10.14639/0392-100X-suppl.1-42-2022-07
Objective. The Coronavirus disease 2019 (COVID-19) pandemic has posed significant problems for patients who have undergone total laryngectomy (TL). The lack of specif- ic guidelines and paucity of information available to the public on this topic has clearly emerged during the ongoing pandemic. The aim of the present study is to investigate our personal experience in managing the stoma in TL patients during the COVID-19 pandemic. Methods. A questionnaire was administered by phone to laryngectomised patients who had previously been seen at the outpatient otolaryngology clinics of Vittorio Veneto and Barletta Hospitals from January to December 2020.Results. A total of 92 patients were included. Twenty-five patients (27%) had been tested for SARS-CoV-2. Among these, 19 (76%) had been investigated with a nasal swab, 5 (20%) with a tracheal swab and 1 with a serological assay. Five patients were positive for SARS- CoV-2 (in 4 cases as a result of the nasal swab, in one case with the bronchial aspirate). Eighty-four patients (91%) used a heat moisture exchanger over the stoma every day, but 6 patients (6.5%) were unaware of the importance of protecting the stoma.Conclusions. We conclude that TL patients should always be adequately informed by healthcare staff about how to manage their stoma. Specific guidelines are needed for testing TL patients for SARS-CoV-2.
text/xml
1827-675X
2111
en
Michele Barbara
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
larynx
Fragility and contagiousness of the total laryngectomy patient in the COVID-19 pandemic
Text.Serial.Journal
https://www.actaitalica.it/
42
Annual congress report
2022-04-26
2022-04-06
2022-04-28
2022-04-28
S68-S72
1
Michele Barbara
2022/04/26
10.14639/0392-100X-suppl.1-42-2022-07
S68
UOC Otorhinolaryngology Head and Neck Surgery, Ospedale Mons. R. Dimiccoli, ASL BAT, Barletta, Italy
1827-675X
larynx
S72
Fragility and contagiousness of the total laryngectomy patient in the COVID-19 pandemic
https://www.actaitalica.it/article/download/2111/774
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42(SUPPL.1):S68-S72; doi: 10.14639/0392-100X-suppl.1-42-2022-07




Fragility and contagiousness of the total laryngectomy
patient in the COVID-19 pandemic
Peculiarità (fragilità e contagiosità) del paziente con laringectomia totale
nella pandemia da COVID-19
Andy Bertolin1, Marco Lionello1, Valentina de Robertis2, Francesco Barbara3, Francesco Cariti2, Michele Barbara2
1
 UOC Otorhinolaryngology, Ospedale Vittorio Veneto, AULSS 2 Marca Trevigiana, Treviso, Italy; 2 UOC Otorhinolaryngology Head
and Neck Surgery, Ospedale Mons. R. Dimiccoli, ASL BAT, Barletta, Italy; 3 UOC Otorhinolaryngology Head and Neck Surgery,
Ospedale Di Venere, ASL BA, Bari, Italy


SUMMARY
Objective. The Coronavirus disease 2019 (COVID-19) pandemic has posed significant
problems for patients who have undergone total laryngectomy (TL). The lack of specif-
ic guidelines and paucity of information available to the public on this topic has clearly
emerged during the ongoing pandemic. The aim of the present study is to investigate our
personal experience in managing the stoma in TL patients during the COVID-19 pandemic.
Methods. A questionnaire was administered by phone to laryngectomised patients who had
previously been seen at the outpatient otolaryngology clinics of Vittorio Veneto and Barletta
Hospitals from January to December 2020.
Results. A total of 92 patients were included. Twenty-five patients (27%) had been tested
for SARS-CoV-2. Among these, 19 (76%) had been investigated with a nasal swab, 5 (20%)
with a tracheal swab and 1 with a serological assay. Five patients were positive for SARS-
CoV-2 (in 4 cases as a result of the nasal swab, in one case with the bronchial aspirate).
Eighty-four patients (91%) used a heat moisture exchanger over the stoma every day, but 6
patients (6.5%) were unaware of the importance of protecting the stoma.
Conclusions. We conclude that TL patients should always be adequately informed by
healthcare staff about how to manage their stoma. Specific guidelines are needed for testing
TL patients for SARS-CoV-2.
KEY WORDS: COVID-19, SARS-CoV-2, otolaryngology, laryngectomy, larynx                           Received: January 31, 2022
                                                                                                Accepted: February 7, 2022

RIASSUNTO                                                                                       Correspondence
Obiettivi. La pandemia da COVID-19 (COVID-19) ha posto alcuni problemi significativi            Andy Bertolin
ai pazienti sottoposti a laringectomia totale (TL). La mancanza di linee guida specifiche e     UOC Otorhinolaryngology, Ospedale Vittorio Vene-
la scarsità di informazioni a disposizione del pubblico su questo argomento sono chiara-        to, AULSS 2 Marca Trevigiana, via C. Forlanini 71,
mente emerse durante la pandemia in corso. Lo scopo del presente studio è stato quello di       31029 Vittorio Veneto (TV), Italy
indagare l’esperienza personale dei nostri pazienti sottoposti a TL nella gestione della loro   Tel. + 39 0438 665231
stomia durante la pandemia da COVID-19.                                                         E-mail: andy.bertolin@aulss2.veneto.it
Metodi. Un questionario è stato somministrato telefonicamente ai pazienti laringectomiz-
zati che erano stati precedentemente visitati presso gli ambulatori otorinolaringoiatrici         How to cite this article: Bertolin A, Lionello M,
degli ospedali di Vittorio Veneto e Barletta da gennaio a dicembre 2020.                          de Robertis V, et al. Fragility and contagiousness
Risultati. L’indagine ha riguardato in tutto 92 pazienti. Venticinque pazienti (27%) erano        of the total laryngectomy patient in the
stati testati per COVID-19. Tra questi, 19 (76%) erano stati studiati con tampone nasale, 5       COVID-19 pandemic. Acta Otorhinolaryngol
(20%) con un tampone tracheale e 1 con un test sierologico. Cinque pazienti sono risultati        Ital 2022;42(SUPPL.1):S68-S72. https://doi.
positivi al COVID-19 (con tampone nasale in 4 casi, su aspirato bronchiale in 1). Ottan-          org/10.14639/0392-100X-suppl.1-42-2022-07
taquattro pazienti (91%) utilizzavano ogni giorno un filtro scambiatore di calore e umidità
al davanti dello stoma, mentre 6 pazienti (6,5%) non erano consapevoli dell’importanza di       © Società Italiana di Otorinolaringoiatria
                                                                                                e Chirurgia Cervico-Facciale
proteggere lo stoma.
Conclusioni. In conclusione, si può affermare che i pazienti con TL dovrebbero sempre
                                                                                                               OPEN ACCESS
essere adeguatamente informati dal personale sanitario su come gestire la propria stomia.
Sono necessarie linee guida specifiche per testare i pazienti TL durante la pandemia da         This is an open access article distributed in accordance with
COVID-19.                                                                                       the CC-BY-NC-ND (Creative Commons Attribution-Non-
                                                                                                Commercial-NoDerivatives 4.0 International) license. The
PAROLE CHIAVE: COVID-19, SARS-CoV-2, otorinolaringoiatria, laringectomia, laringe               article can be used by giving appropriate credit and mentio-
                                                                                                ning the license, but only for non-commercial purposes and
                                                                                                only in the original version. For further information: https://
                                                                                                creativecommons.org/licenses/by-nc-nd/4.0/deed.en




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                                                                                     Total laryngectomy patients in the COVID-19 pandemic




Introduction                                                     sis, or replace it in the event of a malfunction. Sixty-five of
                                                                 these patients came from other Italian regions. Ninety-two
Early in 2020, the World Health Organization described a
                                                                 (81 males and 11 females; mean age 69.2 ± 9.7 years, me-
new coronavirus related severe acute respiratory syndrome
                                                                 dian 71 years, range 47-88 years) agreed to answer the ques-
caused by severe acute respiratory syndrome coronavirus 2
                                                                 tionnaire shown in Table I and were included in the present
(SARS-CoV-2) 1. The pathogenetic agent is a coronavirus,
                                                                 investigation. The questionnaire was administered by phone
and the disease it causes, Coronavirus disease 2019 (COV-
                                                                 by the same otolaryngologists (ML and VdR) to all partici-
ID-19) – first reported in Wuhan (Hubei Province, China)
in December 2019 – spread rapidly across the globe 2,3. Italy    pants, whose answers were recorded anonymously.
was the first European country to have documented cases,
and by May 1st, 2020, it already had 204,576 confirmed           Results
cases and 26,049 deaths according to the Istituto Superiore
di Sanità 4. To contain the viral contagion, the Italian gov-
                                                                 COVID-19 tests
ernment adopted extraordinary measures that culminated
                                                                 Twenty-five of the 92 patients (27%) had been tested for
on March 9th, 2020 with a nationwide lockdown to restrict
                                                                 SARS-CoV-2. The reasons for testing were due to specific
people’s movements.
                                                                 symptoms in 9 cases; to close contact with people who had
The most common initial symptoms of COVID-19 infec-
                                                                 tested positive in 7 cases; because they had to start chemo-
tion were cough, fever, fatigue, increased mucus produc-
                                                                 therapy in 3 cases; 2 patients were scheduled to be hospi-
tion, dyspnoea, sore throat and myalgia 5. People who had
                                                                 talised for cardiological treatment; 1 had to be tested be-
undergone total laryngectomy (TL) were considered at
higher risk of poor outcomes in the event of contracting         fore resuming work; and the remaining 3 underwent testing
COVID-19 because of their history of cancer and likely           by their own initiative. Nineteen patients (76%) had been
medical comorbidities. Such patients commonly have               tested with a nasal swab, 5 (20%) with a tracheal swab (1 of
chronic lung disease, peripheral vascular disease, cardiac       these 5 patients had both a nasal and a tracheal swab) and 1
disease, cerebrovascular disease, diabetes and a propensity      had undergone a serological test (before returning to work).
for atelectasis due to loss of upper airway resistance 6. Fur-   Five patients (20%) tested positive for SARS-CoV-2. A
ther aggravating factors might include a history of smok-
ing, and impaired mucociliary function due to inhalation of
                                                                 Table I. COVID-19 questionnaire for TL patients.
cold, dry air through the stoma 7.
                                                                  1. How long do you generally use a heat moisture exchanger (HME)?
The COVID-19 pandemic has brought to light the lack of
                                                                      a. < 3 hours a day
specific guidelines and paucity of information available
regarding people who have undergone TL. We found that                 b. 3-6 hours a day
numerous patients arrived at our outpatient’s clinic wearing          c. > 6 hours a day
face masks but insufficient protection over their tracheosto-     2. Have you had a positive test for SARS-CoV-2?
my. Several reported having been submitted to nasal swabs         3. What kind of test did you have?
because tracheal swabs were not envisaged by COVID-19                 a. Nasal/tracheal rapid antigen detection test
diagnostic protocols at the time. Some patients also com-             b. Nasal/tracheal molecular test
plained of the difficulties and/or delays they experienced in         c. Serological test
accessing hospital facilities.                                    4. Would it bother you to get a swab on your tracheostoma?
The aim of the present study was to investigate our TL pa-        5. Have you been in close contact with people who tested positive for
tients’ personal experience with managing their stoma dur-            SARS-CoV-2?
ing the COVID-19 pandemic.                                            a. If so, did you use any kind of airway protection?
                                                                  6. Do you wear a face mask outside the home?
Methods                                                           7. Are you aware or have you been told that you need to protect your
                                                                      tracheostoma?
From January to December 2020, 129 people who had                 8. Have you had flu symptoms since the beginning of the COVID-19
undergone TL in previous years at institutions of Vittorio            pandemic?
Veneto Hospital – Center for Laryngeal Cancer Diagnosis           9. Do you consider yourself at higher risk of contracting COVID-19 than
and Treatment in the Veneto region of north-east Italy, and           non-TL people?
UOC Otorhinolaryngology Head and Neck Surgery – Os-               10. Have you been advised to take more precautions than non-TL people?
pedale Mons. R. Dimiccoli of Barletta, came to our outpa-         11. Have you encountered difficulties or delays in accessing the hospital
tient clinics for follow-up and to check their voice prosthe-         during the COVID-19 pandemic?




                                                                                                                                       S69
A. Bertolin et al.




nasal swab was positive in 4 cases (three complained of                             because of their TL, and another 3 because they were
symptoms). The fifth patient, a 77-year-old male, had                               receiving chemotherapy. Thirteen patients (14%) reported
a negative nasal swab but was hospitalised with severe                              feeling at higher risk of contracting COVID-19 due to their
symptoms compatible with COVID-19, and the virus                                    laryngectomised condition. All had been advised by family
was detected on bronchial aspirates. The patient received                           members to take particular care. One of these patients
appropriate treatment and recovered after two weeks.                                reported specific symptoms, but tested negative on both
                                                                                    nasal and tracheal swab.
Personal experiences of TL patients                                                 When asked about their experiences of accessing hospital
When asked about their personal experience of COVID-19                              facilities during the pandemic, 12 (13%) patients complained
testing, 88 patients answered that they would agree to a                            about delays, which were always due to difficulties with
tracheal swab, while 4 said they would refuse it. Seven                             arranging transport to the hospital.
patients reported having been in close contact with people
who tested positive for the virus while they were wearing
                                                                                    Discussion
their heat moisture exchanger (HME). None subsequently
tested positive for SARS-CoV-2 (on nasal swabs in 2 cases,                          The COVID-19 pandemic has posed some significant
and both a nasal and a tracheal swab in one).                                       problems for TL patients related not only to their higher
Eight patients complained of flu symptoms starting in                               risk of contagion 6,7, but also to the lack of specific
February 2020, with fever in all cases, and cough in 6. Four                        guidelines on the management of their stoma and the
of the latter had a positive swab, and one was hospitalised                         difficulty of reaching hospital facilities during periods of
for COVID-19.                                                                       lockdown (Tab. II).
Concerning their personal habits, 84 patients (91%)                                 Nasopharyngeal swab is acknowledged as the gold
reported using a conventional HME daily, while 4 used                               standard for testing people for SARS-CoV-2 infection 8.
a specific antivirus filter. Five patients used the HME (or                         The best approach for testing laryngectomised patients
antivirus filter) for less than 3 hours a day, 10 used it for 3                     for the virus is a matter of debate, however. These patients
to 6 hours a day and 72 used it for more than 6 hours a day.                        have no significant airflow through the nasal cavity and
All patients reported wearing face masks. Ninety patients                           nasopharynx, making a nasopharyngeal swab seem
used a form of protection for their stoma (the HME in 84                            nonsensical. That said, it has been demonstrated that TL
cases, while 6 patients who found the HME uncomfortable                             patients can still develop sinonasal disease 9. Loss of the
used a scarf). Two patients said they did not usually protect                       nose’s filtering function also raises the risk of inhaling
the stoma. All but 6 patients were aware of the importance                          pathogens and developing respiratory infections 10.
of protecting the stoma.                                                            In our sample of TL patients, 25 were tested for SARS-CoV-2,
Forty-eight patients were advised to take greater precautions                       but a tracheal swab was only used for 5 (20%), while only


Table II. Total laryngectomy patients in COVID-19 pandemic. Fragilities and contagiousness: the highlights.
                                                   Total laryngectomy patient in COVID-19 pandemics
                                   Fragilities                                                                    Contagiousness
  The definitive tracheostomy represents an element of fragility, as the nasal     Isolation of the elderly laryngectomised patient may be difficult to be managed
                                filter is missing                                                                        at home
 The average age of laryngectomized patients is at greatest risk of developing       The tracheostomy generates a greater aerosol load in comparison to normal
     serious complications in case of SARS-CoV-2 infection, due to their                                  respiration through the upper airway
                                 comorbidities
      The pulmonary status of laryngectomised patients is often already             The aerosolisation of tracheal secretions leads to a high risk of transmitting
      compromised due to smoking-related chronic pulmonary disease                                  viral droplets to members of the community

   The state of immunodeficiency, possibly related to the need for adjuvant        The high viral load present in the upper aerodigestive tract determines a high
   chemotherapy, is a risk factor for developing serious complications from                 transmission hazard for the physician and health care staff
                                      COVID-19
 Hospitalisation in the medical area in case of nosocomial infection can lead to     The frequent manipulation of the tracheostoma leads to a higher risk of
           difficulties in postoperative management and rehabilitation                                         contact transmission
         Greater difficulties may arise in pulmonary rehabilitation of the           The use of HMEs and covers over the stoma can help limit exposure and
               laryngectomised patient, after COVID-19 pneumonia                                transmission risk related to this patient population




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                                                                                    Total laryngectomy patients in the COVID-19 pandemic




nasal mucosa was sampled in most cases. All the patients           and 5 (20%) were positive. Most of our patients reported
tested with nasal swabs alone reported that tracheostomal          having been very cautious during the COVID-19 pandem-
swabs were not mentioned in the guidelines adopted at their        ic. They avoided crowded places and did not meet people
hospital. For the 5 TL patients who tested positive for SARS-      from outside the family. This behaviour was prompted part-
CoV-2, diagnosis was established on a nasal swab in 4 cases,       ly by their having undergone TL, but was mainly due to the
while three developed specific COVID-19 symptoms. This             awareness of belonging to the age group at highest risk of
might reasonably mean that nasal swabs are not inappropriate       serious consequences if they contracted the infection.
in the TL patient. There is some evidence in the literature        All the patients in our sample reported being rather anxious
to suggest that, although the upper airways are functionally       about the risk of contagion when attending hospital facilities.
separate from the lungs after TL, the finding of SARS-CoV-         Their concern is justified by evidence in the literature of the
2in nasopharyngeal swabs could indicate haematogenous              risk of infection being higher in hospital environments than
dissemination from a primary lung infection 11. On the other       in the community 19. Those of our patients who reported feel-
hand, in our patient who developed COVID-19, diagnosis             ing at higher risk of contracting COVID-19 (52%) had been
was obtained by testing bronchial aspirates, while a nasal         advised by their family to take special precautions. This evi-
swab was negative. This would point to the main viral load         dence would suggest a role for family members in contribut-
primarily affecting the lungs via the stoma.                       ing to their anxiety. On the other hand, all the patients who
There are published studies demonstrating that the two re-         complained of having difficulty managing their stoma (13%)
ceptors required for SARS-CoV-2 infection are co-expressed         said the problems were mainly related to delays in arranging
in type II pneumocytes, ileal enterocytes and nasal epithe-        travel to our hospital facility due to the lockdown.
lial cells 12. The type of local immune response in the nasal      Several authors agree in spreading the following rules to
mucosa may drive the systemic cytokine response, and the           protect laryngectomees from contagion 20:
priming of lung immunity 13,14. On the other hand, as the pri-     • to be wearing an HME, especially when around other people;
mary respiratory flow in TL patients is via their stoma, the       • protect the stoma with a filter and prevent direct con-
trachea and lungs would be additional sites of direct inocula-        tact of fingers to the tracheostoma 21. Moreover, there
tion. During the severe acute respiratory syndrome (SARS)             are commercially available specific antiviral filters that
outbreak of 2003, high concentrations of viral RNA were               allow a filtration rate > 99.9%, also suitable for COV-
detected in intratracheal aspirates, indicating that the virus        ID-19 positive laryngectomies 22:
can also replicate in tracheal secretions 15. For TL patients it   • for people using trachea-oesophageal speech, hands-free
is therefore important to consider testing for SARS-CoV-2 in          HME is available; such a device does not require touch-
tracheal aspirates as well as in the nasal cavities 7.                ing while speaking. When it is not available, use a non-
In suspected cases of COVID-19 with negative nasal swabs,             dominant hand for stoma occlusion 23;
samples of sputum, endotracheal aspirates and bronchoalveolar      • to be wearing a surgical mask (preferably an N95 respi-
lavage should be collected and sent directly to the microbiol-        rator) over the stoma and an additional surgical mask or
ogy laboratory for processing, as they may reveal the virus with      respirator over the nose and mouth, along with protec-
a greater sensitivity than upper respiratory tract specimens 16.      tive glasses or a face guard;
In responding to our telephone questionnaire, 84 of the            • wash hands often with soap and water for at least 20 sec-
patients in our sample reported using the HME every day.              onds. Use an alcohol-based hand sanitiser that contains at
Unfortunately, only 4 patients had obtained a specific anti-          least 60% alcohol if soap and water are not available. This is
virus filter. To minimise the spread of aerosolised particles         especially important before managing the stoma and touch-
to and from TL patients, their tracheostoma should be cov-            ing the HME when using trachea-oesophageal speech 24.
ered with an HME, preferably with integrated viral/bacte-
rial hydroscopic filters 17. These devices, available from
many commercial suppliers, are effective in reducing the
                                                                   Conclusions
incidence of tracheobronchial infections in TL patients 18.        The COVID-19 pandemic has posed significant problems
A physical barrier over the stoma, such as a surgical mask,        for TL patients. It is important to ensure they always receive
scarf, or shirt could also be considered. However, 6 patients      adequate information from healthcare staff about the man-
(6.5%) reported being unaware of the importance of pro-            agement of their stoma in this situation. Specific guidelines
tecting the stoma, which indicates that they had been inad-        are also needed for testing TL patients for SARS-CoV-2.
equately informed by healthcare staff.
When we examined SARS-CoV-2 tests performed in our                 Conflict of interest statement
sample of TL patients, only 25 patients (27%) were tested,         The authors declare no conflict of interest.



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A. Bertolin et al.




Funding                                                                      10
                                                                                  Parrilla C, Minni A, Bogaartd H, et al. Pulmonary rehabilitation after
                                                                                  total laryngectomy: a multicenter time-series clinical trial evaluating
This research received no specific grant from any funding                         the Provox XtraHME in HME-naive patients. Ann Otol Rhinol Laryn-
agency in the public, commercial, or not-for-profit sectors.                      gol 2015;124:706-713. https://doi.org/10.1177/0003489415579219
                                                                             11
                                                                                  Gallo O, Trotta M, Orlando P, et al. SARS-CoV-2 in upper and lower air-
Authors’ contributions                                                            way samples of a TL patient: new insights and many lessons. Oral Oncol
                                                                                  2020;107:104841. https://doi.org/10.1016/j.oraloncology.2020.104841
AB, FB, FC and MB: study concept, supervision and revi-                      12
                                                                                  Ziegler C, Allon SJ, Nyquist SK, et al. SARS-CoV-2 receptor ACE2 is
sion; ML and VdR: study concept, questionnaire admin-                             an interferon-stimulated gene in human airway epithelial cells and is
istration, data collection and processing, drafting of the                        enriched in specific subsets across tissues. Cell 2020;181:1016-1035.
manuscript.                                                                       e19. https://doi.org/10.1016/j.cell.2020.04.035
                                                                             13
                                                                                  Togias A. Rhinitis and asthma: evidence for respiratory system in-
                                                                                  tegration. J Allergy Clin Immunol 2013;111:1171-1183. https://doi.
Availability of data and materials                                                org/10.1067/mai.2003.1592
The datasets used and/or analyzed during the current study are               14
                                                                                  Hua X, Vijay R, Channappanavar R, et al. Nasal priming by a murine
available from the corresponding author on reasonable request.                    coronavirus provides protective immunity against lethal heterologous
                                                                                  virus pneumonia. JCI Insight 2018;3:e99025. https://doi.org/10.1172/
                                                                                  jci.insight.99025
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