Infection Control Precautions in Total Laryngectomy Patients
Direct examination and instrumenting the head and neck region during physical examination of the infected patient represents a significant transmission hazard for the physician and ancillary support staff due to the high viral load present in the upper aerodigestive tract.4 Unfortunately, many patients are asymptomatic early in infection, and some patients may remain asymptomatic throughout the course of the infection. Currently, COVID-19 testing is limited by access to supplies and lengthy turnaround times, and therefore, patients with unknown COVID-19 testing should be presumed positive until testing becomes readily available with rapid results.
The best approach for testing laryngectomy patients for COVID-19 also requires consideration. COVID-19 testing is most commonly performed via nasopharyngeal swab. Although laryngectomy patients have no significant airflow through the nasal cavity or nasopharynx, they can still develop sinonasal disease.10 However, as the primary respiratory flow is via the tracheostoma, the trachea and lungs may serve as an additional site of direct inoculation. Therefore, is important to consider testing for SARS-CoV-2 in tracheal aspirates as well as in the nasal passages for laryngectomy patients. This is consistent with CDC recommendations of lower respiratory track specimens if available.11
Any manipulation of the upper aerodigestive tract that precipitates cough, including endoscopic examination of the nasal cavity, oral cavity, and pharynx must be treated as an aerosol-generating procedure that has a high risk of virus transmission. To limit COVID-19 transmission and preserve medical resources including personal protective equipment (PPE), the American College of Surgeons (ACS) and the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) have recommended otolaryngologic procedures be deferred unless the procedure is medically necessary in a high acuity.12,13
Given the extensive alterations in anatomy, their cancer history, and risk of airway complications related to tracheoesophageal fistulae (TEF) or tracheoesophageal prostheses (TEP), laryngectomy patients may still require acute face to face encounters. As such, special considerations to minimize the risk of SARS-CoV-2 transmission should be undertaken. The proper use of PPE is important in the setting of COVID-19. In these patients, unconditioned air enters the tracheostoma, which can lead to increased coughing.3 Inherently, tracheostomas generate a greater aerosol load in comparison to normal respiration through the upper airway.9 During the SARS outbreak in 2003, viral RNA was detected in high concentrations in tracheal aspiration samples, indicating the virus also replicates in tracheal secretions.14 With this in mind, extra care must be taken to protect against aerosolized particles generated when examining and interacting with laryngectomy patients in both the inpatient and outpatient setting.
We recommend using enhanced PPE, which we define as an N95 respirator and face shield or a powered air-purifying respirator (PAPR), as well as a disposable surgical cap, gown, gloves, and consideration for shoe covers when evaluating any laryngectomy patient with unknown, suspected, or positive COVID-19 status. Standard PPE, as defined by the Occupational Health and Safety Administration (OSHA), can be used for COVID-19-negative patients.15 Proper PPE compliance is critical in maintaining its efficacy and the appropriate sequence of donning and doffing of the equipment is vital.11 It is important to note, however, that the use of an N95 respirator and face shield may not be 100% effective at preventing COVID-19 transmission. In fact, two recent meta-analyses failed to demonstrate the superiority of N95 respirators over standard surgical masks in preventing influenza.16,17 Due to the increased protection afforded and possible reusability, a PAPR is preferred over an N95 respirator and face shield for high-risk procedures, when available, so long as there is appropriate physician comfort and training with a PAPR.4,18,19 The availability of PAPR can vary greatly from center to center. Additional options for enhanced PPE to consider include N100 and reusable elastomeric respirators if available.