2 PATIENTS AND METHODS As of this writing, we continue to experience the ascending portion of the COVID‐19 crisis, where resources are being protected but are still available. We have not had to deny access to surgery in a way that would not meet normal standards of care, but we did have to make choices that would not have been made in normal times. We would like to share the process and approach that was used to make these decisions in three example cases, and provide a table listing 65 patients triaged over a 3‐week period with their diagnosis, history, and disposition (Table 1). TABLE 1 Diagnosis, history, planned procedure, and disposition of 65 triaged patients during the ascending pandemic. Anticipated date of surgery Location Patient history Diagnosis Surgical procedure Disposition/risk of viral transmission Notes 1 March 23, 2020 University A 69‐year‐old male with two masses in the left parotid gland, fine‐needle aspiration (FNA) with “reactive lymphoid hyperplasia” and benign epithelial cells Neoplasm of unknown behavior of parotid gland Superficial parotidectomy, sternocleidomastoid muscle flap Delayed Low risk Rescheduled to June 2 Mid‐March, date not specified University Case 1 in the text Metastatic papillary cancer of the thyroid to retropharyngeal nodes Bilateral parapharyngeal/retropharyngeal Exploration, neck dissections Delayed Low risk Repeat magnetic resonance imaging (MRI) (previous study 3 months ago). Plan surgery for June 3 Mid‐March, date not specified University A 53‐y‐old female with a nonpalpable cytologically proven deep recurrence of parotid cancer after surgical treatment several years ago in another institution. Normal facial nerve function Intermediate‐grade mucoepidermoid cancer of parotid Revision parotidectomy Delay Low risk Repeat MRI (previous study 4 months ago). Plan surgery for late May. Postoperative radation will be needed 4 March 23, 2020 University A 43‐y‐old female with 2 cm left parotid mass growing over the last 10 y, previous FNA showing pleomorphic adenoma, now experiencing discomfort, but not rapid growth Pleomorphic adenoma of the parotid gland Superficial parotidectomy, sternocleidomastoid muscle flap Delayed Low risk Rescheduled to late April 5 March 24, 2020 University A 62‐y‐old male with history of basal cell carcinoma of the left upper lip s/p surgical resection in 2005 now with slow recurrence Recurrent basal cell carcinoma of the lip Lip resection, local advancement flap reconstruction Delayed Low risk Patient moved from 3/24 to 5/1 due to COVID‐19 and patient's wife having compromised immune system. Combined case with facial plastic surgeon 6 March 30, 2020 University A 62‐y‐old female with T4bN0 hypopharyngeal cancer extensively involving supraglottis, who had emergency tracheostomy recently Malignant neoplasm of larynx Total laryngectomy, partial pharyngectomy, possible composite glossectomy and tongue base resection, bilateral neck dissection, free flap Approved High risk Operated the following week 7 March 30, 2020 University Case 3 in the text Malignant neoplasm of oral cavity Composite procedure with resection of floor of mouth and mandibular resection, neck dissection, anterolateral thigh free flap vs radial forearm free flap vs scapula free flap Approved High risk Operated the following week. Had false‐positive postoperative SARS‐CoV‐2 Reverse Transcriptase Polymerase Chain Reaction (RT PCR). Otherwise he had an uneventful recovery. 8 March 30, 2020 County Hospital Case 2 in the text Retrosternal multinodular goiter, severe tracheal compression, hyperparathyroidism Left hemithyroidectomy for retrosternal goiter, possible sternotomy, possible total thyroidectomy, parathyroid exploration Approved Low‐risk surgery High‐risk airway management Change in surgical approach suggested Goiter with severe airway impingement and respiratory distress. It was recommended that patient be prepared for standby extracorporeal membrane oxygenation to prior to fiberoptic awake intubation, to reduce likelihood of emergency cricothyroidotomy 9 March 30, 2020 County Hospital A 57‐y‐old female with acoustic neuroma, brainstem compression, and symptomatic Acoustic neuroma Right retrosigmoid approach for removal of acoustic neuroma Approved Low risk Surgery performed 10 March 31, 2020 University A 64‐y‐old female with desmoplastic melanoma, 3.5 mm depth Lower lip melanoma Lip resection, sentinel lymph node biopsy, adjacent tissue transfer or rearrangement for primary reconstruction Approved High risk Surgery performed 11 March 31, 2020 County A 48‐y‐old female with a history of kidney transplant, immunosuppression, had a large scalp cancer resected with negative margins by a surgical oncologist with plan for staged free flap reconstruction by our service Secondary scalp defect with bone exposure, immunosuppression Latissimus dorsi muscle free flap, scalp debridement, neck exploration for preparation of vessels Delayed Low risk It was felt paramount to keep this immunosuppressed transplant patient out of hospital. Wound care with wound‐vac, wound granulating. 12 March 31, 2020 County A 36‐y‐old female with large right parapharyngeal space mass. FNA—salivary neoplasm. Well circumscribed on imaging Parapharyngeal space mass of uncertain behavior Transcervical parapharyngeal space resection Delayed Low risk Repeat imaging 3 months 13 March 31, 2020 County Hospital A 79‐y‐old female from nursing home with sacral ulcer, pneumonia, vent dependence, COVID negative Ventilator dependence Tracheostomy Approved High risk Medical intensive care unit, inpatient, add on, surgery performed 14 March 31, 2020 University A 54‐y‐old male with tongue squamous cell carcinoma (SCCA) Malignant neoplasm of anterior two‐thirds of tongue Hemiglossectomy, direct laryngoscopy with biopsy, bronchoscopy, esophagoscopy, possible tracheostomy, possible split thickness skin graft from the thigh Approved High risk Surgery performed 15 March 31, 2020 University A 56‐y‐old male with FNA + SCCA cystic left neck mass Neck mass, progressive, growth, cystic, left tonsil suspicious, but not enough for office biopsy Direct laryngoscopy with biopsy, bronchoscopy, esophagoscopy, tonsillectomy, possible neck mass excision, possible neck dissection Approved, Reduce extent of surgery. High risk Left tonsil removed and positive for Human Papilloma Virus (HPV)‐related SCCA. Did not perform panendosopy and contralateral tonsillectomy as originally planned. Would have been a TORS candidate but will go for radiation therapy (RT). 16 March 31, 2020 University A 64‐y‐old female with asymmetric tonsils, lymphoma suspected Tonsil neoplasm, suspect lymphoma Direct laryngoscopy with biopsy, Bronchoscopy, esophagoscopy, possible bilateral tonsillectomy Approved High risk Changed surgical approach suggested Recommendation was to remove one tonsil and frozen section. If suspicious for lymphoma can avoid contralateral tonsillectomy and panendoscopy. This is exactly what happened 17 March 31, 2020 University A 86‐y‐old male with growing scalp lesion Sarcoma of scalp Radical tumor resection, skin substitute graft to scalp Approved Low risk Surgery performed. 18 April 1, 2020 University A 67‐y‐old male former smoker Malignant neoplasm of tonsil and tongue base Radical resection of tonsil, tonsillar pillars and/or retromolar trigone, limited pharyngectomy, near complete tongue base resection, neck dissection, tracheostomy, radial forearm free flap vs anterolateral thigh free flap, split thickness autograft Approved High risk Salvage surgery after chemotherapy and radiation. Prior surgery on a different primary years before. Forearm flap used 19 April 1, 2020 University A 34‐y‐old male presented with hoarseness and has a diagnosis of superficially invasive cancer Malignant neoplasm of glottis LASER(Light Amplification by Stimulated Emission of Radiation) direct laryngoscopy‐ bilateral lesion excision with microscope direct laryngoscopy‐ bilateral vocal fold injection, therapeutic with microscope Approved High risk Patient is young and strongly prefers surgical therapy over radiation. Due to his young age and relatively superficial tumor, it was felt appropriate to proceed with surgery. Avoidance of LASER suggested but felt to be difficult. Extra suction at high power and N95 mask as in all surgeries. 20 April 2, 2020 University A 58‐y‐old female with advanced laryngeal cancer. Radiation failure Malignant neoplasm of larynx Total Laryngectomy, bilateral neck dissection, radial forearm free flap, split thickness autograft Approved High risk Surgery performed 21 April 2, 2020 University A 75‐y‐old male with right‐sided visual loss Nasal/sinus tumor, suspected malignancy Nasal/sinus endoscopy with biopsies Approved High risk Surgery performed. Result was inflammatory rather than malignant 22 April 2, 2020 University A 62‐y‐old male smoker with T4 N1 SCCA larynx Right glottic cancer Total laryngectomy, bilateral neck dissections Approved High risk Surgery performed 23 April 2, 2020 University A 61‐y‐old male smoker, drinker Tongue Cancer Hemiglossectomy with composite resection of floor of mouth, partial pharyngectomy, neck dissection possible bilateral, tracheostomy, radial forearm free flap, split thickness skin graft Approved High risk Surgery performed 24 April 2, 2020 University A 67‐y‐old male with T2 N2c base of tongue cancer suspected Neoplasm of uncertain behavior of base of tongue, neck mass Direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy Approved High risk Endoscopy performed. Biopsy revealed HPV‐related base of tongue cancer. Not a good candidate for TransOral Robotic Surgery (TORS), crosses midline, bilateral adenopathy, so chemoradiation regardless of situation. 25 April 2, 2020 University A 22‐y‐old female with growing, massive adenopathy Castleman's disease, rule out lymphoma Right Neck Node Excision Approved Low risk Surgery performed 26 April 2, 2020 University A 46‐y‐old male with high‐grade carcinoma of nasal cavity and ethmoid, presented with eye, sinus pain Malignant neoplasm of ethmoidal sinus Craniofacial approach to anterior cranial fossa with maxillectomy, anterior skull base resection of bilateral lesion, intradural with dural repair Approved High risk Suggested changes in technique Surgery performed. Avoid drill and microdebrider. Plastic cover recommended over face and nose with small holes for scope to divert plume from cautery and aerosolized debris 27 April 2, 2020 University A 67‐y‐old male presented with hoarseness T4aN2 SCCA of larynx Total Laryngectomy Approved High risk Surgery performed 28 April 2, 2020 University A 56‐y‐old female with a midline neck mass consistent with a benign thyroglossal duct cyst Thyroglossal duct cyst Sistrunk procedure Delayed Low risk Patient rescheduled 6/11/20 due to COVID‐19, and her surgery being elective and non‐urgent 29 April 2, 2020 County Hospital A 42‐y‐old female with superficial supraglottic SCCA Malignant neoplasm of the supraglottis Microdirect laryngoscopy with LASER Approved High risk Suggested changes in technique Recommendation to avoid use of LASER. Instead of laser, cold technique used with electrocautery at low setting 30 April 2, 2020 County Hospital A 65‐y‐old male with dysphagia, lesion on fiberoptic examination Supraglottic/ hypopharyngeal mass Direct laryngoscopy with biopsy Approved High risk Needs biopsy to proceed with non‐surgical therapy 31 April 2, 2020 County Hospital A 41‐y‐old male with tonsil lesion, throat discomfort Tonsil lesion Direct laryngoscopy with biopsy Approved High risk Tonsillar fossa ulcer in patient with history of left tonsil cancer. Soft tissue radionecrosis vs cancer 32 April 2, 2020 County Hospital A 71‐y‐old male with pain in throat, palpable tongue base mass, neck mass Tongue base mass, neck mass Direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy Approved High risk Rescheduled 2/2 positive COVID test. We will need to wait at least 2 wk and retest COVID‐19 RT‐PCR 33 April 3, 2020 County Hospital A 64‐y‐old male with growing neck mass Cervical lymphadenopathy, concern for lymphoma Neck excisional lymph node biopsy Approved Low risk Surgery performed 34 April 3, 200 University A 88‐y‐old male with advanced laryngeal cancer Malignant neoplasm of larynx Total Laryngectomy, partial pharyngectomy, bilateral neck dissection, adjacent tissue transfer or rearrangement Approved High risk Surgery performed 35 April 3, 2020 University A 48‐y‐old male smoker with right tail of parotid mass and FNA showing oncocytic neoplasm. Growth of tumor has been slow over 2 y Neoplasm of uncertain behavior of the parotid gland Superficial parotidectomy, sternocleidomastoid muscle flap, abdominal fat graft Delayed Low risk Concern with low‐grade malignancy. Due to COVID‐19 patients elective surgery has been rescheduled for late May 8, 2020 36 April 6, 2020 University A 76‐y‐old male smoker with T3N1M0 HPV+ SCCA of the left tonsil (just over 4 cm in vertical dimension) TORS candidate Malignant neoplasm of the tonsil TORS radical tonsillectomy, neck dissection Canceled High risk Transfer to radiation. Initially was scheduled for TORS. Due to COVID‐19 situation, as well as presence of a second node on Positron Emission Tomography Computed Tomography (PET CT), he was strongly advised to proceed with RT. Patient was insistent on surgical therapy, but eventually agreed 37 April 6, 2020 University A 27‐y‐old male with thyroid nodule, positive FNA for papillary cancer Thyroid cancer Total thyroidectomy, Central compartment neck dissection Delayed, Low risk Thyroid Ca with metastases in the neck; plan for repeat FNA to confirm diagnosis in neck; suspected slow growing papillary cancer 38 April 6, 2020 University A 71‐y‐old female with prominent growing lymph nodes Lymphadenopathy Excisional biopsy of upper neck node Approved Very Low risk since intubation avoided Likely lymphoma. Excisional biopsy under local anesthesia with sedation 39 April 6, 2020 County Hospital A 58‐y‐old male, smoker with progressive dysphagia Malignant neoplasm of hypopharynx Pharyngectomy, total laryngectomy, bilateral neck dissections, radial forearm vs anterolateral thigh free flap reconstruction, split thickness skin graft Canceled High risk It meets criteria for being considered unresectable. Borderline for surgery, and plan is for chemotherapy/RT based on tumor board presentation 40 April 6, 2020 County Hospital A 31‐y‐old female with cerebrospinal fluid leakage occurring after discharge from craniofacial resection for anterior fossa meningioma Cerebrospinal fluid leak after craniofacial resection Bilateral sinus surgery complex/skull base with CSF leak repair Approved High risk Suggested changes in technique Proceed with surgery. Plastic face cover. Avoid use of microdebrider and drill 41 April 9, 2020 University A 64‐y‐old male with growing neck mass Neck mass, + FNA for SCCA Direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy Approved High risk Tonsil cancer suspected but not definite. May require tonsillectomy. 42 April 9, 2020 University A 63‐y‐old male, progressive odynophagia Malignant neoplasm of base of tongue Direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy Approved High risk Submucosal recurrence in BOT; risk of bleeding and airway 43 April 9, 2020 University A 79‐y‐old female with painful growing tongue lesion. Biopsy + SCCA Tongue SCCA Partial glossectomy, possible hemiglossectomy, neck dissection, possible split thickness skin graft Approved High risk Change in surgical approach suggested Surgery performed. Original plan for tracheostomy changed to intubation for one to two nights and avoid tracheostomy if possible. Original indication for tracheostomy felt to be borderline 44 April 9, 2020 University A 64‐y‐old male with painful tongue lesion Tongue SCCA Hemiglossectomy, neck dissection, trachesotomy, radial forearm free flap, split thickness skin graft Approved High risk Surgery performed 45 April 9, 2020 University A 63‐y‐old male with change in voice and tongue mobility Neoplasm of uncertain behavior midline skull base, progressive 10th and 12th nerve weakness Endoscopic endonasal clival tumor biopsy, probable subtotal resection or excision of neoplastic, vascular, or infectious lesion of base of anterior cranial fossa, intradural, Approved High risk Surgery performed. Plastic cover used and minimized drill and microdebrider during approach 46 April 9, 2020 University A 20‐y‐old female transferred from a hospital in Tampa with periorbital cellulitis. Eye swollen closed, pain with eye movement, no loss of vision Subperiosteal abscess of left orbit with orbital involvement Nasal/sinus endoscopy surgical with ethmoidectomy, possible orbitotomy Delay or Cancel High risk Patient tested Positive for COVID‐19. Delay and temporize with intravenous antibiotics and operate if becomes negative or if vision deteriorates. Watch vision closely and symptoms for signs of COVID‐19 infection. Repeat testing when appropriate. Patient signed out against medical advice and was given oral antibiotics. He will follow‐up with an otolaryngologist in Tampa. 47 April 10, 2020 University A 50‐y‐old male with recurrent laryngeal cancer after RT Malignant neoplasm of larynx Total laryngectomy, bilateral neck dissection, left anterolateral thigh free flap, possible pectoralis major muscle flap Canceled by patient High risk The patient is from our area but opted to drive 7 hours away to Jacksonville for consultation with plan to receive surgery there due to lowerCOVID‐19 prevalence. 48 April 10, 2020 University A 60‐y‐old male, Human Immunodeficiency Virus (HIV)+, diabetic, renal failure on dialysis, with new oral lesion on frenulum, nasal vestibular lesion Oral mass, Neoplasm of uncertain behavior of base of tongue, cancer vs papilloma, nasal papilloma Direct laryngoscopy with biopsy, rigid esophagoscopy, midline oral vestibule lesion excision with complex repair, left benign lesion excision of the nose Delay High risk Nasal vestibule and floor of mouth papillomatous lesion; Recommend biopsy in office for now 49 April 10, 2020 University A 73‐y‐old male with hoarseness Fiberoptic exam and review of outside pathology consistent with severe dysplasia Direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy, microdirect laryngoscopy with removal of lesion, tracheoscopy Delay High risk Tumor board review of pathology confident lesion is “in situ” carcinoma at most. Microlaryngoscopy in 8 wk 50 April 10, 2020 University A 62‐y‐old male with papillary thyroid cancer requesting surgery as soon as possible Thyroid cancer Total thyroidectomy, Possible paratracheal lymph node dissection Delay Low risk Well‐differentiated cancer and no airway issues. Recommend waiting 3 months 51 April 10, 2020 University A 72‐y‐old male painful superficial oral lesion, equivocal biopsy Tongue cancer Partial glossectomy, direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy Approved High risk Surgery performed 52 April 10, 2020 University A 91‐y‐old male with excellent performance status with growing parotid tumor. History of skin cancer. FNA reveals carcinoma with squamous features Malignancy of parotid Parotidectomy, neck dissection, sternocleidomastoid flap, possible pectoralis major muscle flap, cervicofacial advancement, radical resection of tumor neck, auriculectomy Cancel Low risk Patient presented at Tumor board April 9, 2020. Patient has likely metastases 53 April 10, 2020 University A 77‐y‐old female with dysphagia and history of hypopharyngeal stenosis Dysphagia, hypopharyngeal stenosis Pharyngoplasty, dilation, direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy Delay High risk Attempt at radiologic gastrostomy first to allow delay in procedure. Ultimately this was successful 54 April 13, 2020 University A 38‐y‐old female with tongue lesion Tongue SCCA Partial glossectomy, neck dissection Approved High risk Depth of invasion was 3 mm on biopsy. Clinical examination consistent with a superficial lesion. Surgeon questioned whether there was any benefit to deferring neck dissection and performing watchful waiting. Recommendation per Tumor board was to maintain standard of care and perform the neck dissection, particularly since the neck dissection represented the low‐risk portion of the procedure 55 April 14, 2020 University A 81‐y‐old female with supraclavicular mass, chronic lymphocytic leukemia (CLL). Metastatic SCCA of skin Neck dissection, advancement flap Approved Low risk Surgery performed 56 April 15, 2020 University A 52‐y‐old male with SCCA floor of mouth Oral cancer, Neck mass Composite resection of oral cavity cancer, left neck dissection, direct laryngoscopy, rigid esophagoscopy, bronchoscopy, tracheostomy, radial forearm free flap vs fibula free flap, left split thickness skin graft Approved High risk Surgery performed 57 April 16, 2020 University A 63‐y‐old female with recurrent laryngeal SCCA after RT Malignant neoplasm of larynx Direct laryngoscopy with biopsy, rigid esophagoscopy, bronchoscopy, total laryngectomy, possible flap Approved High risk Surgery scheduled in the near future 58 April 16, 2020 University A 37‐y‐old male with parotid mass, equivocal FNA. Surgeon concerned regarding risk of malignancy in a young person and wants to proceed Neoplasm of uncertain behavior of parotid gland Parotidectomy, sternocleidmastoid flap, possible neck dissection Delayed Low risk Case was discussed with our ethicist. Low‐grade malignancy is a possibility, but imaging (CT) is stable between December and April and tumor is well encapsulated. Recommend delay for two months. Surgeon and patient are comfortable with the recommendation. 59 April 16, 2020 University A 75‐y‐old female with tongue SCCA Malignant neoplasm determined by biopsy of tongue Direct laryngoscopy with biopsy, rigid esophagoscopy, partial glossectomy, neck dissection, adjacent tissue transfer of the mouth Approved High risk Surgery performed 60 April 17, 2020 University A 63‐y‐old female with a large pigmented lesion of face which has undergone recent changes Invasive Melanoma, at least 0.9 mm depth, occurring withing a larger insitu lentigo maligna Wide resection of face, cheek, integra graft face, sentinel node biopsy. Secondary reconstruction will occur after final margins available Approved Low risk Committee suggested consideration for doing only wide local excision and not performing sentinel node biopsy, in order to simplify the procedure and reduce chance of inpatient stay, particularly in a lesion of borderline thickness. However biopsy was felt potentially to underrepresent depth and the surgeon proceeded with sentinel node biopsy. False positive RT PCR led to 4 day delay. 61 April 16, 2020 University A 83‐y‐old female for transfer from another hospital, with respiratory deterioration, chronic aspiration, after previous chemoradiation failure and subsequent pharyngectomy with laryngeal preservation, and free flap by our service. She has a tracheostomy and gastric tube and was just weaned from 5 weeks of mechanical ventilation related to aspiration pneumonia. Chronic aspiration, recurrent aspiration pneumonia Total laryngectomy, narrow field, possible regional flap, possible free flap Initially delayed Later approved a week later after the patient showed further signs of respiratory deterioration.Visible aspiration reported on fiberoptic examination High risk Case was discussed with ethicist. Patient was initially refused with a request that they temporize at her inpatient facility with tracheostomy cuff inflation and increased suctioning and ambulation. The patient continued to deteriorate and we agreed to accept in transfer for urgent laryngectomy to treat aspiration. She has been transferred. Surgery was delayed by a false positive RT PCR. After multiple subsequent negative tests she underwent a successful total laryngectomy and pectoralis major flap. 62 April 17, 2020 University A 46‐y‐old obese male with submandibular mass growing slowly for 2 y Submandibular gland mass Submandibular gland excision Delay for 3 months Low risk FNA suggestive of myoepithelial cell‐rich neoplasm with differential diagnosis of myoepithelial cell‐rich pleomorphic adenoma, basal cell adenoma, and myoepithelioma 63 April 17, 2020 University A 75‐y‐old male with T2N0M0 HPV+ SCCA of the right tonsil. TORS candidate Malignant neoplasm of the tonsil TORS radical tonsillectomy, neck dissection Canceled TORS canceled, referred for radiation, due to risks associated with COVID‐19 64 April 15, 2020 University A 42‐y‐old male with history of chemoradiation and 4 wk postoperative from major head and neck surgery, with fistula, suspected late necrosis of radial forearm free flap Oropharyngeal cancer, fistula, free flap loss Wound debridement, pectoralis major flap, pharyngeal repair Approved High risk Surgery pending repeat COVID‐19 PCR testing 65 April 17, 2020 University A 55‐y‐old male with right neck mass and sore throat. No office throat exam done due to COVID and fact that seen only by telemedicine. FNA suspicious for lymphoma New neck mass Direct Laryngoscopy, rigid esophagoscopy, rigid bronchoscopy Approved. High risk if panendoscopy performed May do a simple awake head and neck physical examination and nasopharyngoscopy in the OR after COVID testing and proceed with lymph node biopsy under local anesthesia Our system of triage evolved over this period of time, both in terms of the number of negative RT PCR tests for Severe Acute Respiratory Distress Syndrome Coronavirus Two (SARS‐CoV‐2)required to approve patients for surgery, and in terms of the emphasis on avoiding surgery. We sought to maintain previous standards of care, while making adjustments based on the ascending COVID‐19 crisis. The primary goal was always the well‐being of the patient. If any potential harm from not proceeding immediately with surgery was not felt to be outweighed by the benefit of keeping the patient away from the hospital during the pandemic, then the surgery was performed, albeit with technical modifications to increase safety. In cases where delays were believed to have little impact, or where nonsurgical therapies were thought to represent reasonable alternatives, the benefit of keeping the patient safe from viral infection or the risk of unknowingly operating during the prodrome of a COVID‐19infection, 20 might be judged to tip the scales away from surgery. The public health benefits related to other patients and providers were noted but assigned lower weight. We created a committee of six senior faculty from a department of 32 clinical otolaryngologists. This Surgical Review Committee reviewed all proposed operative cases from our university and county hospitals, nearly all of which involved head and neck tumors. There were five stages to the triage process:The primary surgeons evaluated their preoperative patients and made decisions with each patient regarding treatment adjustment. If a variation occurred relative to the original plan or to our standard practice, it generally was one of the following:Delay of surgery for 2 to 3 months. Transfer to a nonsurgical treatment, only if that approach met normal standards of care. Change in surgical approach (ie, reduction of powered instrumentation during endoscopic transnasal resection of neoplasms). In all but the most straightforward cases, the surgeon as a next step would consult electronically with a colleague from the Surgical Review Committee. This allowed for an initial review of the case prior to the formal committee discussion. Multidisciplinary questions were taken to a Head and Neck Tumor Board (conducted virtually), where issues related to triage during the pandemic drove the discussion. Subspecialized medical and radiation oncologists participated and could confirm agreement with the plans and acceptance of patients in those cases where a shift to nonsurgical care was advised. For those cases in which the surgeon felt surgery was essential, the discussion was taken to the formal Surgical Review Committee again conducted “virtually.” Presentation at the committee could result in suggested alterations of the surgical plan, delay of surgery, or transfer to a nonsurgical approach. If the surgeon, colleagues, or committee members, felt uncomfortable with the committee recommendations, consultation with our hospital ethicists was an option. Later, if uneasiness was expressed by the patient or family, involvement of the ethicist was again considered. In fact, we consulted with individual ethicists intermittently regarding our processes and approach, but never needed to involve the formal university ethics committee regarding specific patients. Various new standards evolved during this process. Some of these overlap with those suggested by Day et al in their recent guidelines. 23 Some were uncontroversial, such as a delay of surgery for most benign diagnoses. Yet even a benign diagnosis can entail critical airway obstruction or aspiration, or other acute loss of vital function for which the window of intervention could not be extended. When magnetic resonance imaging (MRI) or computed tomography (CT) findings suggested a more aggressive and rapidly evolving process despite a benign biopsy, clinical features, and imaging took precedence. An example of this was an intranasal mass, suspected to be a benign inverted papilloma or juvenile angiofibroma, with progressive optic nerve compression and increasing vision loss. A second standard was to consider delay of surgery for slow‐growinglow‐grade malignant tumors. Equivocal fine‐needle aspiration (FNA) cytologic results could create uncertainty, but these situations were usually resolved by examining the clinical scenario and comparing serial imaging. In some cases, repeat biopsy or imaging was suggested, but the additional risk of more medical interventions to the patient and staff in the coronavirus setting was always weighed. Delays were justified for these more indolent malignancies, particularly if serial observation confirmed stability on physical examination and/or imaging, and if the patient had risk factors for a worse outcome with COVID‐19 infection. However, given the reports of poor outcomes in healthy patients operated on during the prodrome of a COVID‐19 infection, 8 even healthy patients were considered at risk. A third standard was the transfer of the patient from a high‐risk surgical procedure to nonsurgical therapy when this represented an equivalent standard of care. The most common type of surgery for which this transition occurred was for T1 and T2 oropharyngeal cancer, with negative or early stage neck disease, where radiation with or without chemotherapy is a standard alternative treatment. Endoscopic LASER (Light Amplification by Stimulated Emission of Radiation) resections (transoral LASER microscopic [TLM] surgery), usually performed for supraglottic or glottic cancer at our institution, represented a similar category. The possibility of inhalation of smoke plume and the proximity of the surgeon to the endoscope and the patient's oral cavity make these high‐risk procedures for viral transmission in either direction. A fourth standard was that if delay or transfer to nonsurgical therapy could not be justified, such as for high‐grade cancers, an unsafe wound needing reconstruction, or respiratory issues, then surgery should proceed as soon as possible, but—with the exception of immediate life or death emergencies—should wait for appropriate COVID‐19 testing. We quickly realized however, that even with negative testing we still needed to proceed with full personal protective equipment (PPE) especially for high‐risk procedures involving mucosal incisions or use of instrumentation resulting in potential aerosolization of viral particles, as testing could give a false sense of security. Initially one negative SARS‐CoV‐2 test was required, but early on, after case 3 (below), this was converted to two negative test results with the last negative result within 24 hours of surgery. Apparent false negatives and false positives occasionally occurred, disrupting surgical planning and postoperative care. This is consistent with early reports from China, which report false‐negative rates as high as 30% in known COVID‐19 patients. 24 No data are available on sensitivity and specificity of routine testing of asymptomatic preoperative patients. We were greatly assisted by the rapid institution of reverse transcriptase polymerase chain reaction (RT‐PCR) testing of nasopharyngeal swabs for SARS‐CoV‐2 by our clinical laboratories, progressing within 10 days from a test that took 3 or 4 days to produce results to one that produced results in a few hours. Quigen Rotorgene Platform using U.S. Centers for Disease Control and Prevention primer pairs and the Genmark platform were the two principal types of tests used.25, 26 If proceeding with surgery, suggestions were often given to reduce the scope of surgery or make the surgical technique safer. For example, in one case it was thought unjustified to send an early, relatively superficial T1 supraglottic cancer in a young patient to radiation, but it was excised by cold technique instead of LASER, in order to avoid the aerosolized LASER plume. Another modification was the use of plastic covers for nasal endoscopic skull base surgery (Figure 1) along with additional suctions used to evacuate bone dust and cautery‐induced plumes, similar to smoke evacuators used in LASER surgery. FIGURE 1 Plastic cover for nasal endoscopic skull base surgery [Color figure can be viewed at http://wileyonlinelibrary.com] A fifth standard was that scheduling of tracheostomy required special consideration. Tracheotomy is potentially one of the highest risk operations we perform for possible COVID‐19 transmission due to the possibility of aerosolized secretions. At the same time, tracheostomy on an intubated patient may allow for weaning from the ventilator and exit from the intensive care unit (ICU), freeing the spot for another patient. Tracheostomy in a COVID‐19 positive patient presents a high risk. The likelihood that tracheostomy would truly facilitate weaning for a particular patient was carefully considered, and several guidelines and publications and recommendations from our recently created departmental COVID‐19 tracheotomy advisory committee were seriously weighed. Our department developed institutional guidelines and protocol for tracheotomy during the pandemic based on available published national and international guidelines, taking into account the specific situation of our institution during the pandemic. Current guidelines recommend delay of tracheostomy when appropriate in the setting of acute SARS‐CoV‐2 infection until the patient becomes less infectious. 27