The Coronavirus disease-2019 (COVID-19) pandemic has rapidly spread across the world, placing unprecedented strain on the healthcare system. Healthcare resources including hospital beds, ICUs, as well as personal protective equipment (PPE) are becoming increasingly rationed and scare commodities. In this environment, the laryngectomee (patient having previously undergone a total laryngectomy) continues to represent a unique patient with unique needs. Given their surgically altered airway, they pose a challenge to manage for the otolaryngologist within the current COVID-19 pandemic. In this brief report, we present special considerations and best practice recommendations in the management of total laryngectomy patients. We also discuss recommendations for laryngectomy patients and minimizing community exposures.
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.
Introduction: The COVID-19 pandemic caused by the SARS-CoV-2 virus has put healthcare workers at risk when exposed to aerosolized viral particles during upper airway mucosal surgery. The objective of this review was to discuss topical preparations that could be utilized preoperatively to help to decrease viral load and potentially reduce the risks of viral transmission. Methods: PubMed/MEDLINE database review of articles studying topical preparations with virucidal activity against coronaviruses. Results: Povidone – Iodine (PVP-I) solutions ranging from 0.23% to 7% have been found to demonstrate highly effective virucidal activity against a broad range of viruses including several coronaviruses responsible for recent epidemics: SARS-CoV-1, MERS-CoV.
Judy Overton, BFA, MLAProgram Manager, Office of Patient Experience OfficerThe University of Texas M.D. Anderson Cancer CenterT. Boone Pickens Academic Tower1400 Pressler StHouston, Texas 77030 Kathy Denton, BS, MED, PhDThe University of Texas M.D. Anderson Cancer Center,Director, Patient ExperienceThe University of Texas M.D. Anderson Cancer CenterT. Boone Pickens Academic Tower1400 Pressler StHouston, Texas 77030 Michael Frumovitz, MD, MPHGynecologic Oncology and Reconstructive MedicineThe University of Texas M.D. Anderson Cancer CenterDan L. Duncan Building1155 Pressler StHouston, Texas 77030 Carol Lewis, MD Department of Head and Neck SurgeryThe University of Texas M.D. Anderson Cancer CenterT. Boone Pickens Academic Tower1400 Pressler StHouston, Texas 77030 Sarah Christensen, MADirector, Patient EducationThe University of Texas M.D. Anderson Cancer CenterDan L. Duncan Building1155 Pressler StHouston, Texas 77030 Jaymesson Bezerra, MSHAManager, Patient RelationsThe University of Texas M.D. Anderson Cancer CenterRotary House International 1600 Holcombe BlvdHouston, Texas 77030 Chris HernandezExec. Director, Patient Services, Patient AdvocacyThe University of Texas M.D. Anderson Cancer CenterAnderson West1515 Holcombe BlvdHouston, Texas 77030 Michele S. WalkerAssoc. Dir, Pt Advo & Pt Rel, Patient AdvocacyThe University of Texas M.D. Anderson Cancer CenterAnderson West1515 Holcombe BlvdHouston, Texas 77030 Janice P. Finder, BSN, MSN, RNDirrector, Patient Exp Clin Services, askMDAndersonThe University of Texas M.D. Anderson Cancer CenterMid Campus Building 1MC7007 Bertner AvenueHouston, Texas 77054 Ashlyn A. Proske, BSProgram Manager, askMDAndersonThe University of Texas M.D. Anderson Cancer CenterMid Campus Building 1MC7007 Bertner AvenueHouston, Texas 77054 Sanchita Jain, MBAInnovation Strategist, InnovationThe University of Texas M.D. Anderson Cancer CenterMid Campus Building 1MC7007 Bertner AvenueHouston, Texas 77054 Julai Whipple, BAInnovation Designer, InnovationThe University of Texas M.D. Anderson Cancer CenterMid Campus Building 1MC7007 Bertner AvenueHouston, Texas 77054 Wendi L. Martinez, ADN, BSN, RNDir QA & Perf Improvement, Inst Cancer Care InnovationThe University of Texas M.D. Anderson Cancer CenterMid Campus Building 1MC7007 Bertner AvenueHouston, Texas 77054 Jarod EskaInst Cancer Care InnovationThe University of Texas M.D. Anderson Cancer CenterMid Campus Building 1MC7007 Bertner AvenueHouston, Texas 77054 Elizabeth W. Sutherland, MPASPhysician Asst, Surgical OncologyThe University of Texas M.D. Anderson Cancer CenterT. Boone Pickens Academic Tower1400 Pressler St.Houston, Texas 77030 Lisa L. Triche, DNP, MS, RNAdvanced Prac Registered Nurse, Pediatrics - Patient CareThe University of Texas M.D. Anderson Cancer CenterAnderson East1515 Holcombe BlvdHouston, Texas 77054Elizabeth A. Garcia, BSN, MPA, RNAssoc VP, Patient Experience, Ofc of Chief Operating OfficerThe University of Texas M.D. Anderson Cancer Center1515 Holcombe BlvdUnit 1485Houston, Texas 77030Corresponding Author:Randal Weber, MD Chief Patient Experience Ofc, Chief Patient Experience OfficerThe University of Texas M.D. Anderson Cancer CenterT. Boone Pickens Academic Tower1400 Pressler StHouston, Texas 77030
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.
Background The COVID-19 pandemic has reduced clinical volume with a negative impact on trainee education. Methods Survey study of Otolaryngology trainees in North America, during the COVID-19 pandemic in April 2020. Results Of 216 respondents who accessed the survey, 175 (83%) completed the survey. Respondents reported a universal decrease in clinical activities (98.3%). Among participants who felt their program utilized technology well, there were significantly decreased concerns to receiving adequate educational knowledge (29.6% vs. 65.2%, p=0.003). However, 68% of trainees still expressed concern in ability to receive adequate surgical training. In addition, 54.7% of senior trainees felt that the pandemic had a negative impact on their ability to secure a job or fellowship after training. Conclusions Trainees universally felt a negative impact due to the COVID-19 pandemic. Use of technology was able to alleviate some concerns in gaining adequate educational knowledge, but decreased surgical training remained the most prevalent concern.
Introduction: The COVID-19 pandemic caused by the SARS-CoV-2 virus has altered the healthcare environment for the management of head and neck cancers. The purpose of these guidelines is to provide direction during the pandemic for rational Head and Neck Cancer management in order to achieve a medically and ethically appropriate balance of risks and benefits.Methods: Creation of consensus document.Results: The process yielded a consensus statement among a wide range of practitioners involved in the management of head and neck cancer patients in a multi-hospital tertiary care health system. Conclusions: These guidelines support an ethical approach for the management of head and neck cancers during the COVID-19 epidemic consistent with both the local standard of care as well as the head and neck oncological literature.
Background: Otolaryngologists are amongst the highest risk for COVID-19 exposure.Methods: A cross-sectional, survey-based, national study evaluating academic otolaryngologists. Burnout, anxiety, distress, and depression were assessed by the single-item Mini-Z burnout assessment, 7-item Generalized Anxiety Disorder scale, 15-item Impact of Event Scale, and 2-item Patient Health Questionnaire, respectively.Results: 349 physicians completed the survey. 165 (47.3%) were residents and 212 (60.7%) were males. Anxiety, distress, burnout and depression were reported in 167 (47.9%), 210 (60.2%), 76 (21.8%) and 37 (10.6%) physicians respectively. Attendings had decreased burnout relative to residents (OR 0.28, CI [0.11-0.68]; p=0.005). Females had increased burnout (OR 1.93, CI [1.12.-3.32]; p=0.018), anxiety (OR 2.53, CI [1.59-4.02]; p<0.005), and distress (OR 2.68, CI [1.64-4.37]; p<0.005). Physicians in states with greater than 20,000 positive cases had increased distress (OR 2.01, CI [1.22-3.31]; p=0.006). Conclusion: During the COVID-19 pandemic, the prevalence of burnout, anxiety, and distress is high among academic otolaryngologists.
Unprecedented times call for extraordinary measures. While surgeons across the globe try to comprehend the evolving façade of the COVID 19 pandemic and improvise surgical practice to the best of their ability, the psychological impact of the stress on their own mental health and wellbeing has been underestimated. This paper aims to review the indirect and overt factors that may affect the mental health of a surgeon in the present circumstances. Furthermore, it will aim to highlight key coping mechanisms at individual and institutional level, so as to mitigate the negative psychological impact on surgeons.
Background: Management of head and neck cancers (HNC) in Radiation Oncology in the COVID-19 era is challenging. Aim of our work is to report organization strategies at a Radiation Therapy (RT) Department in the first European area experiencing the COVID-19 pandemic. Methods: We focused on 1) dedicated procedures for HNC, 2) radiation treatment scheduling and 3) healthcare professionals’ protection applied during the Covid-19 breakdown (from 1st March to 30th April 2020). Results: Applied procedures are reported and discussed. Forty-three pts were treated. Image-guided, Intensity Modulated RT was performed in all cases. Median overall treatment time (OTT) was 50 (IQR: 47-54.25) days. RT was interrupted/delayed in seven pts (16%) for suspected COVID-19 infection. Two health professionals managing HNC pts were proven as COVID-19 positive. Conclusion: Adequate and well-timed organization allowed for the optimization of HNC pts balancing at the best of our possibilities pts’ care and personnel’s safety.
Background: There are no reports regarding false positive reverse transcriptase polymerase chain reaction (RT-PCR) for novel coronavirus in preoperative screening.Methods: Pre-operative patients had one or two nasopharyngeal swabs, depending on low or high risk of viral transmission. Positive tests were repeated. Results: Forty-three of 52 patients required 2 or more pre-operative tests. Four (9.3%) had discrepant results (positive/negative). One of these left the COVID unit against medical advice despite an orbital abscess, with unknown true disease status. The remaining 3 of 42 (7.1%) had negative repeat RT-PCR. Although ultimately considered false positives, one had been sent to a COVID-unit postoperatively, and two had urgent surgery delayed. Assuming negative repeat RT-PCR, clear chest imaging, and lack of subsequent symptoms represent the "gold standard”, RT-PCR specificity was 0.97.Conclusions: If a false positive is suspected, we recommend chest computed tomography and repeat RT-PCR. Validated immunoglobulin testing may ultimately prove useful.
The coronavirus disease 2019 (COVID-19) pandemic has become a major public health crisis. The diagnostic and containment efforts for the disease have presented significant challenges for the global healthcare community. In this brief report, we provide perspective on the potential use of salivary specimens for detection and serial monitoring of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), based on current literature. Oral healthcare providers are at an elevated risk of exposure to COVID-19 due to their proximity to nasopharynx of patients, and the practice involving the use of aerosol-generating equipment. Here we summarize the general guidelines for oral healthcare specialists for prevention of nosocomial transmission of COVID-19, and provide specific recommendations for clinical care management.
Background: Diagnosis of Severe Acute Respiratory Coranavirus-2 (SARS-CoV-2) infection is currently based on Real-Time PCR (RT-PCR) performed on either nasopharyngeal (NPS) or oropharyngeal (OPS) swabs; saliva specimen collection can be used, too. Diagnostic accuracy of these procedures is suboptimal, and some procedural mistakes may account for it.Methods and results: The video shows how to properly collect secretions from the upper airways for non-serologic diagnosis of COVID-19 by nasopharyngeal swab (NPS), oropharyngeal swab (OPS), and deep saliva collection after throat-cleaning manoeuvre, all performed under videoendoscopic view by a trained ENT examiner.Conclusions: We recommend to perform NPS after elevation of the tip of the nose in order to reduce the risk of contamination from the nasal vestible, and to let it flow over the floor of the nasal cavity in parallel to the hard palate in order to reach the nasopharynx. Then the tip of the swab should be left in place for few seconds, and then rotated in order to achieve the largest absorption of nasopharyngeal secretions. Regards OPS, gentle anterior tongue depression should be used to avoid swab contamination from the oral cavity during collection of secretions from the posterior pharyngeal wall. These procedural tricks would enhance diagnostic reliability.
The COVID-19 pandemic has had a significant impact on many aspects of head and neck cancer care. The uncertainty and stress resulting from these changes has led many patients and caregivers to turn to head and neck cancer advocacy groups for guidance and support. Here we outline some of the issues being faced by head and neck cancer patients during the current crisis and provide examples of programs being developed by advocacy groups to address them. We also highlight the increased utilization of these organizations that has been observed as well as some of the challenges being faced by these not-for-profit groups as they work to serve the head and neck community.
Background: As reported by increasing literature, a significant number of patients with SARS-CoV-2 infection developed smell/taste disorders.Aim of this study is to determine prevalence and severity of these symptoms among laboratory confirmed SARS-CoV-2 patients. Secondary objective is to determine their onset/recovery time.Methods: This cross-sectional study was conducted from March 10th to March 30th 2020 at Novara University Hospital during the COVID-19 Italian outbreak. The 355 enrolled patients answered a questionnaire at 14th (or more) days after proven infection.Results: The overall population prevalence of both smell/taste or one of the two disorders was 70%. They were first symptoms in 31 (8,7%) patients.Most patients reported a complete loss that in half of the cases (49.5%) was fully recovered after 14 days, with a median recovery time of 10 days.Conclusion: This study confirms high prevalence of smell/taste disorders in COVID-19 infection with self-recovery for half cases after about two weeks.
Much has been discussed about the curve of COVID-19 as it ravages through our countries, our cities, our homes. Politicians readily refer to it in addressing the various nations of the world. They ask us to “flatten the curve to save lives” 1,2. Effectively, the way to flatten the curve is to abide by social distancing measures.Nevertheless, even among medical specialists, there are common misconception about the curve and how it affects population outcomes. Understanding the fundamental characteristics of a problem can allow us to see the problem with more clarity. Herein, I aim to provide a simple understanding of the various population dynamics at play. We will review how principles such as the area under the curve and thethreshold of capacity can be conceptualized.The discussion will begin as rudimentary. However, it will add gentle layers of complexity. Hopefully, by the end, it will provide the reader a sense of insight.
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
Oreste Gallo, MD; Luca Giovanni Locatello, MDDepartment of Otorhinolaryngology, Careggi University Hospital, Florence - Largo Brambilla, 3 - 50134 Florence, Italy* Corresponding author: Prof. Oreste Gallo, MD, Department of Otorhinolaryngology, Careggi University Hospital, Florence - Largo Brambilla, 3 - 50134 Firenze, Italy. +39 0557947989, oreste.gallo at unifi.itKeywords: COVID-19, laser-assisted surgery, surgical plume, prevention, surgical safetyAuthors’ contributions: Gallo: Conceptualization, supervision and writing - review and editing; Locatello: Conceptualization, resources, supervision, and writing - review and editing.Conflict of Interest: all authors declare they have nothing to disclose.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Many of the safety issues related to the novel COVID-19 in our routine surgical practice were thoroughly presented in this Journal.  However, the authors did not discuss an important field of head and neck surgery: laser-assisted procedures. Historically, human-papillomavirus (HPV) in the setting of respiratory recurrent papillomatosis is the prototype of the biological hazards of the laser-generated surgical plume. In the past, it was shown that surgical vaporization was capable to contaminate the staff’s personal protective equipment (PPE) with viable and infectious HPV virions.  Despite the growing evidence documenting a key role of high-risk HPV infections in the pathogenesis and development of head and neck cancer, the risk assessment of potential viral infection after exposure to laser plume is still controversial.  The biohazard might not be limited to HPV airborne transmission, but also other bacteria and viruses, including (possibly) SARS-CoV-2. For instance, Kwak et al. documented Hepatitis B (HBV) DNA in surgical smoke from 10 out of 11 HBV+ patients undergoing robotic laparoscopic surgery thus suggesting a potential risk of airborne HBV infection. Heat-generating procedures by electrosurgical equipment or lasers can induce thermal disruption of viable human cells and they are able to aerosolize hazardous particles. The thermal effect of lasers on biological tissues is a complex process resulting from the conversion of light to heat whose effects depend upon several factors: the physical denaturation and/or destruction is a function of laser settings (wavelength, power, time and mode of emission, beam profile, and spot size) and the target of the procedure (thermal parameters, optical coefficient, etc.).[5,6] During ablative surgery, the tissue is heated by the absorbed laser energy and it evaporates or sublimates, while, at higher power, the tissue is typically converted to plasma. This means that during laser-tissue interaction aerosolized blood and interstitial and intracellular fluids, along with their possible burden of viral pathogens and hazardous chemicals are forcefully ejected in the operating room. Nonetheless, controversies exist in the literature regarding efficient viral infection of healthcare staff after exposure to surgical smoke. [3,5,6]Surgical use of different types of lasers (CO2, Nd:YAG, KTP…) is common not only in the head and neck but also in gynecology, dermatology, and respiratory medicine among other fields. Even though there is a lack of conclusive data on plume-borne contamination, there is an urgent need to raise awareness of its risks during the COVID-19 pandemic. In the next years, our daily practice of transoral laser-assisted surgery, an incontournable strategy to treat several benign and malignant lesions of the upper aerodigestive tract with excellent oncological and functional results, is going to be deeply modified. High viral loads, especially in the nose and the pharynx, can be detected after symptom onset but general consensus exists on SARS-CoV-2 diffusion by droplet transmission even from asymptomatic individuals, therefore it is conceivable that every laser procedure is to be considered as high-risk.While waiting for more robust specific evidence, we would like to recall some precautionary measures, inspired by the most recent literature, that ought to be implemented for all laser-assisted procedures:Always discuss alternative therapeutic strategies in a multidisciplinary team and postpone laser therapy if it is not urgent;Perform RT-PCR test for detection of SARS-CoV-2 RNA before every procedure;During routine preoperative exams, non-enhanced chest computed tomography is reported to have a higher sensitivity for COVID-19 detection than RT-PCR;For small and easily accessible lesions, resection by cold instruments should be preferred;Laser surgery should be performed in an operating room with a highly efficient negative-pressure system;Sterilize laser handpieces after use and frequently change surgical gloves, especially after direct contact with the instrument;8. All the staff should wear highly protective PPE, including goggles and gloves and highly protective masks (i.e., N95) with gas adsorption filters;9. Disposable double plume evacuation systems with filters that remove particulates up to 0.1 microns (the so-called ULPA, ultra-low particulate air filters) should be available;10. Reduce the presence in the theater of all the unnecessary personnel and perform adequate training for all staff members to enhance awareness about the hazards of the surgical smoke in the COVID-19 outbreak.In this evolving context, head and neck laser-assisted surgery must be in all cases considered a high-risk aerosol-generating procedure and the highest attention must be paid to surgical safety until evidence-based protocols are available.