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\begin{document}

\title{Early Institutional Head and~ Neck Oncologic and Microvascular Surgery
Practice Patterns Across the United~ States During the SARS-CoV-2
(COVID19) Pandemic}



\author[1]{Rusha J. Patel et al.}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\begin{abstract}
Background: The SARS-CoV-2 (COVID-19) pandemic has caused rapid changes
in head and neck cancer (HNC) care. `Real-time' methods to monitor
practice patterns can optimize provider safety and patient care.Methods:
Head and neck surgeons from 14 institutions in the United States
regularly contributed their practice patterns to a shared spreadsheet.
Data from March 27\textsuperscript{th}, 2020 to April
5\textsuperscript{th}, 2020 was analyzed.Results: All institutions had
significantly restricted HNC clinic evaluations. 2 institutions stopped
free flap surgery with the remaining scheduling surgery by committee
review. Factors contributing to reduced clinical volume included lack of
personal protective equipment (PPE) (35\%) and lack of rapid COVID-19
testing (86\%).Conclusions: The COVID-19 pandemic has caused a reduction
in HNC care. Rapid COVID-19 testing and correlation with infectious
potential remain paramount to resuming the care of head and neck cancer
patients. Cloud-based platforms to share practice patterns will be
essential as the pandemic evolves.%
\end{abstract}%



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\textbf{}

INTRODUCTION

The COVID-19 pandemic, caused by SARS-CoV-2, has been implicated in over
360,000 cases in the United States alone and has been found to affect as
many as 28\% of HCW worldwide\textsuperscript{1,2}. Physicians across
specialties have had to make rapid decisions about personal protective
equipment (PPE), patient care triaging, and navigating national and
international guidelines that continue to evolve. These decisions are
not uniform and vary within the context of individual location's
infection rate and available resources.

This is of special concern to otolaryngologists, who are among the
highest risk specialties for COVID-19 exposure from nasal and mucosal
procedures and examinations\textsuperscript{3,4}. The highest
concentration of viral particles is found in the nasopharynx and routine
procedures performed by otolaryngologists can easily aerosolize viral
particles and allow for airborne trasmission\textsuperscript{5,6}. In
these early days of the pandemic, recommendations to keep both patients
and providers safe were made based on data from Wuhan, China, northern
Italy, and extrapolations from the SARS-CoV-1 epidemic. Givi et al
distilled these recommendations into specifics regarding protective
equipment (PPE) and practice considerations for head and neck surgeons
during the COVID-19 pandemic\textsuperscript{7}. The implementation of
these recommendations has been variable across institutions, likely
based upon regional COVID19 case load and resource availability.

As a subspecialty, head and neck cancer surgeons have had to balance
infection risk with patient care. Surgery remains a mainstay for head
and neck cancer treatment, but poses a high risk of viral exposure.
Surgical treatment delays have been shown to significantly increase the
risk of recurrence and reduce overall survival\textsuperscript{8,9}.
Thus, head and neck surgeons are tasked with triaging patient care and
balancing their decisions with the safety of themselves, their team, and
support staff. Cancer patients have significantly higher rates of
morbidity and mortality if infected with the novel coronoavirus, but a
cohesive approach to testing patients and weighing the risks of patient
exposure with resource utilization and patient survival is
lacking\textsuperscript{10}.

In the absence of readily available peer-reviewed information, North
American head and neck surgeons discussed the complicated issue of
protecting the providers, operating room staff, clinic staff and
patients via email chains, social media messaging platforms, message
boards, and text groups. Sensing this need for `real-time' information,
institution-specific data on head and neck surgery practice patterns
during the COVID19 pandemic was collected and distilled into an
accessible spreadsheet. Here is presented the data from 14 different
institutions, focusing specifically on early practice patterns related
to head and neck surgery and patient care.

METHODS

A shared spreadsheet with no patient-specific data included was created
with Google Docs. Contributors, all otolaryngology/head and neck
surgeons practicing in the United States, were solicited via email and
text. All contributors were given the option of remaining anonymous.
Data collected included current COVID-19 burden in the state, PPE
practices, perioperative COVID-19 testing, cancer case scheduling
concerns, and utilization of residency cadres. Information gathered is
updated regularly and available on the American Head and Neck Society
(AHNS) Bulletin Board at https://www.ahns.info/covid-19-info/. This
study is based on data collected from March 27\textsuperscript{th}, 2020
to April 5\textsuperscript{th}, 2020. Data were converted into discrete
variables and presented numerically and as percentages.

RESULTS

Fourteen institutions from multiple tertiary care sites across the
country contributed to data analysis. The highest COVID-19 burdens were
reported from three programs in California, with over 12,267 cases in
the state at the time of analysis. The lowest was from West Virginia
with 282 cases reported. Practice pattern results are summarized in
Figure 1.

In-house COVID-19 testing was available at 12 of 14 institutions, but
was limited at one site. Ten institutions (71\%) were performing
pre-operative COVID-19 testing, with rapid testing available at two
institutions.

High-risk procedures for COVID-19 transmission were defined as mucosal,
endoscopic, or aerodigestive surgery (including tracheostomy) by all
institutions. Six institutions included mastoid surgery as high-risk,
and two additionally defined salivary surgery as a high-risk procedure.
10 institutions were using N95 masks with a face shield in addition to
standard operating room PPE for high-risk procedures in COVID-19 tested
negative patients. One of these institutions additionally used a powered
air-purifying respirator (PAPR) for prolonged high-risk cases such as
free tissue transfer. The remaining four institutions used standard
surgical PPE alone for COVID-19 tested negative patents. For COVID-19
positive patients, 3 institutions used a PAPR. The remaining 11
institutions used either a PAPR or an N95 mask (Figure 2).

Twelve institutions (83\%) were continuing free flap surgery. One
institution was continuing on a limited basis, and the other two had
temporarily stopped free flap surgery. Most institutions had implemented
a review process for cancer surgery scheduling (Figure 3). Ten
institutions were using a case review by another individual or a
multidisciplinary committee. Two institutions were reviewing cases via
regular tumor board meetings. The remaining two institutions were asking
surgeons to limit cases to those he or she deemed essential. All
institutions reported prioritizing cancer cases that could not be
delayed 6-12 weeks. Transoral robotic surgery (TORS) was temporarily
deferred at four institutions. Most institutions reported using an N95
mask for microvascular anastomoses. Five institutions reported that a
lack of appropriate PPE had interfered in their ability to continue
surgical cases. Thirteen of 14 institutions reported intentionally
limiting resident participation in high-risk cases.

All institutions had limited clinical visits to those that were urgent
or selected by the provider. All but one institution were using
telemedicine for clinic appointments; one institution had the platform
pending. No institutions were offering antibody testing for providers at
the time of analysis. At the time of analysis, no providers had been
reassigned to alternate health care roles. Four institutions reported
providers being queried about reassignment should the need arise.

DISCUSSION:

The COVID-19 pandemic has shifted the structure of health care rapidly
and continues to do so on a daily basis. In the absence of precedent,
physicians have turned to each other to determine best practices and to
prepare for the long-term effects of the COVID-19 pandemic.

Utilizing multiple platforms, head and neck surgeons have been able to
rapidly disseminate information regarding evolving important updates to
practice patterns that allow for optimal patient care in times of
crisis. Not all platforms are equal: text and email can provide one-time
narrative information; social media, while useful for the rapid exchange
of information, can propagate false or misleading information which can
be easily perpetuated and place providers at risk for retaliation from
their institution. We created an anonymous, secure, and reliable method
to allow for real-time information regarding head and neck cancer care.
This system is modular and has provided valuable data about current
practice patterns and changes in these patterns as institutions and
guidelines adjust.

The majority of reporting institutions had implemented in-house COVID-19
testing abilities and followed similar PPE practices, including the use
of an N95 mask for high-risk procedures. Several institutions
recommended a personal air purifying device (PAPR) for patients with
unknown or positive COVID-19 status. PAPRs are reusable, but not widely
available. The PPE needs of major head and neck oncologic surgery depend
both on rapid and accurate COVID-19 testing, and a determination of the
true infectious risk of head and neck procedures. 35\% of institutions
reported lack of PPE prevented their surgical care. Until testing
results and infectious risk are shown to correlate, head and neck
surgery may continue to be prohibitively resource-heavy during the
COVID-19 pandemic. Rapid pre-operative testing, such as that reported by
two institutions, has some promise in mitigating PPE needs but this
remains to be assessed.

Our early results additionally show a significant decrease in the volume
of clinical care provided to head and neck cancer patients. Patients
seen in clinic have an `unknown' COVID-19 status, placing staff and
providers at high risk from a standard head and neck exam. As such, the
majority of institutions limited in-person evaluations to urgent visits.
While most institutions had implemented telemedicine, this format
precludes a full mucosal site exam and therefore has intrinsic
limitations in the evaluation and follow-up of head and neck cancer
patients. As the duration of limited clinical evaluation continues,
consideration will have to be given as to how safely evaluate new head
and neck cancer patients and effectively provide surveillance to
patients who have recently completed treatment. This could include a
reliable method of pre-clinical symptom screening, such as that
currently being performed on providers at three reporting institutions.

Adding to the gap in head and neck cancer care, we found that several
institutions in areas of higher COVID-19 burden had severely limited or
temporarily halted head and neck surgery requiring free tissue transfer.
As infection rates in other regions rise there is a potential for more
institutions to be unable to support these procedures. The majority of
institutions that were proceeding with free flap surgery were working
with limited intraoperative assistance and were scheduling via a review
process that could potentially delay surgery pending more urgent
operating room needs. Major head and neck oncologic surgery is
resource-intense from the perspectives of PPE use, critical care
support, and blood blank supplies. However, these surgeries are not only
important for improved function, they are often the best or only option
for oncologic control in patients suffering from head and neck cancer.
Triaging cancer cases in the setting of a pandemic is an unfortunate
reality. Specialty societies such as the American Head and Neck Society
(AHNS), Society of Endocrine Surgeons, the American College of Surgeons,
and the Society of Surgical Oncology have provided useful guidance to
support these difficult decisions being made by surgeons across the
country\textsuperscript{11, 12, 13}. As surgical resources continue to
be limited, serious multidisciplinary consideration will need to be
given to alternate methods of head and neck cancer care. The decision to
suspend these procedures during this time of crisis places an
immeasurable ethical burden on surgeons who have dedicated their lives
to the care of head and neck cancer patients, and incredible potential
for morbidity in patients who cannot receive their anticipated care.

Peer-reviewed data is not available to guide head and neck surgeons
through this pandemic when it is most needed. Real-time data sharing has
allowed head and neck surgeons to share and improve local practices in
order to mitigate harm and prevent the spread of infection. Our data
show that head and neck cancer care has been restricted, and will likely
continue to be restricted as COVID-19 incidences rise across the
country. The long-term effects on survival remain unknown, and the
greater need of preserving health care resources to the population
during the COVID-19 pandemic remains a priority while infection rates
continue to rise. Current focus should be on rapid and accurate
perioperative COVID-19 testing to mitigate PPE needs, allowing for
similar testing and/or screening practices to resume clinic evaluations,
and focusing on methods of least-harm during times of limited surgical
care. We hope this platform will continue to evolve and provide valuable
information to head and neck surgeons as the pandemic progresses.

\textbf{REFERENCES}

\begin{enumerate}
\tightlist
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  ''COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures''
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  Randolph G, Stack B. ''Endocrine Surgery during the Covid-19
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\end{enumerate}

\par\null

\textbf{Full author list}

Rusha J. Patel, MD FACS\textsuperscript{1}; Alexandra Kejner, MD
FACS\textsuperscript{2}; Caitlin McMullen, MD FACS\textsuperscript{3}

\begin{enumerate}
\tightlist
\item
  West Virginia University, Morgantown, West Virginia
\item
  University of Kentucky Markey Cancer Center, Lexington, KY
\item
  Moffitt Cancer Center, Tampa, FL
\end{enumerate}

\textbf{Corresponding Author}: Rusha J. Patel1 Medical Center Drive PO
Box 9200 Morgantown, WV
26505~\href{mailto:Rusha.patel@hsc.wvu.edu}{\nolinkurl{Rusha.patel@hsc.wvu.edu}}~O:
304-293-3457

\textbf{Acknowledgements}: The authors would like to acknowledge the
contributing members of each institution, both past and future, as well
as the American Head and Neck Society for their support.

\par\null

\textbf{Figures}

\par\null\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/C19-HN-F1/C19-HN-F1}
\caption{{Summary of Institutional Practices by Head and Neck Surgeons during the
COVID-19 Pandemic.
{\label{778433}}%
}}
\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/C19-HN-F2/C19-HN-F2}
\caption{{Personal Protective Equipment (PPE) for High-Risk Surgical Procedures
{\label{910080}}%
}}
\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/C19-HN-F3/C19-HN-F3}
\caption{{Institutional Methods of Surgical Case Selection
{\label{415394}}%
}}
\end{center}
\end{figure}

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