DISCUSSION
This case illustrates the new challenges presented by the COVID-19 (SARS CoV-2) pandemic and brings into focus numerous challenges that are being evaluated by Otolaryngologist-Head and Neck Surgeons and multidisciplinary airway teams across the globe. Numerous institutional and specialty society guidelines have been developed in the United States as well as in Europe and Asia.1-8
While the scenario in this case would likely otherwise have been relatively straightforward, the fact that the patient was consider a PUI complicated every step of his evaluation and management. First was the decision of who would perform primary assessment, as we have determined that more senior level responses to such consultations are needed. This prompted a discussion including faculty about whether to do NPL, which would ordinarily be performed by a resident (with topical anesthesia as needed) prior to involving the rest of the team. Second, in determining what PPE was needed for primary assessment and NPL, it became apparent that things might progress, so we activated our ARR system. This type of system brings key personnel and equipment to the bedside during an airway emergency or for intubation in a difficult airway, but may also be used to allow for planning discussions during nonemergent but “metastable” situations that are at risk of rapid escalation.9,10 In this case, due to “social distancing” practices, the team consultation generated by the ARR was with six feet distance maintained among the team members.
Airway assessment by NPL was needed to allow us to get COVID testing due to a shortage of testing at the time of this scenario. In addition, it provided vital information that the obstruction was below the level of the glottis. We could not be sure the patient could be intubated with rapid sequence induction, which is the gold standard for COVID positive patients, due to his mallampati grade, trismus, challenges with upper lip bite test, and his obesity.11,12 Prior tracheostomy and altered anatomy from his resection and free flap were also factors making him a potentially difficult airway. In addition, even if laryngoscopy was achieved, neither oral nor nasal intubation beyond the obstruction could be guaranteed. We believed that CT scan of the chest should be performed as it would help evaluate the trachea for lesions as well as COVID lung lesions, however this required the COVID testing to be negative.13,14
We have established a new set of guidelines for tracheostomy in ventilated patients in our institution but there are also unique issues associated with the postop management of patients with tracheostomy, whether they are COVID positive or negative, during this pandemic.5 For this patient, the psychological impact of tracheostomy was extraordinary, particularly given the possibility of needing permanent tracheostomy in the setting of likely incurable head and neck cancer. However, we felt that his complicated anatomy necessitated consent for tracheostomy if he desired airway intervention. We were also aware of and discussed potential challenges with securing necessary supplies and home nursing to manage a trach at home during the current global healthcare crisis.
Fortunately, we found that the patient had a Cormack and Lehane grade I view with both the videolaryngoscope and the Lindholm laryngoscope, was able to be ventilated both proximal and distal to the obstruction, and remained stable.15 The tracheal mass was easily removed endoscopically. We decided that this more palliative approach was in line with the patient’s current goals for airway management, particularly in light of the discovery of metastatic disease in the lungs by CT (pulmonary nodules) and the trachea on final pathology. Tracheostomy, which would have required longer admission and the risk of repeated ARR calls, was thus avoided.16 The patient was allowed to go home with the understanding that this could progress but with a plan to revisit radiation and explore options for immunotherapy pending analysis of pathology for specific mutations. Of note, while this case represents a very unusual airway complication and a poor oncologic outcome from his initial surgery, we wish to emphasize that this is an aberration from the typical treatment course of p16+ SCCA at our institution. Our institution is submitting a report of 90 cases of TORS resections and free flaps with excellent functional and oncologic outcomes (Gomez et al, manuscript in preparation).
The issues discussed in his case apply not only to tracheostomy but to all oral, nasal and pharyngolaryngeal surgery including endoscopy for cancer. Undoubtably, management of head and neck cancer patients is a major dilemma during this pandemic. While we must protect our staff and have begun employing N-95 masks and face shields for all head and neck aerosolizing procedures, we do not yet have widespread availability of COVID testing prior to managing these patients.17-19Despite that, surgery remains the best option for many head and neck cancer patients, even if it requires tracheostomy.20Without surgery, patients are faced with repeated visits to healthcare facilities for radiation and possible immune compromise associated with the addition of chemotherapy, all of which increases patients’ exposure and risk of serious infection from COVID-19 during cancer treatment. This case highlights the importance of careful and collaborative decision making for the management of head and neck cancer and other “difficult airway” patients during the COVID epidemic.
Figure 1. Representative CT images demonstrating pedunculated tracheal lesion (A, C) pedicled anterolaterally on the tracheal wall just superior to the prior tracheostomy site (B). Panel D demonstrates multiple new pulmonary nodules concerning for metastases. A subcarinal mass was also seen on CT.
Figure 2. Endoscopic view of the trachea after resection of pedunculated mass demonstrating base of lesion anterolaterally on the left (labeled with a star) and mild A-frame deformity from prior tracheostomy.
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