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BAHNO laryngectomy guidance during COVID-19 pandemic

 

Proposed guidance for laryngectomy surgery during the COVID-19 pandemic

Issued: 24 March 2020

To: UK head and neck multidisciplinary teams

 

BAHNO recognises that the management of many patients with cancer will have to be modified and sometimes delayed during the current COVID-19 crisis.  One particular group that will cause management dilemmas are those patients with advanced and potentially-airway obstructing laryngeal and hypopharyngeal cancers.

 

Emergency airway management

  • We refer members to the recent ENT UK tracheostomy guidance

https://www.entuk.org/tracheostomy-guidance-during-covid-19-pandemic

  • Tracheostomy is preferable to debulking procedures given the potential for high-volume aerosol contamination.

 

Choice of treatment

  • As with all head and neck cancers during this crisis patients planned for curative treatment should be prioritised according to need, availability of alternative treatment options and potential for cure
  • The laryngectomy procedure itself and all patients who are laryngectomised are significantly aerosol-generating.  Therefore avoid performing a laryngectomy unless deemed absolutely necessary
  • Many patients with advanced cancers will be suitable for radiotherapy. Of the proportion who recur locally some will be suitable for salvage laryngectomy at a time when the current COVID-19 situation has improved
  • Surgery should be avoided in patients with advanced disease and a poor overall chance of survival.

 

The laryngectomy / laryngectomy-pharyngectomy procedure

  • COVID-19 testing must be performed before a tracheostomy and certainly before laryngectomy is performed. Two tests over an interval period would provide more definitive results
  • Do not perform a laryngectomy in a COVID-19 positive patient.  Intubate or perform a tracheostomy to alleviate airway obstruction and wait for the patient to become COVID-19 negative before further definitive treatment
  • All patients should be managed peri-operatively on the assumption that they may be COVID-19 infected - full PPE and FFP3 respirators are necessary for all theatre staff
  • Avoid a primary tracheoesophageal puncture to reduce the associated risks in the immediate and short-term recovery period. A secondary TEP can be performed at a later date
  • Avoid microvascular free flaps where possible
  • For patients requiring pharyngeo-laryngectomy avoid a circumferential resection which will allow for pedicled flaps such as pectoralis major or SCAP flaps
  • Consider, when primary pharyngeal closure is possible, an augmentation myofascial flap in cases at higher risk of fistula.

 

Cyrus Kerawala

President BAHNO