On March 27, 2020, the Center for Disease Control reported that 85,356 individuals in the United States were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) – exceeding, for the first time, the number of cases in Wuhan, China, where the pandemic began in November, 2019. US federal, state and local agencies are facing an unprecedented public health emergency. The scale of the pandemic has never been seen in US; the way forward uncertain.In 2003, the Hong Kong SAR (HK) healthcare system was thrust into a similar crisis, responding to an outbreak of SARS coronavirus 1 (SARS-CoV-1), that developed in Guangdong Province, China late in 2002. Lessons from how HK physicians adapted their practices to this new disease may hold important lessons for the many countries now facing the pandemic .Based upon experience and evidence from SARS-CoV-1 and early-experience with SARS-CoV-2, we provide our perspective and guidance on mitigating transmission risk during head and neck examination, upper airway endoscopy, and head and neck mucosal surgery including tracheostomy. We set out below, recommendations that every physician performing head and neck examination should consider. The goal is to protect healthcare workers (HCW), caregivers, patients, and the community at large in this Personal Protective Equipment (PPE) limited environment, while conforming to their local guidelines.Early on in the 2003 SARS epidemic, the risk of nosocomial spread of infection to HCW posed a critical challenge. At the Prince of Wales Hospital, HK, a single infected patient caused an outbreak, of which over 50% were HCW, devastating human resources to treat and contain the infection . Seventeen years later HK was inflicted with SARS-CoV-2 late January 2020. A benefit of SARS-COV-1 in HK HCW has been the modus operandi since 2003: including wearing surgical masks in hospital wards, wearing gowns and surgical masks in outpatient clinics and scrubs only in the operating room. The resultant individual and institutional appreciation of infection control measures have served HK well in the current pandemic, relative to other countries, with no HCW COVID-19 nosocomial infections to date 1.In the 2003 SARS-CoV-1 outbreak in HK, an otolaryngologist died after being infected during a routine head and neck examination. In 2020, the first COVID-19 physician fatality was an otolaryngologist in Wuhan, China. Patients with COVID-19 caused by SARS-CoV-2 can carry high viral load in the nasal cavity, nasopharynx, and throat. The anatomic viral distribution of these SARS-CoV viruses in the nasopharynx and mucosal airways, coupled with these disquieting cases, indicate that head and neck examinations and procedures must be approached cautiously with thoughtful preparation and protections. HCW who have these exposures are at heightened risk of transmission.In the outpatient setting, all non-essential clinic visits should be transitioned to virtual “video-visits” or postponed. This will reduce the number of patients in the clinic, minimizing patient flow and potential contamination and freeing up valuable medical resources. On March 18, 2020, the Center for Medicare and Medicaid Services in the US released recommendations to postpone all non-essential dental exams and procedures until further notice.Within the clinic, separate gown up and down areas must be designated to prevent cross-contamination. Visual guides and mirrors for self-visualization in these areas on the steps involved in gowning up and gowning down have, from past experience, proven extremely useful particularly for gowning down, where most HCW self-contaminate (Figure 1). Another critical area is the bedside examination of patients. Currently, there are no CDC guidelines on respiratory and aerosol-generating procedures within the scope of the head and neck surgery, but our experience with SARS-CoV-1 highlights that these are potentially high-risk examinations. Therefore, in HK, there is official guidance for Otolaryngology departments to label several common head and neck examination and procedures as having a potential risk of aerosol generation. This designation carries implications on PPE allocations of as seen in table 1.Anesthetic practices vary but local anesthetic is commonly administered via aerosolized spray in the head and neck examination and procedures. This practice has been abandoned in HK since the SARS-COV-1 epidemic and must be avoided in the current COVID-19 environment. Aerosol spray should be replaced by topical local anesthetic on pledgets or dripped via syringe. Table 1 shows guidelines of PPE use within the outpatient clinic with a dedicated endoscopy room, including flexible laryngoscopy - one of the most common procedures performed in head and neck examination. Unless there is gross contamination there is no need to change the gown, mask or eye protection between each patient.For inpatient rounds, all physicians are recommended to wear a surgical mask and scrubs which are changed daily prior to leaving the hospital. Patient visitors to the hospital should be severely restricted, and visiting hours cut, to minimize people flow and maintain social distancing.For all operative procedures, intubation represents an aerosol-generating procedure as first learned during the 2003 SARS-COV-1 epidemic. Therefore, during intubation anyone in the operating room should have appropriate PPE including a fit-tested N95 mask. This should similarly apply to all open airway procedures such as direct laryngoscopy where they may be a leak during ventilation, tracheostomy, or laryngectomy.Tracheostomies for patients with known COVID-19 should be delayed where possible to minimize viral shedding from the patient, as we know from SARS-COV-1, delaying the tracheostomy does not negatively impact the patient. Guidance for a safe tracheostomy emerged from the 2003 epidemic. The following should be considered for tracheostomies in the COVID-19 pandemic:PPE: AAMI level 3 or waterproof apron on top of AAMI level I isolation gown, N95 mask, face shield, waterproof cap and disposable shoe covers. Powered air purifying respirators (PAPR) may be needed in cases with high viral load.Minimize personnel: One intensivist, one surgeon, one nursing member.Procedure: Use a negative pressure operating room. The patient should be completely paralyzed and preoxygenated. Stop ventilation before tracheotomy and only resume once tracheostomy tube balloon cuff is inflatedPost procedure: Gown down safely, and shower.Ideally, the procedure should be done in a negative pressure operating room with senior personnel and not used as a training procedure. Cautery use should be limited as this can produce small particles that may act as a vehicle for the virus . Again, gowning down following the procedure is of utmost importance and is often overlooked. Dry runs prior to the actual procedure may also help reduce errors and prevent the contamination of HCW.For patients with a tracheostomy they should all be covered with a closed system (Figure 2) identical to when a patient is connected to a mechanical ventilator to minimize the aerosol generated that could cross contaminate the surrounding patients and HCW given the suction requirements of these patients . Humidified tracheostomy collars and nebulized therapies must be avoided. All bedside procedures should be performed in a separate treatment room away from patient cubicles with all HCW wearing PPE. The requirements for PPE will be the same as in the outpatient clinic.In summary, with the use of these broad guidelines which reduces the number of procedures and patients seen, coupled with an appreciation that the head and neck examination cannot be taken lightly in the current pandemic, the risk of exposure and contamination in clinics of patients, HCW and in particular, physicians performing a head and neck examination should be reduced.
Dear Editor,The COVID-19 infection can be diagnosed from a variety of upper and lower respiratory sources including the oropharynx (OP), nasopharynx (NP), sputum, and bronchial fluid [1-3]. In general the most sensitive detection of COVID-19 is obtained by the collecting and testing of both upper and lower respiratory samples [4].However, bronchoscopy is a highly technical procedure requiring advanced diagnostic tools as well as well-trained staff which are not always available. Furthermore the collection of sputum and particularly BAL via bronchoscopy increases the biosafety risk to healthcare workers through the creation of aerosol droplets.Upper respiratory specimens such as OP and NP swabs are easy to collect especially in limited resource settings. They should be collected within the first few days from the onset of symptoms since RNA positive rates peak in upper respiratory tract specimens at 7–10 days after symptom onset and then they steadily decline [5].In China during the COVID-19 outbreak, Wang et al reported that oropharyngeal (OP) swabs (n = 398) were used much more frequently than NP swabs (n = 8). However, the COVID-19 RNA was detected only in 32% of OP swabs, compared to NP swabs (63%)[4].It appears to be extremely important to properly collect nasopharyngeal swabs reaching the posterior rhinopharyngeal tonsil region. This implies the presence of a regular nasal cavity floor. Some anatomical variants, such as nasal septum deviation, can prevent reaching of the nasopharynx and therefore to collect a proper sample. Numerous studies of nasal septal deviation have revealed a wide range of prevalence [6,7]. In 1978, Gray reported a prevalence of 48% to 60% in neonates [6].1 In adults, a recent international study found a prevalence of approximately 90% [7]. Sooknundun et al. reported a clinically relevant septal deviation prevalence of 15% to 25% [8].Current national and international guidelines do not include any special recommendations in the execution of the rhinopharyngeal swab in patients with documented nasal pathology or in patients in which a bilateral nasal fossa obstacle is encountered. We believe that in these selected cases the ENT support should be mandatory in order to obtain a representative sample. Furthermore the use of endoscopes could be very useful in the direct visualization of obstacles and to guide safely the swab toward the rhinopharynx. This would possibly also reduce the false negative rate which is reported to be more than 30% [4].
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: shahj@mskcc.orgReferences: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)
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.
INTRODUCTIONWe are quite familiar with the COVID-19 epidemic and its unprecedented implications. It has clearly changed our lives, healthcare, clinical practice, urgency of the health problems, financial implications and mental health. The issues of mental health are applicable both to the patients and healthcare providers. Obviously, we need to pay special attention to the patients suffering from COVID-19 especially those who are symptomatic or having major health crisis such as pulmonary issues and multiorgan failure.As of the 8th of April, globally there have been approximately 1.52 million confirmed cases of COVID-19 of whom 90,000 are dead. In the United States, the confirmed COVID-19 cases are reported to be 435,564 while the reported deaths are 14,829. New York State has faced the major brunt of this pandemic with confirmed cases of 147,037 and death number of 6,220.In spite of this major health crisis patients are always concerned about their own problems in relation to other health issues especially with fear of proven or suspicious cancers. Clearly, some of the cancers are life-threatening and will require urgent attention while other tumors may be monitored or treated at a later date when the COVID-19 issues are relatively settled. In a referral center or a tertiary care cancer center it is fairly common to receive consultations regarding thyroid problems or thyroid tumors.Even though, there are no set guidelines in the management of patients asking for thyroid surgery it would be appropriate to manage these patients based on the risk group analysis and the overall risks of progression to life-threatening issues. We need to explain every patient that thyroid tumors grow slowly and there is no need for active and emergent intervention. It is quite appropriate to wait for 4-6 months.If the patient is extremely anxious a follow up ultrasound may be performed in 3-4 months to document the stability of thyroid tumor. We have divided thyroid cancer patients for almost 50 years into low, intermediate and high-risk groups based on their prognostic features1. We popularly described this as good, bad and ugly tumors. The prognostic factors were described as age, grade of the tumor, size of the tumor, extrathyroidal extension, distant metastases, etc. Other prognostic factors such as multiple lymph node metastases and the molecular analysis should go into the equation of management of these patients. Needless to say, patients are extremely concerned for the fear of any cancer whether it is thyroid or pancreatic cancer. It is our responsibility to explain to the patients the concern about these cancers on their overall prognosis and the best timeline definition for active intervention. The new American Thyroid Association guidelines published in 2015 have done a fantastic job in line with the biology of these tumors and appropriate management 2. As a matter of fact, the ATA endorsed observation as a definitive approach in proven microcarcinomas. This clearly reflects the management of these tumors in relation to their biology and avoiding over treatment. Let the punishment fit the crime or let the treatment not be worse than the disease is quite appropriately applied to thyroid cancer. However, it would be important to define certain indications and road map of active management of some these thyroid cancers. If we use the analogy of management of thyroid cancer during pregnancy and delaying the treatment by 9-10 months, it would be the same philosophy of managing these patients during the COVID-19 pandemic. Clearly, some patients will require urgent or active intervention in a timely fashion. The following summary will describe some of the decision-making issues.Anaplastic Thyroid Cancer – patients with rapidly growing thyroid tumors with proven anaplastic thyroid cancer will obviously require emergent management. The decision regarding surgical intervention should be made based on the extent of the disease and cross-sectional imaging. Appropriate BRAF based therapies and external radiation therapy should be implemented. If the tumor appears to be unresectable there is no reason to bring these patients to the operating room. The definitive diagnosis could easily made with ultrasound guided core biopsy, and appropriate immunohistochemistry. The issue of airway management is always a difficult problem in anaplastic thyroid cancer and more so during COVID-19 pandemic. Obviously, testing the patient for Covid-19 is important since patient may require either active airway intervention or hospitalization with concern of exposing healthcare workers. As mentioned in the first anaplastic thyroid cancer guidelines, elective tracheostomy is best avoided however may be necessary if the patient is having acute airway distress 3. A due consideration should be given to controlled cricothyrotomy.Medullary Thyroid Cancer – Appropriate evaluation of extent of the disease with calcitonin, CEA, ultrasound and cross-sectional imaging is very important before consideration of timely surgical intervention. If the disease appears to be limited and calcitonin levels are not high (under 400) patients can be monitored for a few months without surgical intervention hoping for COVID-19 peak to settle. Generally, medullary carcinoma is a chronic disease and observation with close monitoring would be quite appropriate until the social circumstances get better. Obviously, this will require extensive discussion with the patient and the family which can be easily done even by phone conversations or Facebook. A discussion directly by responsible attending surgeon would give a lot of confidence to the patient and the family. They need to understand that waiting for the best time for surgery is unlikely to hurt them or lead to major progress of the disease. The prognosis essentially would remain the same.Locally Aggressive Thyroid Cancer – These are the patients who will require detailed evaluation of the extent of the disease, its involvement in relation to the central compartment vital organs such as recurrent laryngeal nerve, trachea, esophagus, and major vascular structures. Appropriate cross-sectional imaging will be of great help. If patient does require fiberoptic evaluation it would be best done with the hospital guidelines and appropriate protection to the healthcare staff. Obviously, COVID-19 testing would be important prior to any active intervention. The decisions about surgery in light of COVID-19 pandemic would be quite critical as to how long we can delay the surgical procedure without compromising the total surgical resection and encroachment on vital central compartment structures. The decisions may be slightly different if the preoperative FNA has resulted in poorly differentiated thyroid cancer. It would be quite appropriate to discuss some of these cases with our colleagues in multidisciplinary team since we are able to hold virtual tumor boards. Avoiding surgical compromise is important in these patients however waiting for a reasonable time would not be inappropriate.Patients with Large Primary Tumors and Bulky Nodal Disease – The history of the presence of tumor and the duration of the nodal metastasis would be quite helpful to project the best timing of surgery in these patients. Again, appropriate cross-sectional imaging and approximation of the tumor to the vital structures is critical in making the best decision regarding appropriate timing of surgery in these patients.Low and Intermediate Risk Thyroid Carcinomas – These patients can wait for surgery for a period of time (3-6 months) until we have a better handle on COVID-19, and they are not a risk to the healthcare workers. If the patients need extended period of observation, a repeat imaging with ultrasound in 3-4 months will encourage the patients to delay the surgery further.Microcarcinomas – As reported by a large series of patients from Kobe, Japan; Sloan Kettering, these patients with microcarcinomas can definitely be observed 4,5. Most of these patients can be encouraged not only to delay the surgery but to remain under active surveillance or deferred intervention. Again, appropriate ultrasound will define the exact location of the disease and need of active intervention.Recurrent Thyroid Carcinoma – The majority of the recurrences especially in the central compartment nodes or lateral neck nodes are essentially the persistent diseases. They could be observed for an extended period of time with repeat imaging studies in 4-6 months. The only time one would consider active surgical intervention, if the tumor is plastered against the trachea for the fear of future encroachment into the trachea. Alternate treatment choices such as alcohol injection, radio frequency ablation may be considered for localized nodal recurrences.Indeterminate Thyroid Nodules – most of these patients will be in the group of Bethesda III and IV categories. These patients can be easily monitored and if the tumors are small even if they’re BRAF or TERT positive, could be monitored for a period of time before active surgical intervention. The positivity of the molecular markers and the quantification of the risk of malignancy is not a determinate for emergent surgical intervention.Large Goiters – the majority of the large goiters have generally been there for a long period of time and surgery could be easily avoided even with tracheal deviation and mild compression unless there is a rapid progression, major compression symptoms or impending acute airway issues.Benign Thyroid Conditions – benign thyroid nodules, Hashimoto’s thyroiditis, or Graves’ disease could be managed appropriately as before and probably may not be in-person consultation. The majority of these patients can be easily consulted on telephone, Skype or Facetime which will give patients a sense of confidence and make them feel that the treating physician is actively involved in their care and follow up. The guidelines recommended by ATA for fine needle aspirations of incidental thyroid nodules should be applied vigorously. It would be best to avoid FNA on smaller and non-suspicious thyroid nodules.Moral Dilemma – I am sure there will be many discussion points in above recommendations. These are not written in any of the textbooks or guidelines. These are clinical observations during the early period of COVID-19 pandemic. Hopefully, God willing, the pandemic will be over soon, and we will go back to our regular clinical practices. However, until then, it is our responsibility to manage our patients best, give them a full sense of confidence and avoiding major progression of their tumors and life-threatening issues. We also have a responsibility to the healthcare workers who take the major brunt of exposing themselves to the COVID-19 which may become lethal in a few individuals. This definitely raises a major new dilemma to the healthcare workers. Every profession has certain risks and concerns. For example, a frontline army personnel, a firefighter, or a policeman where both the individuals and their families are aware about the life-threatening risks. However, until the COVID-19 pandemic occurred nobody realized the life-threatening risks to the healthcare workers. This clearly creates a major social and ethical dilemma amongst healthcare workers and their families. Even though the non-essential staff can work from home, the essential staff such as frontline healthcare workers have to be exposed themselves to proven and unproven COVID-19 patients. This may lead to major ethical issues and mental depression amongst healthcare workers. What would be the answer to the 10-year-old child when he tells his father, “Dad, please don’t go to work. I’m afraid you may catch COVID-19 and you are the only one I have.”We don’t have the answers to these questions, however, I would like to salute the frontline healthcare workers who have been actively involved in offering the best medical care to the patients suffering from COVID-19 and offering them and the society a Glimpse of Hope. These are the true Noble Laureates.References:Shaha, AR. Implications of prognostic factors and risk groups in the management of differentiated thyroid cancer. Laryngoscope. 2004, 114; 393-402.Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association – Management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer; the American Thyroid Association Guidelines Task Force on Thyroid nodules and differentiated thyroid cancer. 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