RESULTS
In the study period, 52 patients were scheduled for surgery, of which 45 (86.5%) were “high risk” procedures for SARS-CoV-2 transmission. Forty patients (76.9%) had mucosal pathology (e.g., malignant neoplasm, infection, inflammation); 37 patients (71.1%) carried current diagnoses of head and neck cancer, including mucosal and cutaneous malignancies. Ten patients (19.2%) had a prior history of radiation to the head and neck. There was no significant difference in the makeup of the groups with and without discrepant results with regard to mucosal pathology, current cancer diagnoses, or history of radiation (Table 2).
Forty-three (82.7%) patients had at least two preoperative tests performed. A total of 102 tests were performed: 52 (51.0%) were for the first preoperative test, and 43 (42.2%) were the second preoperative test, when applicable. An additional seven tests were performed beyond the two initial tests: 2 were for patients with 2 previously negative tests, due to unrelated surgical delays; the remaining 5 were for patients with conflicting results on the first two tests.
Of the 43 patients with more than one preoperative test, four patients (9.3%) had discrepant results on the first two tests, with the clinical implications for each discussed below (Table 3). One of these patients left against medical advice and thus his true disease status is unknown. For the remaining three out of forty-two patients (7.1%), repeat RT-PCR testing was negative. They remained asymptomatic from COVID-19 official symptomatology,20 and chest radiographs were clear without signs of interstitial pneumonia. For two of these patients, positive tests were re-reviewed by clinical pathologists, and tests were found to have achieved positivity with titers that were borderline, just over the cutoff values. All three of these patients were discussed by multi-disciplinary teams including infectious disease specialists, otolaryngologists, intensivists, pulmonologists, and pathologists, which ultimately concluded that the positive test were false positives. Assuming this determination is correct, and using prior and subsequent negative RT-PCR, chest imaging and close follow up of clinical course as the “gold standard” in the absence of a true gold standard test, the calculated specificity of this test in asymptomatic patients in the preoperative setting is 0.97.
Patient #1 – Late-March : A 60-year-old male with buccal squamous cell carcinoma required composite oral cavity resection, neck dissection, and free flap reconstruction. At the time of this patient’s surgery, testing turnaround was at least 3 days. Four days prior to scheduled surgery, the patient had a negative RT-PCR drawn as an outpatient. On the morning of surgery, a second RT-PCR was drawn due to a policy change requiring two tests before surgery. A positive result was reported on postoperative day (POD) 3. Chest computed tomography (CT) with contrast was normal. He was moved to a designated COVID-19 ward. A repeat RT-PCR was performed on POD 4 with a negative result reported on POD 5, and the patient was transferred out the designated ward. During that time, he remained asymptomatic with 2 normal chest radiographs.6
Over the next month he developed no symptoms to suggest COVID-19 and repeat a CT chest was negative.
Patient #2 – Mid-April: An 81-year-old female was transferred for recurrent aspiration pneumonia. She had originally been treated for oropharyngeal squamous cell carcinoma by definitive chemoradiation, followed by salvage pharyngectomy and tongue base resection with neck dissection, and radial forearm free flap reconstruction. Her postoperative course after discharge had been complicated by a nonfunctional larynx and recurrent aspiration pneumonias, with multiple admissions to outside hospitals over several months. On her current admission to an outside facility, the decision was made for transfer to our hospital for narrow-field laryngectomy and pectoralis major flap as treatment for recurrent aspiration. Prior to transfer, she had two negative COVID-19 RT-PCR tests, and an additional negative test on the day of arrival (hospital day 1) with plans for surgery on hospital day 3. On hospital day 2, a second RT-PCR was performed per departmental protocol, and the result was positive. A third RT-PCR on the morning of hospital day 3 was negative, however surgery was cancelled due to discrepant results. Three additional tests were drawn between hospital days 3 and 7, which were all negative. Multiple chest CTs were stable or improved, although abnormal given her underlying history of recurrent aspiration pneumonia over 6 months. Discussion with our clinical pathologists revealed that the positive test was based on weakly positive titers. Given the multiple repeat negative tests, this was deemed a false positive, and surgery was performed on hospital day 7. As a result of the positive test, surgery was delayed 4 days while the patient remained an inpatient.
Patient #3 – Mid-to-late April: 63-year-old female with melanoma of the cheek requiring wide local excision and sentinel lymph node biopsy. Four days prior to scheduled surgery, an outpatient RT-PCR was done and resulted positive. Immediate discussion with pathology colleagues revealed a weakly positive titer, just above the level necessary to be considered positive. The positive test had been conducted at the affiliated institution, and the negative test was at her primary hospital. One option discussed was to delay surgery for three weeks anticipating possible development of COVID-19 symptoms. However, with a negative CT chest for metastatic workup in the days before surgery, the decision was to repeat two additional RT-PCR tests. These were performed the following day and were both negative. The patient was completely asymptomatic. Surgery proceeded with a three-day delay. The process was quite stressful for the patient, whose surgery was already delayed by several weeks due to the pandemic, and the reconstructive plastic surgery team had to reschedule other surgeries to accommodate the new schedule. Over the next three weeks she developed no symptoms of any type, and repeat CT chest was normal.
Patient #4 – Early April: 20-year-old male with bilateral pansinusitis complicated by unilateral orbital abscess and progressive vision impairment with diffusely restricted extraocular movements and an intraocular pressure of 41 mmHg. He was transferred from an outside hospital without any testing or chest radiographs. On the day of arrival, hospital day 1, RT-PCR was performed and was negative. Intravenous antibiotics were instituted, and surgery was planned for hospital day 4 to allow for preoperative COVID-19 testing. Since sinus surgery was considered a high-risk procedure for SARS-CoV-2 transmission, a second RT-PCR was performed according to protocol and unfortunately was positive. The patient remained asymptomatic other than symptoms attributed to sinusitis and orbital abscess. Due to the positive finding, surgery was delayed for further testing, and he was transferred to a designated COVID-19 ward. Patient was uneasy about being on this ward, and subsequently left against medical advice without surgery on hospital day 5, refusing further workup. In telemedicine follow-up three weeks later, he reported never having coronavirus-associated symptoms; however, without additional workup his true disease status is unknown. He has therefore been excluded from statistical calculations related to the test. The patient reported that his infection improved on oral antibiotics, and visual changes normalized.