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.