key: cord-0922534-ywgx1xmh
authors: Mattei, A.; Amy de la Bretèque, B; Crestani, S.; Crevier-Buchman, L.; Galant, C.; Hans, S.; Julien-Laferrière, A.; Lagier, A.; Lobryeau, C.; Marmouset, F.; Robert, D.; Woisard, V.; Giovanni, A.
title: Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the contexte of the COVID-19 pandemic
date: 2020-04-20
journal: Eur Ann Otorhinolaryngol Head Neck Dis
DOI: 10.1016/j.anorl.2020.04.011
sha: 48902331256241d5af8de31f978a346d6840d053
doc_id: 922534
cord_uid: ywgx1xmh

ABSTRACT Procedures putting healthcare workers in close contact with the airway are particularly at risk of contamination by the SARS-Cov-2 virus, especially when exposed to sputum, coughing, or a tracheostomy. In the current pandemic phase, all patients should be considered as potentially infected. Thus, the level of precaution recommended for the caregivers depends more on the type of procedure than on the patient's proved or suspected COVID-19 status. Procedures that are particularly at high risk of contamination are clinical and flexible endoscopic pharyngo-laryngological evaluation, and probably also video fluoroscopic swallowing exams. Voice rehabilitation should not be considered urgent at this time. Therefore, recommendations presented here mainly concern the management of swallowing disorders, which can sometimes be dangerous for the patient, and recent dysphonia. In cases where they are considered possible and useful, teleconsultations should be preferred to face-to-face assessments or rehabilitation sessions. The latter must be maintained only in few selected situations, after team discussions or in accordance with the guidelines provided by health authorities.

As for any caregiver, it is the duty of ENTs specialized in laryngology or phoniatrics and of speech therapists to provide the best care possible to the general population, while at the same time respecting the obligation to prevent as much as possible the spread of COVID-19. In every situation, it is therefore a matter of weighing up the risks for the patient and the health professional against the expected benefits.

For ENT and general laryngological practice, we refer to the recommendations published by the French Society of Otorhinolaryngology, Head and Neck Surgery (SFORL) on its website, especially concerning the proper technique and precautions for flexible naso-endoscopy and laryngoscopy: https://www.sforl.org/actualites-covid-19/. We also recommend to read the documents provided online by the French government (https://solidarites-sante.gouv.fr/soinset-maladies/maladies/maladies-infectieuses/coronavirus/), by the French High Council for Public Health (HCSP) (https://www.hcsp.fr) and by the French Society of Hospital Hygiene (SF2H) (www.sf2h.net).

In the present document, the board members of the French Society of Phoniatrics and Laryngology provide some elements to help decision-making. These recommendations are likely to change over the next weeks or months depending on the evolution of the epidemic and the progress of related research.

Procedures where the health professional comes into close contact with the airway are particularly likely to cause contamination by the SARS-Cov-2 virus. Moreover the risk of transmitting the virus is high, due to spitting or coughing, or during a tracheostomy (situations highly likely to spread contagion due to the projections of droplets).

Page 4 of 8 J o u r n a l P r e -p r o o f Speech therapy should be deemed non-urgent in this context. Therefore, the present recommendations mainly focus on the management of swallowing problems, which can sometimes be dangerous for patients, and on cases of recent dysphonia.

If the patient has already been receiving speech therapy, this can be continued remotely during the lockdown which was imposed in France nationwide on March 25, 2020, including private practice.

The indications and precautions relating to video fluoroscopic swallowing exams are currently being assessed.

In the current pandemic context, patients are theoretically all considered as Covid positive.

To date, however, in the majority of teams, the following categorization is applied: The nasogastric tube must be inserted and removed using the same protection as for other procedures involving the airway, with a minimum number of participants.

In situations where urgent management of swallowing disorders is compulsory, as in some postoperative cases or in some patients with neurodegenerative diseases, tele-rehabilitation is preferable whenever it is technically possible and allowed by the current regulations. When face-to-face consultation is necessary, caregivers must be aware of the high risk of contamination from droplets emitted by the patient and they therefore should wear the same type of PPE as that recommended for any airway procedure such as flexible endoscopy or nasogastric tube insertion,...: head cap, FFP2 mask, protective glasses and possibly a full face protection with visor, gloves and a gown (see the current protocol in the establishment where the procedure is carried out). Caregivers should learn how to properly put on and remove their clothing.

Laryngologists and speech pathologists may need to perform flexible naso-endoscopies and laryngoscopies to explore recent dysphonia. The reader may be referred to the website of the • Vocal rehabilitation should not be considered urgent in the current epidemic context. If the patient has already been taken care of for such a rehabilitation, this can be continued by telerehabilitation.

• The current recommendations therefore mainly concern the management of swallowing disorders and the assessment of acute dysphonia • Since we are currently in the COVID-19 pandemic phase, even asymptomatic patients can be infected and contagious, and as false negatives from coronavirus diagnostic tests are frequent, the same precautions should apply to all patients • Only swallowing disorders management or exploration of recent dysphonia that are regarded as impossible to postpone should be maintained. The decision to maintain these urgent indications must be validated by team discussions or should rely on official recommendations from health authorities • Several procedures are to be considered as at very high risk of caregiver contamination: clinical and flexible endoscopic swallowing assessments (especially since food tests require that the patient not wear a mask), flexible endoscopies, insertions of nasogastric tubes and video fluoroscopic swallowing exams, although the risk level of the latter remains under discussion • When these risky procedures cannot be postponed, the following personal protective equipment (PPE) is recommended for caregivers: protective glasses, FFP2 (N95) mask, cap, gloves and gown). Caregivers must learn the appropriate dressing and undressing technique.

The authors declare that they have no competing interest.

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