Evaluation of an interactive virtual surgical rotation during the COVID-19 pandemic.

OBJECTIVE: To evaluate medical student and attending surgeon experiences with a novel interactive virtual Otolaryngology - Head and Neck Surgery (OHNS) medical student elective during the COVID-19 pandemic. STUDY DESIGN: A virtual OHNS elective was created, with three components: (1) interactive virtual operating room (OR) experience using live-stream video-conferencing, (2) telehealth clinic, (3) virtual didactics. SETTING: OHNS Department at the University of Pennsylvania (May 2020 to June 2020). METHODS: Six medical students from the University of Pennsylvania; five attending otolaryngologists. Two surveys were designed and distributed to participating medical students and attending surgeons. Surveys included 5-point Likert scale items, with 1 indicating "not at all" and 5 indicating "very much so". RESULTS: Response rate was 100% for both surveys. Students on average rated the educational value of the telehealth experience as 4.2 ± 1.2, and the virtual OR experience as 4.0 ± 0.6. Most students (n = 5, 83%) indicated that they had enough exposure to faculty they met on this rotation to ask for a letter of recommendation (LOR) for residency if needed, while attending surgeons had an average response of 3.0 ± 1.0 when asked how comfortable they would feel writing a LOR for a student they met through the rotation. A majority of students (n = 4, 67%) felt they connected enough with faculty during the rotation to ask for mentorship. Half the students (n = 5, 50%) indicated that the rotation allowed them to evaluate the department's culture either "extremely well" or "somewhat well". CONCLUSIONS: Overall, participating students described this innovative virtual surgical rotation as an educationally and professionally valuable experience. With the continued suspension of visiting student rotations due to the COVID-19 pandemic, this virtual model may have continued relevance to medical education.

Long-Term Complications of COVID-19 Infection in Adolescents and Children.

Purpose of Review: Compared to adults, post-COVID-19 symptoms are uncommon and have not been thoroughly evaluated in children. This review summarizes the literature in terms of persistent symptoms in children and adolescents after SARS-CoV-2 infection. Recent Findings: Children were less likely to develop long COVID when compared to adults. Older children (e.g., adolescents) and those who had symptomatic COVID-19 had a higher probability for long COVID. Summary: Families and health care providers need to be aware of a new constellation of long COVID symptoms in the pediatric population. More evidence and time are needed to better understand the potential effects of long COVID-19 in children and adolescents. In comparison to adults, children are less likely to have persistent COVID-19 symptoms.

Multisystem inflammatory syndrome in children: A systematic review.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C), also known as pediatric inflammatory multisystem syndrome, is a new dangerous childhood disease that is temporally associated with coronavirus disease 2019 (COVID-19). We aimed to describe the typical presentation and outcomes of children diagnosed with this hyperinflammatory condition. METHODS: We conducted a systematic review to communicate the clinical signs and symptoms, laboratory findings, imaging results, and outcomes of individuals with MIS-C. We searched four medical databases to encompass studies characterizing MIS-C from January 1st, 2020 to July 25th, 2020. Two independent authors screened articles, extracted data, and assessed risk of bias. This review was registered with PROSPERO CRD42020191515. FINDINGS: Our search yielded 39 observational studies (n = 662 patients). While 71·0% of children (n = 470) were admitted to the intensive care unit, only 11 deaths (1·7%) were reported. Average length of hospital stay was 7·9 ± 0·6 days. Fever (100%, n = 662), abdominal pain or diarrhea (73·7%, n = 488), and vomiting (68·3%, n = 452) were the most common clinical presentation. Serum inflammatory, coagulative, and cardiac markers were considerably abnormal. Mechanical ventilation and extracorporeal membrane oxygenation were necessary in 22·2% (n = 147) and 4·4% (n = 29) of patients, respectively. An abnormal echocardiograph was observed in 314 of 581 individuals (54·0%) with depressed ejection fraction (45·1%, n = 262 of 581) comprising the most common aberrancy. INTERPRETATION: Multisystem inflammatory syndrome is a new pediatric disease associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is dangerous and potentially lethal. With prompt recognition and medical attention, most children will survive but the long-term outcomes from this condition are presently unknown. FUNDING: Parker B. Francis and pilot grant from 2R25-HL126140. Funding agencies had no involvement in the study.

Safely performing percutaneous dilatational tracheostomies on COVID-19 patients in the intensive care unit: A standardized approach.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the resulting coronavirus disease 2019 (COVID-19) have afflicted hundreds of millions of people in a worldwide pandemic. During this pandemic, otolaryngologists have sought to better understand risk factors associated with COVID-19 contamination during surgical procedures involving the airways such as tracheostomies. OBJECTIVE: This study provides a standardized technique of performing an ultrasound (US)-guided percutaneous dilatational tracheostomy (PDT) on COVID-19 patients in the intensive care unit (ICU). It also outlines safety strategies for health care providers that includes proper use of personal protective equipment (PPE) and regular testing of otolaryngologists for COVID-19 contamination. METHODS: This study analyzed data from 44 PDT procedures performed on COVID-19 patients in the ICU of hospitals in Sao Paulo and Santos, Brazil. The PDT procedures were conducted between April 2020 and August 2020, which coincided with a peak of the COVID-19 pandemic in São Paulo, Brazil. Surgeons were tested for COVID-19 using a two-stage serological enzyme-linked immunosorbent assay specific for SARS-CoV-2 antigens. CONCLUSION: This study describes a safe standardized technique of US-guided PDT for COVID-19 patients in the ICU using a method that also decreases the risk of surgeon contamination.

Outcomes After Tracheostomy in COVID-19 Patients.

OBJECTIVE: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ±â€Š6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ±â€Š6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

The Impact of COVID-19 on Otolaryngology Community Practice in Massachusetts.

OBJECTIVES: Coronavirus disease 2019 (COVID-19) significantly affected many health care specialties, including otolaryngology. In response to governmental policy changes, many hospitals and private practices in Massachusetts canceled or postponed nonurgent office visits and elective surgeries. The objective of this study was to quantify the impact of COVID-19 on the provision and practice trends of otolaryngology services for 10 private practices in Massachusetts. STUDY DESIGN: Retrospective review. SETTING: Multipractice study for community practices in Massachusetts. METHODS: Electronic billing records from 10 private otolaryngology practices in Massachusetts were obtained for the first 4 months of 2019 and 2020. Questionnaires from these otolaryngology practices were collected to assess financial and staffing impact of COVID-19. RESULTS: The local onset of the COVID-19 pandemic had a significant decrease of 63% of visits in comparison to equivalent weeks in 2019. Virtual visits overtook in-person visits over time. A greater decline in operating room (OR) procedures than for office procedures was recorded. Ninety percent of practices reduced working hours, and 80% furloughed personnel. Seventy percent of practices applied for the Paycheck Protection Program (PPP). CONCLUSION: COVID-19 has had a multifaceted impact on private otolaryngology practices in Massachusetts. A significant decline in provision of otolaryngology services aligned with the Massachusetts government's public health policy changes. The combination of limited personnel and personal protective equipment, as well as suspension of nonessential office visits and surgeries, led to decrease in total office visits and even higher decrease in OR procedures.

Demographic predictors of hospitalization and mortality in US children with COVID-19.

Understanding which children are at increased risk for poor outcome with COVID-19 is critical. In this study, we link pediatric population-based data from the US Center for Disease Control and Prevention to COVID-19 hospitalization and in-hospital death. In 27,045 US children with confirmed COVID-19, we demonstrate that African American [OR 2.28 (95% CI: 1.93, 2.70)] or mixed race [OR 2.95 (95% CI: 2.28, 3.82)] and an underlying medical condition [OR 3.55 (95% CI: 3.14, 4.01)] are strong predictors for hospitalization. Death occurred in 39 (0.19%) of 20,096 hospitalized children; children with a prior medical condition had an increased odd for death [OR 8.8 (95% CI: 3.7, 21.1)].Conclusion: Hospitalization and in-hospital death are rare in children diagnosed with COVID-19. However, children at higher risk for these outcomes include those with an underlying medical condition, as well as those of African American descent. What is Known: • Demographic factors are independent prognosticators of poor outcome in children with COVID-19. What is New: • Children with an underlying medical condition and those from an African American or mixed race/ethnicity are at high risk for COVID-19 hospitalization. • History of a comorbidity supersedes age, gender, and race/ethnicity as a risk factor for in-hospital pediatric COVID-19 death.

Access to Telemedicine-Are We Doing All That We Can during the COVID-19 Pandemic?

The COVID-19 pandemic has resulted in physicians having to switch from in office visits to telemedicine. Unfortunately, physicians and patients did not have adequate time to anticipate barriers to its implementation. Over the last month, one of the major problems has been patient access to telemedicine. Many patients do not own a smartphone or have broadband access. This "digital divide" is not fair to our patients in need-especially those with a cancer diagnosis. Patients deserve access to care. We need to implore insurance companies to provide tablets with wireless capabilities to patients in need.

Management of a Unique Sinonasal Undifferentiated Carcinoma Subtype in the Era of SARS-CoV-2.

The novel coronavirus (SARS-CoV-2) pandemic has influenced the timeliness of care for patients with both common and rare conditions, particularly those affecting high-risk operative sites such as the upper aerodigestive tract. Sinonasal undifferentiated carcinoma (SNUC) represents a rare malignancy of the sinonasal tract, a unique subset of which has never been previously reported in the otolaryngology literature and is characterized by inactivation of the SMARCB (INI-1) tumor suppressor gene. This subtype exhibits a particularly poor prognosis and is characterized pathologically by its rhabdoid appearance. Here we present the case of an individual who was diagnosed with a sinonasal mass during the SARS-CoV-2 pandemic, which was ultimately found to be SMARCB (INI-1)-deficient sinonasal carcinoma. Advanced imaging was deferred in the interest of limiting the patient's exposure to the virus, and expedited operative management was performed which facilitated prompt referral for adjuvant chemoradiation. The SARS-CoV-2 pandemic presents unique challenges, but the work-up of high-risk lesions must be prioritized; this continues to be paramount as SARS-CoV-2 resurges in many cities across the USA.

Mental health among head and neck surgeons in Brazil during the COVID-19 pandemic: A national study.

PURPOSE: Head and neck surgeons are among the highest risk for COVID-19 exposure, which also brings great risk to their mental wellbeing. In this study, we aim to evaluate mental health symptoms among head and neck surgeons in Brazil surrounding the time it was declared the epicenter of the virus. MATERIALS AND METHODS: A cross-sectional, survey-based study evaluating burnout, anxiety, distress, and depression among head and neck surgeons in Brazil, assessed through the single-item Mini-Z burnout assessment, 7-item Generalized Anxiety Disorder scale, 22-item Impact of Event Scale-Revised, and 2-item Patient Health Questionnaire, respectively. RESULTS: 163 physicians completed the survey (74.2% males). Anxiety, distress, burnout, and depression symptoms were reported in 74 (45.5%), 43 (26.3%), 24 (14.7%), and 26 (16.0%) physicians, respectively. On multivariable analysis, female physicians were more likely to report a positive screening for burnout compared to males (OR 2.88, CI [1.07-7.74]). Physicians 45 years or older were less likely to experience anxiety symptoms than those younger than 45 years (OR 0.40, CI [0.20-0.81]). Physicians with no self-reported prior psychiatric conditions were less likely to have symptoms of distress compared to those with such history (OR 0.11, CI [0.33-0.38]). CONCLUSION: Head and neck surgeons in Brazil reported symptoms of burnout, anxiety, distress and depression during our study period within the COVID-19 pandemic. Institutions should monitor these symptoms throughout the pandemic. Further study is required to assess the long-term implications for physician wellness.

Snapshot Impact of COVID-19 on Mental Wellness in Nonphysician Otolaryngology Health Care Workers: A National Study.

OBJECTIVE: Nonphysician health care workers are involved in high-risk patient care during the COVID-19 pandemic, placing them at high risk of mental health burden. The mental health impact of COVID-19 in this crucial population has not been studied thus far. Thus, the objective of this study is to assess the psychosocial well-being of these providers. STUDY DESIGN: National cross-sectional online survey (no control group). SETTING: Academic otolaryngology programs in the United States. SUBJECTS AND METHODS: We distributed a survey to nonphysician health care workers in otolaryngology departments across the United States. The survey incorporated a variety of validated mental health assessment tools to measure participant burnout (Mini-Z assessment), anxiety (Generalized Anxiety Disorder-7), distress (Impact of Event Scale), and depression (Patient Health Questionnaire-2). Multivariable logistic regression analysis was performed to determine predictive factors associated with these mental health outcomes. RESULTS: We received 347 survey responses: 248 (71.5%) nurses, 63 (18.2%) administrative staff, and 36 (10.4%) advanced practice providers. A total of 104 (30.0%) respondents reported symptoms of burnout; 241 (69.5%), symptoms of anxiety; 292 (84.1%), symptoms of at least mild distress; and 79 (22.8%), symptoms of depression. Upon further analysis, development of these symptoms was associated with factors such as occupation, practice setting, and case load. CONCLUSION: Frontline otolaryngology health care providers exhibit high rates of mental health complications, particularly anxiety and distress, in the wake of COVID-19. Adequate support systems must be put into place to address these issues.

Local spikes in COVID-19 cases: Recommendations for maintaining otolaryngology clinic operations.

The Coronavirus Disease-2019 (COVID-19) pandemic has created an unprecedented economic and public health crisis in the United States. Following efforts to mitigate disease spread, with a significant decline in some regions, many states began reopening their economies. As social distancing guidelines were relaxed and businesses opened, local outbreaks of COVID-19 continue to place person on healthcare systems. Among medical specialties, otolaryngologists and their staff are among the highest at risk for becoming exposed to COVID-19. As otolaryngologists prepare to weather the storm of impending local surges in COVID-19 infections there are several practical measures that can be taken to mitigate the risk to ourselves and our staff.

Optimizing telemedicine encounters for oral and maxillofacial surgeons during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has changed conventional patterns of medical practice across all health disciplines, including oral and maxillofacial surgery. The use of telemedicine has rapidly expanded to uphold safety strategies of physical distancing and disease transmission reduction while maintaining uninterrupted care of patients. To date, there are no specific guidelines to optimize telemedicine encounters in oral and maxillofacial surgery. The goal of this article is to provide best practices for both oral and maxillofacial surgeons and their patients to effectively use telemedicine for the duration of the COVID-19 pandemic and beyond.

Effect of the COVID-19 pandemic on medical student career perceptions: a national survey study.

BACKGROUND & OBJECTIVE: The COVID-19 pandemic and resulting cancellation of medical student clinical rotations pose unique challenges to students' educations, the impact of which has not yet been explored. DESIGN: This cross-sectional survey study collected responses from 13 April 2020 until 30 April 2020. Students at US allopathic medical schools completed the survey online. RESULTS: 1,668 responses were analyzed. A total of 337 (20.2%) respondents thought the pandemic would affect their choice of specialty, with differences across class years: 15.2% (53) of first-years (MS1s), 26.4% (92) of second-years (MS2s), 23.7% (162) of third-years (MS3s), and 9.7% (22) of fourth-years (MS4s) (p < 0.0001). Among all classes, the most common reason chosen was inability to explore specialties of interest (244, 72.4%), and the second was inability to bolster their residency application (162, 48.1%). Out of the MS3s who chose the latter, the majority were concerned about recommendation letters (68, 81.0%) and away rotations (62, 73.8%). As high as 17.4% (119) of MS3s said they were more likely to take an extra year during medical school as a result of the pandemic. Region of the US, number of local COVID cases, and number of local COVID deaths had no effect on whether respondents thought the pandemic would affect their specialty choice. CONCLUSIONS: Our study found that about one-fifth of surveyed medical students currently believe that the COVID-19 pandemic will affect their choice of specialty, with many of these citing concerns that they cannot explore specialties or obtain recommendation letters. With prolonged suspension of clinical rotations, targeted efforts by medical schools to address these concerns through enhanced virtual curriculum development and advising strategies will become increasingly important. Further study is needed to explore whether these cross-sectional student perspectives will manifest as changes in upcoming National Residency Matching Program data.

Patient Perceptions of Head and Neck Ambulatory Telemedicine Visits: A Qualitative Study.

OBJECTIVE: During the COVID-19 pandemic, there has been unprecedented use of telemedicine for otolaryngology ambulatory visits. Patient satisfaction with telemedicine is an important metric, but survey-based questionnaires do not capture the nuances of the patient experience. This study aims to understand head and neck patients' perceptions about telemedicine clinic visits during COVID-19. METHODS: Fifty-six established patients who had video-based telemedicine visits with an otolaryngology-head and neck surgery faculty member between March 25, 2020, and April 24, 2020, completed unstructured telephone interviews. Conventional content analysis was used to analyze the interview data. Retrospective chart reviews were conducted to determine the patients' demographic, disease, and treatment information. RESULTS: The primary benefits of telemedicine were accessibility and cost and time savings. Primary limitations included the ability to perform a physical examination. Most patients expressed a willingness to participate in future remote visits if appropriate or necessitated by social circumstances. DISCUSSION: Telemedicine is a disruptive process, and long-term adoption requires understanding patient perception of and satisfaction with telemedicine. Head and neck cancer patients were generally satisfied with telemedicine. The study elucidated patient perceived benefits and limitations of telemedicine. IMPLICATIONS FOR PRACTICE: Continued implementation of telemedicine in otolaryngology-head and neck ambulatory clinics will require consideration of contextual features surrounding the virtual delivery of care, with particular attention to visit appropriateness for telemedicine and social circumstances.

Assessment of YouTube as an Educational Tool in Teaching Key Indicator Cases in Otolaryngology During the COVID-19 Pandemic and Beyond: Neck Dissection.

OBJECTIVES: YouTube has become the preferred resource for trainees in otolaryngology to prepare for surgery. This study aimed to compare the evaluation by 2 attending physicians and 2 resident physicians of the quality of videos on YouTube on neck dissection, a key indicator case in head and neck surgery. The authors aimed to assess the quality and quantity of YouTube videos available for development of a virtual surgical educational curriculum for trainees in otolaryngology. METHODS: Using the YouTube search feature, the top 10 videos by relevance and view count were compiled using the following search terms: radical neck dissection, selective neck dissection, modified radical neck dissection, lateral neck dissection, levels I-III neck dissection, levels II-IV, left neck dissection, right neck dissection, cervical nodal dissection, and supraomohyoid neck dissection. A total of 37 videos on neck dissection were identified and analyzed using the LAP-VEGaS criteria as well as author-specific modified LAP-VEGaS criteria. RESULTS: The mean comprehensive LAP-VEGaS score was 8.74 (SD 3.10). The majority of videos (24/37) were designated as medium quality; 10 of 37 videos were low quality and 3 of 37 videos were high quality. In the total group analysis, there was excellent inter-rater reliability between attending physicians (Cohen's kappa coefficient of 0.84) and good inter-rater reliability between resident physicians (Cohen's kappa coefficient of 0.58). There was no correlation between total view count, video age, or number of likes/dislikes and the overall LAP-VEGaS score. The presence of audio or written commentary had a moderate positive correlation with LAP-VEGaS score (adjusted R2 of 0.36). There was no statistically significant difference in video quality between videos posted by US and non-US based physicians (95% confidence interval -0.10 to 4.10; p = 0.06). However, videos made by an otolaryngology-trained physician had a LAP-VEGaS score that was 3.93 points higher (95% confidence interval 2.34-5.52; p < 0.001) than that of videos made by a nonotolaryngology-trained physician. CONCLUSIONS: Online videos of neck dissection represent an increasingly ubiquitous and appropriate resource for trainees in learning otolaryngology key indicator cases. While free-to-access video repositories, such as YouTube, have become increasingly popular among trainees as a primary resource for learning and preparing for surgical cases, they lack consistent quality and as such, global efforts should be taken to improve the breadth and depth of educational video content in otolaryngology.

Creation of an Interactive Virtual Surgical Rotation for Undergraduate Medical Education During the COVID-19 Pandemic.

OBJECTIVE: During the coronavirus 2019 pandemic, medical student involvement in direct patient care has been severely limited. Rotations mandatory not only for core curricula but also for informing decisions regarding specialty choice have been postponed during a critical window in the application cycle. Existing virtual rotations are largely observational or lack patient-facing components. SETTING: A virtual Otolaryngology - Head and Neck Surgery rotation at the University of Pennsylvania (Philadelphia, Pennsylvania) was implemented for medical students, comprising interactive live-streamed surgeries, outpatient telehealth visits, and virtual small group didactics. RESULTS: Medical students enrolled in the virtual surgical rotation were able to engage with attending surgeons and operating room staff while remotely viewing surgical procedures captured with first-person audiovisual technology. Students participated in several different aspects of care delivery in both the inpatient and outpatient setting, similar to their typical responsibilities of an in-person rotation. CONCLUSIONS: The authors will continue to develop the virtual surgical education methodology to further disseminate an interactive video-based medical student elective to other procedural specialties and institutions.

Penn Medicine Head and Neck Cancer Service Line COVID-19 management guidelines.

INTRODUCTION: The COVID-19 pandemic caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) virus has altered the health care environment for the management of head and neck cancers. The purpose of these guidelines is to provide direction during the pandemic for rational Head and Neck Cancer management in order to achieve a medically and ethically appropriate balance of risks and benefits. METHODS: Creation of consensus document. RESULTS: The process yielded a consensus statement among a wide range of practitioners involved in the management of patients with head and neck cancer in a multihospital tertiary care health system. CONCLUSIONS: These guidelines support an ethical approach for the management of head and neck cancers during the COVID-19 epidemic consistent with both the local standard of care as well as the head and neck oncological literature.