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
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, 20201. 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.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.
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.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.
Selection of Personal Protective Equipment
Recent studies reported the R0 of SARS-CoV-2 ranged from 5.71-7.235, which is higher than SARS-CoV (2 to 4) in 2003.6 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 µm 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.7 Based on the observation of high viral shredding of coronavirus in the nasal passage/nasopharynx8 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 µm to 100 µm which lie in the range of aerosol generation.9Therefore, 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.
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-2,10 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 (T ravel, O ccupation, C ontact andC lustering phenomenon as 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.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.