unit during COVID-19 pandemic in a head andneck diseases and emergent non-infectiousdiseases Different management between emergentinfectious INFECTIOUS DISEASES

brazjinfectdis2020;24(5):475–477

w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Letter

to

the

editor

Different

management

between

emergent

infectious

diseases

and

emergent

non-infectious

diseases

during

COVID-19

pandemic

in

a

head

and

neck

unit

Yuh

Baba

_,

_Satoshi

_Takada

_,

_Hiroshi

_Segawa

_,

_Yasumasa

_Kato

a_{OhuUniversity,DentalHospital,DepartmentofOtorhinolaryngologyKoriyamaCity,Fukushima,Japan}

b_{OhuUniversity,DentalHospital,DepartmentofOralandMaxillofacialSurgery,KoriyamaCity,Fukushima,Japan} c_{OhuUniversity,DepartmentofDentalPracticeAdministration,KoriyamaCity,Fukushima,Japan}

d_{OhuUniversity,DepartmentofOralFunctionandMolecularBiology,KoriyamaCity,Fukushima,Japan}

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t

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Articlehistory:

Received29June2020

Accepted23July2020

Availableonline8August2020

DearEditor,

InDecember2019,theoutbreakofcoronavirusdisease2019

(COVID-19) infection, which is caused bythe severe acute

respiratorysyndromecoronavirus2(SARS-CoV-2)virus,was

reportedinWuhan,China.1_{DuringCOVID-19pandemic,the}

type of patients receiving treatment in a head and neck

surgery unit differs from it before the pandemic.2 _While

patients with cleft lip and plate, chronic sinusitis, benign

tumors, and so on are recommended to defer the

opera-tion,emergentpatientswithmandibularfracture,malignant

tumors,and severe acute infectious diseases suchas

peri-tonsillarabscess,acute supraglottitis, andacute deep neck

infectionmustreceiveemergentconservativeorsurgical

man-agementevenduringCOVID-19pandemic.ByMarch18,2020,

∗ _{Correspondingauthorat:DepartmentofOtorhinolaryngology,OhuUniversityDentalHospital,31-1MisumidoTomita-machi,Koriyama}

City,Fukushima963-8611,Japan.

E-mailaddress:y-baba@den.ohu-u.ac.jp(Y.Baba).

wemanagedemergentpatientsusingthealgorithmforthe

outbreaksasindicatedbyYanget al.2 _{Namely,accordingto}

the algorithm, whenclinical symptomsor chest computed

tomography(CT)asriskassessmentisnormal,theyreceive

routine treatment, and if clinical manifestations continue

to be suspected of COVID-19, they are transferred to

des-ignated hospital forinfectious diseases in order toreceive

bothreversetranscription-polymerasechainreactiontestto

detect SARS-CoV-2 infection (the SARS-CoV-2 RT-PCR test)

andfurthermanagement.Whenclinicalsymptomsorchest

CT is suspected of COVID-19, they are directly transferred

to designated hospital.However,even whenwe follow the

abovealgorithm,wemightexperiencenosocomialinfection

causedbyCOVID-19asindicatedbyYanget al.2_Therefore,

weneededtore-considermanagementofemergentpatients

duringCOVID-19pandemic.

https://doi.org/10.1016/j.bjid.2020.07.007

1413-8670/©2020SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC

476

Severe acute infectious disease suspected patients

Is there a high risk of upper airway obstructio?

Is there the formation of abscess?

No

No Yes

Yes

Drainage ± tracheostomy wearing high level of PPE in a negative pressure operation room

COVID-19 PCR -Blood test

Enhanced CT from neck to chest Flexible laryngoscopy

± Tracheostomy wearing high level of PPE in a negative pressure operation room

COVID-19 PCR negative COVID-19 PCR positive COVID-19 PCR positive

Infectious ward Antibiotics/steroid treatment

in the general ward

Infectious ward

Fig.1–DiagnosticandtreatmentalgorithmofemergentinfectiousdiseasesduringCOVID-19pandemicinaheadandneck unit.

Problemsforthemanagementofthepatientsaccordingto

theabovealgorithmbyYanget al.were asfollows.Atfirst,

we may misdiagnose asymptomatic patients with

COVID-19orpatientswithCOVID-19whosechestCTisnormal.In

addition, because of the similarities of clinical symptoms

betweensevereacuteinfectious diseaseswiththe

possibil-ityofupperairwayobstructionandCOVID-19regardingfever

anddyspnea,itishardtodifferentiatewhetherthepatient

suffered from only severe acuteinfectious disease or both

severeacuteinfectiousdiseaseandCOVID-19onadmission.

Thus,wecannotusethealgorithmwhichrecommendsthe

SARS-CoV-2RT-PCRtestonlyforsuspectedCOVID-19patients

onthebasisofclinicalmanifestationsofCOVID-19and

epi-demiologicalhistoryforpatientswithsevereacuteinfectious

disease,asindicatedbyLuetal.3Ontheotherhand,wecan

follow the algorithm as indicated byLu et al. forpatients

with non-infectious diseases such as mandibular fracture

andmalignanttumors.Third,someemergentpatientsmust

receive emergent operationwithout knowingthe status of

SARS-CoV-2 infection. Therefore, head and neck surgeons

mustperformtheemergentoperationwearinghighlevelof

personalprotectiveequipment (PPE) inanegativepressure

operationroom.Moreover,healthcareworkers(HCWs)must

manage the patients with unknown status ofSARS-CoV-2

infectionwearinghighlevelofPPEintheisolationwardafter

emergentoperation,whiletheshortageofPPEisremarkable

aroundtheworld.4_{Fourth,itisunclearwhetherpatientswith}

unknownstatusofCOVID-19withsevereacuteinfectious

dis-easealsocomplicatedwithupperairwaystenosisowingto

laryngealedemacanbegivensystematicsteroid,becausethey

mightbeimmunocompromisedwhentheyaregiven

system-aticsteroid.

Inordertoovercometheaboveproblems,wemanagethe

patientswithemergentinfectiousdiseasesusingnew

algo-rithmsinceMarch19,2020asindicatedinFig.1.Namely,on

emergentadmission,patientssuspectedofsevereacute

infec-tiousdiseaseperformSARS-CoV-2RT-PCRtestinadditionto

routinebloodtest,enhancedCTfromnecktochest,and

flex-iblelaryngoscopy.Usingthisstrategy,thereislesspossibility

thatthepatientswithsevereacuteinfectiousdiseasemight

alsoinvolvepatientswithSARS-CoV-2infection.Patientswith

severeacuteinfectiousdiseaseandCOVID-19whosechestCT

isnormalcanbedifferentiatedfromemergentpatients

suffer-ingfromsevereacuteinfectiousdiseaseotherthanCOVID-19.

Furthermore,shortageofPPEmaybeovercometoacertain

degree.IntheSARS-CoV-2RT-PCRnegativecase,HCWsdonot

needtowearhigh levelofPPEafterRT-PCRresult.

Further-more,COVID-19negativepatientsalsowithlaryngealedema

canbegivensystemicsteroid.

Inconclusion,weinsistthatRT-PCRtestforSARS-CoV-2on

admissionisessentialforemergentpatientswithsevereacute

infectious disease inordertopreventnosocomial infection

andcollapseofthemedicalcaresystemduringCOVID-19

pan-demic. Differentmanagementbetweenemergentinfectious

disease and emergent non-infectious disease is important

whilethe SARS-CoV-2RT-PCRtestdoesnotbecomewidely

available.UptoJune29,2020,nonosocomialinfection had

occurred atourhospitalunderthismanagement.Thus,we

areconvincedthatouralgorithmwillbeusefulforthe

preven-tionofnosocomialinfectionalsoinBrazilwhichisoneofthe

brazj infect dis.2020;24(5):475–477

477

Ofcourse,ideallyallpatientsadmittedtohospitalshouldhave

aSARS-CoV-2RT-PCRtestperformedtopreventoverlooking

asymptomatic patientswith COVID-19asit becomes more

widelyavailable.

Conflict

of

interest

Theauthorsdeclarenoconflictsofinterest.

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2.YangY,SohHY,CaiZG,PengX,ZhangY,GuoCB.Experienceof diagnosingandmanagingpatientsinoralmaxillofacial

surgeryduringthepreventionandcontrolperiodofthenew coronaviruspneumonia.ChinJDentRes.2020;23:57–62.

3.LuD,WangH,YuR,YangH,ZhaoY.Integratedinfection controlstrategytominimizenosocomialinfectionof coronavirusdisease2019amongENThealthcareworkers.J HospInfect.2020;104:454–5.

4.O’SullivanED.PPEguidanceforCovid-19:behonestabout resourceshortages.BMJ.2020;369:m1507.

5.CimermanS,ChebaboA,CunhaCAD,Rodríguez-MoralesAJ. DeepimpactofCOVID-19inthehealthcareofLatinAmerica: thecaseofBrazil.BrazJInfectDis.2020;24:93–5.