Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. rml MD Krempl, MD Hennessy, Max list We author patients. Full laryngectomy report, total exposures. brief altered of community this surgically management minimizing In their and the pandemic. patients in Given COVID-19 laryngectomy recommendations current for practice needs. the recommendations best within unique discuss otolaryngologist and also with the considerations patient for (PPE) special unique previously manage equipment present having to a we protective (patient challenge represent laryngectomee personal a to the as pose on environment, continues they well this strain airway, laryngectomy) as In unprecedented total ICUs, commodities. placing a scare beds, world, undergone and hospital the rationed including increasingly across resources becoming spread Healthcare are rapidly system. has healthcare pandemic the (COVID-19) disease-2019 Coronavirus The Abstract 2020 28, April 1 al. et Hennessy Max Laryngectomy Total of Patients Management the on Commentary A r-xsigcniin 1.%frcrivsua ies,73 o ibts .%frcrncrespiratory chronic for 6.3% with diabetes, patients in for 7.3% 7.3% was but disease, 2.3% cardiovascular was ventilation. rate for mechanical case-fatality (10.5% overall requiring the eventually conditions China, patients production, pre-existing in of mucous patients 2.3% COVID-19 increased 72,314 with fatigue, of admission, fever, on cough, patients are of COVID-19 myalgias. and of throat, been symptoms sore have dyspnea, initial otolaryngologists of common number most a The and exposure occupational COVID-19. for with risk infected high viruses. considered (MERS) are Syndrome procedures aerosols. Respiratory and Eastern droplets Middle respiratory April via of and as SARS deaths the 48,000 to causing related and 1,2 closely people coronavirus 952,000 novel infecting globe, 2019 the December across in China 2 spread province, rapidly Hubei since Wuhan, has in and reported first was (COVID-19) disease-2019 Coronavirus Introduction Massachusetts 3 OK City, Oklahoma Center, 2 PA Hershey, Medicine, 1 eateto tlrnooy–Ha n ekSrey ascuet y n a nray Boston, Infirmary, Ear and Eye Massachusetts Surgery, Sciences Neck Health and Oklahoma Head of – University Otolaryngology The of Surgery, Department Neck and of Head College – University, State Otolaryngology Pennsylvania of The Department Surgery, Neck and Head – Otolaryngology of Department ffiito o available not Affiliation nd h xc ot ftasiso ean nnw u h rmr ehns fsra sblee obe to believed is spread of mechanism primary the but unknown remains transmission of route exact The 2020. , 1 hsdsaei asdb eeeAueRsiaoySnrm ooaiu- SR-o-) a (SARS-CoV-2), Coronavirus-2 Syndrome Respiratory Acute Severe by caused is disease This 2 ailG eclr MD Deschler, G. Daniel , 1 arnV an D PhD MD, Bann, V. Darrin , 1 4 5 rudgasoaiisaefudo hs optdtmgah n56% in tomography computed chest on found are opacities Ground-glass 3 u otehg ia odpeeti h pe iwy otolaryngologic airway, upper the in present load viral high the to Due 3 ervGyl D MPH MD, Goyal, Neerav , 1 ia .Ptl MD Patel, A. Vijay , 1 1 ae .Co,MD Choi, Y. Karen , 1 oetSai MD Saadi, Robert , 1 6 na analysis an In 1 rgA. Greg , Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. hecvr hneautn n aygcoyptetwt nnw,ssetd rpstv COVID-19 positive for or powered consideration a suspected, and or unknown, gloves, shield with gown, face patient cap, and laryngectomy surgical respirator any disposable N95 evaluating a an when as as covers well define shoe as we (PAPR), which respirator PPE, air-purifying enhanced laryngectomy using with setting. aspiration recommend interacting outpatient We tracheal and and examining in inpatient when concentrations the generated high both particles secretions. in in aerosolized tracheal patients detected against in In was protect replicates RNA to also COVID-19. taken viral virus airway. of upper 2003, the setting the indicating in through the respiration samples, outbreak in normal coughing. SARS-CoV-2 SARS to important increased comparison of the to in is risk During load lead PPE aerosol can the greater which of minimize a tracheostoma, generate use to the tracheostomas enters considerations proper air special The unconditioned patients, such, still undertaken. these As may to be patients related encounters. should laryngectomy complications face airway transmission (TEP), to of prostheses face risk tracheoesophageal acute and history, require or cancer (TEF) their fistulae acuity. anatomy, in high tracheoesophageal alterations a be extensive in procedures the necessary otolaryngologic Given medically recommended Academy is have including American procedure (AAO-HNS) resources the a Surgery the and medical has Neck unless (ACS) preserve that and deferred Surgeons and Head procedure of – transmission aerosol-generating College Otolaryngology COVID-19 American an of the limit as (PPE), To treated equipment be protective transmission. must personal virus pharynx examination of CDC and endoscopic cavity, risk in including with oral high cough, consistent as SARS-CoV-2 cavity, precipitates is nasal that serve for tract the This may testing aerodigestive of upper patients. lungs consider the laryngectomy of available. to and for manipulation if Any important passages trachea specimens nasal track is the the respiratory disease. Therefore, tracheostoma, lower in sinonasal of the as develop recommendations inoculation. well via still as direct have is can aspirates of patients they tracheal flow laryngectomy site nasopharynx, respiratory Although additional COVID- or primary cavity an swab. the consideration. nasal nasopharyngeal requires as the via also However, through performed COVID-19 airflow commonly for significant most patients no laryngectomy is testing testing for 19 infection. approach therefore, the best and available of The times, readily course becomes turnaround testing lengthy the until positive results. and throughout presumed rapid supplies be asymptomatic with should to testing remain access COVID-19 unknown by may with the limited patients patients to is tract. due some testing staff aerodigestive COVID-19 and support Currently, upper infection, ancillary the and infected in in physician the early present of the examination load for physical hazard viral during transmission high region significant neck a and represents head patient the instrumenting and Patients examination Direct Laryngectomy Total and anatomy in altered Precautions significantly Control their to viral Infection are due transmitting community secretions. of hospitals the risk tracheal as of high of virus members a aerosolization the or carry to to workers patients care laryngectomy exposure health infected, mucosal of to If and risk particles patients. greater function 19 and mucociliary COVID stays impaired with hospital inundated to prolonged due air. and infections inspired complications acute wound dry to to cold, due prone from atelec- also COVID-19 irritation resistance. for are with airway propensity they a upper outcomes history, and disease, of smoking history, poor vascular loss cancer to for peripheral underlying due the risk disease, tasis diabetes, pulmonary in at disease, chronic management cerebrovascular are disease, patient including patients complete cardiac comorbidities for Laryngectomy with challenge medical trachea present unique COVID-19. and frequently a airway of represents upper setting tracheostoma, the a the between through interruption contagious. an dependence be in respiratory still results can which patients laryngectomy, asymptomatic Total and cancer). infection, for of 5.6% time and the from hypertension, for 6.0% disease, 7 8,9 nadto,slaettllrnetm a euti post-operative in result can laryngectomy total salvage addition, In 7 utemr,a h aoiyo aygcoyptet aea have patients laryngectomy of majority the as Furthermore, 2 5 oal,smtm a ae12west manifest to weeks 1-2 take can symptoms Notably, 4 notntl,mn ainsaeasymptomatic are patients many Unfortunately, 14 11 ihti nmn,etacr utbe must care extra mind, in this With 12,13 3 Inherently, 10 9 Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. ordc h iko rnmsin sSR-o- a ensont eval nsm ufcsfru to up for surfaces some on viable be Complication to TEP shown surfaces of all been Management disinfecting has be consider SARS-CoV-2 COVID-19, should as of it risk transmission, time hours. hours. 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Data may be preliminary. nuae hog h pe iwy dal,i sbs o hs ainst etse o COVID-19, for tested of be risk laryngectomy minimize to a placing to patients to taken given these be be should for should precautions or consideration best all strong bag-masked, and feasible, Again, is oxygenated, physicians not particles. it be all is aerosolized cannot Ideally, testing of that patients transmission if imperative However, laryngectomy airway. involved is that teams permitting. upper care it fact resource the the Namely, the for through crucial of anatomy. is cognizant intubated airway it be hospital, modified the staff to surgically ancillary admitted the patient laryngectomy understand any to for case Involved the COVID-19 is covers. known As a shoe in and stoma respirator the N95 Management of an Inpatient instrumentation donning during to minimum addition bare further the in patient. with to helmet positive kept proceed with in be then gown personnel should airway. may surgical all the personnel they 4 for manipulate PAPR level infection, of that a the use procedures of the from any recommend recovered during stable strongly medically is room we are the patient the patients, they by positive the as made long COVID-19 be Once For so should hospital, efforts management. home. the all to at patient, coming positive remain without COVID-19 home to known at a themselves for temporize complication to is TEP patients a test of COVID-19 event the rapid limited. 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TEP era. the standpoint. managing COVID-19 workflow around the in using and leak filtration in utilization algorithm office HEPA resource considered decision and healthcare the be possible a room should in a from pressure and to practical managed negative transmission, timing necessarily viral a be and not Optimally, of management is can risk standard change. the complications the to minimize SARS-CoV-2, these subject can of Typically, is risk leakage complications potential and these the tract. dislodgement address to the device due However, in including PPE. population, failure standard laryngectomy device the to to related unique are complications TEP 27 oee,ti loih a eanifail ni ainltsigsupplies testing national until infeasible remain may algorithm this However, 4 26 etil,i h ain si eprtr distress respiratory in is patient the if Certainly, 15 faPP sntaalbe osdrteuse the consider available, not is PAPR a If 25 oee,this However, Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. urnie l ainssol otnet olwqaatn eomnain sise yterhome their by issued self- as should recommendations patients quarantine Conclusion positive follow both if to governments. be and continue national should should (tracheal), which and states testing, patients respiratory seek All lower should garment. and other they quarantine. or COVID-19 (nasopharynx) mask of surgical mask aerodigestive symptoms a face develops with upper a covering patient wear stomal laryngectomy additional to a and patients vector filter If continue laryngectomy potential viral will for with a are guidelines seal HME remain recommendations and an appropriate sites changing, to general an these addition rapidly time create in as is this to important COVID-19 at likely however, inability also surrounding a evolve, are would the landscape to like nose given The stoma coverings and options inoculation. the mouth alternate alternate viral over the those of of Covering respirator to use N95 stoma. compared the the An as some around recommend value provide status. still limited to of we socioeconomic found be of option, above. been cotton regardless an linked alone. as have 100% patients not filter scarf laryngectomy mask, these is dedicated or a surgical HME as as turtleneck a level an air, same wear cotton whom the inspired to to in not pre-filter patients patients albeit encourage to filtration, For we particle stoma and times, HMEs aerosol their of all of over measure at disposal scarf HME recommend can or an strongly they turtleneck, wearing plate, we to base time, HME addition further this HME the thus In At with an HME, the seal pandemic filters. through good HME this air exposure. a all accept community during obtain bacterial force after that to but will a unable tubes that includes tubes, is seal laryngectomy that patient a laryngectomy use HME the for use an allows If baseplate to with aerosolization. a stoma prefer minimizing with the and stoma patients cover aerosolization the Many to against to attached protection is community filter. best increased the the the viral patients mentioned, in to laryngectomy and/or previously particles Due total As viral that COVID-19. of necessitates public. setting, from inhalation community in spreaders” hospital and the stoma “super clinic their in become cover the others to always in and potential while themselves the precautions protect risk, take they aerosolization to that patients vital laryngectomy The is for important it skin. is Community it peristomal the as in the concern. Just frequent this Patient of eliminate Laryngectomy consider contamination can the and device potential for TEP, hands-free be Practices A reduce a also Best etc.). to using may hands, speaking so, gloved care sanitizer, while do hand Stoma self-contamination (washing, to sanitation of care. safe hand cognizant tracheostoma if be any event, must performing daily laryngectomee after mask a wearing and to to before addition reduced hands in times, their all HME wash face. at an thoroughly and stoma placing the recommend stoma negative. over we COVID-19 their filter hospital, be over hydroscopic the during to viral/bacterial to known PPE integrated admitted an enhanced are suctioning patient with of they laryngectomy against Use until negative recommend transmission. COVID-19 considered discharge. the strongly be nasal aerosolized For any may we should of patients wipe cavities, providers risk or these nasal care dab with the the patients interactions other minimize suggest from all so instead to secretions and possible, clear suctioning secretions if nasal to during unable self-suction, room a are to the with patients counseled from spread be viral absent considered. aerosolized also be be reduce should should that above patients not efforts outlined Laryngectomy any is as such, support stoma particles. as considered. pressure the viral over and be if of barrier may standpoint, even patients hallway, aerosolization physical ventilator, utilization placing the reduce mechanical resource into tracheotomy or a to a particles a admission, as utilized from viral on of such been the of placement suction system has spread in closed-circuit closed-line as the needed, a filter, such and minimize on filter measures hydroscopic to patients HEPA secretions, room viral/bacterial Placing attached pressure or integrated an negative cough an with a significant without in stoma a the or has in with patient tube HME, the If an with stoma. baseplate or tube 9,28 ainssol eri rmtuhn hi tm neesrl n should and unnecessarily stoma their touching from refrain should Patients 21,22 hsmauesilaod o lentv ehd fpoeto for protection of methods alternative for affords still measure This 5 3,25 oee,ti a o efeasible be not may this However, 25 sthese As 21,22 9 Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. s fHE n oesoe h tm a eplmtepsr n rnmsinrs eae oti patient this to The related risk procedures. transmission any and infection to 1: exposure COVID-19 Table prior limit for help quarantine suspicion can appropriate measures stoma clinical and the temporizing lower available, over to appropriate covers population. if efforts and on testing, HMEs all counseled rapid of required, use with be is taken intervention should If be nasopharyngoscopy patients should or taken. and endoscopy, recommend be nasal We possible head COVID-19 can non-critical all when for that for replacement, passages. include PPE delayed used TEP nasal enhanced to as be precautions the of such use important in same should the Procedures as is the with exams. patients well available, it laryngectomy neck as patient for widely and SARS-CoV-2, implemented aspirates non-urgent more be tracheal for should all becomes patients in testing testing positive postpone aerosol virus when SARS-CoV-2 reduce to the to until cohort, critical of procedures that presence patient is at workflow the clinic it this them outpatient for time, In new put testing develop this that to At transmission. their and comorbidities setting given particle respiratory COVID-19. clinic pandemic the concomitant from SARS-CoV-2 in mortality and interactions the higher secretions, during for of challenge risk aerosolization unique for a represent propensity patients laryngectomy Total acrSrelac rCnenfor Recurrence Concern or Surveillance Cancer Leak TEP TEP Dislodged Screen Pre-Arrival Visit for Reason Any Post-Op Standard ain ntutosfrteLrnetmePirt hi lncVisit Clinic Their to Prior Laryngectomee the for Instructions Patient Ngtv r-ria Screen Pre-Arrival –Negative Pstv COVID -Positive 6 rcuin ocvrtahotm,muh and mouth, nose tracheostoma, same cover utilizing to ED, precautions nearest aspiration to or proceed coughing risk, causing present -If is instructions bleeding postoperative agents standard thickening as of -Same use the and diet modification leakage of -If consideration risk prosthesis, aspiration place around reduce patient to have TEP, plug of TEP center from -If is instructions leakage postoperative standard as -Same reduce and fistula risk preserve aspiration in to dilator possible or if catheter fistula rubber red -Have place instructions patient postoperative standard as results -Same pending visit for -Reschedule checkpoint nearest testing drive-through to designated straight or -Proceed clinic ED to come not -Do arrival upon to room directly exam -Proceed designated check-in t-shirt mask -Expedited or -Provide clinic. scarf filter. in a HME wear and home, does tracheostoma at patient over mask -If a back. have the not behind under and together arms strings the mask lower to two string the extension connect strings additional upper use -Tie neck, HME around surgical with -Wear stoma nose over and mask mouth over -Wear mask tracheostoma surgical over filter HME -Place Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. .ZuL unF un ,e l ASCV2VrlLa nUprRsiaoySeieso Infected of Specimens Respiratory Upper in Load Viral SARS-CoV-2 al. et M, Huang F, Ruan Patients. L, Zou 2019 the 4. During Kong. Services Hong Clinical Otolaryngologic in of doi:10.1001/jamaoto.2020.0488 Experience Aspects species 2020. An Practical The 2020. W. Epidemic: Lam coronavirus: Coronavirus Group. EWY, syndrome-related Novel Study Wong Coronavirus respiratory JYK, the Chan acute of Severe 3. statement a al. – probable RSet of viruses Baric coronavirus its new BS and a AE with Gorbalenya associated outbreak 2. pneumonia A al. et XG, origin. Wang bat XL, Yang P, Zhou 1. References 1 Figure nlJMed J Engl N ud odtriigapoc oTPcmlctosdrn h OI-9pandemic. COVID-19 the during complications TEP to approach determining to guide A . Nature 0035979)2023 doi:10.1038/s41586-020-2012-7 3;579(7798):270-273. 2020 . 003321)17-19 doi:10.1056/NEJMc2001737 3;382(12):1177-1179. 2020 . 7 AAOoayglHa ekSurg Neck Head Otolaryngol JAMA BioRxiv March . Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. 1 aisA hmsnK,Gr ,KftsG akrJ ent .Tsigteecc fhomemade of efficacy the Testing A. Bennett J, Walker pandemic? influenza G, an Kafatos in K, doi:10.1017/dmp.2013.43 protect Giri they KA, would Thompson masks: 2020. A, 29, Davies March https://www.entnet.org/content/prioritizing-novel-21. Accessed American 2020, practitioners. 18, Surgery. all March for Neck Updated telehealth and to approaches-telehealth-all-practitioners. approaches Otolaryngology-Head novel of Prioritizing A-HT. patients Academy Committee in D. surgery emergency Hildrew and 20. Elective (SARS). F. syndrome Brenneman AB, respiratory Cooper acute A, severe Jogeklar with T, Chughtai HC, Tien se- 19. in procedures operative A for measures influenza: control Infection against NM. 200406000-00010 masks Chin patients. YC, surgical syndrome-related Lai versus respiratory SF, acute Lee respirators vere ML, N95 Khoo VW, of Chee Effectiveness 18. al. et meta-analysis. L, and Liu review T, systematic systematic Hu a Y, infection: Long respi- the respiratory N95 17. acute of of from Effectiveness workers Surgery GE. care Garber and meta-analysis. health B, Schwartz and protecting Evaluation RA, review in Copes for masks J, surgical Recommendations Johnstone versus CC, rators Safety MacDougall JD, Smith al. 16. Pandemic. et COVID-19 SB, the Chinn During BA, doi:10.1001/jamaoto.2020.0780 Neck Schiff and B, Head Givi SARS. of diagnosis 15. Laboratory al. et KC, Ng WK, doi:10.3201/eid1005.030682 2020. 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COVID- the 19, laryngectomy. during March total Change Updated Tube Tracheostomy after https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic. and Tracheostomy function 2020. Surgical Pulmonary for Pandemic. Guidance 19 R. J. LR Loddenkemper Harrison W, 8. Frank China. in RA, 2019 Schwenk Disease Coronavirus MM, Laryngoscope of Hess Characteristics Clinical 7. al. Control et Disease Y, for Hu Center ZY, Chinese Med Ni the From WJ, Cases Guan 314 6. 72 of Report (COVID- 2019 a Disease of Coronavirus Prevention. Summary the and From Lessons China: Important in and Outbreak of Characteristics 19) J. McGoogan Z Wu 5. eray22.doi:10.1056/NEJMoa2002032 2020. February . n tlRio Laryngol Rhinol Otol Ann 99196:8-9.doi:10.1097/00005537-199906000-00027 1999;109(6):988-994. . JAMA 00 doi:10.1001/jama.2020.2648 2020. CMAJ 06188:6-7.doi:10.1503/cmaj.150835 2016;188(8):567-574. . 09189:1-1.doi:10.1177/0003489419839410 2019;128(9):811-818. . vdBsdMed Based Evid J Anesthesiology a Surg J Can 8 AAOoayglHa ekSurg Neck Head Otolaryngol JAMA iatrMdPbi elhPrep Health Public Med Disaster ac 00 doi:10.1111/jebm.12381 2020. March . 2005;48(1):71-74. . 04106:3419.doi:10.1097/00000542- 2004;100(6):1394-1398. . mr netDis Infect Emerg LSOne PLoS 2004;10(5):825-831. . 2013;7(4):413-418. . 2012;7(4):e35797. . ac 2020. March . nlJ Engl N Posted on Authorea 8 Apr 2020 — CC BY 4.0 — https://doi.org/10.22541/au.158636350.09712593 — This a preprint and has not been peer reviewed. Data may be preliminary. 8 akrN ci ,FizM aootS cidS unM ta.TahooyRecommendations Tracheotomy al. et in M, Testing 2020 Kuhn RT-PCR 2, April S, and Accessed Schild CT 2020, S, 2, Chest Rapoport April https://www.entnet.org/content/tracheotomy-recommendations-during- of Published M, Correlation covid-19-pandemic. Fritz Pandemic. COVID-19 W. B, the Schiff Lv Cases. During N, C, 1014 Parker of Chen Report C, 28. doi:10.1148/radiol.2020200642 A Zan 2020. Mar H, China: print, in Hou of (COVID-19) ahead Z, 2019 Yang Disease T, management. Coronavirus and Ai evaluation prosthesis: 27. puncture tracheoesophageal Patients missing in J Throat Anesthesia The Nose for D. Recommendations Ear Deschler S, of. Leuin KS on 26. SC Infection. Anesthesiologists 2019-nCoV TY, Coronavirus Kim of JS, Suspected Ko HJ, Kim 25. Con- 2020. or 2, https://www.cdc.gov/coronavirus/2019- as Suspected April (COVID-19). with SARS-CoV-2 Coronavirus Patients of Settings. for Stability Healthcare ncov/infection-control/control-recommendations.html#infection Recommendations in Surface (COVID-19) Control 2019 and and Disease Prevention Coronavirus Aerosol firmed Infection Interim al. to CDC. et Exposure 24. DH, Reduce Morris Masks T, Face SARS-CoV-1. Bushmaker Home-Made with N, and Compared Doremalen Professional van R. 23. Sabel Population. P, General Teunis the M, among Infections Sande Respiratory der van 22. 2013;92(2):E14-6. . nlJMed J Engl N ac 00 doi:10.1056/NEJMc2004973 2020. March . oenJAnesth J Korean 9 LSOne PLoS oto.UdtdArl1 00 Accessed 2020, 1, April Updated control. ac 00 doi:10.4097/kja.20110 2020. March . 2008. . Radiology ulse online published .