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| LETTER TO THE EDITOR |
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| Year : 2022 | Volume
: 9
| Issue : 4 | Page : 373-374 |
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Dilemma of perioperative steroid use in diabetic mucormycosis patients undergoing airway-related surgeries: a letter to the editor
Mridul Dhar, Anirban Brahma Adhikary, Ramesh Roopesh, Mohammed S Shajahan, Abhishek Kumar Singh
Department of Anaesthesiology, AIIMS, Rishikesh, Uttrakhand, India
| Date of Submission | 30-Dec-2021 |
| Date of Decision | 17-Feb-2022 |
| Date of Acceptance | 05-Mar-2022 |
| Date of Web Publication | 29-Dec-2022 |
Correspondence Address:
SR Mohammed S Shajahan
Department of Anesthesiology, 6th Floor, Academic Block, AIIMS, Rishikesh, Uttrakhand 249203
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/roaic.roaic_91_21
How to cite this article:
Dhar M, Brahma Adhikary A, Roopesh R, Shajahan MS, Kumar Singh A. Dilemma of perioperative steroid use in diabetic mucormycosis patients undergoing airway-related surgeries: a letter to the editor. Res Opin Anesth Intensive Care 2022;9:373-4 |
How to cite this URL:
Dhar M, Brahma Adhikary A, Roopesh R, Shajahan MS, Kumar Singh A. Dilemma of perioperative steroid use in diabetic mucormycosis patients undergoing airway-related surgeries: a letter to the editor. Res Opin Anesth Intensive Care [serial online] 2022 [cited 2023 Mar 26];9:373-4. Available from: http://www.roaic.eg.net/text.asp?2022/9/4/373/365803 |
A 42-year old male patient of type 2 diabetes mellitus on oral hypoglycemic agents presented to the emergency department with complaints of nasal congestion for past 2 weeks, progressive swelling and reddening of the cheeks on the right side for 1 week, and persistent and gradually increasing pain of the right cheek for 4 days. Contrast-enhanced MRI was suggestive of fungal hyphae in the right maxillary sinus, which was extending up to the ethmoid sinus, suggestive of mucormycosis. The patient was planned for right open maxillectomy.
On the day of surgery, the patient was induced with fentanyl, propofol, and vecuronium injections. The airway was secured with an 8 mm flexometallic tube. The patient was handed over to the surgical team after throat packing. The surgery lasted for 3 h. At the end of the surgery neuromuscular blockade was reversed and the trachea was extubated. Following extubation, the patient was maintaining all parameters including oxygenation but gradually started developing respiratory distress with mild stridor. Oxygen saturation levels also started to drop. Suspecting some sort of airway compromise or spasm, initially Continuous Positive Airway Pressure (CPAP) and intermittent manual assistance were done using bag and mask ventilation, but it was largely ineffective. Next, the plane of anesthesia was deepened using sevoflurane and propofol (in aliquots). A supraglottic airway device was finally introduced to maintain a patent airway while the waiting for the effect of anesthetics to wear off. Hydrocortisone 100 mg intraveous injection was then administered after tiding over the initial airway problem and stabilization of the patient. Airway parameters gradually improved after 15 min and the device was removed soon to avoid further insult to the edematous airway after good spontaneous efforts, and responsiveness was achieved.
The use of perioperative steroids such as hydrocortisone and dexamethasone is fairly common in airway-related surgeries like the one described in the present case. Here, our initial intent was to avoid giving steroid intraoperatively in view of the preexiting diabetes mellitus and active mucormycosis. However, the amount of airway edema and airway handling is difficult to judge and may cause airway problems toward the end of the procedure, like what was observed in the present case. Our patient had most likely benefitted from corticosteroid administration by reducing airway edema and inflammatory response of the airways.
There is evidence for significant increase in the incidence of angioinvasive maxillofacial fungal infections in diabetic patients treated for SARS-CoV-2 with a strong association with corticosteroid administration [1]. In these cases, the risk of upper airway obstruction resulting from postoperative laryngopharyngeal edema and, in some cases, from the use of bulky flaps in reconstruction is obvious [2]. Upper airway edema predisposes the patient to postoperative airway obstruction. It presents mostly as postextubation stridor and at times warrant postoperative elective ventilation [3]. Meta-analyses have shown that preemptive administration of glucocorticosteroids can reduce the incidence of laryngeal edema and subsequent reintubation [4].
Thus, we conclude that preemptive single intraoperative dose of short-acting steroids for mucormycosis surgeries with airway manipulation may be justified for decreasing postoperative airway morbidity. However, more studies and data are needed to justify continuation of steroids in the postoperative period in such cases.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
| References | |  |
| 1. | Moorthy A, Gaikwad R, Krishna S, Hegde R, Tripathi KK, Kale PG et al. SARS-CoV-2, uncontrolled diabetes and corticosteroids—an unholy trinity in invasive fungal infections of the maxillofacial region? A retrospective, multi-centric analysis. J Maxillofac Oral Surg 2021; 20:418–425.  |
| 2. | Lin HS, Wang D, Fee WE, Goode RL, Terris DJ. Airway management after maxillectomy: routine tracheostomy is unnecessary. Laryngoscope 2003; 113:929–932. |
| 3. | Ambasta S, Rudingwa P, Kundra P, Gnanasekar R. Treatment of upper airway oedema prior to extubation. Indian J Anesth 2016; 60:10. |
| 4. | Wittekamp BH, van Mook WN, Tjan DH, Zwaveling JH, Bergmans DC. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care 2009; 13:1–9. |
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