Disparate Nasopharyngeal and Tracheal COVID‐19 Diagnostic Test Results in a Patient With a Total Laryngectomy

Abstract

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has been declared a pandemic by the World Health Organization.1 In the setting of this current pandemic, reliable diagnostic testing for COVID-19 is essential to health care institutions worldwide to appropriately treat those with the disease and to limit contagion to healthy patients and health care providers. Most diagnostic tests identify SARS-CoV-2 genetic material in patient samples of airway secretions. Specimens are most commonly obtained by swabbing the nasopharynx or oropharynx.2 Patients with a laryngectomy require special consideration for the site of diagnostic testing due to their surgically altered airway anatomy and may require sampling from multiple sites.3 Here, we report a case of a patient with a total laryngectomy who had a positive COVID-19 diagnostic test result from a nasopharyngeal swab and a negative result from a tracheal swab. This case report was waived from review by the Rush University institutional review board. A 54-year-old woman with a history of salvage total laryngectomy 13 years ago for recurrent laryngeal cancer presented to the speech-language pathology clinic for evaluation of dysphagia with solid foods after a recent change in length of her tracheoesophageal prosthesis (TEP), which had been placed previously. Prior to the scheduled appointment, she received point-of-care testing for SARS-CoV-2 according to clinic protocol. The patient did not endorse symptoms of COVID-19 at the time of testing. Two specimens were obtained: one from a nasopharyngeal swab and another from a tracheal swab via the tracheostoma. The nasopharyngeal specimen tested positive for SARS-CoV-2 genetic material while the tracheal specimen tested negative. Because of the positive test result, the patient was interviewed and counseled by a provider wearing the appropriate personal protective equipment as advised by our institution. Manipulation of the TEP and endoscopy were both deferred during the clinic visit due to the risk of aerosolization of infectious secretions. The patient was discharged home and given instructions to continue a diet of soft foods, self-isolate at home, and seek care urgently if experiencing severe symptoms of COVID-19. SARS-CoV-2 is primarily transmitted via inhalation of respiratory droplets containing the virus.4,5 Because patients with a total laryngectomy do not generate significant inspiratory airflow through the upper airway, it logically follows that specimens obtained from their nasopharynx are unlikely to contain SARS-CoV-2. The upper airway and the tracheostoma, however, may both be inoculated by contact with a contaminated surface, such as one’s hands.5 This case supports authors who have recommended diagnostic testing of patients with a total laryngectomy using specimens from both the upper and lower airways.3 The presence of a TEP is another important consideration in patients with a total laryngectomy. Placement of a TEP necessitates creation of a fistula connecting the trachea and esophagus. Due to this connection, it is plausible that the viral colonization or infection of the pharynx could propagate to the trachea and vice versa. As a result, a patient who tests positive for COVID-19 in only the nasopharynx—such as the patient presented here—may still be at risk for the more severe sequelae of the disease, such as acute respiratory distress syndrome. Many patients with a total laryngectomy are also at high risk of severe complications of COVID-19 due to a history of smoking and pulmonary comorbidities. Patients who test positive in only the upper airway are at risk of transmitting the virus to others in certain circumstances. Esophageal or tracheoesophageal speech has the potential for creating aerosolized droplets containing virions. In a health care setting, aerosolizing procedures of the nasal cavity, pharynx, or esophagus may also pose a risk for providers. Patients who communicate via tracheoesophageal speech require in-person visits for TEP management and failure, even during the current pandemic. Therefore, proper testing of patients with a total laryngectomy can inform appropriate personal protective equipment use for providers. This report highlights the case of a patient with a total laryngectomy who had a positive COVID-19 test result from a nasopharynx swab and a negative result from a tracheal swab obtained via the tracheostoma. The case supports previous recommendations for multiple-site testing in this patient group.3 Sampling of both the upper and lower airways should be strongly considered when performing COVID-19 diagnostic testing in patients with a total laryngectomy. Tirth R. Patel, conception and design; data acquisition; drafting, revision, final approval of article; Joshua E. Teitcher, conception and design; data acquisition; drafting, revision, final approval of article; Bobby A. Tajudeen, conception and design; drafting, revision, final approval of article; Peter C. Revenaugh, conception and design; drafting, revision, final approval of article Competing interests: None. Sponsorships: None. Funding source: None.