Abstract
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.
KEYWORDS
Dysphagia, head and neck, coronavirus, COVID-19, management
Introduction
The worldwide healthcare system has been inundated by a sudden surge of
suspected and confirmed cases of the novel coronavirus disease
(COVID-19) since the World Health Organization (WHO) declared the global
pandemic of this viral illness on March 11, 2020. In just over a month,
1,914,916 confirmed cases of COVID-19 were reported globally with
123,010 deaths by April 14, 20201. This represents a
10-fold increase in confirmed cases and 15-fold increase in deaths since
the declaration of pandemic. While this global pandemic has flooded and
imposed unprecedented challenges to the health care system, the global
shortage of personal protective equipment (PPE) has created extra burden
to frontline health care personnel.
There are 550,000 new cases of head and neck cancer (HNC) registered
worldwide per year.2 The incidence of HNC is not
anticipated to be affected by pandemic of COVID-19. Dysphagia is one of
the most common complaints for HNC patients before, during, and after
treatment. These patients often require multidisciplinary care by
speech-language pathologists and otolaryngologists in dedicated
swallowing disorders clinics. A detailed symptom inventory, oromotor
examination, clinical swallowing assessment, objective instrumental
swallowing studies, swallowing intervention, and monitoring of progress
are still essential for these patients during the COVID-19 pandemic.
However, given the significant challenges involving transmission risk
and limited PPE, alteration to the typical provision of swallowing
services must be considered during this outbreak. As this pandemic of
COVID-19 may last longer than SARS in 2003, a practical workflow for
managing dysphagia is of utmost importance. In these clinical
guidelines, we propose a strategic plan to facilitate safe practice in
dysphagia management for health care personnel and patients with
dysphagia, without jeopardizing the standard of care.
Selection of Swallowing Studies
Fiberoptic endoscopic evaluation of swallowing (FEES) and
videofluoroscopic swallowing studies (VFSS; also sometimes called
modified barium swallow) are two common instrumental swallowing studies.
During FEES examination, a fiberoptic endoscope is passed by the
clinician through the nose of the patient into the pharynx, which allows
observation of anatomy of the pharynx/larynx, management of saliva and
food/liquid boluses, coordination of the pharynx, tongue and larynx
during swallowing, and presence of laryngeal penetration or aspiration
into the airway. It is commonly performed by speech-language
pathologists and otolaryngologists. VFSS utilizes real-time X-ray to
assess the different phases of swallowing and swallowing physiology as
the bolus passes through the oral cavity, pharynx and upper cervical
esophagus using barium impregnated food materials of different
consistencies. It allows for observation of swallowing biomechanics and
any consequences of dysfunction including penetration and aspiration of
food materials into the airway. VFSS is typically performed by
radiologists and speech-language pathologists. While FEES and VFSS have
their own merits and limitations, both can be used to assess head and
neck cancers patients.
While both VFSS and FEES are appropriate tests to utilize in assessment
of swallowing, in the context of the COVID-19 outbreak, clinicians need
to consider relative risk with these procedures. The higher risk of
aerosolization of matter from the nasal passage and nasopharynx with
FEES may suggest that VFSS may be the safer option in the current
climate. Additionally, some centers may still practice testing of
laryngeal sensation by air-pulse stimulator which fires air-pulses in 50
milliseconds duration with pressure from 2 to 10 mmHg to elicit the
reflexive twitching of vocal cords before endoscopic evaluation of
swallowing.3-4 These air-pulses may either create air
current in the pharynx or induce cough if the air pressure is high,
which may generate droplets and aerosol. In light of the pandemic of
COVID-19, suspension of laryngeal sensory testing and FEES examinations
should be seriously considered to minimize aerosol generation.
Selection of Personal Protective Equipment
Recent studies reported the R0 of SARS-CoV-2 ranged from
5.71-7.235, which is higher than SARS-CoV (2 to 4) in
2003.6 Therefore, the virulence of COVID-19 is far
higher than SARS and may well explain the seemingly uncontrolled
pandemic of COVID-19 in many countries. There has been some confusion
throughout the health care community in regard to droplet versus aerosol
transmission of COVID-19, and subsequently the different levels of PPE
required to minimize transmission risk. Aerosol is formed by droplets of
smaller sizes, usually smaller than 5 µm in diameter, allowing them to
remain suspended in the air, to travel longer distances, and and to
penetrate face masks with larger pore sizes. High level PPE such as N95
respirators are mandatory with any aerosol generating procedures (AGP).
The recent findings of hyposmia, anosmia and dysgeusia in a sizable
proportion of confirmed COVID-19 cases may suggest a higher viral load
in the nasal cavity/nasopharynx.7 Based on the
observation of high viral shredding of coronavirus in the nasal
passage/nasopharynx8 and anecdotal evidence of
increased risk of transmission in the otolaryngology community, use of
positive airway power respirators (PAPR) has been advocated for any
nasal procedures which generate aerosol. This recommendation would thus
apply to FEES exams.
Evidence shows coughing can generate droplets of size from 0.1 µm to 100
µm which lie in the range of aerosol generation.9Therefore, we can categorize procedures that may induce coughing, such
as FEES and VFSS, as AGP and recommend adoption of the highest level of
PPE with face shield or goggles, N95 respirator and isolation gown when
undertaking these procedures. Face shield can practically provide more
coverage to the eyes and face and prevent contamination of the facial
skin which is commonly overlooked by most health care personnel during
doffing of PPE leading to later transmission of virus through the nose
and eyes through hand spread. Careful donning and doffing of isolation
gowns is critical to minimize potential contamination.
Screening and Timing of Examination
FEES and VFSS can trigger sneezing and/or coughing, leading to
aerosolization during the procedure. The unpublished data of 982
patients attending the combined dysphagia clinic in Prince of Wales
Hospital showed that of those with dysphagia following head and neck
cancer treatment, nearly 80% had impaired laryngeal protective reflex.
Thus, the incidence of intense coughing during FEES and VFSS may be low
in head and neck cancer patients as their nose and pharynx are less
sensitive to instrumentation and penetration/aspiration. However, as
evidence shows speaking can generate a sufficient amount of droplets to
transmit SARS-CoV-2,10 and patients are generally not
able to wear a face mask during the swallowing evaluation, we should be
more conservative when considering these instrumental swallowing
procedures. If the condition is not urgent, we suggest postponing any
FEES or VFSS for 14 days, as suggested according to the incubation
period of COVID-19 in any high-risk patients based on history
(T ravel, O ccupation, C ontact andC lustering phenomenon as TOCC ) and symptomatology such
as fever, cough, shortness of breath, and expectorant. It must also be
considered that the patient must self-isolate for that 14-day period in
order for the healthcare team to be confident of low risk for completion
of the swallowing assessment. Additionally, olfactory disturbance has
been noticed to occur in high proportion of confirmed cases of COVID-19
(15 to 60%) globally, and can be an early or solitary symptom of
infection.11 With more supporting evidence in our
unpublished data on smell loss (47%) and taste loss (45%) in COVID-19
confirmed patients, smell and taste disturbance may serve as markers for
potential COVID-19 to enhance surveillance in clinic. For patients who
require urgent swallowing evaluation in extenuating circumstances (such
as acute status change or newly diagnosed aspiration pneumonia),
SARS-CoV-2 testing or full aerosol PPE are recommended to minimize
transmission risk.