The patient remained relatively stable but was in need of airway intervention. Of note, the patient was strongly opposed to tracheostomy and almost refused to proceed, as we could not guarantee that we could safely manage his airway without a tracheostomy, nor could we guarantee safe decannulation given his prognosis. The patient was given the option of leaving AMA or choosing hospice but ultimately agreed to proceed with surgery.
Given the negative COVID test, clinical picture with absence of fever, and the likely structural source of airway distress on imaging, we decided that the patient could be taken to the operating room without the need for a negative pressure room or PAPRs. Per current hospital guidelines for aerosolizing procedures (even in presumed COVID-negative patients), all staff wore N-95 masks, face shields, gowns and gloves. Our thoracic anesthesiologist (EAO) believed he could likely intubate the patient orally, and we all agreed that awake tracheostomy or awake fiberoptic intubation would be difficult due to the tracheal lesion and the patient’s anxiety. We prepared for rigid and flexible bronchoscopy as well as possible emergent tracheostomy but proceeded with a rapid sequence induction using videolaryngoscopy. The anesthesiologist had a grade I Cormack and Lehane view with the C-Mac videolaryngoscope and was able to pass an 8.0 endotracheal tube (ETT) through the glottis. Once ventilation was confirmed, we passed a flexible bronchoscope through the ETT and visualized the tracheal lesion. We were then able to carefully pass the tube over the bronchoscope beyond the mass as it was soft. The table was turned 90 degrees and the patient suspended for telescopic laryngoscopy with an excellent view using a Lindholm laryngoscope. Ventilation was held, the ETT cuff was deflated, and the tube was withdrawn, revealing a pedunculated, friable mass. The mass was removed with upbiting cupped forceps and sent to pathology (Figure 2 ). Bleeding was controlled with topical oxymetazoline cottonoids. With the airway now clear and the patient now known to be an easy intubation via direct laryngoscopy, the decision was made to extubate the patient. The patient had immediate resolution of stridor and dyspnea and was discharged the following day. Pathology of the tracheal mass revealed carcinoma with similar appearance to his tonsil cancer, strongly suggesting metastatic disease involving the anterior tracheal wall.