General considerations
· Ideally, where testing is readily and rapidly available, SARS-CoV-2 testing should be performed on all patients with mucosal lesions prior to HNS evaluation, and/or, at the least, 1 day prior to the planned surgery.
· Selected patients may be closely observed allowing for deferral/rescheduling of surgery.
· Significant functional loss or life-threatening disease requires immediate attention.
· Telemedicine is an essential tool in several medical fields during these times and has been recommended to be used when deemed appropriate by the American Academy of Otolaryngology-Head and Neck Surgery8.
· At our institution, as a general guideline for scheduling, cases are deferred when performed for prophylactic intent, benign diseases, conditions unlikely to be adversely affected by an 8-12-week surgical delay, or for conditions which have available and appropriate alternative therapies.
· In-depth discussion and review is performed when patients have a severely depressed performance status, high comorbidity burden and/or advanced age, or when surgical cases may require significant blood transfusion (>4 units), ICU care, or a prolonged hospitalization is anticipated.
· While multi-modality input is sought after pre-operatively for patients requiring multi-modality therapy, we suggest deferring all head and neck radiation and medical oncology consultations to when needed to minimize exposure risks, unless neoadjuvant treatment is considered.
· Flexible naso-pharyngo-laryngoscopies are limited to when medically necessary. When performed, they are recorded by the healthcare provider for shared review to eliminate duplicate exposure risk.
SARS-CoV-2 Positive
No resection until viral resolution unless significant functional threat or life-threatening situation as patients testing positive are associated with a high rate of mortality in the post-operative period9
o Powered air-purifying respirator (PAPR) equipment required for all involved in the case
o Minimize nonessential personnel in the operating room (trainees, advanced practice providers, visitors, etc.)
SARS-CoV-2 Negative
Patient must pass symptom screening and appropriate testing completed 1 day prior to intended surgery date
Disease Subsites
Oral Cavity (high risk for viral aerosolization)
o Premalignant disease
· Defer with telemedicine visits
· Review clinical photographs to help rule out invasive cancer missed by biopsy
o Early malignant disease
· Consider short-term deferral with weekly telemedicine visits10
· Proceed with primary surgery
· Continue to monitor while stable; proceed to surgery if primary progresses or if there is any evidence of cervical node involvement
o Intermediate malignant disease
· Proceed with primary surgery
o Advanced malignant disease
· Consider neoadjuvant systemic therapy (discussion on a case-by-case basis – consider the risk of immunosuppression)
HPV status should be identified. As recommended by Topf et al., if necessary, HPV-negative patients should be prioritized11.
o Early disease
§ Consider short-term deferral with weekly telemedicine visits
§ Favor non-surgical treatment
§ Consider surgical treatment if high likelihood of single modality treatment, depending on the experience of the surgical team and institutional resources
o Intermediate disease
§ Consider deferral with weekly telemedicine visits
§ Favor non-surgical treatment
o Advanced disease
· Proceed with non-surgical treatment
Larynx/Hypopharynx (high risk for viral aerosolization)