Pituitary tumor resection in a patient with SARS-CoV-2 (COVID-19) infection. A case report and suggested airway management guidelines

Abstract

The 2020 pandemic caused by the novel coronavirus, COVID-19, had its headquarters in China. It causes Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and presents a broad spectrum of clinical manifestations, ranging from entirely asymptomatic through severe acute respiratory failure and death. Presuming a significant quantity of ventilator-dependent patients, several institutions strategically delayed elective surgeries. Particularly procedures performed involving the nasal mucosa, such as a transsphenoidal approach of the pituitary gland, considering the tremendous level of viral shedding. Nevertheless, critical cases demand expeditious resolution. Those situations are severe pituitary apoplexy, declining consciousness level, or risk of acute visual loss. This case presents a successful urgent perioperative management of a 47 year-old male COVID-19 positive patient who presented to the Emergency Department with a left frontal headache that culminated with diplopia, left eye ptosis, and left visual acuity loss after 5 days. Transsphenoidal hypophysectomy was uneventfully performed, and the patient was discharged from the hospital on postoperative day four. It additionally describes in detail the University of Mississippi Medical Center airway management algorithm for patients infected with the novel coronavirus who need emergent surgical attention.

Keywords: Airway management; Pituitary tumor; SARS-CoV-2 infection (COVID-19).

Figure 1

(a and b) Computed tomography without contrast. Axial (a) and coronal (b) slices show predominantly hyperdense sellar mass measuring 1.9 × 2.8 × 2.0 cm eccentric to the left with extension into the suprasellar cistern, impingement on the left optic chiasm, and dehiscence of the bilateral posterior sphenoid sinus walls.

Figure 2

(a–c) Pituitary MRI with and without contrast. (a) Sagittal T1 Sellar mass with obscuration of the pituitary stalk; (b) and (c) coronal and axial T2 – heterogeneous peripherally T2 isointense centrally dark mass with diminished enhancement in the sella turcica extending into the suprasellar cistern with local mass effect. Elevation of the optic chiasm as well as prechiasmatic portion of the left greater than right optic nerve. Findings compatible with pituitary macroadenoma with central hemosiderin deposition suggesting remote hemorrhage.

Figure 3

Plastic drape over the patient while airway instrumentation to secure airway.

Figure 4

Donning order (UMMC protocol) for COVID-19 positive patients.

Figure 5

Doffing order (UMMC protocol) for COVID-19 positive patients. Hand hygiene**: Hand hygiene with foamed antiseptic hand sanitizer.