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.
IntroductionAs the novel coronavirus (2019-nCov) globally spreads, the coronavirus disease (COVID-19) pandemic is straining healthcare workers worldwide . In hospitalized patients with severe COVID-19, endotracheal intubation is one of the most common and indispensable life-saving interventions. In a recent report from the City of New York, 12% of COVID-19 patients required invasive mechanical ventilation . Since difficult weaning and prolonged mechanical ventilation represent the two most common indications for tracheostomy in Intensive Care Unit (ICU), it may play a central role in COVID-19 management . During the 2019-nCov pandemic the aerosol generating procedures, such as tracheostomy, expose physicians at high risk to contract the \soutCOVID-19 infection . Accordingly, special consideration may be done to protect otolaryngologists, general surgeons and critical care physicians from the risk of infection while performing a tracheostomy in COVID-19 patients . Percutaneous tracheostomy (PT) is routinely performed at the bedside in intensive care unit (ICU); unfortunately, a modified protocol to perform PT in COVID-19 patients included several critical steps associated with increased risk of aerosol generation, such as changing the catheter mount, repositioning the endotracheal tube cuff to the level of the vocal cords and removal of large dilator . So far, there has been no prior description in the literature of how to minimize the aerosol generation during PT. We reported a modified percutaneous tracheostomy technique aiming to minimize the risk of aerosol generation and to increase the staff safety in COVID-19 patients.
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.
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: 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.
Background. Italy was the first European country suffering from COVID-19. Healthcare resources were redirected to manage the pandemic. We present our initial experience with the management of urgent and non-deferrable surgeries for sinus and skull base diseases during the COVID-19 pandemic. Methods. A retrospective review of patients treated in a single referral center during the first two months of the pandemic was performed. A comparison between the last two-month period and the same period of the previous year was carried out. Results. Twenty-four patients fulfilled the inclusion criteria. A reduction of surgical activity was observed (-60.7%). A statistically significant difference in pathologies treated was found (p = .016), with malignancies being the most frequent indication for surgery (45.8%). Conclusions. Although we feel optimistic for the future, we don’t feel it is already time to restart elective surgeries. Our experience may serve for other centers who are facing the same challenges.
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.
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.
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: 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.
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.
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.
Background: In light of the COVID-19 pandemic, there has been a rapid increase in telemedicine visits. Otolaryngology patient satisfaction with these visits has not yet been extensively studied using a validated survey. Methods: All patients who had telemedicine visits with three head and neck surgeons, by phone or video-based platform, between March 25, 2020 and April 24, 2020. Retrospective chart reviews were conducted to determine demographic, disease and treatment information. Patients who had a video visit were contacted by telephone and, if they could be reached and consented, were administered the Telehealth Usability Questionnaire (TUQ).Results: 100 surveys were completed. The average score across all questions was 6.01 on a scale from 1-7, where 7 indicated the highest level of patient agreement. The highest scores were for questions related to satisfaction with telehealth (6.29), while the lowest were related to reliability (4.86). Conclusions: Patients are generally highly satisfied with telemedicine.
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.
Background : Testing for SARS-CoV-2 is important for decision making prior to surgery in otolaryngology. An understanding of current and developing testing methods is important for interpreting test results.Methods : We performed a literature review of current evidence surrounding SARS-CoV-2 diagnostic testing highlighting its utility, limitations, and implications for otolaryngologists.Results : The currently accepted RT-PCR test for SARS-CoV-2 has varying sensitivity according to which subsite of the aerodigestive tract is sampled. Nasal swab sensitivities appear to be about 70%. Chest CT imaging for screening purposes is not currently recommended.Conclusion : Due to the current sensitivity of RT-PCR based testing for SARS-CoV-2, a negative test cannot rule out COVID-19. Full PPE should be worn during high risk procedures such as aerosol generating procedures even if testing is negative. Patients who test positive during screening should have their surgeries postponed if possible until asymptomatic and have tested negative for SARS-CoV-2.
Objective : To investigate olfactory dysfunction (OD) in patients with mild COVID-19 through patient-reported outcome questionnaires and objective psychophysical testing.Methods : COVID-19 patients with self-reported sudden-onset OD were recruited. Epidemiological and clinical data were collected. Nasal complaints were evaluated with the sino-nasal outcome-22 (SNOT-22). Subjective olfactory and gustatory status was evaluated with the National Health and Nutrition Examination Survey (NHNES). Objective OD was evaluated using psychophysical tests.Results : Eighty-six patients completed the study. The most common symptoms were fatigue (72.9%), headache (60.0%), nasal obstruction (58.6%) and postnasal drip (48.6%). Total loss of smell was self-reported by 61.4% of patients. Objective olfactory testings identified 41 anosmic (47.7%), 12 hyposmic (14.0%), and 33 normosmic (38.3%) patients. There was no correlation between the objective test results and subjective reports of nasal obstruction or postnasal drip.Conclusion : A significant proportion of COVID-19 patients reporting OD do not have OD on objective testing.