To the best of our knowledge, we have presented the first cohort analysis of the therapeutic treatment offered by emergency ENT units during a pandemic, in terms of acute dyspnea in HNC patients. We based our observations and conclusions on a comparison of the patients admitted in the periods September-February 2019/2020 and 2020/2021. As an overview of the total medical activities of the ENT department, we have summarized the number of services provided. Overall, a decrease in planned surgeries was observed, which ranged across different centers from − 48% to -10%, depending on the local exacerbation of the pandemic and locally imposed healthcare restrictions on the normal functioning of hospitals.
Our analysis of four University Departments of Otolaryngology showed that the number of urgent tracheotomies in HNC patients increased in all of them, but proportionally, the most in those where the primary activity was limited. On the one hand, it proves that the system of admissions and life-saving procedures was maintained, although some of these Departments had been converted to meet the needs of the pandemic. On the other hand, however, the greater the involvement in combating the pandemic, the fewer planned interventions were carried out, and the higher the percentage of emergency procedures. A large proportion of patients awaiting planned surgeries had them postponed, which showed that capacity was fixed, with no possibility to expand the Department’s activity. Our findings have been partially reflected in the recent literature. The coronavirus pandemic, and the subsequent need for disease transmission mitigation efforts, significantly altered the delivery of cancer care [1, 2]. In developed countries, the use of inpatient care and subsequent hospitalization deficit in oncology was estimated to be 7%-35% [19–22]. All oncological subspecialties in the US experienced significant decreases in new patient visits and surgery capacity during COVID-19 [23], with a 25% reduction in newly diagnosed head and neck malignancies [24].
In our experience, the limitations of cancer care were not reflected in the number and proportion of urgent tracheotomies between the two cohorts. Regardless of their place of residence, oncological patients with extreme dyspnea are mainly neglected health cases. Another observation is the change in the proportion of primary lesions and the overrepresentation of laryngeal cancer. This is probably related to the fact that during the pandemic, primaries with a rapid progression could not wait anyway, while those with slowly developed cancers, who adapted to the dyspnea, more often reported in an extreme state.
Our results point out that telemedicine was a popular means of providing healthcare during the pandemic, which has also been observed across different healthcare systems [17, 22, 25]. Patients developing acute, dynamic dyspnea mostly had one telemedical consultation, which led to an immediate referral to the hospital. A full analysis of the effects of telemedicine is limited, due to missing data regarding the time between the actual consultation and the patient’s date of admission to the hospital. Nonetheless, patients who presented with acute dyspnea and who had been directed to the hospital constituted a minority of cases in the COVID-19 cohort. Comparing the pre-pandemic use of telemedicine to the pandemic period, all the individuals in the COVID-19 cohort in this study, who underwent a telemedical consultation, developed symptoms over a longer period and constituted a minority of all cases in that cohort. Possibly, the lack of standardized IT platforms results in serious challenges in replacing frontal visits, often making a concrete reduction in patients’ hospital access unfeasible [22]. Although telemedicine may improve healthcare access, patient preferences, technology-related barriers, and limitations regarding cancer surveillance must be addressed moving forward [25]. When given a choice, patients with head and neck cancer preferred in-person visits over telemedicine [25].
Although the aim of the analysis was not to investigate the differences between the four University Departments, some aspects are worth highlighting. Initial surgical load in the pre-COVID-19 period, the number of emergency departments in the given regions, and breaks/closures due to the pandemic constitute some reasons for the differences in the numbers of procedures. The density of ENT departments in the region and round-the-clock emergency care availability, a reduction in available beds, fewer outpatient clinic appointments, as well as limited access to the operating room also mattered.
Strengths and limitations of the study
To the best of our knowledge, this study constitutes the largest clinical group analyzed regarding emergency department services related to severe dyspnea in HNC patients.
One of the biggest limitations of this study was the relatively small study group, which was then divided into two Cohorts. Sample sizes below 5 individuals for some variables required the use of the conservative Fischer’s exact test.
In summary, the number of tracheotomy procedures in HNC patients was higher in the COVID-19 period. This may indicate both the higher advancement of a larger number of patients, as well as higher reporting to the four analyzed Departments, probably due to the limited availability of other healthcare providers. However, the first theory should be considered more likely because HNC patients are directed to the analyzed University Departments anyway. However, this premise will require confirmation in subsequent analyses, i.e., the total number of patients from the oncological pathway.
The degree of advancement of HNC during urgent tracheotomy is the same between the cohorts, which is logical, but the higher percentage of tracheotomies performed under local anesthesia is noteworthy. It is a category of extremely urgent procedures with complete airway obstruction. This means that in these patients, intubation was attempted, but the glottis was not visualized, so the tracheotomy was performed immediately, or the procedure was even performed in the Emergency Department, without intubation attempts.