General considerations
·         Ideally, where testing is readily and rapidly available, SARS-CoV-2 testing should be performed on all patients with mucosal lesions prior to HNS evaluation, and/or, at the least, 1 day prior to the planned surgery.
·         Selected patients may be closely observed allowing for deferral/rescheduling of surgery.
·         Significant functional loss or life-threatening disease requires immediate attention.
·         Telemedicine is an essential tool in several medical fields during these times and has been recommended to be used when deemed appropriate by the American Academy of Otolaryngology-Head and Neck Surgery8.
·         At our institution, as a general guideline for scheduling, cases are deferred when performed for prophylactic intent, benign diseases, conditions unlikely to be adversely affected by an 8-12-week surgical delay, or for conditions which have available and appropriate alternative therapies.
·         In-depth discussion and review is performed when patients have a severely depressed performance status, high comorbidity burden and/or advanced age, or when surgical cases may require significant blood transfusion (>4 units), ICU care, or a prolonged hospitalization is anticipated.
·         While multi-modality input is sought after pre-operatively for patients requiring multi-modality therapy, we suggest deferring all head and neck radiation and medical oncology consultations to when needed to minimize exposure risks, unless neoadjuvant treatment is considered.
·         Flexible naso-pharyngo-laryngoscopies are limited to when medically necessary. When performed, they are recorded by the healthcare provider for shared review to eliminate duplicate exposure risk.
SARS-CoV-2 Positive
No resection until viral resolution unless significant functional threat or life-threatening situation as patients testing positive are associated with a high rate of mortality in the post-operative period9
o   Powered air-purifying respirator (PAPR) equipment required for all involved in the case
o   Minimize nonessential personnel in the operating room (trainees, advanced practice providers, visitors, etc.)
 
SARS-CoV-2 Negative
Patient must pass symptom screening and appropriate testing completed 1 day prior to intended surgery date
 
Disease Subsites
Oral Cavity (high risk for viral aerosolization)
         o   Premalignant disease
                    ·              Defer with telemedicine visits
                    ·              Review clinical photographs to help rule out invasive cancer missed by biopsy
                       o   Early malignant disease 
                     ·             Consider short-term deferral with weekly telemedicine visits10
                    ·              Proceed with primary surgery
                    ·              Continue to monitor while stable; proceed to surgery if primary progresses or if there is any evidence of cervical node involvement
          o   Intermediate malignant disease
                    ·              Proceed with primary surgery
          o   Advanced malignant disease
                    ·              Consider neoadjuvant systemic therapy (discussion on a case-by-case basis –                                 consider the risk of immunosuppression)
 Oropharynx (high risk for viral aerosolization)
HPV status should be identified. As recommended by Topf et al., if necessary, HPV-negative patients should be prioritized11.
o   Early disease
                       §         Consider short-term deferral with weekly telemedicine visits 
                        §         Favor non-surgical treatment
                        §         Consider surgical treatment if high likelihood of single modality treatment,                                depending on the experience of the surgical team and institutional resources
  o   Intermediate disease
                        §      Consider deferral with weekly telemedicine visits
                        §      Favor non-surgical treatment
  o   Advanced disease
·                                             Proceed with non-surgical treatment
 
Larynx/Hypopharynx (high risk for viral aerosolization)