Rhinology in review: from COVID-19 to biologicals

We look back at the end of what soon will be seen as an historic year, from COVID-19 to real-world introduction of biologicals influencing the life of our patients. This review describes the important findings in Rhinology over the past year. A large body of evidence now demonstrates loss of sense of smell to be one of the most common symptoms of COVID-19 infection; a meta-analysis of 3563 patients found the mean prevalence of self-reported loss to be 47%. A number of studies have now shown long-term reduced loss of smell and parosmia. Given the high numbers of people affected by COVID-19, even with the best reported recovery rates, a significant number worldwide will be left with severe olfactory dysfunction. The most prevalent causes for olfactory dysfunction, besides COVID-19 and upper respiratory tract infections in general, are trauma and CRSwNP. For these CRSwNP patients a bright future seems to be starting with the development of treatment with biologics. This year the Nobel prize in Medicine 2021 was awarded jointly to David Julius and Ardem Patapoutian for their discoveries of receptors for temperature and touch which has greatly enhanced our understanding of nasal hyperreactivity and understanding of intranasal trigeminal function. Finally, a new definition of chronic rhinitis has been proposed in the last year and we have seen many papers emphasizing the importance of endotyping patients in chronic rhinitis and rhinosinusitis in order to optimise treatment effect.

EPOS 4 Patients

EPOS2020 is the 4th and most recent version of the European Position Paper on Rhinosinusitis and Nasal Polyps which was first published in 2005. It aims to provide the most up to date scientifically robust information on the topic published in the literature which has been critically analysed by an international group of clinicians drawn from all disciplines dealing with these problems together with patients. The guidelines offer evidence-based recommendations and care pathways for acute and chronic rhinosinusitis in both adults and children. Management of these diseases from the patients' perspective is an important part of EPOS2020. Not only is this included in the main document but, for the first time, we have produced a separate supplement dedicated to and in collaboration with patients, EPOS4Patients, which aims to provide information in an accessible format, to answer frequently asked questions about these diseases and their treatment options as well as including useful patient resources and websites. It has never been more important for patients to be actively involved in their care. Being well informed helps you to make the best decisions together with your doctor.

Patients Unmet Needs in Chronic Rhinosinusitis With Nasal Polyps Care: A Patient Advisory Board Statement of EUFOREA

Background: European patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have had only limited occasions to unite to have their voices heard, hence missing the opportunity to contribute to the improvement of CRSwNP care.

Aims: To identify unmet needs in CRSwNP from the perspective of CRSwNP patients from the Patient Advisory Board (PAB) of the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA).

Methodology: Semi-structured interviews were conducted individually with 15 European patients with CRSwNP and with a disease history of more than 2 years. Patients shared their burden of the disease and frustrations related to CRSwNP care, experiences with key pillars of current treatment options, shortcomings of the current care pathways and recommendations for improvement of care. A panel of 30 members of the Patient Advisory Board reviewed the interview report and provided further input during 2 virtual meetings.

Results: CRSwNP patients indicated the need for greater awareness from society and physicians of the disease burden with impact on social function and well-being. Along with a loss of ability to smell and the continuous presence of secretions in the nose, most patients reported poor sleep quality and psychological impact as the most bothersome symptoms. Patients' frustrations relate primarily to the underestimation of the disease burden, the lack of coordination of care and the limited treatment options available to them. Treatment options with oral corticosteroids and/or sinus surgery both have positive and negative aspects, including the lack of long-lasting efficacy. Better coordination of care, more patient-centered care, greater public awareness, increases in research on the disease mechanisms and better therapeutic options would be warmly welcomed by CRSwNP patients.

Conclusions: This statement of the EUFOREA Patient Advisory Board on CRSwNP provides novel insights on the underestimation of the burden of CRSwNP and shortcomings of current care. Multiple recommendations made by the patients can underpin action plans for implementation of better care for CRSwNP among all physicians treating patients with this disabling disease.

Complications of combination intranasal corticosteroids and anti-retroviral therapy

BACKGROUND

Intranasal corticosteroids are widely used for management of many upper airway diseases because of their ability to effectively deliver local relief of inflammation.

CASE REPORT

This paper presents the case of a 51-year-old man with human immunodeficiency virus treated with ritonavir who was started on fluticasone intranasal spray for presumed chronic rhinosinusitis. Months after starting this therapy, he developed symptoms of Cushing's syndrome and avascular necrosis of the shoulder due to the pharmacological interactions between fluticasone and ritonavir.

CONCLUSION

Although intranasal corticosteroids are deemed a low-risk route of drug administration, clinicians need to be vigilant in appropriately prescribing corticosteroids in the setting of drug potentiators, particularly in these high-risk patients. Alternative corticosteroids such as beclomethasone dipropionate should be considered in such cases.

High prevalence of long-term olfactory, gustatory, and chemesthesis dysfunction in post-COVID-19 patients: a matched case-control study with one-year follow-up using a comprehensive psychophysical evaluation

BACKGROUND

Using an age and gender matched-pair case-control study, we aimed to estimate the long-term prevalence of psychophysical olfactory, gustatory , and chemesthesis impairment at least one year after SARS-CoV-2 infection considering the background of chemosensory dysfunction in non-COVID-19 population.

METHODOLOGY

This case-controlled study included 100 patients who were home-isolated for mildly symptomatic COVID-19 between March and April 2020. One control regularly tested for SARS-CoV-2 infection and always tested negative was matched to each case according to gender and age. Chemosensory function was investigated by a comprehensive psychophysical evaluation including ortho- and retronasal olfaction and an extensive assessment of gustatory function. Differences in chemosensory parameters were evaluated through either Fisher's exact test or Kruskal-Wallis test.

RESULTS

The psychophysical assessment of chemosensory function took place after a median of 401 days from the first SARS-CoV-2 positive swab. The evaluation of orthonasal smell identified 46% and 10% of cases and controls, respectively, having olfactory dysfunction, with 7% of COVID-19 cases being functionally anosmic. Testing of gustatory function revealed a 27% of cases versus 10% of controls showing a gustatory impairment. Nasal trigeminal sensitivity was significantly lower in cases compared to controls. Persistent chemosensory impairment was associated with emotional distress and depression.

CONCLUSION

More than one year after the onset of COVID-19, cases exhibited an excess of olfactory, gustatory , and chemesthesis disturbances compared to matched-pair controls with these symptoms being associated to emotional distress and depression.

Dupilumab reduces systemic corticosteroid use and sinonasal surgery rate in CRSwNP

BACKGROUND

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disease with a high symptom burden and poor quality of life. Treatment options include recurrent surgeries and/or frequent systemic corticosteroids (SCS). Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4 and interleukin-13, key drivers of type 2-mediated inflammation. We report results of pooled analyses from 2 randomised, double-blind, placebo-controlled phase 3 studies (SINUS 24 [NCT02912468]; SINUS-52 [NCT02898454]) to evaluate dupilumab effect versus placebo in adults with CRSwNP with/without SCS use and sinonasal surgery.

METHODOLOGY

SINUS-24 patients were randomised 1:1 to subcutaneous dupilumab 300 mg (n=143) or placebo (n=133) every 2 weeks (q2w) for 24 weeks. SINUS-52 patients were randomised 1:1:1 to 52 weeks of subcutaneous dupilumab 300 mg q2w (n=150), 24 weeks q2w followed by 28 weeks of dupilumab 300 mg every 4 weeks (n=145) or 52 weeks of placebo q2w (n=153).

RESULTS

Dupilumab reduced the number of patients undergoing sinonasal surgery (82.6%), the need for in-study SCS use (73.9%), and SCS courses (75.3%). Significant improvements were observed with dupilumab vs placebo regardless of prior sinonasal surgery or SCS use in nasal polyp, nasal congestion, Lund-MacKay, and Sinonasal Outcome Test (22-items) scores, and the University of Pennsylvania Smell Identification Test.

CONCLUSIONS

Dupilumab demonstrated significant improvements in disease signs and symptoms and reduced the need for sino-nasal surgery and SCS use versus placebo in patients with severe CRSwNP, regardless of SCS use in the previous 2 years, or prior sinonasal surgery.

Does time from previous surgery predict subsequent treatment failure in Chronic Rhinosinusitis with Nasal Polyps?

INTRODUCTION

When considering the introduction of biological treatments for Chronic Rhinosinusitis with nasal polyps (CRSwNP), treatment guidelines must consider not only which patients will best respond to biologicals, but also which patients derive least benefit from current treatment pathways. Using data collected as part of the National Audit of Surgery for Chronic Rhinosinusitis and Nasal Polyps, we sought to evaluate if patients with a history of prior surgery are more likely to need a further revision operation, and whether the interval between surgery may help predict the need for further surgical intervention.

METHODS

In the original study, patients were prospectively and consecutively enrolled at the time of sinus surgery in multiple centres in England and Wales. Follow-up captured symptomatic outcomes and revision surgery rates at 3, 12, 36 and 60 months after surgery. Revision surgery rates 5 years after the index procedure, in patients with CRSwNP were analysed with regards to baseline demographics.

RESULTS

Complete data were available for 980 subjects, with a 5 year revision rate of 15.1%. 45.9% had a history of previous surgery before the index procedure, and this group had significantly higher rates of additional surgery compared with those undergoing their first sinus surgery (20.2% versus 9.8%). Patients with an interval of 3 years or less between their previous surgery and the index procedure had the highest rates of further surgery. In a multiple regression, time interval between previous operations was a better prediction of subsequent revision surgery than asthma. Having N-ERD was the strongest predicator of need for further surgery while more extensive surgery was associated with lower revision rates.

CONCLUSIONS

Patients presenting with a symptomatic recurrence within 3 years of surgery have a high risk of treatment failure, defined as the need for further surgery. Time to failure after previous surgery may be used to help select patients who may not benefit from current treatment pathways and may be good candidates for alternative strategies, including biologicals.

Reduced order integration for the radiation efficiency of a rectangular plate

A reduced order integration is proposed for the prediction of radiation efficiency and radiation impedance for a rectangular plate. The formula is simplified using the spatial windowing approach and avoids the singular point at zero radiation distance. Compared with other formulas using similar approaches, the formulation in this letter is computationally efficient and does not require the assumption of an equivalent square plate to reduce the calculation time.

The outcome of olfactory impairment in patients with otherwise paucisymptomatic coronavirus disease 2019 during the pandemic

OBJECTIVE

This study aimed to measure the duration and recovery rate of olfactory loss in patients complaining of recent smell loss as their prominent symptom during the coronavirus disease 2019 outbreak.

METHOD

This was a prospective telephone follow-up observational study of 243 participants who completed an online survey that started on 12 March 2020.

RESULTS

After a mean of 5.5 months from the loss of smell onset, 98.3 per cent of participants reported improvement with a 71.2 per cent complete recovery rate after a median of 21 days. The chance of complete recovery significantly decreased after 131 days from the onset of loss of smell (100 per cent sensitive and 97.7 per cent specific). Younger age and isolated smell loss were associated with a rapid recovery, whereas accompanying rhinological and gastrointestinal symptoms were associated with longer loss of smell duration.

CONCLUSION

Smell loss, occurring as a prominent symptom during the coronavirus disease 2019 pandemic, showed a favourable outcome. However, after 5.5 months from the onset, around 10 per cent of participants still complained of moderate or severe hyposmia.

Six month follow-up of self-reported loss of smell during the COVID-19 pandemic

INTRODUCTION

Loss of smell and taste is now recognised as amongst the most common symptoms of COVID-19 and the best predictor of COVID-19 positivity. Long term outcomes are unknown. This study aims to investigate recovery of loss of smell and the prevalence of parosmia.

METHODOLOGY

6-month follow-up of respondents to an online surgery who self-reported loss of smell at the onset of the CO- VID-19 pandemic in the UK. Information of additional symptoms, recovery of loss of smell and the development of parosmia was collected.

RESULTS

44% of respondents reported at least one other ongoing symptom at 6 months, of which fatigue (n=106) was the most prevalent. There was a significant improvement in self-rating of severity of olfactory loss where 177 patients stated they had a normal smell of smell while 12 patients reported complete loss of smell. The prevalence of parosmia is 43.1% with median interval of 2.5 months (range 0-6) from the onset of loss of smell.

CONCLUSIONS

While many patients recover quickly, some experience long-term deficits with no self-reported improvement at 6 months. Furthermore, there is a high prevalence of parosmia even in those who report at least some recovery of olfactory func- tion. Longer term evaluation of recovery is required.

Efficacy of corticosteroid therapy in the treatment of long- lasting olfactory disorders in COVID-19 patients

BACKGROUND

The growing number of COVID-19 patients with long-lasting olfactory disorders makes it necessary to identify ef- fective treatments that enhance the spontaneous recovery of olfactory function.

METHODS

Multicentre randomised case-control study that involved 18 patients with COVID-19 related anosmia or severe hyposmia for more than 30 days. Nine patients were prescribed systemic prednisone and nasal irrigation with betamethasone, ambroxol and rinazine for 15 days. The other 9, untreated, patients were used as controls. The olfactory function was evaluated with CCCRC test at 20 and 40 days from the first evaluation.

RESULTS

In the control group, a median olfactory score of 20 (IQR 30) was detected at baseline. At the 20-day control there was no significant improvement in olfactory function. The improvement in olfactory performance became significant at the 40-day follow-up compared to baseline scores [60 (IQR 60) versus 20 (IQR 30)]. In the treatment group, patients had a mean olfactory score of 10 (IQR 15) at initial control. At the 20-day control, a significant im-provement in the olfactory scores, compared to the baseline, was detected [70 (IQR 40) versus 10 (IQR 15)]. Olfactory function further improved at 40 days [median score 90 (IQR 50)]. Patients in the treatment group reported significantly higher improvements of the olfactory scores than the controls at both the 20-day [40 (IQR 45) versus 10 (IQR 15)] and 40-day [60 (IQR 40) versus 30 (IQR 25)] evaluations.

CONCLUSIONS

Based on the results of this study, the mix of drugs including steroids could represent a useful specific therapy to reduce the prevalence of this long-term morbidity.

Intelligibility prediction for speech mixed with white Gaussian noise at low signal-to-noise ratios

The effect of additive white Gaussian noise and high-pass filtering on speech intelligibility at signal-to-noise ratios (SNRs) from -26 to 0 dB was evaluated using British English talkers and normal hearing listeners. SNRs below -10 dB were considered as they are relevant to speech security applications. Eight objective metrics were assessed: short-time objective intelligibility (STOI), a proposed variant termed STOI+, extended short-time objective intelligibility (ESTOI), normalised covariance metric (NCM), normalised subband envelope correlation metric (NSEC), two metrics derived from the coherence speech intelligibility index (CSII), and an envelope-based regression method speech transmission index (STI). For speech and noise mixtures associated with intelligibility scores ranging from 0% to 98%, STOI+ performed at least as well as other metrics and, under some conditions, better than STOI, ESTOI, STI, NSEC, CSII_Mid, and CSII_High. Both STOI+ and NCM were associated with relatively low prediction error and bias for intelligibility prediction at SNRs from -26 to 0 dB. STI performed least well in terms of correlation with intelligibility scores, prediction error, bias, and reliability. Logistic regression modeling demonstrated that high-pass filtering, which increases the proportion of high to low frequency energy, was detrimental to intelligibility for SNRs between -5 and -17 dB inclusive.

Olfactory epithelium histopathological findings in long-term coronavirus disease 2019 related anosmia

BACKGROUND

Olfactory dysfunction represents one of the most frequent symptoms of coronavirus disease 2019, affecting about 70 per cent of patients. However, the pathogenesis of the olfactory dysfunction in coronavirus disease 2019 has not yet been elucidated.

CASE REPORT

This report presents the radiological and histopathological findings of a patient who presented with anosmia persisting for more than three months after infection with severe acute respiratory syndrome coronavirus-2.

CONCLUSION

The biopsy demonstrated significant disruption of the olfactory epithelium. This shifts the focus away from invasion of the olfactory bulb and encourages further studies of treatments targeted at the surface epithelium.

Rhinology Future Debates 2018, a EUFOREA Report

The third Rhinology Future Debates was organized by the European Forum for Research and Education in Allergy and Airways diseases (EUFOREA) in 2018 in Brussels. Experts from different specialties and countries, alongside patients, health policy makers and industry representatives discussed relevant topics in Rhinology, in an attempt to improve current clinical practices, through implementation of precision medicine, by empowering patients' participation and the use of eHealth tools. The debates which are available on-line (www.rhinology-future.com) dealt with 5 topics in Rhinology: the adoption of allergen-specific immunotherapy (AIT) by implementing change management strategies, the needs and obstacles in care delivery in respiratory diseases, 3D technology in nose and sinus surgery, ambulatory nasal surgery, and clinical evidence for efficacy of biologicals in CRSwNP and asthma. This report summarizes the outcomes of the brainstorming sessions highlighting novel approaches and unmet needs in the field of respiratory diseases by focusing on integrated care pathways.

Self-reported alteration of sense of smell or taste in patients with COVID-19: a systematic review and meta-analysis on 3563 patients

BACKGROUND

Emerging reports suggest that new onset of smell or taste loss are potential early clinical markers of SARS-CoV-2 infection, but it remains unclear as to what extent. Therefore, the purpose of this study is to systematically assess the prevalence of self-reported altered sense of smell or taste in patients with confirmed SARS-CoV-2 infection, overcoming the limitations of individual studies by meta-analysis of pooled data.

METHODS

The databases Medline, Embase, Web of Science, Scopus and MedRxiv's set were searched from inception to the 4th May 2020. This study was conducted following the PRISMA checklist.

RESULTS

18 studies met the eligibility criteria out of the 171 initially screened citations. The overall prevalence of alteration of the sense of smell or taste was 47% , but estimates were 31% and 67% in severe and mild-to-moderate symptomatic patients, respec- tively. The loss of smell and taste preceded other symptoms in 20% of cases and it was concomitant in 28%.

CONCLUSIONS

Based on this meta-analysis, we recommend self-isolation and testing, where possible, for patients complaining smell or taste impairment during COVID-19 pandemic in order to prevent spread of disease and propose the inclusion of loss of smell and taste as recognized symptoms of SARS-CoV-2 in the World Health Organization and other relevant regulatory body's lists.

Predominance of an altered sense of smell or taste among long-lasting symptoms in patients with mildly symptomatic COVID-19

There is mounting evidence that a new onset of altered sense of smell or taste is related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In order to allow patients to recognize symptoms indicative of SARS-CoV-2 infection and self-isolate at the earliest opportunity, self-reported loss of smell and taste have greater value in controlling disease transmis- sion than psychophysical testing, which is not widely available outside of highly specialized clinics.

The Burden of Non-steroidal anti-inflammatory exacerbated respiratory disease from the patient's perspective - a qualitative analysis of posts from the Samter's Society

BACKGROUND

A subset of patients with chronic rhinosinusitis with nasal polyps and asthma have non-steroidal anti-inflammatory drug exacerbated respiratory disease (N-ERD). Typically, these patients often have more difficult to treat symptoms of both chronic rhinosinusitis and asthma. They also have higher rates of revision after endoscopic sinus surgery. In this paper we aim to include the patient's perspective of living with N-ERD.

METHODS

In this qualitative study, three months of posts from the Samter's Society Support Group on social media were screened and analysed.

RESULTS

Thematic analysis revealed eight main themes with subthemes in relation to patient interpretations when living with NERD. Main themes included symptom severity, quality of life, biological treatment options, diet, surgery, medical treatment, lack of awareness of N-ERD, conflicts between medical professionals and the importance of the support group.

CONCLUSIONS

This study adds to the growing body of evidence that many patients with N-ERD are living with uncontrolled disease which has significant impact on their quality of life. In addition, it has identified important themes that are relevant to know for doctors treating these patients. The results are also important for future research purposes. Finally, it has highlighted the importance of patient advocacy groups in providing support to patients living with chronic disease.

Sniffing out the evidence; It's now time for public health bodies recognize the link between COVID-19 and smell and taste disturbance

Since the outbreak of the pandemic, anecdotal observations have been accumulating rapidly that sudden anosmia and dysgeusia are peculiar symptoms associated with the COVID-19 infection. Prof C. Hopkins, as President of British Rhinological Society, published a letter describing "the loss of sense of smell as a marker of COVID-19 infection" and proposed that adults presenting with anosmia but no other symptoms should self-isolate for seven days. The Hopkins team published the first case report and case series as well as other evidence that isolated sudden onset anosmia (ISOA), should be considered highly suspicious for SARS-CoV-2(1). Subsequently, a larger series of 2428 patients presenting with new onset anosmia during the COVID-19 pandemic has been reported, of whom 16% report loss of sense of smell as an isolated symptom. Only 51% reported the recognized symptoms of cough or fever. A major limitation of this series however, was a lack of access to testing to confirm the COVID-19 status of the patients(2); in the 80 who had been tested 74% were positive. In the same way, the American Academy of Otolaryngology-head and neck surgery (AA0-HNS) proposed "that anosmia could be added to the list of screening tools for possible COVID-19 infection. More, they warrant serious consideration for self-isolation and testing those patients".

Attitudes to Noise Inside Dwellings in Three Megacities: Seoul, London, and São Paulo

This study investigated people's attitudes towards noise inside their homes. Online questionnaire surveys were conducted in Seoul, London, and São Paulo. The questionnaire was designed to assess annoyance caused by noise from neighbours and environmental noise (transportation). Information was also collected on situational, personal, and socio-demographic variables. Respondents that were more annoyed by outdoor noise inside their dwelling reported higher neighbour noise annoyance. In Seoul, neighbour noise was found to be more annoying than outdoor noise, and those with higher noise sensitivity reported higher annoyance towards neighbour noise. However, neighbour noise and outdoor noise was found to be equally annoying in London and São Paulo. For neighbour noise, the average percentage of respondents hearing structure-borne sources compared to airborne sources differed in each city. Most neighbour noise sources in São Paulo gave rise to higher annoyance ratings than Seoul and London. Education and income levels had a limited effect on annoyance and coping strategy. Annoyance with indoor noise from neighbours was found to have stronger relationships with cognitive and behavioural coping strategies than outdoor noise annoyance.

Patterns of smell recovery in 751 patients affected by the COVID-19 outbreak

BACKGROUND AND PURPOSE

Post-viral olfactory dysfunction is well established and has been shown to be a key symptom of COVID-19 with more than 66% of European and US patients reporting some degree of loss of smell. Persistent olfactory dysfunction appears to be commonplace and will drive the demand for general practitioner, otolaryngology or neurology consultation in the next few months - evidence regarding recovery will be essential in counselling our patients.

METHODS

This was a prospective survey-based data collection and telemedicine follow-up.

RESULTS

In total, 751 patients completed the study, of whom 477 were females and 274 males. The mean age of the patients was 41 ± 13 years (range 18-60). There were 621 patients (83%) who subjectively reported a total loss of smell and 130 (17%) a partial loss. After a mean follow-up of 47 ± 7 days (range 30-71) from the first consultation, 277 (37%) patients still reported a persistent subjective loss of smell, 107 (14%) reported partial recovery and 367 (49%) reported complete recovery. The mean duration of the olfactory dysfunction was 10 ± 6 days (range 3-31) in those patients who completely recovered and 12 ± 8 days (range 7-35) in those patients who partially recovered.

CONCLUSIONS

According to our results, at this relatively early point in the pandemic, subjective patterns of recovery of olfactory dysfunction in COVID-19 patients are valuable for our patients, for hypothesis generation and for treatment development.