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\begin{document}

\title{Self-removing passive drain to facilitate post-operative care
via telehealth during the COVID-19 pandemic.}



\author[1]{Ryan K. Orosco, MD, FACS}%
\affil[1]{UC San Diego Health, Moore’s Cancer Center }%


\vspace{-1em}



  
  \date{May 20, 2024}


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\selectlanguage{english}
\begin{abstract}
Background Telehealth post-operative visits are an attractive strategy
to minimize exposure, especially during the SARS-CoV-2 (COVID-19)
pandemic. The use of a surgical drain often prevents this
minimal-exposure approach in that patients return to the outpatient
clinic for drain removal. Methods and Results Following unilateral neck
dissection, the customary closed-suction drain was replaced with a
self-removing, passive drain dressing to facilitate same-day discharge
and telehealth post-operative follow-up. The patient removed the
dressing and drain at home during a telehealth visit on post-operative
day four and she healed favorably without signs of infection or seroma.
Conclusions When thoughtfully applied in the appropriate clinical
context, small practice adaptations like this can facilitate telehealth
solutions that diminish unnecessary exposure for patients, their
caregivers, and healthcare staff.%
\end{abstract}%



\sloppy




Jesse R. Qualliotine, MD\textsuperscript{1} and Ryan K. Orosco,
MD\textsuperscript{1,2}*

\textsuperscript{1} Division of Otolaryngology--Head and Neck Surgery,
Department of Surgery, University of California San Diego, La Jolla, CA,
USA

\textsuperscript{2} Moore's Cancer Center, University of California San
Diego, La Jolla, CA, USA

\textbf{*Corresponding Author:} Ryan K. Orosco, MD, FACS

Assistant Professor, Head and Neck Surgical Oncology

UC San Diego Health, Moore's Cancer Center

3855 Health Sciences Dr, MC\#0987, La Jolla, CA 92093, United States

Telephone: 619-543-7895; Fax: 619-543-5521; Email:
rorosco@health.ucsd.edu

\textbf{Running Title:} COVID neck drain

\textbf{Keywords:} COVID-19, Telemedicine, Neck Dissection, Head and
Neck Neoplasms, Drainage

Conflict of Interest Statement:

None of the authors have published or submitted any related papers from
the same study or have any conflicts of interest or financial
disclosures to report.

\subsection*{Abstract}

{\label{260300}}

Background

Telehealth post-operative visits are an attractive strategy to minimize
exposure, especially during the SARS-CoV-2 (COVID-19) pandemic. The use
of a surgical drain often prevents this minimal-exposure approach in
that patients return to the outpatient clinic for drain removal.

Methods and Results

Following unilateral neck dissection, the customary closed-suction drain
was replaced with a self-removing, passive drain dressing to facilitate
same-day discharge and telehealth post-operative follow-up. The patient
removed the dressing and drain at home during a telehealth visit on
post-operative day four and she healed favorably without signs of
infection or seroma.

Conclusions

When thoughtfully applied in the appropriate clinical context, small
practice adaptations like this can facilitate telehealth solutions that
diminish unnecessary exposure for patients, their caregivers, and
healthcare staff.

\subsection*{Introduction}

{\label{173813}}

The SARS-CoV-2 (COVID-19) pandemic is a rapidly developing challenge
that affects all aspects of clinical care. As of April 11, 2020, the
Centers for Disease Control and Prevention (CDC) reports 492,416 cases
and 18,559 deaths from the United States alone.\textsuperscript{1} In
order to increase the capacity of hospitals to care for the predicted
volume of cases and decrease virus transmission rates, the US Center for
Medicare and Medicaid Services issued recommendations to postpone all
non-essential surgeries and procedures.\textsuperscript{2} To this end,
many health systems and individual surgeons have adjusted their surgical
caseloads appropriately and dramatically increased their utilization of
telehealth encounters.

For many malignancies of the head and neck, a significant delay to
treatment is known to be associated with worse overall
survival,\textsuperscript{3} and such cases are proceeding to the extent
that health systems can accommodate the case load. Statements published
by AHNS leadership and others advocate that surgeries for cancer should
be prioritized among others, especially when delay would adversely
affect outcome.\textsuperscript{4,5} In this COVID era, telehealth
post-operative visits are an attractive strategy to minimize exposure in
a variety of circumstances including initial triage, counseling, and
even post-operative settings.\textsuperscript{6} In the post-operative
period, the use of a surgical drain often prevents this minimal-exposure
approach in that patients return to the outpatient clinic for drain
removal. Herein we present a case illustrating one solution using a
self-removing, passive drain dressing after a neck dissection to
facilitate same-day discharge and telehealth post-operative follow-up.

\subsection*{Case Report}

{\label{390297}}

A 57-year-old female presented in early March 2020 with a 2-month
history of an enlarging 2 cm submandibular mass. She was otherwise
asymptomatic and the remainder of her physical examination including
flexible laryngoscopy was unremarkable. An ultrasound-guided fine needle
biopsy demonstrated malignant adenoid cystic carcinoma and her staging
CT had no evidence of cervical lymphadenopathy or pulmonary metastasis.
In early April 2020 she underwent an uncomplicated ipsilateral neck
dissection, levels I -- III. Perioperative antibiotics were not
administered for this clean site surgery. The neck was closed over a
quarter-inch Penrose drain which was brought out through the posterior
aspect of the incision. The remainder of the incision was closed with
deep absorbable sutures and skin glue. The Penrose drain was sutured to
gauze that was fashioned into a dressing with additional gauze and
transparent film dressing (Tegaderm) in such a fashion that the drain
would be pulled as the patient removed her dressing at home in several
days. The inferior portion of the dressing was not sealed, and the
patient was instructed to change the overlying gauze as needed for
drainage (Figure 1). Detailed wound care instructions and return
precautions were provided regarding seroma, hematoma, and wound
infection. The patient was discharged to home on the day of surgery and
remained in communication with the surgeon via phone. On post-operative
day 4, the patient removed the dressing and drain during a telehealth
visit. The patient's incision was healing favorably without signs of
infection or seroma. Maintaining close communication with the patient,
she has done well without wound issues (Figure 2).

\subsection*{Discussion}

{\label{487917}}

Precautions spurred by COVID have led to an expansion of telehealth
utilization. Video visits can effectively replace post-operative visits
that do not require physical manipulation of the wound or dressings in
order to eliminate non-essential contacts with the healthcare system and
reduce virus transmission risk. If the visit cannot be performed
remotely or postponed, donning of appropriate personal protective
equipment (PPE) is crucial.\textsuperscript{7} Given the anatomic
distribution of high viral load sites in the nasopharynx and mucosal
airways, providers performing head and neck examinations appear to be at
heightened risk of transmission.

In this case, to facilitate a telehealth post-operative visit a simple
Penrose drain sutured to the overlying gauze dressing was used in lieu
of the customary closed-suction drain. Although similar levels of
evidence are not available for the lateral neck, in the
post-thyroidectomy and central neck literature, randomized clinical
trials and meta-analyses have demonstrated no statistically significant
differences in rates of neck hematoma or seroma between patients with or
without an active, closed-suction drain.\textsuperscript{8} Furthermore,
uncomplicated seromas can be managed expectantly with needle aspiration
in the rare cases that they do occur.

Even during a pandemic, patient safety is paramount and clinical
judgement must be utilized when considering alterations to usual
practices. The drain technique and post-operative follow-up method
utilized in this case example must be thoughtfully implemented. Informed
discussions and open lines of communication are paramount. Both patient
and surgical factors should be considered. Alternative drainage methods
are not well-suited for some patients and circumstances. Furthermore,
traditional post-operative pathways should be followed for higher-risk
procedures such as those with a heightened risk of salivary fistula and
chyle leak. When thoughtfully applied in the appropriate clinical
context, small practice adaptations like this can facilitate telehealth
solutions that diminish unnecessary exposure for patients, their
caregivers, and healthcare staff.

\subsection*{References}

{\label{522306}}

1. CDC. Coronavirus Disease 2019: Cases in U.S.

2. Non-Emergent, Elective Medical Services, and Treatment
Recommendations. \emph{Centers for Medicare \& Medicaid Services} .
2020:Mar 18.

3. Murphy CT, Galloway TJ, Handorf EA, et al. Survival Impact of
Increasing Time to Treatment Initiation for Patients With Head and Neck
Cancer in the United States. \emph{J Clin Oncol} . 2016;34:169-178.

4. How COVID-19 is Affecting our Head and Neck Community. \emph{Am Head
Neck Soc From AHNS Leadersh AHNS Patient Care Div} .:March 23, 2020.

5. Hanna T, Evans G, Booth C. Cancer, COVID-19 and the precautionary
principle: prioritizing treatment during a global pandemic. \emph{Nat
Rev Clin Oncol} . 2020.

6. Rimmer RA, Christopher V, Falck A, et al. Telemedicine in
Otolaryngology Outpatient Setting --- Single Center Head and Neck
Surgery Experience. \emph{Laryngoscope} . 2018;128:2072-2075.

7. Chan J, Tsang R, Yeung K, et al. There is no routine head and neck
exam during the COVID-19 pandemic. \emph{Authorea} . 2020;1.

8. Sanabria A, AL C, Silver C, et al. Routine Drainage After Thyroid
Surgery --- A Meta-Analysis. \emph{J Surg Oncol} . 2007;96:273-280.

\textbf{Figure 1:} A dressing was fashioned from gauze and transparent
film dressing (Tegaderm) over a Penrose drain sutured to overlying gauze
so that the drain would be pulled automatically as the patient removes
the adherent dressing. The inferior aspect is left open to allow fluid
egress and the patient was instructed to change the outer gauze as
needed.

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/HED-20-0527-Dressing/HED-20-0527-Dressing}
\caption{{This is a caption
{\label{940818}}%
}}
\end{center}
\end{figure}

\textbf{Figure 2:} Healing incision following removal of the drain and
dressing at home on post-operative day 7. The neck was closed with deep
absorbable suture and skin glue and this photo obtained from the
telehealth encounter shows no evidence of seroma or surgical site
infection.

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/HED-20-0527-Healing-incision-POD7/HED-20-0527-Healing-incision-POD7}
\caption{{This is a caption
{\label{294968}}%
}}
\end{center}
\end{figure}

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