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.