Evaluation of the Head and Neck Surgery During the Pandemic COVID-19: A Tertiary Care Center Study

ABSTRACT

Introduction:

There is a notable shift in the attitude of the admission, review, diagnostics, and follow-up of patients for all the medical sectors and of particular interest of cancer patients. The present study aimed to elaborate on the identification of patients with head and neck cancers (HNCs); the diagnostics, the triage, and the best treatment plan were all evaluated and at the same time compared with the years before the pandemic at a tertiary care center that caters to various other patients also.

Materials and Methods:

A retrospective observational clinical study was conducted at the tertiary care center that catered to all the medical specialties. The demographics, the patient characteristics, the surgeries performed, complications, mortality, and readmissions were evaluated and compared with the pre-coronavirus disease (COVID) time.

Results:

There was a significant difference in the complications for the pre-COVID time when the groups were compared for the matched pair.

Conclusion:

The proper screening and triaging of the patients will help in the early intervention of the patients with the HNCs.

INTRODUCTION

The World Health Organization (WHO) proclaimed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to be a pandemic at the start of the year 2020.[1] The world’s healthcare system has to be completely restructured as a result of the sudden increase in coronavirus disease 2019 (COVID-19) cases. There have been significant negative effects for cancer patients as a result of the state-imposed lockout and the redirection of personnel and resources to the care of COVID-19 patients who are severely ill.[2] There is a notable shift in the attitude of the admission, review, diagnostics, and follow-up of patients for all the medical sectors and of particular interest of cancer patients. There is a chance that this will lead to a drop in survival rates, with high-income nations experiencing drops of 5–10%.[2] In India, 30–40% of all cancer cases are head and neck cancers (HNCs).[3] Due to the possibility of aerosol formation during evaluation and treatment, patients and healthcare professionals participating in HNC care confront additional challenges.[4] In the initial stages of the pandemic, the doctors had a lot of disagreement over the best treatment for HNC patients. Over the last two years, the delivery of the best treatment for these patients has been well established.[5-10] In the present study, the aim was to elaborate on the identification of the patients with the HNCs; the diagnostics, the triage, and the best treatment plan were all evaluated and at the same time compared with the years before the pandemic at a tertiary care center that caters to various other patients also.

MATERIAL AND METHODS

A retrospective observational clinical study was conducted at the tertiary care center that catered to all the medical specialties. The study period was between April 2020 and December 2020 for a period of 9 months. The Institutional Ethical Committee granted this retroactive review an exemption from the requirement for ethical clearance. All participants provided their written consent after being fully informed.

Before surgery workup

The patient was evaluated for the symptoms of COVID. Along with that, they were advised reverse transcriptase–polymerase chain reaction (RT-PCR) tests; once the tests were obtained, the patients were grouped as positive and negative. The surgery was postponed for the elective surgeries until they got a negative report. The negative cases were admitted to the surgical wards for the needful. The doctors followed all the precautionary methods like personal protective equipment (PPE) wears and followed quarantine methods.

Workflow for patients and operating rooms

The patients were admitted to the surgical ward for the procedures based on the status of the infection of the virus. They were isolated and evaluated. Once the RT-PCR was available, they were put on a waiting period of 48 h and then again evaluated for COVID symptoms. Once confirmed as negative for COVID, they were operated on routinely. If they were confirmed as positive, they were left to wait for at least 3 weeks before the elective surgery was performed. Once all the symptoms subsided, they were treated with universal precautions followed by the additional wearing of the Personal Protective Training (PPT) suits by all the admitted staff. However, for the emergencies, these steps were skipped and routine emergency protocols were followed in the isolation wards. SARS-Cov-2 RT-PCR deep nasal and oropharyngeal swabs were concurrently obtained. In an operating room designed for COVID, patients had emergency surgery. Personnel working in healthcare must wear level 3 PPE. On diagnosed cases of COVID-19, emergent and semi-emergency surgeries were also carried out in an operating room equipped for COVID while wearing level 3 PPE.

Manage airway and anesthesia

The routine examination for the pre-anesthetic check-up was done for the negative patients. The anesthetists were left to choose the intubation methods. The common methods were either pre-procedural tracheostomy or fiberoptic nasal intubation. The routine procedure was followed at the end of the elective cases who were negative for COVID. On the other hand, for the positive cases, intensive care unit’s (ICU) ventilatory and sedation guidelines were followed throughout the surgery with acute respiratory distress syndrome (ARDS) who needed tracheostomies.

Variables are examined

All patients’ COVID-19 statuses were classed as positive, negative, or unknown. The 11-point modified frailty score (MFI) was used to assess the performance status and comorbidities of patients undergoing major head and neck surgeries.[6] The “Clavien-Dindo score” for post-operative complications,[7] commencement of oral feeds, time required for decannulation, 30-day mortality, 30-day hospital readmission rate, and 30-day hospital readmission rate were used to appraise the perioperative outcomes.

RESULTS

A total of 50 cases were finalized in the study. The subjects were all COVID-negative. The procedures are done after the COVID-19 and the various demographics along with the patient characteristics have been described in Table 1. In the pre-COVID time, the numbers of patients that have been admitted for a similar reason was nearly twice as that of the number of subjects that were admitted after the pandemic for the time period of nine months. As described in Table 1, the majority were in the stages III, IV. Modified frailty score and the Clavien-Dindo (CD) score were also considered and compared in the study with that of the non-COVID time. In the comparison, it was found that there was a significant variation in the study characteristics of the stage of the disease, MFI score, reconstruction, and CD score 3. There was no medical staff nor the patients who reported positive after the procedure during the recovery period and follow-up until three weeks. There was no significant difference in the complication rates.

Table 1.

Pre- and post-covid study characteristics

Characteristics	COVID –ve patients n=50	Before COVID n=100	P
Age	47.0±10.2	47.1±12.5	NS
Men	35	80	NS
Women	15	20
Subsite			NS
Upper respiratory tract	35	90
Others	15	10
Stage			0.01
I,II	10	5
III, IV	40	95
Surgery			NS
Method 1	10	35
Method 2	30	45
Method 3	10	20
MFI Score			<0.001
0	25	85
1	20	10
2	5	5
Reconstruction
Nil	15	75	0.002
Free-Flap	5	10	<0.001
Pedicled	30	15
CD Score
0	30	40	NS
1	2	5	NS
2	10	1	NS
3	3	50	0.002
4	5	4	NS
Complications	2%	11%	NS
Readmissions	1	2	NS

Method 1=Transoral resection with no reconstruction; Method 2=Composite resection with laryngectomy; Method 3=Extramucosal surgery (thyroid/parotid/skin)

In Table 2, the comparisons were done after the two groups of pre- and post-COVID were equalized. For the matched pair, analysis with a retrospective cohort was used. A finding of this comparison was that only the Clavien-Dindo score was the only variable that was significantly different than the COVID patients. All other variables were similar in distribution when both groups were matched.

Table 2.

Pre- and post-covid study characteristics that were matched

Characteristics	COVID –ve patients n=50	Before COVID n=50	P
Age	47.0±10.2	47.1±12.5	NS
Male	25	27
Female	7	5
Subsite			NS
Upper respiratory tract	35	32
Others	15	18
Stage			NS
I,II	10	8
III, IV	40	42
Surgery			NS
Method 1	10	15
Method 2	30	35
Method 3	10	10
MFI Score			NS
Zero	25	25
1	20	20
2	5	5
CD Score
Zero	30	18	0.007
1	2	2
2	10	8
3	2	15
4	5	12

Method 1=Transoral resection with no reconstruction; Method 2=Composite resection with laryngectomy; Method 3=Extramucosal surgery (thyroid/parotid/skin)

DISCUSSION

Many restrictions were imposed on the general public due to the pandemic. The patients who required immediate attention had to suffer under these restrictions. In a country with an inappropriate medical staff and population ratio, attending to elective procedures may be a task to debate about.[11-15] The HNCs may be elective if there is no secondary sepsis and asphyxia. In the present study, the number of patients who attended tertiary care after the pandemic for the treatment of the HNCs and those who normally attended the hospital before the pandemic were compared. The motive was to check for the patient survival as well as the type of surgeries the medical attention was sought for. We also evaluated the change in the procedure for surgeries after the pandemic.

The results showed that there were no mortalities, and no readmissions, the complications were 2% in the pandemic population. The most common procedure was the tracheostomy. The observation made in this study was that there were complications in a greater percentage among the COVID positive patients than the pre-COVID times. This observation is in unison with the study by Werner where he observed that post-operative complications were more in the COVID patients. The findings also pointed to pulmonary complications being the most common. It can be understood that HNC patients might have common etiological factors like tobacco habits, and medical health conditions like immunosuppression, they may also be at risk of infection from these viral strains.[16-20] The elective surgeries have been reported to be postponed for the HNCs. It is established that the treatment should be done within a month after diagnosis. However, if there is a life-threatening risk, then the surgical treatment can be deferred. Nevertheless, this can make the tumor progress by two folds. There may also be a risk of metastasis.[21-25] The pandemic has led to a backlog in the cases. This will put undue pressure on the fast movement of the cases and may hamper the attention of the surgeon. There have been many guidelines put forward to treat patients on how to handle elective cases. In the present study, the only major variation observed for the matched pair patients was with the CD score. This shows a greater complication rate in the post-COVID period. It was evident that normal protocols were not followed after the pandemic.[22-28] This is one of the first studies to evaluate the HNCs in tertiary care centers. Hence, the comparisons were difficult to make. However, the outcomes observed were notable.

The limitation was that the study was retrospective in nature, the study was at a single center, and the population was limited to a specific area. Hence, the findings cannot be generalized to the entire population.

CONCLUSION

Within the limitations, it can be concluded that the complication rates were significantly different before and after the pandemic. There were no other differences in the characters of the population groups. The inclination has been there to defer the elective surgeries. Further studies are encouraged to corroborate the present study’s findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.