Introduction
Coronavirus disease-2019 (COVID-19) was first reported in Wuhan, Hubei province, China in December 2019 and has since rapidly spread across the globe, infecting 952,000 people and causing 48,000 deaths as of April 2nd, 2020.1 This disease is caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), a novel coronavirus closely related to the SARS and Middle Eastern Respiratory Syndrome (MERS) viruses. 1,2 The exact route of transmission remains unknown but the primary mechanism of spread is believed to be via respiratory droplets and aerosols.3Due to the high viral load present in the upper airway, otolaryngologic procedures are considered high risk for occupational exposure and a number of otolaryngologists have been infected with COVID-19.4
The most common initial symptoms of COVID-19 are cough, fever, fatigue, increased mucous production, dyspnea, sore throat, and myalgias.5 Ground-glass opacities are found on chest computed tomography in 56% of patients on admission, with 2.3% of patients eventually requiring mechanical ventilation.6In an analysis of 72,314 COVID-19 patients in China, the overall case-fatality rate was 2.3% but was 7.3% in patients with pre-existing conditions (10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer).5 Notably, symptoms can take 1-2 weeks to manifest from the time of infection, and asymptomatic patients can still be contagious.
Total laryngectomy, which results in an interruption between the upper airway and trachea with complete respiratory dependence through a tracheostoma, represents a unique challenge for patient management in the setting of COVID-19. Laryngectomy patients are at risk for poor outcomes with COVID-19 due to frequently present medical comorbidities including chronic pulmonary disease, peripheral vascular disease, cardiac disease, cerebrovascular disease, diabetes, the underlying cancer history, and a propensity for atelectasis due to loss of upper airway resistance.7 Furthermore, as the majority of laryngectomy patients have a smoking history, they are also prone to acute infections due to impaired mucociliary function and mucosal irritation from cold, dry inspired air.7 In addition, salvage total laryngectomy can result in post-operative wound complications and prolonged hospital stays and greater risk of exposure to the virus as hospitals are inundated with COVID 19 patients. If infected, laryngectomy patients carry a high risk of transmitting viral particles to health care workers or members of the community due to their significantly altered anatomy and to aerosolization of tracheal secretions.8,9