The importance of head and neck counselling in the COVID-19 era.

Dear Editor,

We truly appreciated the editorial entitled “Surgical management of head and neck tumours during the SARS-CoV (COVID-19) pandemic” [1] presenting an effective action plan of an Ear, Nose and Throat (ENT) regional cancer hub during the COVID-19 pandemic. Given the fragility of patients affected by head and neck cancer together with the importance for otolaryngologists to work in a safe environment, we found the strategy described in the present editorial highly recommended during these unprecedented times. Although the Puglia region has not been hit as severely as others in northern Italy such as Lombardy, COVID-19 has led to a profound reorganisation of the activities carried out by the head and neck departments that were forced to suspend all elective clinical activities and surgeries [2]. In our region, the National Institute of Health (ISS) ordered that all scheduled follow-up visits of non-urgent patients affected by head-neck cancer should be postponed, and that “virtual” clinics should be organised according to the guidelines of the Canadian Association of Head & Neck Surgical Oncology (CAHNSO) [3]. Virtual follow-up visits and telephone counselling allow monitoring patients and establish “in-person” visits for a restricted number of patients. This was the case for patients with poor prognosis due to the advanced status of their cancers, patients who developed new or alarming symptoms, such as dysphonia, dyspnoea and dysphagia, and the occurrence of new lesions that needed to be investigated through endoscopic examination and/or biopsy confirmation. The scheduling of “in-person” visits rarely depended on the preferences of the patient.

According to the Sunnybrook Health Center experience, a centralised database was created in order to contact and monitor patients, while four experienced head and neck surgeons rotated every four-weeks from March 15 to May 15, 2020, in order to guarantee at least monthly phone consultation. Through the implementation of the plan, the surgeons guaranteed prompt assistance even to patients who were quarantined or hospitalised for COVID-19, always respecting formal regulations, correct use of personal protective equipment (PPE) and social distancing [4].

The protocol was adopted by the most important departments of Otolaryngology specialised in head and neck surgery of our region (Foggia, San Giovanni Rotondo, Barletta, Bari “Aldo Moro”, Bari “Di Venere”, Brindisi, Tricase).

A group of 340 patients who underwent head and neck surgical procedures from 2001 to 2020 were considered potentially eligible for counselling and, therefore, included. Eighty-three patients (24.4%) did not answer and, after two attempts to reach them by phone, were therefore excluded. A total of 257 patients (75.6%) were contacted by phone (221 males, 36 females; mean age 70.59 ± 12.76). Of this group, 168 patients (65.4%) underwent total laryngectomy, 35 partial laryngectomy (13.6%) and 54 other types of surgery (21.0%). Mean follow-up time from surgery was 5 years.

During the first phone call, patients were invited to answer a simple questionnaire aimed at assessing the current condition of their disease and the eventual presence of new symptoms. Additionally, they were questioned about suspected COVID-19 symptoms [5]; key questions concerned family history of SARS-CoV-2 infection (reverse transcription polymerase chain reaction [RT-PCR] confirmed cases), body temperature check, occurrence or worsening of suspected symptoms in the last 30 days, such as cough, dyspnoea, fatigue, myalgia, cephalalgia and smell and taste alterations. Patients were invited to rate their symptoms by using a 0-5 scale, where 0 indicated ‘no problem’ and 5 a ‘very intense problem’. Results of the counselling are presented in Table I.

Table I.

Results of the counselling conducted by the Apulian working group in patients affected by head and neck cancer.

	Number of patients(%)	Severity of symptoms(± SD) *
Family history of COVID-19(RT-PCR confirmed cases)	1 (0.4%)	N/A
Body temperature (≥ 38°)	5 (2.0%)	N/A
Cough	154 (60%)	1.5 (± 1.4)
Dyspnoea	66 (25.7%)	0.4 (± 0.7)
Fatigue	56 (21.8%)	0.3 (± 0.7)
Myalgia	54 (21.0%)	0.3 (± 0.7)
Cephalalgia	39 (15.2%)	0.2 (± 0.6)
Smell/taste impairment (worsening)	101 (39.3%)	0.7 (± 1.2)

* Patients were invited to rate their symptoms by using a 0-5 scale, where 0 indicated ‘no problem’ and 5 a ‘very intense problem’. N/A: not applicable; RT-PCR: reverse transcription polymerase chain reaction.

Answers were analysed in cooperation with the section of Hygiene of the Department of Medical and Surgical Science of Foggia University Hospital. When patients gave a score ³ 2 to more than 2 questions, they were considered as suspect and invited to contact their family physician. Through this phone counselling, 11 patients (4.3%) were considered at risk of SARS-CoV-2 infection and underwent a nasopharyngeal swab; one tested positive and was immediately hospitalised at the COVID-19 regional reference hub “Miulli”.

Regarding oncological status, 7 patients (2.7%) were considered as suspect and in-person ENT visits and radiological examinations were consequently scheduled; out of this group, four subjects (1.5%) were disease free. Three patients who underwent parotidectomy referred the onset of a cervical swelling and one had a disease relapse confirmed by ultrasound and computed tomography (CT) of the head and neck. Another patient who underwent transoral robotic supraglottic laryngectomy had a disease relapse and was submitted to the regional referral centre for electrochemotherapy and immunotherapy. Finally, three patients who underwent laser cordectomy for glottic carcinoma reported positive margins; two of these were scheduled for open supraglottic laryngectomy, while another received radiotherapy.

The decision to monitor these patients with such attention was given by their fragility [6]. In fact, patients affected by head and neck cancer are at high risk of COVID-19 and related complications because of immunodeficiency, the high prevalence of risk factors and treatments such as chemotherapy/radiotherapy [7]. This is particularly evident in elderly patients affected by head and neck cancer who tend to be more susceptible to severe complications of SARS-CoV-2 infection [8].

COVID-19 will probably change the management of head and neck cancer patients by implementing systems of telehealth and online/phone consultations. Even though patients suffering from COVID-19 and other urgent and emergent conditions have been considered as a priority during the current pandemic, it is extremely important to not overlook oncologic patients [9]. Our experience confirms the importance of head and neck counselling, especially in this new COVID-19 era that has just begun.