Confronting Catastrophe

Amid a once-in-a-lifetime pandemic, faculty from the Department of Otolaryngology–Head and Neck Surgery at Harvard Medical School conducted research to combat the spread of COVID-19 and mitigate its long-term symptoms.

When the COVID-19 pandemic began in March 2020, a sense of panic surged through the medical community worldwide. The virus responsible for the novel coronavirus, SARS-CoV-2, was spreading at an alarming rate. Even worse, misinformation about the virus had made its spread difficult to stop. By July, over 10 million people had been infected and more than 500,000 had died, according to data collected by the World Health Organization (WHO).

Few medical specialties felt the seismic effects of the pandemic more than otolaryngology–head and neck surgery. The SARS-CoV-2 virus is concentrated in areas of the body regularly exposed to ear, neck and throat (ENT) surgeons and clinicians: the upper respiratory tract, sinuses, trachea, larynx and skull base. There, the virus can easily spread from person to person through aerosols produced by talking, sneezing, coughing and breathing.

Endoscopic procedures are also capable of producing large amounts of aerosols, but their exact quantity and spread remained a mystery to ENTs, who needed to pause non-emergency surgeries and reassess safety measures. Meanwhile, patients who had been hospitalized with COVID-19 were returning to clinics months after their discharge with difficulty breathing and, in some cases, a total or partial loss of smell.

“The enormity of the problem was staggering,” said Phillip C. Song, MD, Assistant Professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School and Director of the Division of Laryngology at Mass Eye and Ear. “While oxygen had to be rationed and personal protective equipment was few and far between, the most significant medical shortage was the lack of knowledge about the virus’ spread and long-term effects.”

Using the Joseph B. Nadol, Jr., MD, Otolaryngology Surgical Training Laboratory at Mass Eye and Ear as a base of operations, faculty from the Department of Otolaryngology–Head and Neck Surgery at Harvard Medical School (HMS) combined their resources in an attempt to close these knowledge gaps. After collectively publishing more than 25 peer-reviewed articles about the virus, the department quickly emerged as a global thought leader in COVID-19 research.

Their work has since transformed the way surgeons and clinicians understand and treat this disease, and future public health threats, for years to come.

Containing the spread

At the pandemic’s onset, the immediate concern of ENTs was understanding the spread of the virus during airway and endoscopic procedures. Skull base and nasal endoscopic procedures were widely known to generate the widest ranges of airborne aerosols, and neither the Center of Disease Control and Prevention (CDC) nor the WHO had issued any formal guidance on how to contain viral transmission during these procedures.

Without knowing the quantity of the aerosols produced by each endoscopic procedure, ENTs could not properly assess how dangerous their procedures on COVID-19 patients were and what kind of personal protective equipment was necessary inside the clinic and operating room.

“When we went back and looked at the medical literature, there was no data written about aerosolization in ENT procedures,” said Benjamin Bleier, MD, FACS, Associate Professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School and Director of Otolaryngology Translational Research at Mass Eye and Ear. “We were really the first to test how we should be protecting ourselves from COVID-19 during these procedures.”

Dr. Bleier worked with Alan Workman, MD, a PGY-4 in the Harvard Otolaryngology Residency Program, to quantify the size and spread of aerosols generated from endonasal procedures performed on cadavers, as well as those generated from clinical simulation. They also tested how well different masks protected physicians from these aerosols.

In a study published in Otolaryngology–Head and Neck Surgery, their findings revealed that high-speed drilling and cauterization produced significant airborne aerosols in surgical settings, as did speech and sneezing when tested in office settings. Aerosols produced from the procedures were measured in the 1-to-10-micron range, a range too small for surgical masks to contain. Only N95 masks modified to permit endoscopy of the nose and throat could adequately limit the spread of such aerosols during these procedures.

As a whole, their work offered valuable guidance to the ENT community on how to safely resume surgeries and patient visits.

Tackling long-term effects

The most serious consequence of a severe COVID-19 infection is acute respiratory failure. During a severe infection, the virus causes pneumonia, which inflames the lungs and fills them with fluid. If too much fluid fills the lungs, acute respiratory distress syndrome ensues and breathing capacity is restricted. Ventilator support, often through intubation, is then needed to maintain basic oxygen requirements for the body and prevent systemic collapse.

Three months into the pandemic, Dr. Song noticed a troubling trend among those intubated: patients were returning to the hospital with breathing difficulties. Those who had required ventilator support had sustained significant damage to their trachea, larynx and lungs. Most of this damage was considered irreparable, which prompted Dr. Song to investigate further.

In a study published in Laryngoscope: Investigative Otolaryngology, Dr. Song found laryngeal complications in 20 former COVID-19 patients, 13 of whom had been hospitalized and intubated for an average period of over three weeks. Intubated patients were commonly diagnosed with vocal fold immobility, glottic stenosis and subglottic stenosis, whereas those who avoided intubation did not display any evidence of paralysis or stenosis.

Unsure of whether the trauma in the airways resulted from intubation, the virus or a combination of both, Dr. Song launched the COVID-19 Central Airway Consortium to better understand and mitigate longterm conditions affecting COVID-19 patients. The consortium consists of dozens of critical care providers, anesthesiologists, pulmonologists, thoracic surgeons and comprehensive ENTs from across Mass Eye and Ear, Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Massachusetts General Hospital, the Spaulding Rehabilitation Hospital and Boston Children’s Hospital.

Together, the specialists combined their expertise to implement new strategies to reduce intubation times, limit the frequency of prone positioning and broaden the use of non-invasive ventilation. They also collaborated on tracheal dilations, steroid injections, endoscopic surgeries and chemotherapy to partially restore the normal function of the damaged airways.

“Our protocols made an immediate difference across the system,” Dr. Song said. “Despite the surges, we were reducing mortality rates and simultaneously preventing further trauma to the airway.”

A lasting legacy

With an in-depth understanding of aerosol production and a consortium of doctors working together to mitigate the long-term effects of COVID-19, the Department of Otolaryngology–Head and Neck Surgery at Harvard Medical School has trailblazed new preventive and mitigative practices that will linger far into the future.

In fact, Dr. Workman believes patients shouldn’t be surprised to see ENTs wearing masks in the clinic or working in rooms with heightened ventilation long after the pandemic ends. The aerosol study conducted by Drs. Bleier and Workman has been replicated and cited by hundreds of world-renowned physicians who have further assessed the risk endonasal procedures pose to physicians and patients and have confirmed the protective benefits masks provide during these procedures.

“I think we’ll be much more prepared to think about what we’re doing in the clinic and in the operating room if another widespread pandemic occurs,” Dr. Workman said. “With our knowledge, we’d be able to address safety concerns quickly and in a way that wouldn’t require us to completely shut down operations.”

By transitioning to post-COVID recovery efforts directed at central airway disease, Dr. Song hopes to better manage a plethora of long-term symptoms beyond airway trauma. He believes conditions such as anosmia, chronic respiratory failure, dysphagia, neuropathy and CNS dysfunction will continue to plague patients recovering from COVID-19. By establishing screening guidelines, launching clinical trials and sharing resources across the Harvard network, the consortium could create a much more effective and efficient protocol for treating COVID-19 patients, as well as future outbreaks.

“Moving forward, we need to start thinking of the long-term effects of COVID-19 since millions of more people around the world will be infected by the time the pandemic ends,” Dr. Song said. “With our department’s full resources at our disposal, the ability to address many of these serious issues is within our grasp.”