CASE REPORT
A 60-year-old male presented to the emergency department (ED) with
progressive stridor. His history was notable for radical tonsillectomy,
neck dissection, radial forearm free flap and tracheostomy for a locally
and regionally advanced p16+ squamous cell carcinoma (SCCA)
approximately two months earlier. The patient’s tracheostomy had been
removed one month prior to presentation, and he had just begun
postoperative chemoradiation. The patient was known to our head and neck
team having had his surgery in our division.
The otolaryngology consult resident (JED) was called for urgent airway
evaluation. As a result of new residency policies, the junior resident
consulted with the attending consult faculty (CHR) prior to seeing the
patient, who determined a need for a conference call with the junior and
senior resident (CMJ). We developed a plan for definite hospital
admission and likely nasopharyngolaryngoscopy (NPL). Complicating this
was the fact that the patient was considered a “PUI” (patient under
investigation/rule out COVID-19). Although the patient had stridor and
positional dyspnea (when lying down), he was reportedly not having any
oxygen requirement and was otherwise stable.
A plan was made for the consult team to arrive at the ED together,
assess the patient, and discuss with the ED attending prior to
performing any procedure. We realized that in the setting of a potential
COVID infection, team members were at risk of exposure even during a
standard head and neck exam and that any airway procedure including NPL
would ideally require full personal protective equipment (PPE). The
added risks and resources needed for airway evaluation and management in
a PUI prompted us to activate the Airway Rapid Response (ARR) team for a
more comprehensive team huddle. Airway Rapid Response mobilized the key
personnel and equipment that might be needed if the situation
deteriorated, and it allowed us to discuss the consequences of the
options available with all key personnel. Notably, in the COVID era,
team members attempted to maintain six feet of distance between each
other during the huddle.
Ultimately, it was determined that the consult faculty should don full
PPE (powered air-purifying respirator [PAPR], gown, and gloves) and
enter the room to do an airway assessment while the rest of the airway
team prepared to don PPE in the event they were also needed. Upon entry
into the room, the patient, who was wearing a surgical mask, was
extremely anxious, had loud stridor but had no oxygen requirement and a
regular respiratory rate when calm. Further history revealed he had
progressive dyspnea since decannulation one month prior and was sent to
the ED by his radiation oncologist during a routine visit. He had a
history of sleep apnea and chronic renal insufficiency. Primary
assessment revealed that he had trismus, a well healed free flap in the
lateral oropharynx, and a Mallampati grade of 3. He had a large neck and
a nearly healed tracheostomy site with a small amount of granulation
tissue in the residual tract.
The patient was notified of the need for NPL evaluation and that topical
anesthesia would be avoided due to the risk of virus aerosolization and
of worsening his airway. He became more anxious and had increasingly
loud stridor and tachypnea. A disposable bronchoscope, tracheostomy set,
kerrison rongeurs, endotracheal tubes of varying size, and a
videolaryngoscope were opened at bedside. The head and neck senior
resident, anesthesia attending, and a respiratory therapist donned full
PPE and prepared for intubation or tracheostomy in the ED negative
pressure room in case of decompensation.
The patient was preoxygenated in case a rapid sequence induction was
needed for oral intubation. Fiberoptic NPL revealed mild laryngeal edema
and normal vocal cord mobility, thus suggesting a subglottic or tracheal
source of obstruction. The patient tolerated the procedure well,
remained stable, and was weaned back to room air. Despite the potential
need for revision tracheostomy to manage the patient’s presumed
infraglottic airway obstruction, it was determined that it would be best
to avoid further intervention until COVID-19 testing resulted and, if
possible, a CT chest could be performed. CT chest would be helpful in
looking for COVID lesions and also to assess the trachea but was
deferred pending COVID testing. Due to limited availability for COVID
testing, all of the above steps were needed to provide a “golden
ticket” to get the fastest COVID testing possible at that time. Even
though the patient was not febrile, we felt that it was important
because of the need for PPE, location and timing of the intervention.
The patient was instructed to again don his mask, and he was transferred
to a negative pressure room in the surgical ICU where the airway
equipment was again placed at bedside. Eventually, COVID-19 testing
resulted and was negative. A chest CT was obtained without contrast (due
to the patient’s history of renal insufficiency) and revealed multiple
pulmonary metastases, a subcarinal mass (likely nodal), slight narrowing
of the subglottis, and a mass in the trachea near the prior tracheostomy
site, felt to be most consistent with a granuloma (Figure 1 ).