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\begin{document}

\title{Head and Neck Oncologic Surgery in the COVID-19 Pandemic: Our Experience
in a Deep South Tertiary Care Center}



\author[1]{Erin Buczek, MD}%
\affil[1]{University of Alabama at Birmingham}%


\vspace{-1em}



  
  \date{May 18, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Introduction

The ongoing worldwide pandemic due to COVID-19 has forced drastic
changes on the daily lives of the global population. This is most
notable within the healthcare sector. The current paper outlines the
response of the head and neck oncologic surgery (HNS) division within
our academic otolaryngology department in the state of Alabama.

Methods

Data with regard to case numbers and types were obtained during the
pandemic and compared with time matched data. Our overall approach to
managing previously scheduled and new cases, personal protective
equipment (PPE) utilization, outpatient clinic, and resident involvement
is summarized.

Discussion

Our HNS division saw a 55\% reduction in surgical volume during the peak
of the COVID-19 pandemic. We feel that an early and cohesive strategy to
triaging surgical cases, PPE usage, and minimizing exposure of personnel
is essential to providing care for HNS patients during this pandemic.%
\end{abstract}%



\sloppy


\textbf{Morrison, Daniel R MD\textsuperscript{1*}, Gentile, Christopher
MD\textsuperscript{1*}, McCammon, Susan MD\textsuperscript{1}, Buczek,
Erin MD\textsuperscript{1}}

\textbf{Department of Otolaryngology, University of Alabama at
Birmingham}

\textbf{*co-first authors}

\textbf{Corresponding Author:}

\textbf{Erin Buczek}

Mailing Address:

Department of Otolaryngology -- Head and Neck Surgery

1720 2\textsuperscript{nd} Avenue S

Birmingham, AL 35294-3412

Email: epartington@uabmc.edu



\textbf{Abstract}

\textbf{Introduction}

The ongoing worldwide pandemic due to COVID-19 has forced drastic
changes on the daily lives of the global population. This is most
notable within the healthcare sector. The current paper outlines the
response of the head and neck oncologic surgery (HNS) division within
our academic otolaryngology department in the state of Alabama.

\textbf{Methods}

Data with regard to case numbers and types were obtained during the
pandemic and compared with time matched data. Our overall approach to
managing previously scheduled and new cases, personal protective
equipment (PPE) utilization, outpatient clinic, and resident involvement
is summarized.

\textbf{Discussion}

Our HNS division saw a 55\% reduction in surgical volume during the peak
of the COVID-19 pandemic. We feel that an early and cohesive strategy to
triaging surgical cases, PPE usage, and minimizing exposure of personnel
is essential to providing care for HNS patients during this pandemic.

\textbf{Introduction}

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known
colloquially as COVID-19, is a novel zoonotic infection that has caused
a worldwide pandemic \textsuperscript{1}. In many parts of the world the
medical system has been severely stressed by the burden of this novel
illness as the demand for medical care exceeds capacity. The illness is
highly contagious and is spread through respiratory droplets. The highly
contagious nature and relatively high mortality compared to other viral
respiratory illnesses has made COVID-19 a ``perfect storm'' for a
pandemic \textsuperscript{2}. Otolaryngologists are at high risk for
transmission of COVID-19 due to the high risk of contact with
aerosolized nasal, pharyngeal, or tracheal secretions during many of our
routine procedures \textsuperscript{3,4}. The first reported physician
death in Wuhan was an otolaryngologist \textsuperscript{5}.

As of April 26, 2020 there were 6,213 confirmed COVID-19 cases in the
state of Alabama (71,334 overall tested) with 213 reported
deaths\textsuperscript{6}. Of all patients tested, 8.7\% were positive.
For comparison, the state of New York, the hardest hit state in the
United States thus far, had 282,143 total cases and 16,599 deaths
(777,568 overall tested) \textsuperscript{7}. 36.3\% of tests given in
NY state have been positive. Our institution is a large, tertiary care
center situated in Birmingham, AL and receives patients from our entire
state as well as portions of neighboring states (TN, MS, GA, FL). This
is in contrast with NY, which has a much larger healthcare system, with
multiple large hospital systems in the city of New York alone. Our
relatively low overall case numbers compared with other regions are due
to a multitude of reasons, including our relatively low population
density, low amount of travel in and out of the state, and testing
limitations. At our institution (University of Alabama-Birmingham), the
number of COVID-19+ inpatients has not exceeded 62. We have had no
documented positive COVID-19 tests among faculty, residents, advanced
practice providers (APPs), or ancillary staff in our otolaryngology
department. A focused timeline of events is shown in Figure 1.

There have been several recent publications focused on the response to
COVID-19 within the otolaryngology community. Currently, the American
Academy of Otolaryngology--Head and Neck Surgery (AAO-HNS) has
recommended delaying all non-emergent operations and postponing all
non-essential face-to-face clinic encounters \textsuperscript{8}.
Consistent with this is the recommendation that all tier 1 and 2
procedures as defined by the Centers for Medicaid and Medicare Services
(CMS) should be deferred during the pandemic \textsuperscript{9,10}.
Early data from the pandemic also showed that cancer patients have
significantly worse outcomes when infected with
COVID-19\textsuperscript{11}. These data are to be interpreted with
caution given possible regional differences in practice patterns with
regard to resource utilization. With this context in mind, the current
paper will retrospectively discuss the approach of the head and neck
surgery (HNS) division of our tertiary care center in Birmingham, AL
with regards to surgical care, outpatient care, and academics.

\textbf{Methods}

Current COVID-19 case numbers were reviewed nationally, statewide, and
institutionally. Surgical volume was analyzed within the affected
timeframe and compared with the year prior. As noted in Figure 1,
hospital administration made the decision on March 17 to move to a
limited OR model. Therefore, we selected March 18 as the starting point
for our analysis and have analyzed up to April 21, 2020. Our approach to
managing clinic outpatients is also reviewed as well as a brief overview
of changes to resident involvement and inpatient management.

\textbf{Approach to Surgery}

Throughout February and early March, our department and hospital
administration were closely monitoring the COVID-19 outbreak, however
there were no changes to clinical operations. On March 16, one HNS case
was cancelled due to blood shortages. UAB administration decided on
March 17 to move to a limited operating room (OR) model, where only 6
ORs were to be opened daily, with 2 additional rooms open as needed for
emergencies. Our freestanding outpatient surgical center was reduced to
3 working ORs with 1 available as needed for emergencies. At this point
all elective cases were postponed indefinitely. For reference, our
institution has 44 total ORs in our main hospital and 16 ORs at our
outpatient center.

The HNS division began meeting virtually at this point to collectively
triage cases. Remote conferences with this goal were held twice weekly
during the limited OR model period. Cases were organized first into
elective versus non-elective cases. Patients requiring non-elective
surgery were defined as having a surgical disease process that will
irreversibly worsen in a way that affects survival or extent of surgical
intervention if surgical intervention were delayed. Elective cases were
postponed indefinitely to be reassessed by each individual surgeon when
conditions allow. Among the non-elective cases, 3 categories were
described and are as follows: cases which should be done within 2 weeks,
cases that should be done within 2-4 weeks, and cases that are
non-elective but can wait \textgreater{}4 weeks. These definitions were
based on the likelihood of significant morbidity or mortality occurring
within the defined time periods. For example, patients with significant
airway concerns such as advanced laryngeal cancers and airway stenosis
were placed in the 2 week category, while most thyroid malignancies were
placed in the \textgreater{}4 week category (Figure 3).

Perioperative leadership including chairs of the surgical departments
met to outline an appropriate triage strategy for operative cases. Per
these institutional guidelines, each case scheduled required department
chairman approval and was subject to review by the Chief of Surgical
Services. This model remains in place. Our division now has a secure
online calendar showing all HNS cases which is accessible by all
faculty. This was used to streamline the chairman approval process.
Figure 2 represents our case numbers during the time period under
investigation. Of the utmost importance in triaging and completing these
cases was a collective willingness in our division to cover cases for
other surgeons in the case of mandated quarantines. Particularly early
in UAB's response to the pandemic, pre-op testing was not available.
During this time, we recognized there were approximately 5-10 patients
that we considered urgent but also very high risk (endoscopic airway for
stenosis, laryngeal carcinomas with airway compromise, etc.). We decided
collectively that we would not perform these urgent but high risk cases
without pre-op COVID testing or if not made available we would utilize
all necessary PPE (see below) to perform these cases. Particularly, we
met with anesthesia and operating room leadership to discuss the
specific logistics of doing these cases. This decisive action led to
early pre-op testing for our high risk patient population and likely
saved the use of needed PPE.

Availability of COVID-19 testing nationwide has been a major issue
during this pandemic. Initially, we were not able to preoperatively test
our surgical patients. During this time, we were avoiding any procedure
that risked exposure to aerosolized procedures such as tracheotomy and
oral cavity cases. On March 28, our first preoperative COVID-19 tests
were performed for planned operations on outpatients. Initially, we had
only the capacity for 10 COVID-19 tests per day. Therefore, anesthesia
staff selected the cases with highest risk exposures for preoperative
testing. These patients were tested within 48 hours of their planned
surgery. By April 6 we had increased our testing capacity and all
surgical patients were tested once preoperatively within 48 hours of
their surgery. All testing was RT-PCR via nasopharyngeal swab. At the
current time, our institution is not using serologic testing to direct
management.

Personal protective equipment (PPE) is paramount in protecting the
surgeon as well as the patients and limiting disease spread. As the
crisis progressed, we began concerted efforts to conserve essential PPE,
most notably N95 respirators, gowns, gloves, and face shields. Although
the data are conflicting regarding efficacy, N95 respirators are
recommended for healthcare providers dealing with patients with unknown
COVID-19 status during aerosol generating
procedures\textsuperscript{12,13}. Per recommendations from the Stanford
group we used tiered PPE depending on the case type
\textsuperscript{14}. Extreme airborne precautions (PAPR in addition to
surgical gowns/gloves) was used for COVID positive cases and were
considered high risk of transmission (upper aerodigestive tract,
sinonasal cases, mastoidectomy). Enhanced airborne precautions (N95
respirator, eye protection, surgical gown/gloves) were used in COVID
negative cases with high risk of transmission, any emergent case with
unknown COVID status, urgent cases with COVID status unknown, positive
symptoms or high risk cases. Standard PPE was used in low risk of
transmission COVID negative cases and COVID unknown, asymptomatic
patients undergoing urgent but low risk of transmission procedures.
These guidelines are comparable to precautions outlined by other
institutions\textsuperscript{15-18}. Additionally, we have been
extending the use of N95 respirators in accordance with the CDC's
recommendations and prior data\textsuperscript{19,20}. Our institution
has been reprocessing N95 respirators for repeated use using a
combination of UV light radiation and vaporized hydrogen
peroxide.\textsuperscript{21-23}.

Notably, once the decision was made to operate we did not alter our
surgical approach for cases. Some data have shown a reduction or
complete cessation in free flap surgeries during the pandemic at other
institutions \textsuperscript{24}. Free tissue transfer and
tracheostomies were still performed when indicated. We continued holding
weekly multidisciplinary tumor board (MDTB), albeit this was done
remotely via videoconferencing.

\textbf{Approach to Outpatient Clinics}

The multidisciplinary HNS clinic includes 8 specialists and 5 APPs and
typically sees 1100 to 1200 new cancer cases every year. Beginning March
15\textsuperscript{th}, a widespread clinic freeze was instituted by the
department. Clinicians were asked to review their schedules for the next
several weeks in order to identify patients on a case-by-case basis that
could not be postponed. Patients were contacted individually by phone to
reschedule although clinics were still open from an institutional
standpoint. Until March 27\textsuperscript{th}, clinics were continued
on a limited basis and patients were limited to head and neck patients
with an urgent need; new confirmed cancer diagnoses, post-op care, or
patients with worsening symptoms due to their malignancy.

Beginning March 30\textsuperscript{th}, all HNS clinics were
consolidated to initially one clinic, one day per week. Due to volume, a
second clinic day was added beginning April 6\textsuperscript{th}. With
the removal of dedicated clinic and OR block time, clinicians were able
to remain flexible when covering the clinic days to allow for back up in
the event of clinician exposure. Our department was fortunate to not
have any confirmed cases of COVID-19 amongst the health care team,
however one attending was symptomatic and subsequentially
self-quarantined although ultimately tested negative. This clinician was
able to continue to participate in telemedicine from quarantine.

Additionally, our department instituted a proactive and aggressive plan
to pursue telemedicine for suitable patients to maintain continuity of
care. It was left to the discretion of providers to determine patient's
that would require in-person visits. As mentioned earlier, patients with
a new cancer diagnosis, with recent surgery requiring wound checks or
drain removals, or patients symptomatic with malignancy related symptoms
were prioritized for in person clinic visits. When clinically
appropriate, imaging was substituted for a physical exam to limit
physical contact. While telemedicine certainly has its limitations, it
also has notable advantages that merit discussion. Immunocompromised and
medically infirm patients are able to stay at home and not risk
exposure. There is more time for discussions regarding diagnoses, goals
of care, etc. as well as a possibility of more frequent follow up. We
anticipate that our practice patterns in the future will be adjusted to
include more telemedicine as a result of this pandemic.

There continue to be limitations to this model. Telemedicine visits
require patient access to an internet network or a ``smartphone'',
limiting its use in some more isolated patient populations. Limiting the
use of flexible scope exams in clinic and relying more heavily on
imaging will likely have unforeseen consequences with regards to cancer
surveillance, although this has yet to be seen and more data necessary
to draw conclusions.

\textbf{Logistics and Resident education}

Outside of the clinic and OR setting, our department made several
changes in the residency structure that will be detailed briefly.
Institutionally, residents were not allowed to take care of COVID-19
positive patients or patients under investigation (PUIs). From a
surgical standpoint, only one resident was allowed in a case at a time
to conserve PPE. Beginning on March 19, the residency program was
platooned into two groups, which alternated weekly shifts. The team that
was not actively deployed at the hospital was responsible for continuing
didactics and to remain on reserve in the event residents needed to be
quarantined or became ill. During this time, the head and neck service
accounted for two fellows, a senior level resident, and three junior
level residents. Operative cases were performed with the least amount of
personnel in the room, with the most experienced members performing the
cases. Junior level residents (PGY 1-3) were generally not involved in
operative cases during this time period unless needed. Many cases were
done only by attending surgeons or by fellows. When junior residents
were involved it was for assistant purposes only in order to maximize
efficiency.

In attempts to minimize exposures, inpatient rounds were still performed
by the resident teams with fellow assistance. Only senior residents
examined inpatients and wore appropriate PPE depending on COVID status.
If a patient had unknown status, a gown, gloves, and N95 respirator were
worn. COVID+ patients were only seen in person by attending physicians
wearing appropriate PPE (N95, gown, gloves, face shield).

By order of the Alabama governor, inpatient guest visitation was
extremely limited. This hindered family education of trach care, wound
care, use of nasogastric or gastrostomy tube, among other routine
postoperative care. Residents were tasked with telephone updates
following rounds. We anecdotally suspect this led to slightly longer
inpatient stays due to the decreased hands-on training of family
members. HNS patients are particularly reliant on family assistance
after discharge. We did have some patients cancel their surgeries
initially due to these restrictions. We ultimately were able to have
family members receive in-person teaching towards the end of the
hospital stay. A ``compassionate'' exception was made for patient with
dementia or other factors requiring close caregiver participation (this
was allowed with two patients). Another unforeseen circumstance of the
visitation restrictions was the occasional cancellation of urgent cases
by patients. In addition, patients were not routinely screened
post-operatively for COVID-19 unless they began to develop symptoms.

\textbf{Discussion}

At the current time (April 26, 2020), there are 943,865 cases of
COVID-19 in the United States, 6,213 of which are in
Alabama\textsuperscript{6}. For comparison, surrounding southern states
Louisiana, Georgia, and Mississippi have 26,512, 23,401, and 5718 cases
respectively while New York has 282,143 cases\textsuperscript{25}. These
numbers highlight the variability to which the pandemic has affected
different states thus far, even within the same geographic region. New
York State contains 411.2 people per square mile compared to 168 people
per square mile of neighboring Georgia, 94.4 people per square mile in
Alabama and 63.2 people per square mile in
Mississippi\textsuperscript{26}. While there are many factors involved,
the overall low population density, early mitigation in Alabama's
largest urban area (Birmingham), and limitations in testing have
contributed to lower COVID-19 case numbers.

Due to the trajectory and distribution of new COVID-19 cases, our
department has been able to implement strategies used in other states
and countries\textsuperscript{15,16,18,27-30}. The authors would direct
you to Patel et al. for a recent description of HNS practice patterns
nationwide during the pandemic \textsuperscript{24}. Since the beginning
of the pandemic, the maximum number of COVID-19 patients at our
institution has not exceeded 62 and therefore, our institution has not
yet experienced ventilator or PPE shortages suffered by other health
care centers. We feel that thus far our division has been able to
effectively triage HNS patients and complete their oncologic surgeries
safely, while simultaneously reducing non-urgent surgeries. We reduced
our surgical volume by 55\% during the critical time period and this was
predominantly by postponing elective, outpatient surgeries. Of note, we
feel strongly that a team-based approach toward completing surgical
cases is of the utmost importance in this situation. This requires
inter-provider consistency with regard to management strategies, a high
level of communication, and an understanding between the patient and
provider that another surgeon may be involved or primarily responsible
for their care. A foundation of trust between the patient and provider
is elemental in the success of this model. We would advocate a high
level of detail with regard to documentation and completion of the
surgical consent with these principles in mind.

An early and constantly evolving response to the COVID-19 crisis remains
critical to avoid an overwhelming surge on our medical system. At this
time, ORs both at our institution and around the country are beginning
to re-open to clear the logjam of semi-urgent and elective cases. We
feel the keys to safely moving forward with increased head and neck
surgical volume is with widespread, reliable pre-operative COVID
testing, adequate PPE and a clear mechanism to triage cases according to
urgency and safety via a team-based approach. While our experience may
not be reproducible for smaller community hospitals or tertiary centers
located in more urban settings, they do serve to highlight the response
and experience of a high-volume head and neck cancer tertiary center
situated in the deep South.

\textbf{Literature Cited}

1. Huang C, Wang Y, Li X, et al. Clinical features of patients infected
with 2019 novel coronavirus in Wuhan, China.
\emph{Lancet.}2020;395(10223):497-506.

2. Medicine JHUo. COVID-19 Dashboard by the Center for Systems Science
and Engineering (CSSE) at Johns Hopkins University.
https://coronavirus.jhu.edu/map.html. Published 2020. Accessed 2020,
April 26.

3. Meng L, Hua F, Bian Z. Coronavirus Disease 2019 (COVID-19): Emerging
and Future Challenges for Dental and Oral Medicine. \emph{J Dent
Res.}2020;99(5):481-487.

4. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 Viral Load in Upper
Respiratory Specimens of Infected Patients. \emph{N Engl J
Med.}2020;382(12):1177-1179.

5. Chan JYK, Wong EWY, Lam W. Practical Aspects of Otolaryngologic
Clinical Services During the 2019 Novel Coronavirus Epidemic: An
Experience in Hong Kong. \emph{JAMA Otolaryngol Head Neck Surg.} 2020.

6. Health ADoP. Alabama's COVID-19 Data and Surveillance Dashboard.
https://alpublichealth.maps.arcgis.com/apps/opsdashboard/index.html\#/6d2771faa9da4a2786a509d82c8cf0f7.
Published 2020. Accessed 2020, April 22.

7. Health NYSDo. NYSDOH COVID-19 Tracker.
https://covid19tracker.health.ny.gov/views/NYS-COVID19-Tracker/NYSDOHCOVID-19Tracker-Map?\%3Aembed=yes\&\%3Atoolbar=no\&\%3Atabs=n.
Published 2020. Accessed 2020, April 23.

8. Surgery AAoO-HaN. New Recommendations Regarding Urgent and Nonurgent
Patient Care.
https://www.entnet.org/content/new-recommendations-regarding-urgent-and-nonurgent-patient-care.
Published 2020. Accessed.

9. Bann DV, Patel VA, Saadi R, et al. Impact of coronavirus (COVID-19)
on otolaryngologic surgery: Brief commentary. \emph{Head Neck.} 2020.

10. Services CfMaM. Non-Emergent, Elective Medical Services, and
Treatment Recommendations.
https://www.cms.gov/files/document/cms-non-emergent-elective-medical-recommendations.pdf.
Published 2020. Updated 2020, April 7. Accessed 2020, April 23.

11. Liang W, Guan W, Chen R, et al. Cancer patients in SARS-CoV-2
infection: a nationwide analysis in China. \emph{Lancet
Oncol.}2020;21(3):335-337.

12. Smith JD, MacDougall CC, Johnstone J, Copes RA, Schwartz B, Garber
GE. Effectiveness of N95 respirators versus surgical masks in protecting
health care workers from acute respiratory infection: a systematic
review and meta-analysis. \emph{CMAJ.} 2016;188(8):567-574.

13. Long Y, Hu T, Liu L, et al. Effectiveness of N95 respirators versus
surgical masks against influenza: A systematic review and
meta-analysis.\emph{J Evid Based Med.} 2020.

14. Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19
and the Otolaryngologist: Preliminary Evidence-Based
Review.\emph{Laryngoscope.} 2020.

15. Vukkadala N, Qian ZJ, Holsinger FC, Patel ZM, Rosenthal E. COVID-19
and the otolaryngologist - preliminary evidence-based review. \emph{The
Laryngoscope.} 2020.

16. Day AT, Sher DJ, Lee RC, et al. Head and neck oncology during the
COVID-19 pandemic: Reconsidering traditional treatment paradigms in
light of new surgical and other multilevel risks. \emph{Oral
Oncology.}2020;105:104684.

17. Pichi B, Mazzola F, Bonsembiante A, et al. CORONA-steps for
tracheotomy in COVID-19 patients: A staff-safe method for airway
management. \emph{Oral oncology.} 2020;105:104682-104682.

18. Zimmermann M, Nkenke E. Approaches to the management of patients in
oral and maxillofacial surgery during COVID-19 pandemic. \emph{Journal
of Cranio-Maxillofacial Surgery.} 2020.

19. Bergman MS, Viscusi DJ, Zhuang Z, Palmiero AJ, Powell JB, Shaffer
RE. Impact of multiple consecutive donnings on filtering facepiece
respirator fit. \emph{Am J Infect Control.} 2012;40(4):375-380.

20. Control CfD. Strategies for Optimizing the Supply of N95
Respirators.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html.
Published 2020. Accessed April 23, 2020.

21. Mills D, Harnish DA, Lawrence C, Sandoval-Powers M, Heimbuch BK.
Ultraviolet germicidal irradiation of influenza-contaminated N95
filtering facepiece respirators. \emph{Am J Infect
Control.}2018;46(7):e49-e55.

22. Mackenzie D. Reuse of N95 Masks. \emph{Engineering
(Beijing).}2020:10.1016/j.eng.2020.1004.1003.

23. Schwartz A, Stiegel M, Greeson N, et al. Decontamination and Reuse
of N95 Respirators with Hydrogen Peroxide Vapor to Address Worldwide
Personal Protective Equipment Shortages During the SARS-CoV-2 (COVID-19)
Pandemic. \emph{Applied Biosafety.} 2020:1535676020919932.

24. Patel RJ, Kejner A, McMullen C. Early Institutional Head and Neck
Oncologic and Microvascular Surgery Practice Patterns Across the United
States During the SARS-CoV-2 (COVID19) Pandemic. \emph{Head Neck.} 2020.

25. Centers for Disease Control and Prevention. Cases of coronavirus
disease (COVID-19) in the U.S.
https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html\#1.
Published 2020. Updated April 23. Accessed April 26, 2020.

26. Bureau USC. 2010 Census: Population Density Data.
https://www.census.gov/data/tables/2010/dec/density-data-text.html.
Published 2020. Updated May 4, 2018. Accessed April 26, 2020.

27. Givi B, Schiff BA, Chinn SB, et al. Safety Recommendations for
Evaluation and Surgery of the Head and Neck During the COVID-19
Pandemic. \emph{JAMA otolaryngology-- head \& neck surgery.} 2020.

28. Kettering CSotORECaMS. Cancer Surgery and COVID19. \emph{Ann Surg
Oncol.} 2020:1-4.

29. Ansarin M. Surgical management of head and neck tumours during the
SARS-CoV (Covid-19) pandemic. \emph{Acta Otorhinolaryngol Ital.} 2020.

30. Boccalatte LA, Larra\selectlanguage{ngerman}ñaga JJ, Perez Raffo GM, et al. Brief guideline
for the prevention of COVID-19 infection in head and neck and
otolaryngology surgeons. \emph{American Journal of
Otolaryngology.}2020:102484.

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