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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.
Introduction:The 2019 novel coronavirus disease (COVID-19) was initially identified in December 2019 in Wuhan, China. Following its spread across the globe within a matter of months, the World Health Organization classified COVID-19 as a pandemic.1 Its rapid transmission and high hospitalization rate have forced health professionals to drastically alter their practices in order to slow its proliferation. The rapid influx of COVID-19 related admissions in hospitals around the United States has led to a widespread shortage of crucial healthcare resources, particularly personal protective equipment (PPE), ventilators, and free ICU beds. Surgical procedures further deplete such resources in a time of acutely high need. Additionally, evidence has shown that healthcare workers may be particularly susceptible to infection from the causative pathogen, SARS-CoV-2, with roughly 20% of exposed professionals becoming infected in Italy.2Following these developments, the Centers for Disease Control and Prevention (CDC) recommended that all inpatient facilities postpone or cancel any elective surgeries.3 In the ensuing weeks, the American College of Surgeons and the American Academy of Otolaryngology-Head and Neck Surgery followed suit with this recommendation.4,5Furthermore, many hospitals and practices have opted to cancel in-person outpatient clinic visits, where patients oftentimes receive critical longitudinal care. Like other surgeons, otolaryngologists, and specifically head and neck surgical oncologists, have been deeply affected by these drastic measures. It is evident, however, that physicians must find ways to continue to monitor such patients’ conditions or treat them in some aspect. The popularity and prevalence of telemedicine has grown rapidly during this pandemic as many physicians have sought ways to maintain a continuum of care with their patients.6 Such initiatives have previously been shown to decrease costs, decrease visit time, and lead to high patient satisfaction in surgical fields.7,8Within otolaryngology specifically, certain telehealth assessments have been shown to allow for quicker examinations without compromising the communication of crucial information from the patient to the physician, or vice versa.9 However, the rapid implementation of telehealth has been a relatively new phenomenon during the COVID-19 pandemic, meaning that physicians oftentimes have to learn how to optimize their virtual visits to maximize their efficiency and effectiveness. In otolaryngology, telemedicine has not been routinely used to evaluate patients, despite estimates that 62% of otolaryngology patients would be amenable to virtual appointments.10Thus, it may be difficult for physicians to anticipate barriers to their care during a telehealth visit. Based on the authors’ experience, there exists a steep learning curve following the onset of such visits due to a variety of factors on both the patient’s and physician’s side.To our knowledge, there are no set guidelines or best practices for patients or head and neck cancer physicians conducting virtual visits. Drawing upon our experience, we aim to compile a set of guidelines for physicians and patients alike to navigate telehealth visits during the era of COVID-19. We also created a handout that can be distributed to patients prior to the visit, such that patients can familiarize themselves with general expectations and key examination steps that they may be asked to perform during the visit.
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. Thyroid. 2016, 26; 1-133.Smallridge RC, Ain KB, Asa SL, Bible KC, Brierley JD, Berman KD et al, American Thyroid Association Guidelines for Management of patients with anaplastic thyroid cancer. Thyroid. 2012, 22; 1104-39.Miyauchi, A. Clinical trials of active surveillance of papillary microcarcinoma of the thyroid. World J Surg. 2016, 40; 516-22.Tuttle, RM, Fagin JA, Minkowitz G, Wong RJ, Roman B, Patel S et al, Natural history and tumor volume kinetics of papillary thyroid cancers during active surveillance. JAMA Otolaryngol Head Neck Surg. 2017, 143; 1015-1020.
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.
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.