Neopharyngeal or esophageal narrowing during COVID-19 pandemic

The corona (COVID-19) pandemic presents many challenges for head and neck cancer patients and their medical providers. Because of the reduction or decrease in outpatient services, the availability of neopharyngeal and /or esophageal dilation for esophageal narrowing may not be available.

Enclosed are suggestions how to cope with these challenges:

• Performing dilation at-home using self-dilation device
• Considering treatment that resolve the narrowing (i.e., stent, laser treatment)
• Temporarily altering the diet to soft or liquid one
• Using a gastric tube for feeding

It is helpful to contact one’s speech and language pathologist and/or physician for guidance. Many institutions perform dilation to those who are unable to consume sufficient calories and liquids.

Hopefully these temporary measures will be helpful.

Going outside during the COVID-19 pandemic

Laryngectomee may experience social and medical challenges when they leave their home during the COVID-19 pandemics. Most non-neck breathers do not understand or recognize their medical condition and may react in a negative way toward them. They may be alarmed when the laryngectomee coughs or sneezes, or take care of their stoma in public.

Included are some of the steps that laryngectomees can take when in public:

• Cleaning the stoma and trachea including inserting saline into the trachea and coughing out the secretions before going out
• Taking care of the stoma and it’s secretions at a private location away from others (e.g., bathroom, separate room)
• Covering the stoma (with napkin, cloth or elbow) whenever coughing or sneezing. Preferably this is done away from other people. When coughing forcefully the stoma can produce large amount of droplets that can spread and infect others when the laryngectomee carries a respiratory virus such as COVID-19
• Keeping a distance of at least 6 feet (2 meters) from others
• A useful routine is to use the non-dominant hand to touch the stoma and the dominant hand for other activities (e.g., touching a door handle).
• Wearing a surgical mask or garment over the mouth and nose (in addition another one over the stoma). This is done to protect the laryngectomee from becoming infected, as well as others the laryngectomee is infected. Wearing a mask over the mouth and nose in public prevent the laryngectomee from standing out from others. Wearing the mask on the stoma and face also serves in preventing laryngectomees from touching these locations with unclean hands.

Hopefully these measures can assist laryngectomees in public locations.

As home confinement and other restrictions are being slowly lifted, it would be prudent for laryngectomees to continue to observe these precautionary measures. As more clinical experience in managing COVID-19 infection is gained and new medications and  vaccines are available the consequences of becoming infected may become less dangerous.

Preventing COVID-19 infection in laryngectomees

Most individuals experience less “colds” after laryngectomy. This is believed to be because respiratory viruses generally first infect the nose before spreading to other body sites (including the lungs). Because laryngectomees do not inhale through their noses this mode of transmission is rare.

However, all respiratory viruses (including COVID-19) can also access the body through the nose, mouth, conjunctiva and stoma (in neck breathers) after they are inhaled or introduced by a contaminated object or hand. It is therefore prudent that laryngectomees are extra vigilant in protecting themselves.

Laryngectomees may also be at risk for poor outcomes with COVID-19 due to other medical comorbidity (including chronic pulmonary disease, peripheral vascular disease, cardiac disease, cerebrovascular disease, diabetes, the underlying cancer history), and the propensity for lower lobs collapse (atelectasis) due to loss of upper airway resistance. Additionally, because many laryngectomees have a smoking history, they are also prone to acute infections due to impaired mucociliary function and mucosal irritation from cold, dry inspired air.

There have been several laryngectomees who acquired COVID-19 infection. Those who were diagnosed had a broad spectrum of symptoms from minimal to severe. There were at least 2 who also had comorbidities that died from COVID-19 infection. 

The information and knowledge about the prevention and management of COCID-19 is growing and constantly evolving. Because the recommendations for COVID-19 prevention and treatment may change, it is important to follow the local health department and Center of Disease Control and Prevention updates and consulting with medical professionals. .

If someone in close contact with laryngectomee is exposed or infected with COVID-19, he/she should self-quarantine themselves  and avoid any contact with the neck breather. 

it is important for laryngectomees to protect themselves and others in the community from COVID-19. Due to the increased aerosolization risk from their stoma, the potential to become “super spreaders” necessitates that total laryngectomy patients always cover their stoma in public. The best protection against aerosolization and inhalation of viral particles in the community is to cover the stoma with an HME that includes a bacterial and/or viral filter. Many patients prefer to use laryngectomy tubes, but during this pandemic an HME attached to the stoma with a baseplate allows for a seal that will force all air through the HME, thus further minimizing aerosolization. If the patient is unable to obtain a good seal with the HME base plate, they can use laryngectomy tubes that accept HME filters is an option. It is strongly recommend disposal of HMEs after community exposure.

Laryngectomees can protect themselves and others by taking these steps:

•           Wearing heat and moisture exchanger (HME) 24/7 especially when being around other people. HME with greater filtering ability would work better in reducing the risk of inhaling the virus ( e.g., Provox Micron TM). (picture below) Provox Micron, has an electrostatic filter and >99.9% filtration rate and it’s cover prevents direct finger contact with the stoma when speaking. Wearing it also protects other individuals when the laryngectomee is infected. It has maximal activity during the first 24 hours of use.  A Provox HME Cassette Adaptor enables the use of a Provox HME Cassette to any tracheostomy tube with a 15 mm ISO connector. Those with tracheostomy can protect themselves by using ProTrach XtraCare HME.

Provox micron

•           Wearing hands free tracheostoma valve (because it does not require touching when speaking) in those using trachea esophageal speech. Those who use a regular HME should wash their hands before touching their HME.

•           Wearing a surgical mask (see pictures below), 100% cotton turtleneck, bib, or scarf  
over the stoma (in addition to the HME). Tie the upper strings of the mask around neck, use additional extension string to connect the two lower mask strings together under the arms and behind the back.

•           Wearing an additional surgical mask or respirator over the nose and mouth, and protective glasses or face shield (see pictures below). This can prevent the virus from entering the body through these sites or spread to other people when infected. Men should shave their facial hair prior to wearing surgical mask or respirator. If worn properly, a surgical mask can help block large-particle droplets, splashes, sprays or splatter that may contain germs (viruses and bacteria). While a surgical mask may be effective in blocking splashes and large-particle droplets, it does not filter or block very small particles in the air that may be transmitted by coughs, and sneezes. Wearing the mask on the stoma and face also serves in preventing laryngectomees from touching these locations with unclean hands. 

                                                   
                                                 Wearing protective glasses and surgical mask

Wearing face shield and protective glasses

•           Washing hands often with soap and water for at least 20 seconds. Use an alcohol-based hand sanitizer that contains at least 60% alcohol if soap and water are not available. This is especially important before managing the stoma, and touching the HME when speaking using tracheoesophageal speech.

•           Avoiding touching the stoma, HME, eyes, nose, and mouth with unwashed hands. A useful routine is to use the non dominant hand to touch the stoma and the dominant hand for other activities (e.g., touching a door handle).

•           Avoiding close contact with sick people and avoid public and crowded places.

•          Staying at least 6 feet from other who don't live with you.

•           Cleaning and disinfecting frequently touched objects and surfaces.

Those in close contact with neck breathers can expose them to the virus when they become asymptomatic carrier or infected with COVID-19. These individuals as well as the neck breathers should observe meticulous hand hygiene and wear face masks, gloves, eye shields, and other protective items whenever they are in contact with each other.



Additional sources about protection of laryngectomees:

Oral Oncology editorial about protection of laryngectomees 

Tracheotomy Education Website: Laryngectomy and Coronavirus Disease (COVID-19)
Message from the Japanese Head and Neck Support Society. (in Japanese and English)

Message from the Singapore Cancer Society

Message from Atos in Spanish: Laringectomía y Total y el nuevo virus corona: Sugerencias para la protección.

Message from Nu Voice ( University of Southern California)  Los Angeles.

                                                                           Wearing a modified face mask over the stoma

Protection using Provox Micron, N95 face mask and protective glasses. 

Adequate hospital care of laryngectomees

Neck breathers are at a high risk of receiving inadequate care when hospitalized. The medical staff is often not aware of their condition, do not know how to care for their airways, and may not know how to communicate with them. 

The COVID-19 pandemic created greater workload for hospital staff and may make it difficult to pay attention to laryngectomee’s special needs. Because most hospital limit or prohibit the presence of patients’ companions, making it more difficult for laryngectomees to communicate with the staff. It is therefore important to take certain steps to ensure that the care is adequate:

1. Inform the ward’s head nurse and attending physician about the laryngectomee’s general and specific needs. In case of elective admission, this can be done prior to the admission to allow the staff time to get ready and to get adequate supplies and equipment.

2. Inform the ward’s head nurse, attending physician and anesthetist (when undergoing a procedure with sedation or surgery) about the proper way of administrating anesthesia, suctioning, ventilating and intubation.   Show them the video in YouTube:  https://goo.gl/Unstch  Show them the video in YouTube:  https://goo.gl/Unstch (See video below). The video is available in DVD from Atos Medical. 

The National Patient Safety Project has developed an algorithm for emergency management of patients with laryngectomy. 

Rescue breathing for laryngctomees

DVD of Rescue breathing for laryngctomees

3. Inform the dietitian about the food requirements of the laryngectomee.

4. Inform and, when possible, meet with the hospital’s speech and language pathologist to ensure adequate care and availability of adequate supplies.

5. Laryngectomees who experience swallowing difficulties should request that the orally administered medications be given in liquid or easy to swallow form.

6. Request specific supplies and equipment to ensure adequate respiratory care, such as saline bullets, humidifier, and suction machine.

7. Keep reminding every staff member caring for the laryngectomee about his or her condition. This can be done by the patient and/or advocate.

8. Inform the head nurse; attending physician, and/or patient’s hospital advocate if medical care is not adequate or if errors are made.

9. Request that signs informing the staff about the laryngectomee are placed in the patient’s room.

10. Wear the hospital patient ID wristband on the same hand that identifies them as neck breathers. (See below) Because staff is required to continuously check the patient ID wristband, they will be reminded of the condition.

11. Make sure that the laryngectomee is able to communicate with staff. Those using tracheoesophageal speech may need to use alternative speech methods such as an electrolarynx and/or communicate through writing and speech generating devices, i.e., laptop, smartphone, etc.

12. Preparing a kit with essential information and material when going to the hospital

• The kit should contain the following:
• An updated and current summary of the medical and surgical history, allergies and diagnoses
• An updated list of the medications taken and the results of all procedures, radiological examinations, scans and laboratory tests. These may be placed on a disc or USB flash drive
• Contact information and proof of medical insurance
• Information (phone, email, address) of the laryngectomee’s physician(s), speech and language pathologist, family members and friend(s)
• A figure or drawing of a side view of the neck that explains the anatomy of the laryngectomee's upper airways and if relevant where the voice prosthesis is located
• A paper pad and pen
•  An electrolarynx with extra batteries (even for those using a voice prosthesis)
•  A box of paper tissues
• A supply of saline bullets, HME filters, HME housing, and supplies needed to apply and remove them (e.g., alcohol, Remove, Skin Tag, glue) and to clean the voice prosthesis (brush, flushing bulb)
• Tweezers, mirror, flash light (with extra batteries)

COVID-19 testing in laryngectomees

Two kinds of tests are available for COVID-19: viral tests and antibody tests.

• A viral test tells if someone has a current infection. It is obtained by collecting a nasopharyngeal specimen (e.g., nasal, oropharyngeal) with a swab.  Neck breathers should be tested in two locations: by collecting a nasopharyngeal specimen as well as a stomal specimen. Click to see the American Academy of Otolaryngology recommendations. 
• An antibody test is obtained by getting a blood sample. It tells if a person had a previous infection.

Those whose viral test is positive and are sick or take care of someone need to take protective steps.

A negative viral test result only means that the person tested did not have COVID-19 at the time of testing. If the viral test is positive or negative for COVID-19, the person tested still should take preventive measures to protect themselves and others.

An antibody test may not be able to show if a person has a current infection, because it can take 1-3 weeks after infection to make antibodies. Currently it is not know if having antibodies to the virus can protect someone from getting infected with the virus again, or how long that protection might last.

CDC has guidance for who should be tested, but decisions about testing are made by state and local health departments or healthcare providers.

Diagnostic swabbing for COVID-19

Facemasks, N95 respirator and face covers for neck breathers

It is recommended that neck breathers including laryngectomees cover their stoma (even when using an HME) and nose and mouth with two surgical masks or respirator (stoma only), and if these are not available with a soft (cloth) cover.

If worn properly, a surgical mask can help block large-particle droplets, splashes, sprays or splatter that may contain germs (viruses and bacteria). Facemasks may also help reduce exposure of the wearer’s respiratory secretions to others.

While a surgical mask may be effective in blocking splashes and large-particle droplets, it does not filter or block very small particles in the air that may be transmitted by coughs, and sneezes. It is important to note that the use of an N95 respirator and face shield may not be 100% effective at preventing COVID-19 transmission. Two recent meta-analyses; by Smith et al., and Long et al, failed to demonstrate the superiority of N95 respirators over standard surgical masks in preventing influenza.

An N95 respirator (the "N" means Not effective against oily materials, the "95" means 95% of non-oily airborne particles are filtered out, and the "respirator" means a device that protects against inhalation of hazardous particles) works by providing both a physical and an electrostatic barrier to incoming droplets carrying SARS-CoV-2 virus particles. They are 95% effective at filtering out particles larger than 0.3 microns. Although the virus particles themselves are smaller than 0.2 microns, they are carried by much larger droplets of water, mucus, and saliva. Because the pores in the respirators are about 1 micron in size, the electrostatic component of filtration is very important in providing protection.

The outer layer of the N95 mask is made of fluid-resistant material to keep moisture from coming in, and the inner layer is made of synthetic fabric. When washed with soap and water, an it loses much of its efficiency. UV light and H₂O₂ fumes as well as warm, moist heat destroy the viruses without damaging the synthetic fabric and may permit reuse without diminishing efficiency.

If a respirator is reused, great care should be taken in removing the mask without touching its surfaces and thus contaminating it. Careful fitting is required. Mask testing is done by spraying saccharine on its surface; if you can inhale and taste the saccharine, the mask doesn't meet standards. If one can smell the onions, garlic, or alcohol on someone's breath, he/she are too close, 6 feet or not.

     Current evidence suggests that it is harder to transmit the COVID-19 via a soft surface such as fabric masks or cloth (survives up to 24 hours) than on hard surfaces such as doorknobs, elevator buttons, table tops, silverware, drinking glasses, etc  were it can survive for 3-4 days. However, fabric masks and cloth can be laundered in hot water from someone with COVID-19 along with that of the rest of the family, as the temperature is high enough to destroy the virus.

Watch a video explaining the way N95 mask works  

https://www.youtube.com/watch?v=eAdanPfQdCA

     

N95 respirator

Beard or facial hair interfere with face mask's efficacy against COVID-19

The CDC recommends wearing face covering (e.g., face mask, respirator) in public settings where other social distancing measures are difficult to maintain (e.g., grocery stores and pharmacies), especially in areas of significant community-based transmission. Although neck breathers (laryngectomee and those with tracheostomy) breathe through their stoma, it is recommended that they wear a facemask in addition to covering their stoma with a modified mask or HME.

Ensuring the face mask seal is a vital part of respiratory protection practices. Facial hair that lies along the sealing area of a respirator, such as beards, sideburns, or some mustaches, will interfere with respirators that rely on a tight face piece seal to achieve maximum protection. Gases, vapors, and virus particles in the air will take the path of least resistance and bypass the part of the respirator that captures or filters hazards out. This can allow the COVID-19 virus access to the respiratory tract.

It is therefore recommended that all individuals including neck breathers remove their facial hair prior to wearing a mask.  Shaving may be challenging for those who had radical neck dissection because of their facial numbness. Using an electrical shavers allows safe removal of the hair without injuring the skin. 

Guidelines for head and neck cancer care during COVID-19 pandemic

Neck breathers (including laryngectomees) infected with COVID-19 carry a high risk of transmitting the virus to other individuals by aerosolizing tracheal secretions to their environment.  Infection control strategies specific to patients with laryngectomy should be adhered whenever they are cared for.

Personal protective equipment (PPE) should be adequately utilized, and only necessary medical providers should be in the treatment or patient’s room.  Patients should always be presumed positive with COVID-19, until proven otherwise. It is recommended that whenever they care for a laryngectomee medical providers wear a N95 respirator and face shield or a powered air‐purifying respirator (PAPR), a disposable surgical cap, gown, gloves, and shoe covers when evaluating a laryngectomee with unknown, suspected, or positive COVID‐19 status.  Standard PPE, as defined by the OccupationalHealth and Safety Administration (OSHA), can be used for COVID‐19‐negative patients. 

It is recommended to defer nasopharyngoscopy and tracheoscopy if possible as these are high risk aerosol generating procedures.  When performing flexible tracheoscopy, attempts should be made to minimize mucosal stimulation and resultant coughing.

A special article just published by DrGivi and colleagues in JAMA Otolaryngology-Head & Neck Surgery, presented guidelines for head and neck physical examination and surgical and non-surgical procedures during the coronavirus (COVID-19) pandemic.

Because head and neck examinations are considered high risk in patients with suspected or confirmed COVID-19, the authors developed recommendations for health care workers based on review of the literature and communication with physicians with firsthand knowledge of safety procedures during the COVID-19 pandemic.

The guidelines state that:

• Non urgent appointments should be postponed to limit infection of patients or health care workers. This may include postponing appointments for patients with benign disease and for those undergoing routine surveillance after treatment for head and neck cancer.
• Patients should be queried by telephone about new or concerning signs or symptoms that may indicate recurrence and/or pending issues, as well as symptoms suggestive of COVID-19.
• In-person clinic visits should be offered to those at risk for significant negative outcomes without evaluation.
• Maintaining relationships with patients and support assessments that can be made without in-person examinations. The use of telephone, video, or telemedicine visits should be considered.
• In-person examinations should be limited to patients who need a thorough head and neck examination ( e.g. postoperative visits, tracheoesophageal prosthesis complications, symptoms concerning for cancer recurrence, etc.).
  Detailed guidelines are provided for physical examinations and associated procedures.

It is expected that following carefully planned routines and procedures, will enable providing adequate care and help protect the safety and health of health providers and patients.

It is helpful to have a plan in place in case one becomes sick. Identifying a caregiver and staying in touch with family, friends, neighbors, and healthcare professionals during the pandemic through email or phone, especially if some lives alone is important. If one is aware of an exposure or are experiencing symptoms such as a sore throat, dry cough, fever, and/or shortness of breath, seek medical help as soon as possible. Trying to contact one’s care team over the phone before coming into a medical center can facilitate their care.

To read the Guidelines click this link. https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2764032


Hennessy et al. present their special considerations and best practice recommendations in the management of total laryngectomy patients. They also presented their recommendations for laryngectomy patients and how to minimizing community exposures. 

Endoscopic examination by an otolaryngologist

Coping with COVID-19 pandemic as head and neck cancer patient

Navigating the COVID-19 crisis: Resources for Patients, Survivors and Caregivers

By The Head and Neck Cancer Alliance (modified)

The global COVID-19 pandemic is particularly stressful for those undergoing treatment for head and neck cancer, their caretakers, and cancer survivors. Because of the increasing numbers of patients with COVID-19 infections, many health systems adopted strategies to provide sound care for non COVID-19 patients while reducing the risk of infection transmission to patients and medical personal. Additional considerations include the limited availability of operating rooms and inpatient beds, and the scarcity of personal protective equipment needed to provide safe and hygienic conditions.

Below is a brief outline of some of the changes in near future.

People undergoing active treatment (especially chemotherapy) are at increased risk of getting an infection. it is very important that they and those in close contact withe them,  follow the CDC and local government instruction:

• Washing hands with soap and water frequently, for 20 seconds, including wrists.
• If unable to wash hands, using hand sanitizer and rubbing them for 20 seconds.
• Disinfecting commonly used surfaces such as tabletops, doorknobs, and phones.
• Avoiding direct contact with others such as hugging or shaking hands, and staying at least 6 feet away from other people.
• Avoiding being in large groups of 6 or more people, especially when in an enclosed space.
• Avoiding sharing cups or utensils with others.
• Covering the mouth or stoma during a cough or sneeze.
• Wearing a face mask and protective glasses when at risk of exposure to the virus
• Avoiding contact with anyone with a known COVID-19 infection or individuals with a cough and/or fever.
• Avoiding air travel or other public transportation.
• Notifying their doctor immediately when feeling sick (develop a cough, fever, muscle aches, or other symptoms) or if after having contact with anyone with a known or suspected COVID-19 infection. It may be necessary to be evaluated and potentially tested for the virus.

Patients who have finished therapy are seen regularly to monitor for cancer recurrence and also to address any of their treatments side effects. In the current crisis, these visits are typically not urgent and may increase the risk of exposure to COVID-19 to both survivors and physicians. As a result, many hospitals are postponing non-urgent surgeries, routine follow-up visits and imaging tests (such as CT and PET/CT scans) to minimize the risk of transmission and to conserve health care resources that may be in limited supply. However, if a patient experiences concerning new signs or symptoms for cancer ( e.g., worsening mouth or throat pain, changes in one’s voice or swallowing, a spot in the mouth that has not healed in 2 weeks, unexplained ear pain, new lump in your neck) he/she should inform their doctor as they may still need to be seen.

While social distancing, isolation, and quarantine at home are effective in reducing the incidence of COVID-19, they do increase health risks from other causes. Social isolation among older adults is associated with heightened risk of cardiovascular, autoimmune, neurocognitive, and mental health problems. It is therefore important that individuals do not neglect their medical problems during the pandemic.

Some institutions are offering virtual clinic visits (Telemedicine) interactions with medical providers by way of a video conference call) in an effort to reduce exposure of both patients and health care staff. While virtual visits and telemedicine will never completely replace in-person interactions, in times of crisis, they can provide an effective means to maintain a patient-doctor relationship, allowing them to engage in a directed conversation about disease-specific symptoms and concerns, and to discuss future plans of care. Virtual visits can be very important for head and neck cancer survivors, as they reduce individual patient exposure in clinics and hospitals, and minimize the risk to other cancer patients with compromised immune systems, as well as health care providers and staff. Survivors and caregivers should be reassured that these encounters are a sound approach to cancer surveillance and can allow providers to identify patients who may require an in-person visit.

Other general considerations:

• Maintaining close communication with family/loved ones and health care team
• Having a sufficient supply (at least a 2-week supply) of easy to preserve food items, prescriptions and cleaning supplies and other essentials. 
• Contacting one’s physician to ensure one has adequate access to prescription medications, and necessary supplies (e.g., tube feedings, tracheostomy supplies and personal protective equipment)

Neck breathers ( Laryngectomees and those with tracheostomy) are likely at higher risk of becoming infected with COVID-19 due to the increased exposure of their airway. These individuals should observe special precautions (Click for precautions).