Effects of Covid-19 Protocols on Treatment of Patients with Head-Neck Diseases

This work aims to report how COVID-19 pandemic affects the operations of the department of Otolaryngology, in two hospitals in Campania: University Hospital "San Giovanni di Dio and Ruggi d'Aragona” of Salerno and at the hospital "A.O.R.N. A. Cardarelli” of Naples (Italy). In the last years, COVID-19 has become the main type of disease affecting subjects with possible lung infections (pneumonia). SARS-cov-2 infection has been reported as severe acute respiratory syndrome that mainly affects the respiratory system and lungs, but the virus also involved other organs such as cardiac, renal and nervous ones. In the study the attention is turned to the department of Otolaryngology because the operators are very exposed. Data were collected for the year 2019, in the absence of Covid-19, and in the year of the pandemic, 2020. The purpose of the work was to make a comparison between the situation of the department before and during the epidemic from Covid-19 to the individual hospital, in addition a comparison was made between the two hospitals. © 2023, The Author(s), under exclusive license to Springer Nature Switzerland AG.

Acquired Tracheomalacia Requiring Urgent Tracheostomy Exchange in Patients With COVID-19.

Tracheostomy for prolonged ventilation of patients with COVID-19 was often delayed due to high viral loads and persistent high ventilatory requirements. With prolonged intubation and significant dose corticosteroid use, patients with COVID-19 are at risk for tracheomalacia, and urgent tube exchange may be required to address persistent cuff leak and to maintain adequate mechanical ventilation. We sought to describe our single center experience with COVID-19 patients requiring tracheostomy and the tracheal complications that followed. We performed a review of patients with COVID-19 who underwent tracheostomy from June 2020 to October 2021. 45 patients were identified; 82.2% survived their index hospitalization. Tracheostomy was performed after 16.4 days of mechanical ventilation. 22.2% required urgent exchange to an extended length tracheostomy tube after 7.2 days from initial tracheostomy. Placement of an extended length tracheostomy tube can reduce cuff leak in ventilated COVID-19 patients and may be considered during initial tracheostomy placement.

Tele-rehabilitation in voice disorders during the pandemic: a consensus paper from the French Society of Phoniatrics and Laryngology.

OBJECTIVES: To establish a consensus protocol for telerehabilitation in speech therapy for voice disorders. METHODS: The study was conducted according to a modified Delphi method. Twenty speech therapist or laryngologist experts of the French Society of Phoniatrics and Laryngology assessed 24 statements of voice telerehabilitation with a 10-point visual analog scale ranging from 1 (totally disagree) to 10 (totally agree). The statements were accepted if more than 80% of the experts rated the item with a score of ≥ 8/10. The statements with ≥ 8/10 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected. RESULTS: The French Society of Phoniatrics and Laryngology experts validated 10, 6, and 2 statements after the first, second and third voting round, respectively. Seven statements did not reach agreement threshold and were rejected. The validated statements included recommendations for setting (N = 4), medical/speech history (N = 2), subjective voice evaluations (N = 3), objective voice quality measurements (N = 3), and voice rehabilitation (N = 5). The experts agreed for a follow-up consisting of combined telerehabilitation and in-office rehabilitation. The final protocol may be applied in context of pandemic but could be assessed out of pandemic period for patients located in rural regions. CONCLUSIONS: This Delphi study established the first telerehabilitation protocol of the French Society of Phoniatrics and Laryngology for patients with voice disorders. Future controlled studies are needed to assess its feasibility, reliability, and the patient perception about telerehabilitation versus in-office rehabilitation.

Injection of Platelet Rich Plasma in the Olfactory Cleft for COVID-19 Patients With Persistent Olfactory Dysfunction: Description of the Technique.

In this paper, we described technique of platelet rich plasma injection into the olfactory cleft in a 22-year-old female with 24-month post-COVID-19 anosmia. The technique starts with the blood extraction and the isolation of PRP through a 10-min centrifugation. The supernatant was injected in nasal regions after a local anesthesia through a 0° rigid optic. Several points of .2-.5 mL were performed in the nasal septum in regard of the head of the middle turbine and in the head of the middle turbine in both sides. The baseline threshold, discrimination, and identification scores were 1, 8, and 0, and the Olfactory Disorder Questionnaire score was 51, respectively. The injection of PRP in olfactory cleft was done without complication and mild pain. The patient perception of recovery of smell sense occurred at 3-week post-injection. From this time, the smell sense progressively improved to the 2-month consultation. At 2-month post-injection, the TDI scores reached 16, 16, and 16 (48), while the Olfactory Disorder Questionnaire was 73. The injection of PRP into the olfactory cleft appears to be a safe and easiness new approach that may improve the recovery of smell sense. Future controlled studies are needed.

RadImageNet: An Open Radiologic Deep Learning Research Dataset for Effective Transfer Learning.

Purpose: To demonstrate the value of pretraining with millions of radiologic images compared with ImageNet photographic images on downstream medical applications when using transfer learning. Materials and Methods: This retrospective study included patients who underwent a radiologic study between 2005 and 2020 at an outpatient imaging facility. Key images and associated labels from the studies were retrospectively extracted from the original study interpretation. These images were used for RadImageNet model training with random weight initiation. The RadImageNet models were compared with ImageNet models using the area under the receiver operating characteristic curve (AUC) for eight classification tasks and using Dice scores for two segmentation problems. Results: The RadImageNet database consists of 1.35 million annotated medical images in 131 872 patients who underwent CT, MRI, and US for musculoskeletal, neurologic, oncologic, gastrointestinal, endocrine, abdominal, and pulmonary pathologic conditions. For transfer learning tasks on small datasets-thyroid nodules (US), breast masses (US), anterior cruciate ligament injuries (MRI), and meniscal tears (MRI)-the RadImageNet models demonstrated a significant advantage (P < .001) to ImageNet models (9.4%, 4.0%, 4.8%, and 4.5% AUC improvements, respectively). For larger datasets-pneumonia (chest radiography), COVID-19 (CT), SARS-CoV-2 (CT), and intracranial hemorrhage (CT)-the RadImageNet models also illustrated improved AUC (P < .001) by 1.9%, 6.1%, 1.7%, and 0.9%, respectively. Additionally, lesion localizations of the RadImageNet models were improved by 64.6% and 16.4% on thyroid and breast US datasets, respectively. Conclusion: RadImageNet pretrained models demonstrated better interpretability compared with ImageNet models, especially for smaller radiologic datasets.Keywords: CT, MR Imaging, US, Head/Neck, Thorax, Brain/Brain Stem, Evidence-based Medicine, Computer Applications-General (Informatics) Supplemental material is available for this article. Published under a CC BY 4.0 license.See also the commentary by Cadrin-Chênevert in this issue.

Teaching gross anatomy during the Covid-19 pandemic: Effects on medical students' gain of knowledge, confidence levels and pandemic-related concerns.

For medical students the dissection course is the preferred method to learn gross anatomy. However, the added value of active cadaver dissection on knowledge gain in multimodal curricula offering a diversity of e-learning resources is unknown. The Covid-19-related lockdown forced educators to replace the dissection course by e-learning resources. At the end of the summer term 2020 loosening of pandemic-related regulations allowed offering a compact, voluntary active dissection course of the head-neck region to first-year medical students at Hannover Medical School. A study was conducted comparing a dissection group (G1, n = 115) and a non-dissection group (G2, n = 23). Knowledge gain and confidence level were measured with a multiple-choice (MC-)test. The use of e-learning resources was recorded. A questionnaire measured motivation, interest and level of concern regarding Covid-19 and anatomy teaching. No differences between groups were found regarding motivation and interest in anatomy of the head-neck region. G2, however, had significantly higher concerns regarding the Covid-19 pandemic than G1. Neither before nor after the educational intervention, differences in the scores of the MC-test were found. However, after the course G1 answered more MC-questions with highest confidence level than G2 (6.7 ± 6.0 vs. 3.6 ± 4.6, p < 0.05) and demonstrated by trend an increased improvement in the scores of image-based questions (30.8 ± 18.2 % vs. 17.1 ± 14.8 %, p = 0.06). In general, frequent users of online quizzes, a part of the e-learning resources, scored significantly better in the knowledge test. Active dissection improves self-assurance to identify anatomical structures and should be re-implemented in multimodal, blended-learning-based anatomical curricula in the post-pandemic era.

Postacute Laryngeal Injuries and Dysfunctions in COVID-19 Patients: A Scoping Review.

OBJECTIVE: To investigate post-acute laryngeal injuries and dysfunctions (PLID) in coronavirus disease 2019 (COVID-19) patients. METHODS: Three independent investigators performed a systematic review of the literature studying PLID in patients with a history of COVID-19. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement. Epidemiological, clinical, hospitalization features, laryngeal diseases, and voice outcomes were extracted from the included papers. RESULTS: Eight papers met our inclusion criteria (393 patients) corresponding to five uncontrolled prospective and three retrospective studies. The most prevalent PLID were vocal fold dysmotility (65%), vocal fold edema (35%), muscle tension dysphonia (21%), and laryngopharyngeal reflux (24%). Posterior glottic stenosis (12%), granuloma (14%), and posterior glottic diastasis (12%) were the most common injuries. Most patients with PLID were obese and had a history of intensive care unit hospitalization, and orotracheal intubation. The delay between the discharge and the laryngology office consultation ranged from 51 to 122 days. The mean duration of intubation ranged from 10 to 34 days. Seventy-eight (49%) intubated patients were in the prone position. The proportion of patients requiring surgical treatment ranged from 39% to 70% (mean = 48%). There was an important heterogeneity between studies about inclusion, exclusion criteria, and outcomes. CONCLUSIONS: COVID-19 appeared to be associated with PLID, especially in patients with a history of intubation. However, future controlled studies are needed to evaluate if intubated COVID-19 patients reported more frequently PLID than patients who were intubated for other conditions.

Proof-of-concept of a new FFP2 mask adapted to Otolaryngological practice in pandemic: a prospective study.

OBJECTIVE: The objective of this study was to appreciate the tolerance and convenience of a new FFP2 mask allowed the realization of nasal examination in period of pandemic. METHODS: Fifty-one patients were prospectively recruited from two European hospitals to test the FFP2 mask prototype. The following outcomes were evaluated in patients after the clinical examination: fear about coronavirus disease 2019 (COVID-19) infection; easiness of mask placement; tolerability; reassurance; and overall satisfaction about the use of this kind of mask in a pandemic context. Seven otolaryngologists evaluated the mask acceptance and usefulness in patients through a standardized physician-reported outcome questionnaire. RESULTS: Fifty patients completed the evaluation. There were 25 males and 25 females. The mean age of patients was 41 years. Ninety percent of patients considered that the use of the mask reduced the risk to be infected during the examination. Seventy percent of patients reported high or very high satisfaction and should recommend mask to other patients in pandemic period. The realization of nasal examination was easier with optic compared with flexible trans-nasal examination (p = 0.001), which significantly impacted the satisfaction level of physician (p = 0.001). The physician difficulty to perform the examination significantly impacted the satisfactory of patient (p = 0.033). CONCLUSION: The new bioserenity FFP2 mask allows the realization of the trans-nasal endoscopic examination during a pandemic. The use of this mask requires little training period of physician. The use of this mask prototype is well received by patients who reported better perception of self-protection against the virus.

Impact of COVID-19 restrictions on hospitalisation and post-operative rehabilitation of head and neck cancer patients.

OBJECTIVE: The COVID-19 pandemic emergency forced the health system in Italy to implement an immediate reorganisation to support the care of tens of thousands of patients and to maintain the quality of care for patients with other pathologies, such as oncologic diseases. The main goal of this study was to evaluate the impact of COVID-19 restrictions on the hospitalisation and post-operative rehabilitation of head and neck oncologic patients and to determine whether the introduction of new technologies such as video-communication may be useful to mitigate social distancing by close family members. METHODS: Fifty-one consecutive patients underwent surgery for head and neck cancer during the period of lockdown caused by the COVID-19 pandemic. The data collected (post-operative pain, post-operative complications, duration of hospitalisation) were compared with those of 51 consecutive patients treated for head and neck cancer in the period immediately preceding lockdown. RESULTS: The average duration of hospitalisation was longer in patients operated on in the COVID-19 period, and, in particular, among patients who underwent a more demanding rehabilitation protocol. Despite this, our study did not show a significant difference in psychological aspects during hospitalisation. CONCLUSIONS: The greatest difficulties that occurred in the COVID-19 period were met by a greater commitment from medical staff, allowing the quality of life of head and neck cancer patients during post-operative rehabilitation to be maintained at a similar level to that before the pandemic. In the future, there will be a need for technological solutions to bring the patient closer to family members.

COVID-19 Pandemic and its Impact on the Management of Head and Neck Cancer in the Spanish Healthcare System.

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has represented a major challenge for healthcare systems worldwide, changing the habits of physicians. A reorganization of healthcare activity has been necessary, limiting surgical activity to essential cases (emergencies and oncology), and improving the distribution of health resources. Objective To analyze the impact of the COVID-19 pandemic on head and neck cancer surgery management in Spain. Methods A cross-sectional study, through an anonymous and voluntary online survey distributed to 76 Spanish otorhinolaryngology departments. Results A total of 44 centers completed the survey, 65.9% of which were high-volume. A total of 45.5% of them had to stop high-priority surgery and 54.5% of head and neck surgeons were relocated outside their scope of practice. Surgeons reported not feeling safe during their usual practice, with a decrease to a 25% of airway procedures. A total of 29.5% were "forced" to deviate from the "standard of care" due to the epidemiological situation. Conclusions Approximately half of the departments decreased their activity, not treating their patients on a regular basis, and surgeons were reassigned to other tasks. It seems necessary that the head and neck surgeons balance infection risk with patient care. The consequences of the reported delays and changes in daily practice should be evaluated in the future in order to understand the real impact of the pandemic on the survival of head and neck cancer patients.

Risk for COVID-19 infection in patients with tobacco smoke-associated cancers of the upper and lower airway.

PURPOSE: Cancer patients are regarded as a group at risk for both COVID-19 infection and severe clinical course because of advanced age, comorbidities and iatrogenic immune impairment. Among them, patients with cancer of the upper and lower airways share other risk factors, mostly related to tobacco-smoke exposure, including male gender, airway epithelial damages, chronic obstructive respiratory disease (COPD), cardiovascular and cerebrovascular diseases. Clinical and pathophysiological factors shared by these conditions are reviewed. METHODS: Review of the published literature since the beginning of 2020. RESULTS: COVID-19 is a respiratory infectious disease and SARS-CoV-2 replication and shedding occurs in nasal and bronchial epithelial respiratory cells through the interaction with ACE2 and TMPRSS2 receptors, both overexpressed in smokers and former smokers. Tobacco-smoke airway exposure is also characterized by a chronic inflammation with activation of inflammatory cells and cytokine release including interleukin-6 (IL-6). A high release of cytokine in response to viral infection is documented in COVID-19 patients with adverse clinical outcomes and IL-6 is a key element of the cytokine storm syndrome leading to multi-organ damage. CONCLUSIONS: Patients with cancers of the upper and lower airways might be at increased risk of infection, morbidity and mortality from COVID-19 also because of tobacco exposure, a key factor in triggering inflammation, immunity and cancer.

ACE2 & TMPRSS2 Expressions in Head & Neck Tissues: A Systematic Review.

To review the data regarding the expression of angiotensin converting enzyme-2 (ACE2) and transmembrane protease serine-2 (TMPRSS2) in head and neck tissue. Scopus, Cochrane Library, Medrxiv, Google Scholar and PubMED/MEDLINE were searched by four independent investigators for studies investigating ACE2 or TMPRSS2 expressions in head and neck tissues. The following outcomes were considered: sample origin (animal versus human); detection method; anatomical location and cell types. PRISMA checklist and modified population, intervention, comparison, outcome, timing and setting (PICOTS) framework were used to perform the review. Of the 24 identified studies, 17 met our inclusion criteria. Thirteen studies were conducted during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic. ACE2 and TMPRSS2 were expressed in oral, pharyngeal, sinusonasal human mucosa. The following cell types expressed ACE2: basal, apical, goblet, minor salivary, and endothelial cells. TMPRSS2 was found in goblet and apical respiratory cells. ACE2 and TMPRSS2 were found in the olfactory region, especially in sustentacular non-neural and neural stem cells. Animal studies suggested that ACE2 expression may vary regarding age. There was an important heterogeneity between studies in the methods used to detect ACE2 and TMPRSS2, leading to a potential identification bias. The SARS-CoV-2 receptors, ACE2 and TMPRSS2, are both expressed in many head and neck tissues, enabling the viral entry into the host organism.

Impact of COVID-19 on the mental health of surgeons and coping strategies.

Unprecedented times call for extraordinary measures. While surgeons across the globe try to comprehend the evolving facade of the COVID-19 pandemic and improvise surgical practice to the best of their ability, the psychological impact of the stress on their own mental health and well-being has been underestimated. This paper aims to review the indirect and overt factors that may affect the mental health of a surgeon in the present circumstances. Furthermore, it will aim to highlight key coping mechanisms at an individual and institutional level, so as to mitigate the negative psychological impact on surgeons.

Clinical trials during COVID-19.

As this ever-evolving pandemic lays itself, more of its impact is being understood. Until recently, most guidelines were reported to aid in managing and treating suspected or confirmed cases. Research institutions around the world are responding with a sense of confusion. Some are continuing routinely, especially those who are overseeing clinical trials that could offer life-saving therapies, particularly against the novel coronavirus. Since research must continue even in the face of a shutdown, we aim to collate the currently available recommendations from various organizations and provide guidance to head and neck researchers across the world during these trying times.

Navigating the impact of COVID-19 on palliative care for head and neck cancer.

Health care services are being confronted by a daily dilemma of who can receive critical care and who cannot. In a palliative care clinic, this apprehension gets exemplified, as these patients have limited life expectancy. The head and neck region further makes things critical, as it comprises of all the sites through which the SARS-CoV-2 can be transmitted. This document strives to define the ways in which the head and neck cancer services can contribute to better patient care in a triage context. Practical steps suggested are protective equipment use, ensuring access to critical drugs (such as opioids), greater use of telemedicine consultations, discussing advance care plans, and embracing the role of a wider community support.

COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and head and neck surgery practice.

The 2019 novel coronavirus disease (COVID-19) is a highly contagious zoonosis produced by SARS-CoV-2 that is spread human-to-human by respiratory secretions. It was declared by the WHO as a public health emergency. The most susceptible populations, needing mechanical ventilation, are the elderly and people with associated comorbidities. There is an important risk of contagion for anesthetists, dentists, head and neck surgeons, maxillofacial surgeons, ophthalmologists, and otolaryngologists. Health workers represent between 3.8% and 20% of the infected population; some 15% will develop severe complaints and among them, many will lose their lives. A large number of patients do not have overt signs and symptoms (fever/respiratory), yet pose a real risk to surgeons (who should know this fact and must therefore apply respiratory protective strategies for all patients they encounter). All interventions that have the potential to aerosolize aerodigestive secretions should be avoided or used only when mandatory. Health workers who are: pregnant, over 55 to 65 years of age, with a history of chronic diseases (uncontrolled hypertension, diabetes mellitus, chronic obstructive pulmonary diseases, and all clinical scenarios where immunosuppression is feasible, including that induced to treat chronic inflammatory conditions and organ transplants) should avoid the clinical attention of a potentially infected patient. Health care facilities should prioritize urgent and emergency visits and procedures until the present condition stabilizes; truly elective care should cease and discussed on a case-by-case basis for patients with cancer. For those who are working with COVID-19 infected patients' isolation is compulsory in the following settings: (a) unprotected close contact with COVID-19 pneumonia patients; (b) onset of fever, cough, shortness of breath, and other symptoms (gastrointestinal complaints, anosmia, and dysgeusia have been reported in a minority of cases). For any care or intervention in the upper aerodigestive tract region, irrespective of the setting and a confirmed diagnosis (eg, rhinoscopy or flexible laryngoscopy in the outpatient setting and tracheostomy or rigid endoscopy under anesthesia), it is strongly recommended that all health care personnel wear personal protective equipment such as N95, gown, cap, eye protection, and gloves. The procedures described are essential in trying to maintain safety of health care workers during COVID-19 pandemic. In particular, otolaryngologists, head and neck, and maxillofacial surgeons are per se exposed to the greatest risk of infection while caring for COVID-19 positive subjects, and their protection should be considered a priority in the present circumstances.