Patient Counselling and Treatment Recommendations
Patients with the FNAB results concerning for salivary gland malignancy and patients with confirmed salivary gland malignancies diagnosed after an office-based or CT-guided biopsy should be counselled about the prognosis and the need for surgical management despite of the surgical case delays due to COVID-19 pandemic. It is important to discuss with the patient the fact that salivary gland FNAB interpretation based on MSRSGC has excellent, but variable reported sensitivity (86-100%) and specificity (90-100%) in differentiating between benign and malignant lesions.16 Unless the FNAB results are categorized as “non-neoplastic” based on MSRSGC (Table 2),14surgical management should be discussed, while serious considerations are given to higher risk of contracting COVID-19 and related complications in cancer patients (Table 1).13,14
The current prevalence of COVID-19 positive patients in the geographic area and within the hospital must be taken into account when discussing surgery. Prior to any surgical intervention, patients should ideally undergo COVID-19 testing. Clinicians must be aware of false negatives with COVID-19 testing, and the fact that repeat testing for COVID-19 is not feasible in most patients. Chest CT may be considered in select cases for further evaluation and risk stratification to assess for signs of COVID-19 related pulmonary involvement or metastases.17 Surgery should be postponed for all patients with suspicious chest CT findings, those with symptoms of COVID-19 or positive COVID-19 test results.
When surgery is deemed necessary, surgical teams need to consider the risk of aerosolization. For minor salivary gland tumors of the oral cavity, sinonasal region and pharynx, appropriate PPE of the entire operating room staff is highly recommended. Operating room personnel must be minimized. For parotid and submandibular gland neoplasm surgeries, the risk of aerosolized mucosal secretions is only encountered during intubation and extubation. All non-essential personnel should leave the room during intubation and extubation for these surgeries, with appropriate PPE worn by all staff present in the room.1
Management of obstructive salivary gland disease should be carried out remotely in most cases. In rare cases, office-based evaluation and treatment interventions or an intraoperative drainage and biopsy may be required to rule out cancer, to manage an abscess or to relieve severe pain not controlled after appropriate medical management. Sialendoscopy should be avoided during the COVID-19 pandemic, given the irrigation and the aerosolization.