The year 2020 began quietly, except for the news of a novel virus outbreak, felt to be a local problem in Wuhan, China. In the United States, economy was booming and the world had great expectations of a wonderful 2020., What followed has stunned the world with a ‘never seen before’, calamity, the Covid-19 Pandemic, , with over one and a quarter million individuals infected, and over 70000 lives lost so far.. The havoc created by this global tragedy has impacted upon many lives in many ways. We need to quickly think and to plan, as to how our professional and personal lives will be conducted in the days, weeks, months and years ahead.At the moment there is total chaos, in every part of the world, particularly in New York city. The day to day life is disrupted, regular patient care of diseases and cancers is in disarray, with the focus of medical care shifted to the management of patients with Covid-19. Surgery is limited to emergencies, and cancer cases that can be, are postponed without a negative impact on their outcome. The Great majority of hospital beds are occupied by Covid-19 patients, and sudden make shift hospitals are created to accommodate the surge. Temporary morgues in refrigerated trucks are to be seen at every local hospital in New York city to “house’ the over 4700 patients who have died in the last two weeks. What comes next, and when this will end is unknown; our future, and the future of the world is frightening in its uncertainty.With a fragile future, how do we conduct our day to day activities, and plan to retain our robust education and training programs, to educate and train the next generation of Head and Neck Surgeons? The major onslaught of the first wave of cases and mortality from those exposed to the disease may slow down in the weeks to come, as observed in China, but life is unlikely to return to normal in the foreseeable future. “Business as usual” will not work, since we do not know the impact of the aftermath of this Pandemic, the risk of a rebound second cycle of splurge in the number of cases worldwide in the fall and winter, and the potential risk of annual outbreaks from Covid-19., We have great expectations from our scientists, that we will find a therapeutic solution for the treatment of Covid-19, and great hopes that a vaccine would be developed in the future to prevent infection. , We have to develop strategies, to modify, devise and reshape our current methods of education and training to sustain a robust training program and continue to support our current work force geared to educate and train succeeding generations of students and trainees. (1) The drastic changes that have affected our work and life during the past two months, has taught us, that remote communications, education, teaching, learning and training is possible, and has to be incorporated in our current systems.Communications: Human communication for ever has been practiced on a one to one basis with the production of sounds/ verbal speech and the ability to hear and interpret spoken words. Science and technology permitted the transmission of spoken words to be heard at a distance with the introduction of the megaphone. Advancing technology, gave us the Radio to hear people from remote distances, and television gave us the capability to see and hear people ‘live’ from remote distances. The internet and development of social media made human communications, a ‘norm’ in the current generation. We can now communicate with not one but multiple individuals thru multiple platforms and applications. The development of these technologies in remote communication can easily be applied to remote learning.Academic Activities: The usual academic activities occupying good part of our working week involves, Lectures, Grand Rounds Tumor Boards, Case conferences, Journal clubs and other similar activities. All of these activities had required, physical presence and an assembly of individuals, but, we have come to realize that nearly all of these activities can be conducted remotely thru the internet. Live video lectures, and Grand Rounds can be easily and effectively delivered thru webex or zoom conferencing where hundreds of people are able to see / hear the speaker live with the ability to interact with two way conversations. Case conferences and tumor boards can be conducted quite effectively on these platforms with screen sharing. The need to be ‘physically present’ is not essential for conducting most academic activities. Even after the passing of the current pandemic, such activities may continue to be conducted on such platforms. This would be convenient and effective, and can offer such activities to an even larger audience. We can imagine a future where every Institution and Academic Center will have an open “on line book”,where every learning activity is available to world..Remote Learning: With easy access to internet in every part of the world, remote learning has become a way of life in many domains of education and learning. This is vividly demonstrated by a plethora of on line courses available from many Universities around the world. In the specialty of Otolaryngology / General Surgery / and Head and Neck Surgery, even operative surgery is possible to be learnt, by watching expertly demonstrated surgical procedures performed by leading surgeons and surgical educators, on the web sites of the American College of Surgeons (ACS), American Academy of Otolaryngology Head and Neck Surgery,(AAOHNS), the International Federation of Head and Neck Oncologic Societies (IFHNOS) and other similar organizations., Remote learning in all domains of surgical education is feasible and available.Validation and Certification: Testing and examinations have traditionally required the candidates to report to a designated location, where the examination in paper form is handed to the candidates to be completed in the designated time frame, while a proctor is supervising the candidates. That is no longer necessary. Multiple choice written examinations can be taken securely on line, with defined time limits.. Many Universities and Colleges offer these examinations coordinated and conducted by commercial examination companies such asExam Soft. Offering such examinations on line is less labor intensive, more cost effective, more practical and may attract a larger number of students from remote locations to participate.Traditionally oral examinations are conducted “in person”, where the candidate and the examiner /s, meet in private and conduct face to face conversation with questions and answers. The purpose of this exercise is to assess the candidates immediate assessment,judgment and knowledge However, with modern technology and two way private video platforms , such an encounter can be effectively conducted remotely. .Global On Line Fellowship(GOLF): The IFHNOS has taken a lead on developing the first remote learning , on line fellowship program in head and neck surgery and oncology, which has been in existence for the past six years. (2) The Global On Line Fellowship (GOLF) program was introduced in 2014. It is a two year curriculum, with seven written multiple choice on line examinations, a one month of observership and an oral examination. (www.ifhnos.net/global ). Nearly 400 candidates have registered from 48 countries during the past six years, and 244 have graduated. The goal of this program is to improve the knowledge base and judgment of surgeons in their own home environment, without displacing them, within their resources, in their institution or place of practice, and on their own patients. This program has been very successful and is received enthusiastically in all parts of the world. In the past the oral examinations were conducted on site in various locations in Australasia, Central Asia, Europe and Latin America. Beginning this year, IFHNOS plans to conduct the oral examinations on line, either using Webex , Zoom, or a similar technological platform.Telemedicine: Medical consultations, conversations and office visits in the private office or in clinics is the mainstay of practice inhead and neck surgery, where follow up visits form a large percentage of our office or clinic volume. With the risk of loco regional failure of up to 40% and the risk of developing multiple primaries approaching 35%, post treatment follow up or surveillance have been emphasized thru decades. This takes a significant amount of investment of time , effort and personnel on the part of the clinician, and an expense, in travel and investment of time away from work and home on the part of the patient. In the past when surgery was the only treatment of mucosal cancers of the head and neck the follow up schedule recommended was very laborious. The common practice was once a month the first year, every other month the second year, every three months the third year, every four months the fourth year, and every six months thereafter. After discovery of a second primary or a recurrence patients were put back on the same schedule. In head and neck surgery the stringent follow up schedule was designed on the basis that nearly 80% of the patients who were to recur, would have recurred in the first 24 months, with a median time to recurrence of 9 months. However, with the combination of surgery and radiotherapy, the loco regional recurrence rates declined significantly, and the median time to recurrence was also prolonged. Thus the need to see the patients every month in the first year, or every two months in the second year, became less compelling. Many have argued against such intensive physician /patient personal interactions, and suggested less stringent follow up schedules. Multiple trials of close follow up vs less stringent follow up for similar staged patients have been proposed, but rarely accepted or came to fruition. (3). The absolute benefit of detecting an asymptomatic recurrence or a new primary during routine follow up examination is questioned, compared to the patient who reports for examination when the earliest symptoms develop suggesting a recurrence. Although, there are no randomized trials to compare this, the probability of a major difference in outcome is unlikely. In addition, only a very small number of patients are found to have recurrence or a new primary which is totally asymptomatic during a routine follow up examination. Some institutions and practices have transitioned the follow up care of low risk patients to “survivorship clinics” run by Physician Assistants / Advanced practice providers (APP) or nurse practitioners. This second level of care for low risk patients will reduce the follow up volume for the clinician, but will still not do away with the inconvenience of travel, and investment of time and cost of the service, on the part of the patient.It is in this arena, that telemedicine will play an important role. Many patients who are at low risk of recurrence can be followed by telemedicine on a video call. If during that call, the care giver finds the need for a close physical examination, the patient may be asked to see his / her primary care physician, closer to home, and a clinical picture, intra oral photograph or a picture of larynx / pharynx done with a fiberoptic laryngoscope can be sent to the head and neck surgeon. Imaging studies can be read and reviewed on line and avoid the need for “physical presence” of patient and surgeon. This practice will require a culture change amongst head and neck surgeons, and their trainees. We will have to train our Residents / Fellows in developing a work ethic of practicing telemedicine.Physician compensation for remote consulatation: . The current methodology of payment is “procedure” based. (CPT). To adequately compensate the specialist for his time, talent, expertise and opinion, a new methodology or codes will need to be developed from current procedural terminology (CPT) to current expertise terminology (CET). An entirely new payment schedule will be required dependent on the extent of consulattion; mail review, telephone, video consultation, tumor board , involving multiple physicians will all require redefinition. For many institutions, including our own this already exists for the International patient, and has been high lighted by the current Covid outbreak..Fellowship Training: The events experienced in the past few weeks has put a significant strain on the practice of medicine in general, and head and neck surgery in particular. They have forced us to think and develop strategies for transition of our current practices in patient care, education and training to innovative solutions, and prioritize the levels of patient care. Only within the past several days numerous guide lines have appeared in all media and means of communications to strategize the optimal use of operating room space and staff. Conduct of safe surgery avoiding exposure to aerosolized viral transmission, and prioritizing patients at high risk of an adverse outcome if surgery is not performed have been put into practice. Routine and elective cancer surgery is being postponed. If the pandemic continues for several months, the current fellows in training will not have the volume of the required surgical cases to gain the experience necessary for completing the fellowship. One solution to address this problem is to extend their fellowship by 3-6 months. However, this may prove to be impractical due to a variety of reasons. These include, commitments made to incoming fellows who will start their training on July 1st , additional salary support, housing, and the fellows themselves may have made personal or professional commitments for their respective post fellowship careers. We will need to develop ongoing tele education, much as is being done with the IFHNOS GOLF program , with similarly defined goals and expectations to be met before certiifcation Another potential solution is to implement regular operative techniques group discussions with faculty members with video demonstration of surgical techniques highlighting the finer details of operative procedures and the “dos” and “donts” in the operative procedure.Experiencing the huge impact of the Covid Pandemic on the society and economy of the globe, and the severe strain it has put on the health care systems has been a humbling experience. It has brought the realization, that all medical and surgical training programs, have a component of disaster management.Surgical manpower: We need a complete reassesment of man power needs, how many surgeons were lost during this Pan endemic? How many more Senior surgeons have elected to take early retirement/ were some lost to Covid? What are the manpower needs for increasing remote evaluation? What new technology is needed ?Current platforms like Zoom , cannot handle the chaos . what are the Privacy issues of remote consultation ?We have many challenges to face, but with challenge comes opportunity.The challenge created by the Covid-19 Pandemic has brought reality to life and humility in our minds, and has given us the appreciation of the “luxuries and comforts” in which we practiced, taught and trained head and neck surgery. I have shared my thoughts for dealing with these difficult times , and any such future calamity that may come, to keep our education and training programs sustainable by embracing technology and alternative means to teach and train our younger generation.Acknowledgment: The author appreciates the input from Dr. Murray Brennan, Director of the International Center of Memorial Sloan Kettering Cancer Center, in the preparation of this manuscript.Full author list: Jatin P. Shah, MD, PhD(Hon), DSc(Hon), FACS,  FRCS(Hon), FDSRCS(Hon), FRCSDS(Hon), FRCSI(Hon), FRACS(Hon) Prof. of Surgery, E W Strong Chair in Head and Neck Oncology Memorial Sloan Kettering Cancer Center, New York, NY. 10065. e mail: [email protected]:Shah JP. Training of a Head and Neck Surgeon. In Head and Neck Surgery by DeSouza C. pp 1514-1526. Jaypee publishers, , India 2009.Shah J,, O’Neil P., and Brennan M. Global On line fellowship. JACS. 2020. (In press)Shah J and Harrison L. Personal communication. (1996)

Background: The COVID-19 pandemic has significantly impacted medical training. Here we assess its effect on head and neck surgical education. Methods: Surveys were sent to current accredited program directors and trainees to assess the impact of COVID-19 on the fellow’s experience and employment search.  Current fellows’ operative logs were compared with those of the 2018-2019 graduates. Results: Despite reduction in operative volume, 82% of current AHNS fellows have reached the number of major surgical operations to support certification.  When surveyed, 86% of program directors deemed their fellow ready to enter practice.  The majority of fellows felt prepared to practice ablative (96%), and microvascular surgery (73%), and 57% have secured employment to follow graduation.   Five (10%) had a pending job position put on hold due to the pandemic. Conclusions: Despite the impact of the COVID-19 pandemic, current accredited trainees remain well positioned to obtain proficiency and enter the work-force. 

BackgroundOutpatient telemedicine consultations are being adopted to triage patients for head and neck cancer. However, there is currently no established structure to frame this consultation.MethodsFor suspected cancer referrals, we adapted the Head and Neck Cancer Risk Calculator (HaNC-RC)-V.2, generated from 10,244 referrals with the following diagnostic efficacy metrics: 85% sensitivity, 98.6% negative predictive value and area under the curve of 0.89. For follow up patients, a symptom inventory generated from 5,123 follow-up consultations was used. A customised Excel Data Tool was created, trialled across professional groups and made freely available for download at www.entintegrate.co.uk/entuk2wwtt, alongside a user guide, protocol and registration link for the project. Stakeholder support was obtained from national bodies.ResultsNo remote consultations were refused by patients. Preliminary data from 511 triaging episodes at 13 centres show that 77.1% of patients were discharged directly or have had their appointments deferred.DiscussionSignificant reduction in footfall can be achieved using a structured triaging system. Further refinement of HaNC-RC V.2 is feasible and the authors welcome international collaboration.

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.

The global pandemic of 2019 Novel Coronavirus Disease (COVID-19) has tremendously altered routine medical service provision and imposed unprecedented challenges to the healthcare system. This impacts patients with dysphagia complications caused by head and neck cancers. As this pandemic of COVID-19 may last longer than SARS in 2003, a practical workflow for managing dysphagia is crucial to ensure a safe and efficient practice to patients and healthcare personnel. This document provides clinical practice guidelines based on available evidence to date to balance the risks of SARS-CoV-2 exposure with the risks associated with dysphagia. Critical considerations include reserving instrumental assessments for urgent cases only, optimizing the non-instrumental swallowing evaluation, appropriate use of PPE, and use of telehealth when appropriate. Despite significant limitations in clinical service provision during the pandemic of COVID-19, a safe and reasonable dysphagia care pathway can still be implemented with modifications of setup and application of newer technologies.

Amy Y. Chen, MD, MPHEmory [email protected] Shindo, MDOregon Health Sciences [email protected] author:Amy Y. Chen, MD, MPHEmory Department of Otolaryngology Head and Neck Surgery550 Peachtree St. MOT 1135Atlanta, GA [email protected] title: Ethics Endocrine Surgery COVID 19Ethical Framework for Head and Neck Endocrine Surgery in the COVID 19 pandemicThe COVID-19 pandemic has halted all elective surgeries, allowing only emergent surgeries, and in some hospitals time-sensitive urgent surgeries to proceed. “Mr. X, This is Dr. I’m calling to discuss with you your previously planned surgery. “ I’ve been having many conversations like this with my patients over the past weeks. Surgeries may be delayed or the patient and his/ her family may need to make a heart wrenching decision whether to proceed with surgery in a hospital filling with COVID patients, risking infection themselves, and without any visitors. Endocrine surgery falls into this valley where it is neither life threatening nor totally benign either. The American Association of Endocrine Surgeons1 as well as the endocrine section of the American Head and Neck Surgery2 have put forth recommendations for thyroid and parathyroid conditions that would be considered urgent time-sensitive surgery. These include 1) high risk thyroid cancers such as those with bulky central and lateral neck disease, concern for tracheal or esophageal involvement, or short doubling time 2) Graves’ disease with thyrotoxicosis that cannot be controlled with anti-thyroid medications, 3) compressive large goiters with dyspnea or significant symptomatic vascular compression, 4) Primary hyperparathyroidism with life-threatening hypercalcemia that cannot be managed medically, 5) endocrine disorders in pregnant patient that are dangerous to the health of the mother or fetus that cannot be controlled medically.Certainly, there has been an international push to observe more well differentiated thyroid cancer; however, what about those “smallish” cancers that are near the isthmus, near the trachea/ esophagus, or with extracapsular extension? Despite their small size, these can become invasive to the degree that could result in the need to perform a more morbid procedure if surgery is delayed, and thus should be considered in the category of “time-sensitive surgery”. What about indeterminate thyroid nodules with adverse molecular markers? If such nodules present with ultrasound findings that are concerning for local invasion, even though the cytologic diagnosis is not “malignant”, such lesions should be treated as high risk cancer, and surgery should not be delayed.If proceeding with surgery, the surgeon has an ethical responsibility to discuss with the patient the potential risk of COVID-19 infection. We as surgeons have a responsibility to reduce risk of infection not only to the patient but the healthcare team who will be caring for the patient. At the minimum COVID-19 testing should be performed preoperatively within 2 days of surgery, and the patient should be educated on the importance of self-isolation and necessary precautions.If potential difficult airway is anticipated communication and planning with anesthesia pre-procedure is important. Despite that fact that the patient may test negative for COVID-19, the false negative rate is not zero, and as such, precautions need to be taken to minimize exposure. A difficult airway may result in manipulation of the airway that could potentially be aerosolizing. Having the appropriate protective gear and all necessary difficult airway equipment is essential in such a situation. If the patient needs fiberoptic laryngoscopy or tracheoscopy, nasal pledgets should be used in lieu of sprays. Surgery should certainly be postponed in Covid-19 positive patients.Scarcity of resources, surge planning, and public health mitigation efforts have all combined in a perfect storm to delay and in some situations, to deny treatment to head and neck surgery patients. Whereas some of our patients may afford a delay in their treatment, others do not have that luxury. It is incumbent upon us, as their clinicians, to integrate competing priorities into an acceptable plan.Justice, or to be just/ fair, must include a lens towards equity. One way to honor this ethical principle is to incorporate both clinical and non-clinical factors in risk assessment. Many papers have reported on the profound effect of sociodemographic factors on patient outcomes. An intersection between higher comorbidity burden and lower socioeconomic status can worsen disparities of who gets treatment. For example, algorithms that incorporate comorbidity are necessary so that resources can be allocated for the “greater good;” however, these guidelines risk heightening disparities and health inequity. Strategies to ameliorate these disparities include flexibility of treatment options, creative discharge planning, and thorough pre-operative conditioning. Flexibility of treatment options include consideration of definitive chemoradiation, induction chemotherapy prior to surgery (to buy time), and resection with delayed reconstruction.Beneficence, or to do good, is a guiding principle of ethics. With limited resources, the “good” of society supersedes the “good’ of the individual. Hence, the cancellation of elective, non-emergent cases is instituted. So is the prioritization of surgical cases that are not likely to need ICU care, blood products, extended inpatient stay, and extensive ancillary laboratory/ radiology testing.However, these cancellations/ delays in treatment/ changes in treatment can cause anxiety for both the clinician and his/ her patient. Many of our patients have been waiting for several weeks for their treatment to start, only to have it be delayed or altered. How do we reassure the patient that the new plan is the best plan, given the restrictions that the COVID 19 pandemic places on systems? How do we, as clinicians, resolve our inner turmoil in delaying/ denying/ altering treatment.Early data already demonstrate that COVID 19 is affecting vulnerable racial minorities at a higher disproportionate rate. To compound the adverse effects, this cohort has more access issues due to transportation, hourly job limitations, and lack of stable insurance. The delay in surgery may result in the patient’s loss of insurance status due to loss of income and/ or being furloughed. As we move into the next phase of easing up restrictions, such factors need to be taken into consideration in prioritizing whom we select for surgery.1. https://www.endocrinesurgery.org/assets/COVID-19/AAES-Elective-Endocrine-Surgery.pdf2. https://www.ahns.info/wp-content/uploads/2020/03/Endocrine-Surgery-during-the-Covid.pdf

As COVID-19 continues to challenge the practice of head and neck oncology, clinicians are forced to make new decisions in the setting of the pandemic that impact the safety of their patients, their institutions and themselves.  The difficulty inherent in these decisions is compounded by potentially serious ramifications to the welfare of patients and healthcare staff, amid a scarcity of data on which to base informed choices. This paper explores the risks of COVID-19 incurred while striving to uphold the standard of care in head and neck oncology.  The ethical problems are assessed from the perspective of the cancer patient, healthcare provider, and other patients within the healthcare system.  While no single management algorithm for head and neck cancer can be universally implemented, a detailed examination of these issues is necessary to formulate ethically sound treatment strategies.

Background Telehealth post-operative visits are an attractive strategy to minimize exposure, especially during the SARS-CoV-2 (COVID-19) pandemic. The use of a surgical drain often prevents this minimal-exposure approach in that patients return to the outpatient clinic for drain removal. Methods and Results Following unilateral neck dissection, the customary closed-suction drain was replaced with a self-removing, passive drain dressing to facilitate same-day discharge and telehealth post-operative follow-up. The patient removed the dressing and drain at home during a telehealth visit on post-operative day four and she healed favorably without signs of infection or seroma. Conclusions When thoughtfully applied in the appropriate clinical context, small practice adaptations like this can facilitate telehealth solutions that diminish unnecessary exposure for patients, their caregivers, and healthcare staff.

Background: In the context of COVID-19, cancer survivors represent a particularly vulnerable population that may be “doubly hit” both by costs of cancer treatment and financial strain imposed by the pandemic. Methods: We performed a review of the literature pertaining to cancer, financial toxicity, and economic challenges.Results: Multiple societies have put forth recommendations to modify delivery of cancer care in order to minimize patient exposure to the virus. Cancer survivors, especially patients with head and neck cancer, have been disproportionately affected by rising unemployment levels and economic recessions in the past, both of which are linked to higher cancer mortality. Patients who rely on employer-provided insurance and do not qualify for Medicaid may lose access to life-saving treatments. Conclusions: It is essential to implement interventions and policy changes in order to mitigate the effects of this pandemic but also to ensure this becomes a non-issue during the next one.

The practices of head and neck surgical oncologists must evolve to meet the unprecedented needs placed on our healthcare system by the Coronavirus Disease 2019 (COVID-19) pandemic. Guidelines are emerging to help guide the provision of head and neck cancer care, though in practice, it can be challenging to operationalize such recommendations. Head and neck surgeons at Wuhan University faced significant challenges in providing care for their patients. Similar challenges were faced by the University of Toronto during the severe acute respiratory syndrome (SARS) pandemic in 2003. Herein, we outline our combined experience and key practical considerations for maintaining an oncology service in the midst of a pandemic.

Kimberley L Kiong MBBS 1 , Theresa Guo MD 1 , Christopher MKL Yao MD 1 , Neil D Gross MD 1 , Matthew M Hanasono MD 2 , Renata Ferrarotto, MD 3 , David I Rosenthal MD 4 , Jeffrey N Myers MD 1 , Ehab Y Hanna MD1, Stephen Y Lai MD 1 1 Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 2 Department of Plastics and Reconstructive Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, United States 3Department of Thoracic Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States. 4Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States Corresponding author: Stephen Y Lai, MD PhD Professor Patient Safety Quality Officer The University of Texas MD Anderson Cancer Center Department of Head and Neck Surgery Division of Surgery 1515 Holcombe Blvd, Unit 1445 Houston, TX 77030  [email protected]  This work did not receive any grant support and has not been presented at any meeting Running title: Changing Head & Neck surgical practice during COVID-19 Keywords : Otolaryngology, Oncology, SARS-CoV2 Abstract: Background: The COVID-19 pandemic has changed healthcare, challenged by resource constraints and fears of transmission. We report the surgical practice pattern changes in a Head and Neck Surgery department of a tertiary cancer care center and discuss the issues surrounding multidisciplinary care during the pandemic. Methods: We report data regarding outpatient visits, multidisciplinary treatment planning conference, surgical caseload, and modifications of oncologic therapy during this pandemic and compared this data to the same interval last year. Results: We found a 46.7% decrease in outpatient visits and a 46.8% decrease in surgical caseload, compared to 2019. We discuss the factors involved in the decision-making process and perioperative considerations. Conclusions: Surgical practice patterns in head and neck oncologic surgery will continue to change with the evolving pandemic. Despite constraints, we strive to prioritize and balance the oncologic and safety needs of patients with head and neck cancer in the face of COVID-19. IntroductionThe rapid spread of the novel coronavirus 2019 (COVID-19) has disrupted healthcare systems globally. Some of the biggest challenges include shortage of hospital beds, healthcare workers and personal protective equipment (PPE). Given these constraints, there has been a simultaneous push for a reduction in elective clinical practice, to further reduce transmission and conserve resources 1.Cancer care is generally not considered elective and decision making about when to initiate or delay treatment during the pandemic has raised complex ethical and resource utilization issues. Yet amidst the pandemic, patients continue to develop and seek treatment for cancer. Head and neck cancers (HNC) can challenge essential functions such as eating, speaking and breathing. Tumor doubling time ranges between 15 to 99 days 2,3 and delaying treatment decreases survival and contributes to adverse outcomes 4,5. As such, there are recommendations for prompt initiation of treatment of HNC after diagnosis and to reduce the total treatment package time6,7. In an effort to limit the potential adverse effects of delaying cancer treatment during this pandemic, an increasing number of oncology guidelines have been developed, both general and specific to HNC 8,9.At the University of Texas MD Anderson Cancer Center (MDACC), our Head and Neck surgical practice has gradually changed as a result of evolving internal and external guidelines (Table 1). Harris County, Texas reported its first COVID-19 case on March 5th, 2020. Since then, the number of cases has been steadily rising with the current incidence at 35 per 100,000 residents in Texas 10. At the institutional level, MDACC has taken many pre-emptive actions and policy changes in response to the growing pandemic (Table 1).The institutional policies described have served to limit hospital attendances in anticipation of a surge in COVID-19 cases in the region. The number of new patients visits to the institution have decreased from 782/week in the first week of March to 207/week in the last week of March (-73.5%) while systemic treatment appointments, indicative of patients already in the process of treatment, have remained fairly stable (3864 to 3288 visits, -14.9%). As a downstream effect, the number of diagnostic imaging visits has decreased from 9616 to 3971 (first and last weeks of March respectively, -58.7%). Surgeries within the institution have shown a more drastic decrease, from 463 to 149 cases per week (-67.8%). Current institutional census at the time of writing (April 7th, 2020) shows 55% general bed occupancy and 35% ICU occupancy. The numbers will continue to change in response to the development of COVID-19 within the region, as we have not yet reached the peak of infection. Predictive models have suggested that the peak in COVID-19 cases will occur at the end of April11 and there are institutional plans on standby to repurpose physical facilities and the workforce to shift focus from oncology care to COVID-19 treatment if needed.In the context of the developing pandemic and tightening institutional guidelines, we seek to understand the early impact of the COVID-19 pandemic on head & neck oncologic surgery practices. We performed a review of outpatient clinic and surgical caseload within the MDACC Head and Neck Surgery department during the pandemic and compared this to the same time period in the preceding year, along with the deviations in management of patients due to COVID-19.

Background: Guidelines for ultrasonic devices use are imperative because infectious aerosols arising from airway procedures were a key etiologic factor in prior coronavirus outbreaks. This manuscript aims to summarize the available recommendations and the most relevant concepts about the use of ultrasonic scalpel during the SARS-CoV-2 pandemic. Methods: Literature review of manuscripts with patients, animal models or in vitro studies where the ultrasonic scalpel was used and the plume produced was analyzed in a quantitative and/ or qualitative way. Discussion: Activated devices with tissue produces a biphasic bioaerosol composed (size 68.3 - 994 nm) of tissue particles, blood, intact and no viable cells, and carcinogenic or irritant hydrocarbons (benzene, ethylbenzene, styrene, toluene, heptene, and methylpropene). Conclusion: It is imperative to use an active smoke evacuator, to avoid ultrasonic scalpel use in COVID-19 positive patients and in upper airway surgery, as well as to follow the protection recommendations of the guidelines for management this type of patients.

As an aerosol and droplets generating procedure, tracheostomy increases contamination risks for health workers in the coronavirus disease context. To preserve the health care system capacity and to limit virus cross-transmission, protecting caregivers against coronavirus infection is of critical importance. We report the use of external fixator equipment to set up a physical interface between the patient’s neck and the caregiver performing a tracheostomy in COVID-19 patients. Once the metal frame set in place, it is wrapped with a single-use clear and sterile cover for surgical C-arm. This installation is simple, easy and fast to achieve and can be carried out with inexpensive material available in every hospital. This physical interface is an additional safety measure that prevents the direct projection of secretions or droplets. It should, of course, only be considered as a complement to strict compliance with barrier precautions and personal protective equipment.

IntroductionThe ongoing worldwide pandemic due to COVID-19 has forced drastic changes on the daily lives of the global population. This is most notable within the healthcare sector. The current paper outlines the response of the head and neck oncologic surgery (HNS) division within our academic otolaryngology department in the state of Alabama.MethodsData with regard to case numbers and types were obtained during the pandemic and compared with time matched data. Our overall approach to managing previously scheduled and new cases, personal protective equipment (PPE) utilization, outpatient clinic, and resident involvement is summarized.DiscussionOur HNS division saw a 55% reduction in surgical volume during the peak of the COVID-19 pandemic. We feel that an early and cohesive strategy to triaging surgical cases, PPE usage, and minimizing exposure of personnel is essential to providing care for HNS patients during this pandemic.

The COVID-19 epidemic was not the first coronavirus epidemic of this century and represents one of the increasing number of zoonoses from wildlife to impact global health. SARS CoV-2, the virus causing the COVID-19 epidemic is distinct from, but closely resembles SARS CoV-1, which was responsible for the severe acute respiratory syndrome (SARS) outbreak in 2002. SARS CoV-1 and 2 share almost 80% of genetic sequences and use the same host cell receptor to initiate viral infection. However, SARS predominantly affected individuals in close contact with infected animals and health care workers. In contrast, CoV-2 exhibits robust person to person spread, most likely by means of asymptomatic carriers, which has resulted in greater spread of disease, overall morbidity and mortality, despite its lesser virulence. We review recent coronavirus-related epidemics and distinguish clinical and molecular features of CoV-2, the causative agent for COVID-19, and review the current status of vaccine trials.

Background: Pulmonary complications and infections frequently affect patients with head and neck squamous cell carcinoma (HNSCC). Common characteristics can predispose these patients to the development of severe respiratory illness, which may be particularly relevant during the  2019 coronavirus disease (COVID-19) pandemic. Methods: A scoping review was performed to assess the impact of pulmonary comorbidities and adverse respiratory outcomes in HNSCC patients. Results: Advanced age, history of tobacco and alcohol abuse, and cardiopulmonary comorbidities are significant risk factors for the development of adverse respiratory outcomes. Treatment  toxicities from radiation or chemoradiation therapy significantly increase these risks.  Conclusion: Respiratory complications are a frequent cause of morbidity and mortality among HNSCC patients, and the COVID-19 pandemic may disproportionately affect this population.  Interventions designed to decrease smoking and alcohol use, improve oral hygiene, and aggressively manage medical comorbidities are important to the long-term management and health of these patients.  

BackgroundTracheotomy, through its ability to wean patients off ventilation, can shorten ICU length of stay and in doing so increase ICU bed capacity, crucial for saving lives during the COVID-19 pandemic. To date, there is a paucity of patient selection criteria and prognosticators to facilitate decision-making and enhance precious ICU capacity.MethodsProspective study of COVID-19 patients undergoing tracheotomy (n=12) over a 4-week period (March-April 2020). Association between pre- and post- operative ventilation requirements and outcomes (ICU stay, time to decannulation, and death) were examined.ResultsPatients who sustained FiO2≤50% and PEEP≤8cm H2O in the 24h pre-tracheotomy exhibited a favourable outcome. Those whose requirements remained below these thresholds post-tracheotomy could be safely stepped down after 48h.ConclusionSustained FiO2≤50% and PEEP≤8cm H2O in the 48h post-tracheotomy are strong predictive factors for a good outcome, raising the potential for these patients to be stepped down early, thus increasing ICU capacity.

Introduction: The COVID-19 pandemic has raised controversies regarding safe and effective care of head and neck cancer patients. It is unknown how much the pandemic has changed surgeon practice. Methods: A questionnaire was distributed to head and neck surgeons assessing opinions related to treatment and concerns for the safety of patients, self, family, and staff. Results: A total of 67 head and neck surgeons responded during the study period. Surgeons continued to recommend primary surgical treatment for oral cavity cancers. Respondents were more likely to consider non-surgical therapy for patients with early glottic cancers and HPV-mediated oropharynx cancer. Surgeons were least likely to be concerned for their own health and safety and had the greatest concern for their resident trainees. Conclusions: This study highlights differences in the willingness of head and neck surgeons to delay surgery or alter plans during times when hospital resources are scarce and risk is high.