Discussion
As the Covid-19 pandemic progresses, an increasing number of clinical implications of the disease emerge. SARS-CoV-2 infection can severely affect laryngectomees and although this population is rather small, experiences need to be collected regarding their management and clinical course. In the present paper, we described a series of five laryngectomees presenting with tracheitis characterized by a more severe pattern compared to the usual cases of seasonal tracheitis, in terms of both disease duration and management challenges.
Several criticalities were noticed in those patients: the hemorrhagic component, the detrimental role of oxygen therapy on the tracheal mucosa and crusting, the difficulty in ventilating patients with concomitant pulmonary involvement due to the tracheal obstruction and finally the management of tracheo-bronchial obstruction. The latter aspect needs special attention: due to the increased aerosolizing risk, in fact, laryngectomees have the potential to become “super spreaders” and transmitting viral particles to health care staff 4. When urgent procedures related to bulky obstructing clots are required, the time for disposing proper personal protective equipment may lack. Therefore, we suggest planning a daily precautionary flexible tracheoscopy, to avoid acute airway obstruction, which in the setting of SARS-Cov-2 associated pneumonia can induce a rapid worsening of the respiratory failure in these patients, eventually creating an emergency situation. Moreover, when possible, the avoidance of tracheal intubation permits to reduce further tracheal complications.
Human angiotensin-converting enzyme II (ACE2) has been identified as a functional receptor for SARS-CoV-2. The tracheal epithelium expresses high levels of ACE2 receptors in humans and sustained viral replication in the tracheal epithelium have been showed in ACE2-humanized animal models 5. Indeed, SARS-CoV-2 RNA and antigens have been identified in ciliated epithelial cells of the trachea and bronchi of infected patients 6. Also, evidences of acute and chronic tracheitis due to Sars-CoV2-involvement of the tracheal mucosa have been showed in post-mortem histopathologic examination of Covid-19 cases 7. A previous study by Verger et al.8 demonstrated signs of a tracheobronchitis in a COVID-19+ patient, detected by lung scintigraphy. A report by Paderno et al. 9 described two cases of COVID-19+ laryngectomized patients who presented with respiratory distress due to a concomitant severe pulmonary involvement and tracheal inflammation, who required repeated tracheal toilettes. Similar to our series, one patient had a fatal outcome and the paper focused on the potential higher risk for a worse outcome of this patient’s population; evidences from the present cases allowed us to support these considerations.
Histological samples, collected in two patients, demonstrated a diffuse inflammation along with epithelial erosion. The erosive pattern of Covid-19-related tissue damage has already been described10: two cases of ulcerative lesions of the epiglottis, subglottis and upper trachea were described in patients with a resolution of clinical, radiological and bronchoscopic characteristics of COVID-19 respiratory disease. This histopathological aspect, along with the hemorrhagic component, could be partially responsible for the longest mean duration of the disease in these patients, compared to usual post-laryngectomy tracheitis. In the light of the histological features of tracheitis found in our patients, we can hypothesize two mechanisms wich can play a role in the hemorrhagic phenotype of tracheitis. Indeed, the erosive mucosal damage associated with the endothelial dysfunction caused by SARS-CoV-2 may explain the airway bleeding in these patients, which can be exacerbated by the use of anticoagulants.
The present cases highlight the need for close interdisciplinary working and communication in the management of airway complications of COVID-19 infection. Careful joint planning between anesthesiologist, pneumologist and ENT surgeons is critical and despite it, this category of patients have a high risk for poor outcome.
The main limitations of the present study are the retrospective design and the small study population, which is related to the rarity of the clinical condition. Nonetheless, in the authors’ opinion, the clinical experience in this frail population can be important for improving the management and avoiding critical obstruction of the airway.