Background: The Coronavirus disease – 2019 (COVID-19) pandemic is a global health crisis and Otolaryngologists are at increased occupational risk of contracting COVID-19. There are currently no uniform best-practice recommendations for Otolaryngologic surgery in the setting of COVID-19.Methods: We reviewed relevant publications and position statements regarding the management of Otolaryngology patients in the setting of COVID-19. Recommendations regarding clinical practice during the Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks were also reviewed.Results: Enhanced personal protective equipment (N95 respirator and face shield or powered air-purifying respirator, disposable cap and gown, gloves) is required for any Otolaryngology patient with unknown, suspected, or positive COVID-19 status. Elective procedures should be postponed indefinitely, and clinical practice should be limited to patients with urgent or emergent needs. Conclusion: We summarize current best-practice recommendations for Otolaryngologists to ensure safety for themselves, their clinical staff, and their patients.
The year 2020 began quietly, except for the news of a novel virus outbreak, felt to be a local problem in Wuhan, China. In the United States, economy was booming and the world had great expectations of a wonderful 2020., What followed has stunned the world with a ‘never seen before’, calamity, the Covid-19 Pandemic, , with over one and a quarter million individuals infected, and over 70000 lives lost so far.. The havoc created by this global tragedy has impacted upon many lives in many ways. We need to quickly think and to plan, as to how our professional and personal lives will be conducted in the days, weeks, months and years ahead.At the moment there is total chaos, in every part of the world, particularly in New York city. The day to day life is disrupted, regular patient care of diseases and cancers is in disarray, with the focus of medical care shifted to the management of patients with Covid-19. Surgery is limited to emergencies, and cancer cases that can be, are postponed without a negative impact on their outcome. The Great majority of hospital beds are occupied by Covid-19 patients, and sudden make shift hospitals are created to accommodate the surge. Temporary morgues in refrigerated trucks are to be seen at every local hospital in New York city to “house’ the over 4700 patients who have died in the last two weeks. What comes next, and when this will end is unknown; our future, and the future of the world is frightening in its uncertainty.With a fragile future, how do we conduct our day to day activities, and plan to retain our robust education and training programs, to educate and train the next generation of Head and Neck Surgeons? The major onslaught of the first wave of cases and mortality from those exposed to the disease may slow down in the weeks to come, as observed in China, but life is unlikely to return to normal in the foreseeable future. “Business as usual” will not work, since we do not know the impact of the aftermath of this Pandemic, the risk of a rebound second cycle of splurge in the number of cases worldwide in the fall and winter, and the potential risk of annual outbreaks from Covid-19., We have great expectations from our scientists, that we will find a therapeutic solution for the treatment of Covid-19, and great hopes that a vaccine would be developed in the future to prevent infection. , We have to develop strategies, to modify, devise and reshape our current methods of education and training to sustain a robust training program and continue to support our current work force geared to educate and train succeeding generations of students and trainees. (1) The drastic changes that have affected our work and life during the past two months, has taught us, that remote communications, education, teaching, learning and training is possible, and has to be incorporated in our current systems.Communications: Human communication for ever has been practiced on a one to one basis with the production of sounds/ verbal speech and the ability to hear and interpret spoken words. Science and technology permitted the transmission of spoken words to be heard at a distance with the introduction of the megaphone. Advancing technology, gave us the Radio to hear people from remote distances, and television gave us the capability to see and hear people ‘live’ from remote distances. The internet and development of social media made human communications, a ‘norm’ in the current generation. We can now communicate with not one but multiple individuals thru multiple platforms and applications. The development of these technologies in remote communication can easily be applied to remote learning.Academic Activities: The usual academic activities occupying good part of our working week involves, Lectures, Grand Rounds Tumor Boards, Case conferences, Journal clubs and other similar activities. All of these activities had required, physical presence and an assembly of individuals, but, we have come to realize that nearly all of these activities can be conducted remotely thru the internet. Live video lectures, and Grand Rounds can be easily and effectively delivered thru webex or zoom conferencing where hundreds of people are able to see / hear the speaker live with the ability to interact with two way conversations. Case conferences and tumor boards can be conducted quite effectively on these platforms with screen sharing. The need to be ‘physically present’ is not essential for conducting most academic activities. Even after the passing of the current pandemic, such activities may continue to be conducted on such platforms. This would be convenient and effective, and can offer such activities to an even larger audience. We can imagine a future where every Institution and Academic Center will have an open “on line book”,where every learning activity is available to world..Remote Learning: With easy access to internet in every part of the world, remote learning has become a way of life in many domains of education and learning. This is vividly demonstrated by a plethora of on line courses available from many Universities around the world. In the specialty of Otolaryngology / General Surgery / and Head and Neck Surgery, even operative surgery is possible to be learnt, by watching expertly demonstrated surgical procedures performed by leading surgeons and surgical educators, on the web sites of the American College of Surgeons (ACS), American Academy of Otolaryngology Head and Neck Surgery,(AAOHNS), the International Federation of Head and Neck Oncologic Societies (IFHNOS) and other similar organizations., Remote learning in all domains of surgical education is feasible and available.Validation and Certification: Testing and examinations have traditionally required the candidates to report to a designated location, where the examination in paper form is handed to the candidates to be completed in the designated time frame, while a proctor is supervising the candidates. That is no longer necessary. Multiple choice written examinations can be taken securely on line, with defined time limits.. Many Universities and Colleges offer these examinations coordinated and conducted by commercial examination companies such asExam Soft. Offering such examinations on line is less labor intensive, more cost effective, more practical and may attract a larger number of students from remote locations to participate.Traditionally oral examinations are conducted “in person”, where the candidate and the examiner /s, meet in private and conduct face to face conversation with questions and answers. The purpose of this exercise is to assess the candidates immediate assessment,judgment and knowledge However, with modern technology and two way private video platforms , such an encounter can be effectively conducted remotely. .Global On Line Fellowship(GOLF): The IFHNOS has taken a lead on developing the first remote learning , on line fellowship program in head and neck surgery and oncology, which has been in existence for the past six years. (2) The Global On Line Fellowship (GOLF) program was introduced in 2014. It is a two year curriculum, with seven written multiple choice on line examinations, a one month of observership and an oral examination. (www.ifhnos.net/global ). Nearly 400 candidates have registered from 48 countries during the past six years, and 244 have graduated. The goal of this program is to improve the knowledge base and judgment of surgeons in their own home environment, without displacing them, within their resources, in their institution or place of practice, and on their own patients. This program has been very successful and is received enthusiastically in all parts of the world. In the past the oral examinations were conducted on site in various locations in Australasia, Central Asia, Europe and Latin America. Beginning this year, IFHNOS plans to conduct the oral examinations on line, either using Webex , Zoom, or a similar technological platform.Telemedicine: Medical consultations, conversations and office visits in the private office or in clinics is the mainstay of practice inhead and neck surgery, where follow up visits form a large percentage of our office or clinic volume. With the risk of loco regional failure of up to 40% and the risk of developing multiple primaries approaching 35%, post treatment follow up or surveillance have been emphasized thru decades. This takes a significant amount of investment of time , effort and personnel on the part of the clinician, and an expense, in travel and investment of time away from work and home on the part of the patient. In the past when surgery was the only treatment of mucosal cancers of the head and neck the follow up schedule recommended was very laborious. The common practice was once a month the first year, every other month the second year, every three months the third year, every four months the fourth year, and every six months thereafter. After discovery of a second primary or a recurrence patients were put back on the same schedule. In head and neck surgery the stringent follow up schedule was designed on the basis that nearly 80% of the patients who were to recur, would have recurred in the first 24 months, with a median time to recurrence of 9 months. However, with the combination of surgery and radiotherapy, the loco regional recurrence rates declined significantly, and the median time to recurrence was also prolonged. Thus the need to see the patients every month in the first year, or every two months in the second year, became less compelling. Many have argued against such intensive physician /patient personal interactions, and suggested less stringent follow up schedules. Multiple trials of close follow up vs less stringent follow up for similar staged patients have been proposed, but rarely accepted or came to fruition. (3). The absolute benefit of detecting an asymptomatic recurrence or a new primary during routine follow up examination is questioned, compared to the patient who reports for examination when the earliest symptoms develop suggesting a recurrence. Although, there are no randomized trials to compare this, the probability of a major difference in outcome is unlikely. In addition, only a very small number of patients are found to have recurrence or a new primary which is totally asymptomatic during a routine follow up examination. Some institutions and practices have transitioned the follow up care of low risk patients to “survivorship clinics” run by Physician Assistants / Advanced practice providers (APP) or nurse practitioners. This second level of care for low risk patients will reduce the follow up volume for the clinician, but will still not do away with the inconvenience of travel, and investment of time and cost of the service, on the part of the patient.It is in this arena, that telemedicine will play an important role. Many patients who are at low risk of recurrence can be followed by telemedicine on a video call. If during that call, the care giver finds the need for a close physical examination, the patient may be asked to see his / her primary care physician, closer to home, and a clinical picture, intra oral photograph or a picture of larynx / pharynx done with a fiberoptic laryngoscope can be sent to the head and neck surgeon. Imaging studies can be read and reviewed on line and avoid the need for “physical presence” of patient and surgeon. This practice will require a culture change amongst head and neck surgeons, and their trainees. We will have to train our Residents / Fellows in developing a work ethic of practicing telemedicine.Physician compensation for remote consulatation: . The current methodology of payment is “procedure” based. (CPT). To adequately compensate the specialist for his time, talent, expertise and opinion, a new methodology or codes will need to be developed from current procedural terminology (CPT) to current expertise terminology (CET). An entirely new payment schedule will be required dependent on the extent of consulattion; mail review, telephone, video consultation, tumor board , involving multiple physicians will all require redefinition. For many institutions, including our own this already exists for the International patient, and has been high lighted by the current Covid outbreak..Fellowship Training: The events experienced in the past few weeks has put a significant strain on the practice of medicine in general, and head and neck surgery in particular. They have forced us to think and develop strategies for transition of our current practices in patient care, education and training to innovative solutions, and prioritize the levels of patient care. Only within the past several days numerous guide lines have appeared in all media and means of communications to strategize the optimal use of operating room space and staff. Conduct of safe surgery avoiding exposure to aerosolized viral transmission, and prioritizing patients at high risk of an adverse outcome if surgery is not performed have been put into practice. Routine and elective cancer surgery is being postponed. If the pandemic continues for several months, the current fellows in training will not have the volume of the required surgical cases to gain the experience necessary for completing the fellowship. One solution to address this problem is to extend their fellowship by 3-6 months. However, this may prove to be impractical due to a variety of reasons. These include, commitments made to incoming fellows who will start their training on July 1st , additional salary support, housing, and the fellows themselves may have made personal or professional commitments for their respective post fellowship careers. We will need to develop ongoing tele education, much as is being done with the IFHNOS GOLF program , with similarly defined goals and expectations to be met before certiifcation Another potential solution is to implement regular operative techniques group discussions with faculty members with video demonstration of surgical techniques highlighting the finer details of operative procedures and the “dos” and “donts” in the operative procedure.Experiencing the huge impact of the Covid Pandemic on the society and economy of the globe, and the severe strain it has put on the health care systems has been a humbling experience. It has brought the realization, that all medical and surgical training programs, have a component of disaster management.Surgical manpower: We need a complete reassesment of man power needs, how many surgeons were lost during this Pan endemic? How many more Senior surgeons have elected to take early retirement/ were some lost to Covid? What are the manpower needs for increasing remote evaluation? What new technology is needed ?Current platforms like Zoom , cannot handle the chaos . what are the Privacy issues of remote consultation ?We have many challenges to face, but with challenge comes opportunity.The challenge created by the Covid-19 Pandemic has brought reality to life and humility in our minds, and has given us the appreciation of the “luxuries and comforts” in which we practiced, taught and trained head and neck surgery. I have shared my thoughts for dealing with these difficult times , and any such future calamity that may come, to keep our education and training programs sustainable by embracing technology and alternative means to teach and train our younger generation.Acknowledgment: The author appreciates the input from Dr. Murray Brennan, Director of the International Center of Memorial Sloan Kettering Cancer Center, in the preparation of this manuscript.Full author list: Jatin P. Shah, MD, PhD(Hon), DSc(Hon), FACS, FRCS(Hon), FDSRCS(Hon), FRCSDS(Hon), FRCSI(Hon), FRACS(Hon) Prof. of Surgery, E W Strong Chair in Head and Neck Oncology Memorial Sloan Kettering Cancer Center, New York, NY. 10065. e mail: [email protected]:Shah JP. Training of a Head and Neck Surgeon. In Head and Neck Surgery by DeSouza C. pp 1514-1526. Jaypee publishers, , India 2009.Shah J,, O’Neil P., and Brennan M. Global On line fellowship. JACS. 2020. (In press)Shah J and Harrison L. Personal communication. (1996)
The COVID-19 pandemic has upended head and neck cancer care delivery in ways unforeseen and unprecedented. The impact of these changes parallels other fields in oncology, but is disproportionate due to protective measures and limitations on potentially aerosolizing procedures and related interventions specific to the upper aerodigestive tract. The moral and professional dimensions of providing ethically appropriate and consistent care for our patients in the COVID-19 crisis are considered herein for head and neck oncology providers.
The 2019 novel coronavirus disease (COVID-19) has presented the world and physicians with a unique public health challenge. In light of its high transmissibility and large burden on the healthcare system, many hospitals and practices have opted to cancel elective surgeries in order to mobilize resources, ration personal protective equipment and guard patients from the virus. Head and neck cancer physicians are particularly affected by these changes given their scope of practice, complex patient population, and interventional focus. In this viewpoint, we discuss some of the many challenges faced by head and neck surgeons in this climate. Additionally, we outline the utility of telemedicine as a potential strategy for allowing physicians to maintain an effective continuum of care.
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
EditorialShortly after I finished delivering a keynote lecture on minor salivary gland cancers on February 23, 2020 at the Candiolo Cancer Institute in Turin, Italy, the conference chairs Drs. Giovanni Succo and Piero Nicolai announced that the conference was urgently adjourned and the rest of the program canceled. This unexpected announcement was in compliance with the Italian government’s orders to immediately end all public gatherings. Two days earlier as I set out to travel to Italy, where no cases of coronavirus infection had yet been reported, news reports were focused mostly on South Korea and Iran as hotspots of COVID-19. Out of an abundance of caution, I double-checked again before leaving for the airport and confirmed that Italy had no reported cases. Upon my arrival in Turin I was greeted by the usual warm welcome and well-known hospitality of our Italian colleagues. At the welcome reception they discussed the earlier morning report of the first five confirmed cases of COVID-19 in Lombardy region and its capital Milan. The next day, as the unplanned adjournment was announced on the first day of the 3-day conference, there were more than 120 reported cases ushering what would be the first significant outbreak in Europe. The conference chair read the Italian government emergency prohibition of public gatherings, canceling the Milan fashion week, the Venice carnival, and closing all schools and universities. But when he announced that the football (aka Soccer) game was canceled I knew that the situation was grave. As most of us know it almost takes an act of God to cancel a football game in Italy! Without delay I scrambled to get a flight back home only 24 hours after I arrived in Turin. On my way to the airport I saw on my news app that France had stopped a train of passengers from Italy and diverted it back. I was concerned about my connection in Frankfurt and ultimately getting back to USA. As I passed every step of screening and temperature checks I finally landed in Houston with a huge sigh of relief. Following instructions that were urgently sent that day, I immediately contacted our employee health at MD Anderson where I was carefully screened and cleared to go back to work.
UpdatesA general consensus exists on coronavirus diffusion by droplet transmission, especially the aerosolisation during hospital procedures like intubation or bronchoscopy might represent a big concern, exposing other patients and health-care staff to an increased risk of infection In this context, the general otolaryngology procedures may determine an aerosolisation with nosocomial amplification of the infection.In particular flexible and/or rigid nasolaryngoscopy may include some maneuvers such as puffing out your cheeks, talking, swallowing some coloured water or poking out your tongue. Further, the introduction of the endoscope may cause sneezing and cough.These risks can increase when in-office surgical procedures are applied to cure urgent and emergent pathologies such as epistaxis, removal of foreign bodies in upper aero-digestive tract, cricothyroidotomy as well as elective procedures such as biopsies, inferior turbinoplasty etc.Based on the available evidence, it appears that SARS-CoV-2 can be transmitted by asymptomatic carriers, which contributes to its basic reproduction number and pandemic potential1.Zou et al2 showed higher viral loads after symptom onset, with higher viral loads detected in the nose than in the throat. Further in the asymptomatic patients, the viral load was similar to symptomatic patients, which suggests the transmission potential of asymptomatic or minimally symptomatic patients.The common work-load of a ENT are symptoms related to upper airways inflammations or infections. Sore throat with or without fever, sneezing, hoarseness may be prodromic symptoms of a COVID-19 infection in the incubation period3. Moreover, the coughing patients with a negative chest X-ray is one of the most consultation required.Direct contact of droplet spray produced by coughing, sneezing or talking involves relatively large droplets containing organisms and requires close contact usually within 1 m 4. Indirect contact may take place after the droplets are removed from the air by surface deposition5.Han et al6 studied the dynamic features of bio-aerosolisation by sneezing. The velocity of the airflow exhaled by sneeze is much larger than that of breath and cough. Moreover, the total number of droplets generated during sneeze is also larger than that of other respiratory activities. According to the study on flow dynamics and characterization of cough, the maximum velocity of exhaled airflow can be found at t = 57–110 ms for different persons which is most likely to occur at 100 ms. Usually, sneeze lasts 0.3–0.7 s, so t = 100 ms is in the duration of the sneeze. As the velocity of the airflow exhaled by sneeze is really high, it can be assumed that the droplets that are exhaled at t =0–100 ms will not re-enter the measurement zone before t=100 ms. The high-speed airflow and corresponding turbulence produced by sneeze may also lead to a large number of droplets, i.e. the number of the droplets generated by sneeze is about 18 times larger than that of cough. Further, the size of sneezing droplets is 341.5–398.1 µm for unimodal distribution and 73.6–85.8 µm for bimodal distribution. After the droplets are exhaled into the indoor environment, the evaporation effects will strongly influence the size and mass of the droplets. The final equilibrium diameter of expiratory droplets after evaporation is highly dependent upon the temperature and relative humidity of the environment. In the indoor environment, the relative humidity and temperature are much lower than those in the respiratory tract. So the volatile content of these droplets will keep evaporating and result in the shrinkage of the droplets.Definitively, these findings demonstrate that the routine activities of an otolaryngologist are constantly at high risk of contagion in COVID-19 epidemic areas.Taking a look at the current Italian situation, the experience of the region Veneto demonstrated that the application of COVID-19 screening also in asymptomatic people can reduce the contagion spreading. Thus, it seems clear that extend the screening to all health-workers included otolaryngologists could be a valid strategy to reduce the onset of a worst case scenario, the hospital outbreak.In conclusion, the professional exposure to SARS-CoV-2 is really high for the otolaryngologist and nurse staff, even in in-office settings. Personal protective equipments are strongly recommended as well as for health-workers in close contact with infected patients.REFERENCESZhu W, Xie K, Lu H, Xu L, Zhou S, Fang S. Initial clinical features of suspected Coronavirus Disease 2019 in two emergency departments outside of Hubei, China. J Med Virol. 2020 Mar 13. doi: 10.1002/jmv.25763. [Epub ahead of print]Zou L, Ruan F, Huang M et al. SARS-CoV-2 Viral Load in Upper Respiratory Specimens of Infected Patients. N Engl J Med. 2020 Feb 19. doi: 10.1056/NEJMc2001737. [Epub ahead of print]Lauer SA, Grantz KH, Bi Q et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020 Mar 10. doi: 10.7326/M20-0504. [Epub ahead of print]Leder K, Newman D. Respiratory infections during air travel. Intern Med J. 2005 Jan;35(1):50-5.Chao CYH, Wan MP, Sze To GN. Transport and removal of expiratory droplets in hospital ward environment. Aerosol Sci Technol 2008;42, 377 – 394.Han ZY, Weng WG, Huang QY. Characterizations of particle size distribution of the droplets exhaled by sneeze. J R Soc Interface. 2013 Sep 11;10(88):20130560.
The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities.There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists and otolaryngologists. Health workers represent between 3.8% to 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter).All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55-65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Healthcare facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for cancer patients.For those who are working with COVID-19 infected patients’ isolation is compulsory in the following settings: a) unprotected close contact with COVID-19 pneumonia patients: b) onset of fever, cough, shortness of breath and other symptoms (gastrointestinal complaints, anosmia and dysgeusia have been reported in a minority of cases).For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (e.g.; rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia) it is strongly recommended that all healthcare personnel wear personal protective equipment (PPE) such as N95, gown, cap, eye protection and gloves.The procedures described are essential in trying to maintain safety of healthcare workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.
BackgroundTracheotomy, through its ability to wean patients off ventilation, can shorten ICU length of stay and in doing so increase ICU bed capacity, crucial for saving lives during the COVID-19 pandemic. To date, there is a paucity of patient selection criteria and prognosticators to facilitate decision-making and enhance precious ICU capacity.MethodsProspective study of COVID-19 patients undergoing tracheotomy (n=12) over a 4-week period (March-April 2020). Association between pre- and post- operative ventilation requirements and outcomes (ICU stay, time to decannulation, and death) were examined.ResultsPatients who sustained FiO2≤50% and PEEP≤8cm H2O in the 24h pre-tracheotomy exhibited a favourable outcome. Those whose requirements remained below these thresholds post-tracheotomy could be safely stepped down after 48h.ConclusionSustained FiO2≤50% and PEEP≤8cm H2O in the 48h post-tracheotomy are strong predictive factors for a good outcome, raising the potential for these patients to be stepped down early, thus increasing ICU capacity.
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.
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 protected] 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.
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.
Background: During the SARS-CoV-2 pandemic, tracheostomy may be required for COVID-19 patients requiring long term ventilation in addition to other conditions such as airway compromise from head and neck cancer. As an aerosol generating procedure, tracheostomy increases healthcare worker exposure to COVID-19 infection. Performing surgical tracheostomy and tracheostomy care requires a strategy that mitigates these risks and maintains the quality of patient care.Methods: A multidisciplinary review of institutional tracheostomy guidelines and clinical pathways. Modifications to support clinical-decision making in the context of COVID-19 were derived by consensus and available evidence. Results: Modified guidelines for all phases of tracheostomy care at an academic tertiary care center in the setting of COVID-19 are presented. Discussion: During the various phases of the COVID-19 pandemic, clinicians must carefully consider the indications, procedural precautions, and post-operative care for tracheostomies. We present guidelines to mitigate risk to healthcare workers while preserving the quality of care.
Background: The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) is spread through aerosol and fine droplets, and poses many challenges to medical practitioners. Otolaryngologists are at an exceptionally high-risk, due to common aerosol-generating procedures such as tracheostomy. The purpose of this study was to evaluate clinical guidelines for tracheostomy in reference to SARS-CoV-2 and provide a collective summary of recommendations.Methods: Literature review was performed. Articles reporting clinical practice guidelines for tracheostomy in the context of SARS-CoV-2 were included.Results: Tracheostomies are a common surgical procedure performed by otolaryngologists. There may be expanding indications in the COVID-19 patient population. Ventilation using a tracheostomy has many potential benefits and a summary of recommendations for tracheostomy (elective or emergent) and tracheostomy management in COVID-19 positive patients are detailed within this article. Conclusions: In patients testing positive for COVID-19, this summary of recommendations serves as a guideline along with institutional protocols.
Background: This case highlights challenges in the assessment and management of the “difficult airway” patient in the SARS-CoV-2 (COVID-19) pandemic era. Methods: A 60-year-old male with history of recent TORS resection, free flap reconstruction and tracheostomy for p16+ squamous cell carcinoma presented with stridor and dyspnea one month after decannulation. Careful planning by a multidisciplinary team allowed for appropriate staffing and personal protective equipment, preparations for emergency airway management, evaluation via nasopharyngolaryngoscopy, and COVID testing. The patient was found to be COVID negative and underwent imaging which revealed new pulmonary nodules and a tracheal lesion. Results: The patient was safely transorally intubated in the operating room. The tracheal lesion was removed endoscopically and tracheostomy was avoided. Conclusions: This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other “difficult airway” patients during the COVID-19 epidemic.
Dear Editor,At 29th of February the World Health Organization (WHO) reported 85403 confirmed globally confirmed case of COVID-19 . COVID-19 is dramatically increasing in Italy, the last report from the ministry of health on the 9th of march reported the presence of 9172 confirmed cases and 733 patients in intensive care unit (ICU) . We agree with Chan et al that physicians managing airway procedures are at particularly high risk to contract the COVID-19 infection . We support the authors that claimed for a full protective wearing including N95 respirator, gown, cap, eye protection, and gloves, during aerosol generating procedures (AGP) . However, we’d like to focus the attention on the tracheostomy procedures in COVID-19 patients since otolaryngologists, anesthesiologists and intensive care physicians are at high risk of contracting the infection during tracheostomy . Tracheostomy is required in case of prolonged mechanical ventilation and intensive care unit (ICU) stay . Surgical tracheostomy is an AGP associated with an increased risk severe acute respiratory distress (SARS) infection . Strict adherence to infection control guidelines in SARS is mandatory in performing tracheostomy in ICU or operating room .Few years ago, we proposed the double lumen endotracheal tube (DLET) for percutaneous tracheostomy in critically ill patients . DLET was equipped with an upper channel that allows passage of a bronchoscope during the percutaneous tracheostomy and with a lower channel exclusively dedicated to patient ventilation . The lower channel is equipped with a distal cuff positioned just above the carina that may allow a safe mechanical ventilation by keeping stable gas-exchange and limiting the spread of aerosol during the procedure . During the percutaneous procedure, the puncture of the anterior tracheal wall, Seldinger insertion, dilatation, and cannula positioning were all performed with the DLET correctly placed in the trachea. The DLET was removed at the end of the tracheostomy when the cannula is inserted and correctly positioned with the FFB .Surgical tracheostomy in COVID-19 patients should be done with a close collaboration between otolaryngologists, preforming the surgical procedure, and anesthesiologists or intensive care physicians managing the general anesthesia and the airway.When a surgical tracheostomy is done under general anesthesia, just before the surgeon makes the tracheal stoma, the endotracheal tube is withdrawn, so that the cuff of the tube is not in the surgical field . But when the surgeon makes the tracheal incision, ventilation is lost and the surgeon has to be quick enough to create the soma and insert the tracheostomy tube in a short time . During this procedure a large spread of aerosol may occur. To avoid the aerosol, we suggest to push down the endotracheal tube beyond the site chosen for the tracheal stoma at the beginning of the procedure. The endotracheal tube should reach the tracheal carina so the cuff is surely distal to the tracheostomy site. By checking the airway pressure and the end-tidal CO2, on the mechanical ventilator we can realize if the endotracheal tube is still in the lower tract of the trachea or in the endobronchial tract. Our previous experience with the DLET demonstrated that the endotracheal tube and the tracheal cannula can be simultaneously inserted inside the trachea . According to this, pushing down the endotracheal tube and cuffed it at the level of the carina may avoid the spread of aerosol and, then, may add an extra security for the medical staff during a procedure at high risk of generating aerosol.ReferencesCoronavirus disease 2019 (COVID-19) Situation Report – 40.https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdfItalian Minister of Health. COVID-19 Italian cases.http://www.salute.gov.it/portale/nuovocoronavirus/dettaglioContenutiNuovoCoronavirus.jsp?lingua=italiano&id=5351&area=nuovoCoronavirus&menu=vuotoChan YJK, Wong EWY, Lam W. Practical Aspects of Otolaryngologic Clinical Services During the 2019 Novel Coronavirus EpidemicAn Experience in Hong Kong. JAMA Otolaryngol Head Neck Surg. Published online March 20, 2020. doi:10.1001/jamaoto.2020.0488Vargas M, Sutherasan Y, Antonelli M, Brunetti I, Corcione A, Laffey JG, et al. Tracheostomy procedures in the intensive care unit: an international survey. Critical Care 2015;19:291-301Tran K, Cimon K, Severn M et al. Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to Healthcare Workers: A Systematic Review. . PLoS ONE 2012; 7(4): e35797. doi:10.1371/journal.pone.0035797Chun-Wing A, Yin -Chun L, Kit-Ying L. Management of Critically Ill Patients with Severe Acute Respiratory Syndrome (SARS). Int. J. Med. Sci. 2004 1(1): 1-10Vargas M, Servillo G, Tessitore G, Aloj F, Brunetti I, Arditi E, et al. Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube. A Comparison of Feasibility, Gas Exchange, and Airway Pressures. Chest 2015; 147:1267-74Walts PA, Sudish CM, DeCamp MM. Techniques of surgical tracheostomy. Clin Chest Med 24 (2003) 413 – 422
The 2019 Coronavirus Panademic challenges the delivery of care for patients with head and neck cancer. An important aspect of this care has been the evolution of enhanced survivorship services which include surveillance for recurring cancer and prevention of second primaries. The application of evidence based approaches to identification and management of treatment and tumor related toxicities has embraced the use of validated patient reported outcomes instruments (PROs), health promotion, and care coordination. In this manuscript we describe how our multidisciplinary team of survivorship providers have accommodated to the need to provide patients with social distancing while acknowledging the importance of continued care during treatment and through the spectrum of survivorship.
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.