The COVID-19 pandemic has placed an extraordinary demand on the United States healthcare system. Many institutions have cancelled elective and non-urgent procedures to conserve resources and limit exposure. While operational definitions of elective and urgent categories exist, there is a degree of surgeon judgment in designation. In the present commentary, we provide a framework for prioritizing head and neck surgery during the pandemic. Unique considerations for the head and neck patient are examined including risk to the oncology patient, outcomes following delay in head and neck cancer therapy, and risk of transmission during otolaryngologic surgery. Our case prioritization criteria consist of four categories: urgent – proceed with surgery, less urgent – consider postpone > 30 days, less urgent – consider postpone 30–90 days, and case-by-case basis. Finally, we discuss our preoperative clinical pathway for transmission mitigation including defining low-risk and high-risk surgery for transmission and role of preoperative COVID-19 testing.

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.

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.

Since December 2019, a number of patients with novel coronavirus pneumonia (NCP) have been identified in Wuhan, Hubei Province, China. NCP has rapidly spread to other provinces and cities in China and other countries in the world. Due to the rapid increase in reported cases in China and around the world, on January 30, 2020, the World Health Organization (WHO) Emergency Committee announced that NCP is a Public Health Emergency of International Concern (PHEIC). However, there are relatively few suggestions and measures for tumor patients, especially patients with head and neck tumors. This article summarizes the prevention and control of disease in our medical institution to provide a reference for front-line head and neck surgeons.

Dear Editor,At 29th of February the World Health Organization (WHO) reported 85403 confirmed globally confirmed case of COVID-19 [1]. 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) [2]. We agree with Chan et al that physicians managing airway procedures are at particularly high risk to contract the COVID-19 infection [3]. 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) [3]. 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 [3]. Tracheostomy is required in case of prolonged mechanical ventilation and intensive care unit (ICU) stay [4]. Surgical tracheostomy is an AGP associated with an increased risk severe acute respiratory distress (SARS) infection [5]. Strict adherence to infection control guidelines in SARS is mandatory in performing tracheostomy in ICU or operating room [6].Few years ago, we proposed the double lumen endotracheal tube (DLET) for percutaneous tracheostomy in critically ill patients [7]. 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 [7]. 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 [7]. 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 [7].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 [8]. 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 [8]. 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 [7]. 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

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 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.