key: cord-0894282-pakm9oia
authors: Ota, Ichiro; Asada, Yukinori
title: The impact of preoperative screening system on head and neck cancer surgery during the COVID-19 pandemic: Recommendations from the nationwide survey in Japan
date: 2020-05-16
journal: Auris Nasus Larynx
DOI: 10.1016/j.anl.2020.05.006
sha: c2445d40e0d7a8042d196c4f71b2e1da602d6719
doc_id: 894282
cord_uid: pakm9oia

OBJECTIVE: the pandemic of coronavirus disease 2019 (COVID-19), hospitals worldwide are at risk of nosocomial infection. Preoperative identification of COVID-19 in patients who are scheduled to be admitted to the hospital is essential to preventing the collapse of medical facility. In Japan, the preoperative observation and screening tests with the RT-PCR testing for the new coronavirus (SARS-CoV-2) and chest CT scan are recommended for head and neck cancer surgery during the COVID-19 pandemic. METHOD: We conducted surveys of the current situation in Japan through the internet. RESULTS: Chest CT scan was fully performed (90%), but the RT-PCR testing was not adequately performed (51%). CONCLUSION: Although the current screening system can be considered effective to a certain extent, we recommend further widespread use of pre-admission RT-PCR testing not only for patients with head and neck cancer surgery but also for all the hospitalized patients, in order to promote safer treatments, during the COVID-19 pandemic.

The outbreak of coronavirus disease 2019 (COVID-19) be-2 gan in Wuhan, China, in December 2019, and has since spread 3 exponentially, resulting in a worldwide outbreak. On January 4 30, 2020, the World Health Organization (WHO) declared 5 COVID-19 a public health emergency of international con- 6 cern [1] , and on March 11, the WHO declared COVID-19 7 to be a pandemic [2] . Given the high risk of exposure and 8 infection from aerosol and droplet contamination of the new 9 coronavirus (SARS-CoV-2), the current COVID-19 pandemic 10 presents a significant occupational hazard for physicians and 11 other health care workers who perform and participate in ex-12 * Corresponding author.

E-mail address: iota@naramed-u.ac.jp (I. Ota).

aminations and procedures within the head and neck region 13 and airway [3] [4] [5] [6] [7] [8] [9] [10] [11] . 14 During the COVID-19 pandemic, full personal protective 15 equipment (full PPE: N95 respirator and face shield or pow-16 ered air-purifying respirator, disposable cap and gown, gloves) 17 is required for any otolaryngology patient with unknown, 18 suspected, or positive COVID-19 status. Elective procedures 19 should be postponed indefinitely, and clinical practice should 20 be limited to patients with urgent or emergent needs, such 21 as tracheotomy [3 , 10 , 12] This is because the preoperative observation and screening 37 tests, including RT-PCR testing and chest CT scan, are con-38 sidered essential to preventing perioperative cluster infection 39 of SARS-CoV-2 in the perioperative period and to avoiding 40 wastage of medical resources. 41 In addition, there have been some reports on guidelines 42 for the management of patients with COVID-19, but few re-43 ports have evaluated the preoperative screening with RT-PCR 44 testing and chest CT scan [3] [4] [5] [6] [7] [8] [9] [10] [11] . Therefore, we conducted 45 questionnaire surveys of head and neck cancer specialists in 46 Japan, to determine whether the preoperative screening system 47 for head and neck cancer surgery is widespread and utilized. 48 

The questionnaires ( Cancer Group, such as university hospitals and regional can-53 cer centers in Japan through the internet: Survey #1 on Apr 54 17, 2020, Survey #2 on Apr 24, 2020. The total number of 55 respondents was 38. The regional distribution is shown in 56 Fig. 1 .   57 

The results of the surveys ( Table 3 ) are presented as fol-59 lows: 60 "Q1. Do you perform the surgery in accordance with 61 the Guide to Treating Patients with Head and Neck Tumors 62 (2020/04/07 edition)?" 63 In the survey #1, the guide had already penetrated 64 many facilities (79%), and in the survey #2, most facili-65 ties (92%) have adopted it. These data suggest that the im-66 portance of this guide has been well recognized throughout 67 many head and neck cancer specialists in Japan, since the 68 introduction. 69 "Q2. Do you perform the preoperative RT-PCR testing?" 70 Although the adoption rate of RT-PCR testing had in-71 creased from 38% to 51%, it had not yet been fully imple-72 mented. This may be due to the low capacity of the RT-PCR 73 testing in each institution and the delay in the introduction 74 the RT-PCR testing at the administrative level in Japan. As a 75 result, the number of RT-PCR testing that can be performed 76 as a preoperative test could be limited in Japan. 77 "Q3. Do you perform the preoperative chest CT scan?" 78 The chest CT scan had already been performed in many 79 facilities since the survey #1. 80 This could reflect the current situation in Japan, where 81 the preoperative RT-PCR testing is difficult to introduce at 82 Table 2 The questionnaires about preoperative direction and screening tests for COVID-19. Q1. Do you perform the surgery in accordance with the Guide to Treating Patients with Head and Neck Tumors (2020/04/07 edition)? Q2. Do you perform the preoperative RT-PCR testing? Q3. Do you perform the preoperative chest CT scan? Q4. Do you ask your patients to stay at home for two weeks before surgery? Q5. Does your hospital offer the same preoperative screening system in other departments as your department? Q6. Do you think RT-PCR testing is necessary as the preoperative screening test? (at Survey #2 only) the survey #1, nevertheless chest CT scan is not always 83 recommended as a preoperative test for COVID-19 in low-84 prevalence ( < 10%) countries [11 , 13] . screening system in other departments as your department?" 94 In Japan, there was sufficient penetration in the department 95 of otolaryngology, but hospital-wide recognition of such pro-96 cedures is still inadequate. Leaving this situation untreated is 97 dangerous and will not only lead to the depletion of medical 98 resources, but may also lead to the withdrawal of medical 99 personnel and the collapse of medical care. Table 3 The results of questionnaires.

The result of questionnaire #6. Q3 ( Fig. 2 ) . On the other hand, the fact that some physicians do 107 not feel the need to do so may reflect regional differences in 108 the prevalence of COVID-19 in Japan. 109 

The RT-PCR testing has been deemed the "gold standard" 111 for clinical diagnosis of COVID-19 but takes hours to per-112 form and requires specialized reagents, equipment, and train-113 ing [14] . In a recent meta-analysis, the pooled sensitivity of 114 RT-PCR was 89% (95% CI: 81%, 94%). In low-prevalence 115 ( < 10%) countries, the positive predictive value of RT-PCR 116 ranged from 47.3% to 84.3% [13] . Thus, the RT-PCR testing 117 is not perfect as a screening test. On the other hand, chest 118 CT scan for the primary screening or diagnosis of COVID-19 119 would not be beneficial in a low-prevalence region due to the 120 substantial rate of false-positives [11 , 13] . 121 This screening system in Japan is a flexible guide that com-122 bines observation of clinical symptoms, including 2 weeks of 123 staying at home, with chest CT scan and takes into account 124 the inability to perform the RT-PCR testing. 125 Consequently, this screening system can help us to pre-126 vent intraoperative infection even without the RT-PCR testing, 127 which could lead to the depletion of medical resources, such 128 as full PPE. Thus, it is best to perform the RT-PCR testing 129 as frequently as possible.

isothermal amplification (RT-LAMP) method, has been 145 rapidly developed all over the world [14] . We hope that these 146 methods will be introduced as soon as possible. 147 On the other hand, COVID-19 IgM/IgG Rapid Test has not 148 yet been recommended for triage of patients with suspected 149 COVID-19 [16] . If the accuracy is improved in the future, it 150 will be valuable as a preoperative test. 151 Finally, we would like to recommend that during the 

ANL [mNS

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