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\begin{document}

\title{\emph{Management of Dysphagia in Head and Neck Cancer Patient during
COVID-19 Pandemic: Practical Strategy~~~~}}



\author[1]{Peter KM Ku, MD}%
\affil[1]{United Christian Hospital and Tseung Kwan O Hospital}%


\vspace{-1em}



  
  \date{May 26, 2024}


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\selectlanguage{english}
\begin{abstract}
The global pandemic of 2019 Novel Coronavirus Disease (COVID-19) has
tremendously altered routine medical service provision and imposed
unprecedented challenges to the healthcare system. This impacts patients
with dysphagia complications caused by head and neck cancers. As this
pandemic of COVID-19 may last longer than SARS in 2003, a practical
workflow for managing dysphagia is crucial to ensure a safe and
efficient practice to patients and healthcare personnel. This document
provides clinical practice guidelines based on available evidence to
date to balance the risks of SARS-CoV-2 exposure with the risks
associated with dysphagia. Critical considerations include reserving
instrumental assessments for urgent cases only, optimizing the
non-instrumental swallowing evaluation, appropriate use of PPE, and use
of telehealth when appropriate. Despite significant limitations in
clinical service provision during the pandemic of COVID-19, a safe and
reasonable dysphagia care pathway can still be implemented with
modifications of setup and application of newer technologies.%
\end{abstract}%



\sloppy


Abstract content goes here

\textbf{Authors}

\textsuperscript{1,2}Peter KM Ku, MD

\textsuperscript{3}F. Christopher Holsinger, MD

\textsuperscript{2}Jason YK Chan, MD

\textsuperscript{1}Zenon CW Yeung, MD

\textsuperscript{4}Becky YT Chan, MSc

\textsuperscript{2}Michael CF Tong, MD

\textsuperscript{3}Heather M Starmer, MA CCC-SLP, BCS-S

~\textbf{Authors' Affiliations}

\textsuperscript{1}Department of Otorhinolaryngology - Head and Neck
Surgery, United Christian Hospital and Tseung Kwan O Hospital, Hong
Kong.

\textsuperscript{2}Department of Otorhinolaryngology -- Head and Neck
Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong,
Hong Kong

\textsuperscript{3}{Division of Head and Neck Surgery, Department of
Otolaryngology, Stanford University, Palo Alto, CA, USA}

\textsuperscript{4}Department of Speech Therapy, Prince of Wales
Hospital, Hong Kong

~~

\textbf{Correspondence}

Peter KM Ku, MD

Department of Otorhinolaryngology -- Head and Neck Surgery

United Christian Hospital and Tseung Kwan O Hospital

2 Po Ning Lane, Han Hou, Tseung Kwan O

New Territories, HONG KONG SAR

Email: {pkukm@yahoo.com}

Phone: 852-91995131

~

\textbf{Word Count (Text)}: 3542

\textbf{Abstract}

The global pandemic of 2019 Novel Coronavirus Disease (COVID-19) has
tremendously altered routine medical service provision and imposed
unprecedented challenges to the healthcare system. This impacts patients
with dysphagia complications caused by head and neck cancers. As this
pandemic of COVID-19 may last longer than SARS in 2003, a practical
workflow for managing dysphagia is crucial to ensure a safe and
efficient practice to patients and healthcare personnel. This document
provides clinical practice guidelines based on available evidence to
date to balance the risks of SARS-CoV-2 exposure with the risks
associated with dysphagia.

Critical considerations include reserving instrumental assessments for
urgent cases only, optimizing the non-instrumental swallowing
evaluation, appropriate use of PPE, and use of telehealth when
appropriate. Despite significant limitations in clinical service
provision during the pandemic of COVID-19, a safe and reasonable
dysphagia care pathway can still be implemented with modifications of
setup and application of newer technologies.

KEYWORDS

Dysphagia, head and neck, coronavirus, COVID-19, management

\textbf{Introduction}

The worldwide healthcare system has been inundated by a sudden surge of
suspected and confirmed cases of the novel coronavirus disease
(COVID-19) since the World Health Organization (WHO) declared the global
pandemic of this viral illness on March 11, 2020. In just over a month,
1,914,916 confirmed cases of COVID-19 were reported globally with
123,010 deaths by April 14, 2020\textsuperscript{1}. This represents a
10-fold increase in confirmed cases and 15-fold increase in deaths since
the declaration of pandemic. While this global pandemic has flooded and
imposed unprecedented challenges to the health care system, the global
shortage of personal protective equipment (PPE) has created extra burden
to frontline health care personnel.

There are 550,000 new cases of head and neck cancer (HNC) registered
worldwide per year.\textsuperscript{2} The incidence of HNC is not
anticipated to be affected by pandemic of COVID-19. Dysphagia is one of
the most common complaints for HNC patients before, during, and after
treatment. These patients often require multidisciplinary care by
speech-language pathologists and otolaryngologists in dedicated
swallowing disorders clinics. A detailed symptom inventory, oromotor
examination, clinical swallowing assessment, objective instrumental
swallowing studies, swallowing intervention, and monitoring of progress
are still essential for these patients during the COVID-19 pandemic.
However, given the significant challenges involving transmission risk
and limited PPE, alteration to the typical provision of swallowing
services must be considered during this outbreak. As this pandemic of
COVID-19 may last longer than SARS in 2003, a practical workflow for
managing dysphagia is of utmost importance. In these clinical
guidelines, we propose a strategic plan to facilitate safe practice in
dysphagia management for health care personnel and patients with
dysphagia, without jeopardizing the standard of care.

\textbf{Selection of Swallowing Studies}

Fiberoptic endoscopic evaluation of swallowing (FEES) and
videofluoroscopic swallowing studies (VFSS; also sometimes called
modified barium swallow) are two common instrumental swallowing studies.
During FEES examination, a fiberoptic endoscope is passed by the
clinician through the nose of the patient into the pharynx, which allows
observation of anatomy of the pharynx/larynx, management of saliva and
food/liquid boluses, coordination of the pharynx, tongue and larynx
during swallowing, and presence of laryngeal penetration or aspiration
into the airway. It is commonly performed by speech-language
pathologists and otolaryngologists. VFSS utilizes real-time X-ray to
assess the different phases of swallowing and swallowing physiology as
the bolus passes through the oral cavity, pharynx and upper cervical
esophagus using barium impregnated food materials of different
consistencies. It allows for observation of swallowing biomechanics and
any consequences of dysfunction including penetration and aspiration of
food materials into the airway. VFSS is typically performed by
radiologists and speech-language pathologists. While FEES and VFSS have
their own merits and limitations, both can be used to assess head and
neck cancers patients.

While both VFSS and FEES are appropriate tests to utilize in assessment
of swallowing, in the context of the COVID-19 outbreak, clinicians need
to consider relative risk with these procedures. The higher risk of
aerosolization of matter from the nasal passage and nasopharynx with
FEES may suggest that VFSS may be the safer option in the current
climate. Additionally, some centers may still practice testing of
laryngeal sensation by air-pulse stimulator which fires air-pulses in 50
milliseconds duration with pressure from 2 to 10 mmHg to elicit the
reflexive twitching of vocal cords before endoscopic evaluation of
swallowing.\textsuperscript{3-4} These air-pulses may either create air
current in the pharynx or induce cough if the air pressure is high,
which may generate droplets and aerosol. In light of the pandemic of
COVID-19, suspension of laryngeal sensory testing and FEES examinations
should be seriously considered to minimize aerosol generation.

\textbf{Selection of Personal Protective Equipment}

Recent studies reported the R0 of SARS-CoV-2 ranged from
5.71-7.23\textsuperscript{5}, which is higher than SARS-CoV (2 to 4) in
2003.\textsuperscript{6} Therefore, the virulence of COVID-19 is far
higher than SARS and may well explain the seemingly uncontrolled
pandemic of COVID-19 in many countries. There has been some confusion
throughout the health care community in regard to droplet versus aerosol
transmission of COVID-19, and subsequently the different levels of PPE
required to minimize transmission risk. Aerosol is formed by droplets of
smaller sizes, usually smaller than 5 \selectlanguage{greek}µ\selectlanguage{english}m in diameter, allowing them to
remain suspended in the air, to travel longer distances, and and to
penetrate face masks with larger pore sizes. High level PPE such as N95
respirators are mandatory with any aerosol generating procedures (AGP).
The recent findings of hyposmia, anosmia and dysgeusia in a sizable
proportion of confirmed COVID-19 cases may suggest a higher viral load
in the nasal cavity/nasopharynx.\textsuperscript{7} Based on the
observation of high viral shredding of coronavirus in the nasal
passage/nasopharynx\textsuperscript{8} and anecdotal evidence of
increased risk of transmission in the otolaryngology community, use of
positive airway power respirators (PAPR) has been advocated for any
nasal procedures which generate aerosol. This recommendation would thus
apply to FEES exams.

Evidence shows coughing can generate droplets of size from 0.1 \selectlanguage{greek}µ\selectlanguage{english}m to 100
\selectlanguage{greek}µ\selectlanguage{english}m which lie in the range of aerosol
generation.\textsuperscript{9}Therefore, we can categorize procedures
that may induce coughing, such as FEES and VFSS, as AGP and recommend
adoption of the highest level of PPE with face shield or goggles, N95
respirator and isolation gown when undertaking these procedures. Face
shield can practically provide more coverage to the eyes and face and
prevent contamination of the facial skin which is commonly overlooked by
most health care personnel during doffing of PPE leading to later
transmission of virus through the nose and eyes through hand spread.
Careful donning and doffing of isolation gowns is critical to minimize
potential contamination.

\textbf{Screening and Timing of Examination}

FEES and VFSS can trigger sneezing and/or coughing, leading to
aerosolization during the procedure. The unpublished data of 982
patients attending the combined dysphagia clinic in Prince of Wales
Hospital showed that of those with dysphagia following head and neck
cancer treatment, nearly 80\% had impaired laryngeal protective reflex.
Thus, the incidence of intense coughing during FEES and VFSS may be low
in head and neck cancer patients as their nose and pharynx are less
sensitive to instrumentation and penetration/aspiration. However, as
evidence shows speaking can generate a sufficient amount of droplets to
transmit SARS-CoV-2,\textsuperscript{10} and patients are generally not
able to wear a face mask during the swallowing evaluation, we should be
more conservative when considering these instrumental swallowing
procedures. If the condition is not urgent, we suggest postponing any
FEES or VFSS for 14 days, as suggested according to the incubation
period of COVID-19 in any high-risk patients based on history
(\textbf{T} ravel, \textbf{O} ccupation, \textbf{C} ontact and\textbf{C}
lustering phenomenon as \textbf{TOCC} ) and symptomatology such as
fever, cough, shortness of breath, and expectorant. It must also be
considered that the patient must self-isolate for that 14-day period in
order for the healthcare team to be confident of low risk for completion
of the swallowing assessment. Additionally, olfactory disturbance has
been noticed to occur in high proportion of confirmed cases of COVID-19
(15 to 60\%) globally, and can be an early or solitary symptom of
infection.\textsuperscript{11} With more supporting evidence in our
unpublished data on smell loss (47\%) and taste loss (45\%) in COVID-19
confirmed patients, smell and taste disturbance may serve as markers for
potential COVID-19 to enhance surveillance in clinic. For patients who
require urgent swallowing evaluation in extenuating circumstances (such
as acute status change or newly diagnosed aspiration pneumonia),
SARS-CoV-2 testing or full aerosol PPE are recommended to minimize
transmission risk.

\textbf{Setup of Examination Environment for Dysphagia Evaluation}

VFSS is preferable to FEES in the current situation of COVID-19 as it
does not involve invasive instrumentation during the procedure and the
administering clinician (speech-language pathologists, radiologists or
otolaryngologists) can maintain a greater distance from the patient
while the examination is undertaken. However, it does require patients
to be transferred to radiology department. As most radiology departments
do not have negative pressure rooms for containment of any airborne
particulates during VFSS, the use of IQAir\selectlanguage{ngerman}® HealthPro® (Incen AG,
Switzerland) air-filter with HEPA class H13 filtration system is
recommended. The filter is capable of screening 99.97\% of all particles
\textgreater{} 0.3 microns and would be able to filter any
micro-droplets and aerosol generated during VFSS during coughing events.
In contrast to VFSS, FEES is more portable and can be moved into
negative pressure ventilation rooms. Thus, it may be the preferred
option for SARS-CoV-2 positive patients or those under investigation if
assessment must be performed in an urgent manner. Preferably, FEES would
also be performed in a room with setup of IQAir® air-filter for all
patients to reduce environmental contamination by respiratory droplets
during the COVID-19 pandemic (Figure 1). Figure 2 summarizes the
workflow for instrumental swallowing evaluation in head and neck cancer
patients during the COVID-19 pandemic.

\textbf{Role of Speech-Language-Pathologists and Dysphagia Clinicians in
Head and Neck Patients During COIVID-19 Pandemic}

While instrumental assessment of swallowing is should be limited during
the COVID-19 pandemic, speech-language pathologists (SLP) and dysphagia
clinicians (DC) must still find ways to appropriately evaluate and
manage patients with suspected dysphagia. Various tools may be
implemented to obtain the most objective, comprehensive evaluation
possible. The clinical swallowing assessment should include a thorough
case history, evaluation of oral motor and laryngeal function, and oral
trials of food and liquid. The Mann Assessment of Swallowing Ability --
Cancer (MASA-C)\textsuperscript{12} may be utilized to quantify the
degree of swallowing impairment, though multiple items may be difficult
to capture if conducted through telehealth. When the clinical evaluation
is conducted through telehealth, advanced preparation is necessary to
ensure the patient has appropriate food and liquid boluses available.
Providing the patient with the International Dysphagia Diet
Standardization Initiative (IDDSI)\textsuperscript{13} diet level
descriptions in advance will allow the clinician to better understand
the complexity of the boluses administered. Additional considerations
for performance of a clinical evaluation through telehealth is use of
clear feeding instruments to allow the clinician to best gauge the size
of bolus presented, use of food coloring in boluses to increase
visibility, and application of colored tape at the level of the thyroid
cartilage to aid in visualization of laryngeal elevation during the
swallow.\textsuperscript{14}

A clinical swallowing evaluation, whether in person or via telehealth
should be combined with quantitative swallowing measures to minimize the
potential for bias. A number of patient-reported outcome (PRO) measures
and clinician-rated scales have been validated for use in the head and
neck cancer population. The MD Anderson Dysphagia Inventory is a 20-item
PRO that can be used to capture the patient's perception of their
swallowing difficulties and has been broadly used in the head and neck
cancer population and adapted and validated in many
languages.\textsuperscript{15,16} Other swallowing specific PROs include
the EAT-10\textsuperscript{17}, the Sydney Swallow
Questionnaire\textsuperscript{18,19} and the Royal Brisbane Hospital
Outcome Measure for Swallowing (RBHOMS)\textsuperscript{20}. In addition
to patient reported outcomes, there are several clinician related tools
that can be utilized to quantify dysphagia and its outcomes. The
Performance Status Scale Head and Neck (PSSHN)\textsuperscript{21} has
two items which are routinely administered to quantify dysphagia impact;
the normalcy of diet subscale and the eating in public subscale.
Further, the Functional Oral Intake Scale (FOIS)\textsuperscript{22} and
Food Intake Level Scale (FILS)\textsuperscript{23} can provide
additional information about diet level in regard to tube feeding use.
This combination of thorough case history, clinical observation, PROs,
and clinician rating scales can provide the clinician with needed
information to guide recommendations and treatment planning until
instrumental assessment becomes more readily available.

It is important for the SLP and DC to recognize the limitations of
non-instrumental methods of swallowing evaluation. While agreement
between telehealth and in-person clinical swallowing evaluations is
good, there are limitations to clinical evaluations, particularly in
patients with more severe dysphagia.\textsuperscript{24} Thus,
clinicians may need to adopt a more conservative approach to dysphagia
management with close attention to potential markers of complications
such as increased cough, fever, and weight loss. In those circumstances,
the benefits of completing an instrumental evaluation may outweigh the
disadvantages. Given higher risks associated with aerosolization and
close proximity during FEES exams, the modified barium swallow would be
the preferred tool during the COVID-19 outbreak.

In addition to dysphagia diagnostics, swallowing therapy also may need
to be adapted during the pandemic. In general, swallowing therapy should
be reserved for telehealth whenever possible to minimize transmission
risk. There is a paucity of evidence on the benefits of telehealth in
dysphagia therapy, but there is some suggestion of improved treatment
adherence in patients receiving telehealth in comparison to patient-lead
home treatment.\textsuperscript{25} In addition to telehealth, other
technology-driven options such as mobile applications may play a role
when available.\textsuperscript{26,27} Swallowing therapists should
strive to adapt their virtual visits to provide the highest level of
care possible. Post-irradiated patients with history of virally mediated
nasopharyngeal and oropharyngeal cancer may find these mobile app and
telehealth options very beneficial because they are relatively young,
independent, knowledgeable, and receptive to the use of technology.
Engaging home caregivers and advanced planning of materials needed may
help to facilitate treatment sessions. Table 1 summarize the guidelines
for telehealth in swallowing management.

\textbf{Conclusions}

In the global pandemic of COVID-19 disease when the health care system
is under unprecedented pressure, any implementation of medical care
should be prioritized according to urgency and safety. Dysphagia can be
potentially life threatening if left unattended as it may cause
aspiration pneumonia or airway obstruction. While we suggest deferring
any non-urgent instrumental swallowing studies, particularly in patients
considered at high risk for COVID19 based on TOCC and acute respiratory
symptoms, screening and assessment of swallowing function can still be
possible through telehealth using various non-instrumental methods. Such
assessments can help to mitigate risks associated with dysphagia and to
triage those patients most in need of instrumental evaluation.
Telehealth can also be used to implement swallowing training, for
monitoring, and to review progress as well as to engage home caregivers
and plan future services. In cases where instrumental assessment is
deemed necessary, we advocate for adoption of conservative, high level
PPE use to minimize risk to patients and health care providers.

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\end{enumerate}

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