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IntroductionThe rapid spread of coronavirus disease 2019 (COVID-19) worldwide raised concerns about its heavy impact on the health care delivery system and forced significant changes in the realities of the clinical practice we are accustomed to. With these changes comes a need for a different approach to outpatient evaluation of common otolaryngology complaints in patients with new symptoms.Recently published set of guidelines for evaluation of head and neck during the COVID-19 pandemic recommended to postpone the management of benign disease including benign salivary or thyroid gland disease.1 In order to limit the chance of COVID-19 infection among patients or health care workers, surveying patients via telephone or telemedicine visit was advised, reserving in-person evaluation for the patients at risk for significant negative outcomes. The challenge is that these measures can only be applied in clear-cut clinical scenarios, when the disease process is most likely benign and the care delivery can be postponed.In cases with a high degree of uncertainty based on available clinical information, many physicians will have to decide how to proceed after initial telemedicine encounter. Clinicians will have to consider how to balance a potential delay in diagnosis, including cancer diagnosis, against the risk of COVID-19 exposure, and may need to exercise their best judgement knowing that for head and neck cancer the risk of progression with cancer care delay is high.2 In this communication, we present our approach to triaging and evaluation of patients with complaints concerning for salivary gland disease.

Maria Vargas, MD

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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
Figure 1
As the novel coronavirus (Covid-19) globally spreads, the 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. For patients in need of long-term endotracheal intubation, tracheostomy may be considered. Some patients with unfavorable neck anatomy, such as short neck, enlarged thyroid, and neck cicatricial contracture, are not suitable for percutaneous tracheostomy, a minimally invasive method1. In these circumstances, conventional open tracheostomy is the primary option for surgeons. However, it is one of the most hazardous procedures, because the direct airway opening and the coughing of patients causes aerosolization of the virus potentially exposing healthcare workers2. To prevent healthcare-associated infections, we are willing to share our modified tracheostomy procedures with other surgeons worldwide.Detailed optimized procedures are illustrated in Figure 1. There are three distinct steps to protect healthcare workers from the virus spreading in the surgical environment during tracheostomy. First, all procedures should under general anesthesia, with deprivation of spontaneous respiration and application of muscle relaxants (Figure 1A), regardless of whether patients had spontaneous breathing or not. This step is to restrain the cough reflex caused by tracheal stimulation. Second, after the cervical trachea is exposed and immediately before an incision is made in the trachea, the endotracheal tube (ETT) is inserted deeper, positioned with the tip close to carina of the trachea (Figure 1B). This step would prevent the ETT cuff leak due to an accidental damage to the cuff when making the tracheal opening. Third, when the opening is complete, brief interruption of the ventilator is essential. Then the ETT is pulled out, and subsequently the tracheostomy tube quickly inserted into the opening (Figure 1C). Almost simultaneously, the tracheostomy tube cuff is inflated and the tube rapidly connected to the ventilator, with immediate resumption of the ventilator (Figure 1D). Suspension of ventilation support was usually not more than 15 seconds, with satisfactory oxygen saturation.This report describes the optimized procedures in tracheostomy for Covid-19 patients. The three major modifications can avoid the aerosolization of secretions, and protect healthcare workers. Thus, we strongly recommend the modified procedures to be a choice for all surgeons when tracheostomy is considered for Covid-19 patients. It is important to protect healthcare workers from coronavirus during the intraoperative period for their own health and for preservation of the healthcare workforce.Figure