Nguyen, MD11: Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina.Word Count: 1,260Conflicts of Interest: None to DiscloseCorresponding Author:Flora YanDepartment of Otolaryngology – Head and Neck Surgery135 Rutledge Avenue, MSC 550, Charleston, SC firstname.lastname@example.orgAbstractSince first identified in December of 2019, COVID-19 has disseminated from Wuhan, China rapidly across the globe. 5-8% of these COVID-19 patients are estimated to become critically ill and will require ICU admission. Predictors of severe/critical ill COVID-19 disease may include increasing age, smoking status, immunosuppression and chronic conditions such as cardiovascular disease, diabetes, hypertension and also cancer. In this brief correspondence, we first describe the outcomes of critically ill patients with and without cancer and extrapolate these findings to the head and neck cancer population.Dear Dr. Hanna,Since first identified in December of 2019, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has disseminated from Wuhan, China rapidly across the globe. On March 11th, 2020 the World Health Organization deemed Coronavirus Disease 2019 (COVID-19) a worldwide pandemic, with the global community in a state of emergency.1 As of April 10th, 2020, 1.6 million COVID-19 cases have been reported worldwide.2 Case-fatality rate have ranged from 2% to 7%.3 Clinically, COVID-19 is initially characterized by a constellation of non-specific symptoms such as cough, fever, and dyspnea. However, this can escalate quickly, with the median time from symptom onset to severe hypoxemia necessitating ICU admission seen to be from 7 to 12 days.4-6 It is clear certain populations such as patients with coexisting conditions, older age, an immunocompromised state and a smoking history are at a high risk for severe disease as well as poor outcomes.7 Head and neck cancer patients are placed in a vulnerable state and may equally be of high-risk to the consequences of COVID-19, given their immunosuppressed state from cancer and corresponding treatment as well as high prevalence of the aforementioned risk factors. In this correspondence, we aim to discuss sequelae of severe COVID-19 disease, in addition to describing head and neck cancer patients as a high-risk population.The majority of COVID-19 cases are of mild severity, however 5-8%5,8 of COVID-19 patients may become critically ill, experiencing respiratory failure, septic shock and/or multi-organ failure. This necessitates admission into the intensive care unit (ICU). Two-thirds of these critically ill patients have met criteria for acute respiratory distress syndrome (ARDS) and require advanced respiratory support. The acute severity and rapid progression of COVID-19 is illustrated with over 63% requiring invasive mechanical ventilation in the first 24 hours of admission.9 Mortality of COVID-19 patients in the ICU has been estimated to be 50%7,10. Of these, patients of older age > 70 years old and with severe comorbidities were seen to have mortality rates of 68 and 59%, respectively.9 As defined by the Center for Disease Control’s weekly morbidity and mortality report regarding COVID-19, these comorbidities may include diabetes mellitus, chronic lung disease, cardiovascular disease, chronic renal disease, and other chronic disease, of which a history of cancer falls under.11ARDS secondary to COVID-19 requires time on mechanical ventilation than is usually required. Bhatraju et al.7 reports a median of 10 days of time on mechanical ventilation before COVID-19 patients were extubated. This is in comparison to 3 to 8 days seen on average for non-COVID related indications for mechanical ventilation.12 Even then, most patients are unable to wean off mechanical ventilation, as seen by a tragically high mortality rate of COVID-19 patients on mechanical ventilation (Table 1) . The Intensive Care National Audit & Research Centre (ICNARC) demonstrated a 67.3% mortality rate of patients receiving advanced (i.e. non-invasive or invasive ventilation, tracheostomy or extracorporeal respiratory support) respiratory support.9 Studies from China examining critically ill COVID-19 patients placed on mechanical ventilation have reported mortality rates of 81% to 97%.4,5 A Seattle-based analysis of critically ill patients on mechanical ventilation saw a comparatively lower mortality rate of 50%, however at the time of this study 3 were still on mechanical ventilation without recovery from COVID-19.7 These extraordinary high mortality rates of patients on mechanical ventilation, ranging from 50% to 97%, may reveal that full intensive care support and life-sustaining therapies still cannot overcome the poor prognosis of certain high-risk populations afflicted by COVID-19. Deterioration despite mechanical ventilation may be confounded by multi-organ system failure. Those who fail mechanical ventilation may be placed on extracorporeal membrane oxygen (ECMO) therapy as end of the line care, however this is often accessible in most hospital systems. In fact, even with substantial cases of critically ill COVID-19 patients, ECMO therapy use has ranged from 6 to 12%.4,5As patients with cancer, especially those in active treatment or in the acute post-treatment phase, are in a particularly immunosuppressed conditions, elucidation of the course of COVID-19 in this patient population is paramount. Liang et al.13 describe a cohort of 18 cancer patients (1 [6%] of which with head and neck cancer) having a higher risk of mechanical ventilation or death (39% vs. 8%), compared to non-cancer patients. Cancer patients also more rapidly deteriorated, with a median time to a critical event taking 13 days as opposed to 43 days in non-cancer patients.Multiple other studies have described cancer patients with COVID-19. Desai et al.14 performed a meta-analysis of 11 studies describing clinical courses of COVID-19 cases and found a 2% prevalence of cancer in patients with COVID-19. Desai et al.14also discovered higher risk of severe events for patients recently treated with chemotherapy or surgery in the past 30 days, over non-cancer COVID-19 patients (75% vs. 43%).Zhang et al.15 revealed clinical characteristics of 28 COVID-19 infected cancer patients in Wuhan China, of which 3 (11%) had head and neck cancer. Of this cohort, 10 (36%) of patients required mechanical ventilation and 8 (29%) patients died. If assumed these 8 were on maximum respiratory therapy previous to death, a mortality rate of 80% can be extrapolated and is in line to mortality rates of critically ill non-cancer patients; this, however, is not explicitly validated in the study. Notably, stage IV disease was associated with higher rates of severe events (ICU admission, mechanical ventilation, or death) than stage I-III disease (70% vs 44%). Zhang et al.15 also revealed patients recently treated with chemotherapy, radiation therapy, and/or immunotherapy in the past 14 days had a 4-times increased odds of developing a severe event than those who received any treatment > 14 days.From this we can observe that 1) prevalence of cancer, active or in remission, in COVID-19 patients is higher than in the general population; 2) COVID-19 patients with cancer may deteriorate more rapidly than non-cancer patients 3) active treatment of cancer may be associated with increased risk of severe COVID-19 sequelae than in patients not undergoing treatment; and 4) critically ill COVID-19 patients who have cancer may more likely develop end-stage respiratory failure or death than non-cancer critically ill patients, barring presence of other chronic illnesses. It is difficult to ascertain how cancer patients in remission may far in comparison to the general population, however it is clear patients undergoing active treatment may present as a high-risk population for severe illness following COVID-19 infection. These observations are limited on data provided by retrospective studies of small sample sizes, and thus must be interpreted with caution.Cancer patients present as a high-risk population for COVID-19 development as well as poorer outcomes. Head and neck cancer patients in particularly may be susceptible to the deleterious effects of not only the viral pathogenesis of COVID-19 itself, but also the long-term psychosocial sequelae of intensive critical care, advanced respiratory treatment and other life-saving measures, all amidst a quarantined environment for a patient population characterized as having twice the suicide risk rate of other cancer patients. Given such high death rates of non-cancer patients on mechanical ventilation, the additive vulnerability from head and neck cancer may make severe or critical ill COVID-19 development quite fatal for our patients. Thus, more attention and perhaps additional testing for patients currently undergoing treatment may be warranted. As described in modified head and neck cancer treatment algorithms16, treatment only for advanced head and neck cancers should proceed with full precautions (i.e. COVID testing, PPE) and any possible methods to reduce nosocomial COVID-19 infection is warranted. We hope this correspondence provides insight in the high-risk of head and neck cancer patients for critical illness following COVID-19 infection.Works Cited1. World Health Organization. WHO Director-General’s opening remarks at the media briefing on COVID-19—11 March 2020. 2020; https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020.2. Worldometer. COVID-19 coronavirus pandemic. https://www.worldometers.info/coronavirus/. Accessed April 10th, 2020.3. Onder G, Rezza G, Brusaferro S. Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy.JAMA. 2020.4. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet. 2020;395(10229):1054-1062.5. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020.6. Chen N, Zhou M, Dong X, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. The Lancet.2020;395(10223):507-513.7. Bhatraju PK, Ghassemieh BJ, Nichols M, et al. Covid-19 in Critically Ill Patients in the Seattle Region — Case Series. New England Journal of Medicine. 2020.8. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239-1242.9. ICNARC COVID-19 Study Case Mix Programme Database. ICNARC report on COVID-19 in critica care. 2020; https://www.icnarc.org/About/Latest-News/2020/04/04/Report-On-2249-Patients-Critically-Ill-With-Covid-19.10. Guan W-j, Ni Z-y, Hu Y, et al. Clinical Characteristics of Coronavirus Disease 2019 in China. New England Journal of Medicine. 2020.11. CDC COVID-19 Response Team. Preliminary Estimates of the Prevalence of Selected Underlying Health Conditions Among Patients with Coronavirus Disease 2019 — United States, February 12–March 28, 2020.Morbidity and Mortality Weekly Report. April 3, 2020.12. Seneff MG, Zimmerman JE, Knaus WA, Wagner DP, Draper EA. Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest. 1996;110(2):469-479.13. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol.2020;21(3):335-337.14. Desai A, Sachdeva S, Parekh T, Desai R. COVID-19 and Cancer: Lessons From a Pooled Meta-Analysis. JCO Global Oncology.2020(6):557-559.15. Zhang L, Zhu F, Xie L, et al. Clinical characteristics of COVID-19-infected cancer patients: A retrospective case study in three hospitals within Wuhan, China. Ann Oncol. 2020.16. Day AT, Sher DJ, Lee RC, et al. Head and neck oncology during the COVID-19 pandemic: Reconsidering traditional treatment paradigms in light of new surgical and other multilevel risks. Oral Oncol.2020:104684.
Elderly head and neck cancer patients are at increased risk of adverse outcomes during and after treatment of head and neck cancer. COVID-19 severity and mortality can be expected to be significantly greater in elderly head and neck cancer patients, given that increased age, comorbidities, and presence of malignancy are known risk factors for disease severity and mortality in COVID-19 patients. Therefore, their management requires multidisciplinary consensus and patient input. A thorough geriatric assessment, which has been shown to be beneficial prior to the COVID-19 pandemic, could be particularly helpful in this patient population with the added dimension of COVID-19 risk. In many cases, prudent treatment plan modification may allow for overall best outcomes. Furthermore, recruitment of social services and, when appropriate, palliative care, may allow for optimal management of these patients.
Authors: Arjun Gurmeet Singh MDS (Oral and Maxillofacial Surgery), MFDS (Glasgow) Department of Head and Neck Oncology Tata Memorial Center and HBNI Mumbai, India (Email: email@example.com) Jayita Deodhar, MD Department of Palliative Medicine Tata Memorial Center and HBNI Mumbai, India (Email: firstname.lastname@example.org) Pankaj Chaturvedi, MS, FACS, (Corresponding Author) Department of Head and Neck OncologyTata Memorial Center, Mumbai, India (Email: email@example.com)
Introduction:The 2019 novel coronavirus disease (COVID-19) was initially identified in December 2019 in Wuhan, China. Following its spread across the globe within a matter of months, the World Health Organization classified COVID-19 as a pandemic.1 Its rapid transmission and high hospitalization rate have forced health professionals to drastically alter their practices in order to slow its proliferation. The rapid influx of COVID-19 related admissions in hospitals around the United States has led to a widespread shortage of crucial healthcare resources, particularly personal protective equipment (PPE), ventilators, and free ICU beds. Surgical procedures further deplete such resources in a time of acutely high need. Additionally, evidence has shown that healthcare workers may be particularly susceptible to infection from the causative pathogen, SARS-CoV-2, with roughly 20% of exposed professionals becoming infected in Italy.2Following these developments, the Centers for Disease Control and Prevention (CDC) recommended that all inpatient facilities postpone or cancel any elective surgeries.3 In the ensuing weeks, the American College of Surgeons and the American Academy of Otolaryngology-Head and Neck Surgery followed suit with this recommendation.4,5Furthermore, many hospitals and practices have opted to cancel in-person outpatient clinic visits, where patients oftentimes receive critical longitudinal care. Like other surgeons, otolaryngologists, and specifically head and neck surgical oncologists, have been deeply affected by these drastic measures. It is evident, however, that physicians must find ways to continue to monitor such patients’ conditions or treat them in some aspect. The popularity and prevalence of telemedicine has grown rapidly during this pandemic as many physicians have sought ways to maintain a continuum of care with their patients.6 Such initiatives have previously been shown to decrease costs, decrease visit time, and lead to high patient satisfaction in surgical fields.7,8Within otolaryngology specifically, certain telehealth assessments have been shown to allow for quicker examinations without compromising the communication of crucial information from the patient to the physician, or vice versa.9 However, the rapid implementation of telehealth has been a relatively new phenomenon during the COVID-19 pandemic, meaning that physicians oftentimes have to learn how to optimize their virtual visits to maximize their efficiency and effectiveness. In otolaryngology, telemedicine has not been routinely used to evaluate patients, despite estimates that 62% of otolaryngology patients would be amenable to virtual appointments.10Thus, it may be difficult for physicians to anticipate barriers to their care during a telehealth visit. Based on the authors’ experience, there exists a steep learning curve following the onset of such visits due to a variety of factors on both the patient’s and physician’s side.To our knowledge, there are no set guidelines or best practices for patients or head and neck cancer physicians conducting virtual visits. Drawing upon our experience, we aim to compile a set of guidelines for physicians and patients alike to navigate telehealth visits during the era of COVID-19. We also created a handout that can be distributed to patients prior to the visit, such that patients can familiarize themselves with general expectations and key examination steps that they may be asked to perform during the visit.