Even with the United States now leading the world in the number of coronavirus cases, there is still so much regarding the disease we do not know. The virus continues to spread despite lockdown measures with now more than 550,000 confirmed cases in the U.S. Given the lack of widespread testing, however, the number is likely many times more. The virus is now community-spread, or spread without a known source, and asymptomatic carriers likely play a significant role in the dissemination of the virus.
COVID-19, the disease caused by coronavirus infection, also appears to be evolving as it makes its way around the globe. In New York City, 49 percent of positive patients are under 50, a shift from the initial assessment that this was a disease of the elderly and frail. In South Korea, where the testing rate is highest in the world and people are tested regardless of symptoms, we find nearly 30 percent positive tests in those under age 30.
In order to mitigate the viral spread, therefore, asymptomatic carriers need to be identified.
Anosmia, the loss of sense of smell, may be one unusual symptom to identify these carriers. Earlier this month, a report in the South Korean newspaper Chosun estimated that about 30 percent of those infected with coronavirus reported anomia. The professional association of otolaryngologists in the United Kingdom, ENT UK, released a statement identifying anosmia as a symptom of COVID-19 using reports from Iran, Germany and Italy. The American Academy of Otolaryngology Head and Neck Surgery recently called for the addition of anosmia to the list of screening symptoms.
For those of us who are otolaryngologists, or ear, nose, and throat surgeons, seeing anosmia in patients with a viral illness is not uncommon. It is thought to be caused by a viral neuropathy, or inflammation of the olfactory nerve. From studies of other SARS coronaviruses, we know that the viral load in the nose and nasopharynx is high. What is unusual in COVID-19, however, is that it may present with no other sinonasal or respiratory symptoms: no nasal congestion, no runny nose, no sneezing. My cousin Huma called me earlier this week with new-onset anosmia. She felt it was odd because in the past when this occurred, she definitely felt congested. “I can breathe through my nose just fine, but I just can’t smell,” she told me. Currently, she is not having any other symptoms, but is in self-quarantine as a precaution.
Because of this possible connection, Otolaryngologists likely will play a greater role in identifying asymptomatic carriers of COVID-19 than previously thought. Unfortunately, this compounds the risk to these providers.
Otolaryngologists, especially, are at increased risk of COVID-19 infection according to initial reports out of Wuhan. This finding is supported by anecdotal reports from Italy, Greece and Iran, where at least 40 otolaryngologists are suspected to have been infected and 20 hospitalized. In the U.K., one of two ENTs on life support has already died. Stanford University School of Medicine and the Australian Society of Otolaryngology Head and Neck Surgery have both released statements of caution based on these reports.
Part of this is due to the close contact otolaryngologists have with their patients during physical examinations—especially given the high risk of encountering aerosolized viral particles while using instruments to examine the nasal passages and upper airway. A single endoscopic skull base surgery in China reportedly resulted in 14 operating room health care workers becoming infected with COVID-19. In light of this concern, the American Academy of Otolaryngology–Head and Neck Surgery has strongly recommended all elective outpatient visits and surgeries be rescheduled.
Still, not every ENT procedure is elective. As doctors, we treat head and neck cancer, airway obstruction, sinonasal tumors and skull base infections—all issues that can’t safely be delayed. These patients need to be seen and examined. By doing a proper examination, which often includes nasal endoscopy or laryngoscopy, we are placing ourselves at increased risk of coronavirus infection more than other health care providers. We need proper personal protective equipment (PPE), and we need universal guidelines to mandate this.
To be sure, other medical specialties are on the frontlines of this pandemic as well, including emergency medicine, yet those physicians know they will encounter coronavirus patients and are taking appropriate precautions. For otolaryngologists, the infection may be asymptomatic and unrelated to the reason for the visit. Yet the examination may convert a viral droplet into a viral aerosol, instantly changing its infectiousness and the level of PPE required. Otolaryngologists need to act like their emergency medicine colleagues and assume every patient could infect them.
Otolaryngologists can help in the fight against the COVID-19 pandemic, but only if we are properly prepared.