Tracheostomy in upper airway obstruction on a COVID-19 patient

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Background: Â Stridor due to upper airway obstruction in a COVID-19 positive patient is a big challenge to the medical team, especially anesthetists and otolaryngologists. In this condition, performing aerosol-generating procedures (AGP) is time-sensitive and increases virus transmission risk. The dilemma of treating a stridorous patient with laryngeal carcinoma and concurrent COVID-19 positive with pneumonia is possibly become a new normal in this era.Case Report: A 66-year-old male, chronic smoker, completed six days of in-patient treatment for community-acquired pneumonia when the RT-PCR for COVID-19 was found to be negative. He was seen in the otorhinolaryngology (ORL) clinic two weeks later due to hoarseness for two months associated with worsening shortness of breath and cough. He had soft stridor at rest and was mildly tachypnoeic. Flexible endoscopy revealed a mass on the right immobile vocal cord with a small glottic airway. A repeat nasopharyngeal swab for COVID-19 on the same day was positive. A detailed discussion involving a multidisciplinary team lead to the decision to secure the patient's airway by first intubating him with a small endotracheal tube and followed by tracheostomy in the same setting. Here, the experience in managing upper airway obstruction due to laryngeal carcinoma (at least T3) in a patient with stage 4 COVID-19 is presented and discussed. The challenges emerged due to the inevitable series of AGPs that need to be performed. Multidisciplinary team involvement comprises ORL surgeon, anesthetist, infectious disease, and respiratory physician is pertinent. Â Conclusion:Â This is the first case in the literature on a stridorous COVID-19 positive patient with laryngeal carcinoma that requires emergency tracheostomy. The case highlights the challenges and decision-making in managing such cases that are supposed to be straightforward before the COVID-19 pandemic era. This shall be the new normal for otorhinolaryngologists, anesthetists, and maybe any other specialties who deal with AGPs.