The effect of smell training on COVID-19 induced smell loss

OBJECTIVE

while smell training appears to be effective for post viral smell loss, its effectiveness in COVID-19 induced smell loss is currently not well known. Therefore, we aim to investigate the potential effect of smell training on patients with COVID-19 induced smell loss.

METHODS

we conducted a case-control study with two comparable cohorts. One of which (n=111) was instructed to perform smell training twice daily for 12 weeks, therapeutical adherence was monitored on a daily schedule, while the other cohort (n=50) did not perform smell training. The Sniffin' Sticks Test (SST) was used to objectify participants' sense of smell at baseline and after 12 weeks, reported as a Threshold, Discrimination, and Identification (TDI) score. We also determined the association between therapeutical adherence and the TDI scores.

RESULTS

we found a significant difference in psychophysical smell function between patients with COVID-19 induced smell disorders who performed 12 weeks of smell training and those who did not. Median TDI difference between groups was 2.00 However, there was no association between the therapeutical adherence and olfactory function.

CONCLUSION

we discovered a significant moderate difference in psychophysical smell function between patients with COVID-19-induced smell disorders who performed smell training and those who did not, implying a possible advantage of training. However, no relationship was found between therapeutical adherence of smell training and olfactory function.

Diagnostic accuracy of the screenings Sniffin' Sticks Test (SST-12) in COVID-19 induced olfactory disorders

Objective olfactory function can be assessed using validated olfactory tests like the Sniffin' Sticks Test (SST). However, their extensive nature makes them less suitable for clinical practice. To address this, shorter olfactory tests like the screenings Sniffin' Sticks Test (SST-12) can be used for screening purposes and reduce testing time. The SST-12 serves as a diagnostic tool for screening olfaction in cases unrelated to COVID-19. However, these screening tests are uncertain regarding their accuracy in detecting olfactory dysfunction in patients with COVID-19 as the plausible cause. We aim to determine the diagnostic accuracy of the SST-12 in adults with post-COVID-19 olfactory dysfunction. We performed a diagnostic accuracy study with data from 113 consecutive COVID-19 diagnosed patients who experienced objectified smell loss ever since. At approximately 6 months after their diagnosis, all participants underwent the SST (reference standard), part of the SST was the SST-12 (index test). Diagnostic accuracy of the SST-12 is measured as negative predictive value (NPV), positive predictive value (PPV), sensitivity, and specificity. The SST-12 detected smell loss in 85 patients among 91 patients with smell loss and ruled out smell loss in 15 patients among the 22 patients without smell loss based on the reference standard. Making sensitivity 93.4% (CI 0.87-0.97), and specificity 68.2% (CI 0.48-0.85). Out of the 92 patients with a positive test result on SST-12, 85 patients had indeed smell loss (PPV 92.4% CI 0.86-0.97), and out of the 21 patients with a negative test result, 15 patients had no smell loss regarding the reference standard (NPV 71.4% CI 0.50-0.88). The findings suggest that the SST-12 holds promise as a useful tool for identifying individuals with smell loss, also in individuals with COVID-19 as cause, but it is important to have a good understanding of the interpretation of the results of the SST-12 when considering its implementation in clinical practice.

One-year psychophysical evaluation of COVID-19-induced olfactory disorders: a prospective cohort study

BACKGROUND

Olfactory disorders are common in COVID-19. While many patients recover within weeks, a notable number of patients suffer from prolonged olfactory disorders. Much research has focused on the acute phase of olfactory disorders in COVID-19; however, there is still inconsistency regarding the prognosis. We aim to assess both objective and subjective olfactory function in patients with persisting olfactory disorders following COVID-19, 1 year after diagnosis.

METHODS

We objectively measured olfactory function in 77 patients who initially had COVID-19-induced smell disorders, 1 year after confirmed diagnosis. These patients previously underwent two objective measurements at approximately 3 and 6 months after COVID-19, in the context of the COCOS trial (COrticosteroids for COvid-19-induced loss of Smell). The main outcome measurement was TDI score (threshold-discrimination-identification) on Sniffin' Sticks Test (SST). Secondary outcomes included objective gustatory function on Taste Strip Test (TST), self-reported olfactory, gustatory and trigeminal function on a visual analogue scale (VAS) and outcomes on questionnaires about quality of life, and nasal symptoms.

RESULTS

The findings of this study show that 1 year following COVID-19, the median TDI score increased to 30.75 (IQR 27.38-33.5), regarded as normosmia. The median TDI score started at 21.25 (IQR 18.25-24.75) at baseline and increased to 27.5 (IQR 23.63-30.0) at 6 months following COVID-19. The increase of 9.5 points on the TDI score between baseline and 1 year after COVID-19 marks a clinically relevant improvement. Regarding the self-reported VAS score (1-10) on sense of smell, it increased from 1.2 (IQR 0.4-3.0) at baseline to 3.2 (IQR 1.4-6.0) at 6 months and further improved up to 6.1 (IQR 2.7-7.5) after 1 year. Objective gustatory function increased with 2 points on TST a year after diagnosis. Self-reported olfactory, gustatory, and trigeminal functions also improved over time, as did quality of life.

CONCLUSIONS

Objective and self-reported olfactory function continued to improve 1 year after COVID-19. The median TDI score of 30.75 (IQR 27.38-33.5) is regarded as normosmia, which is a favorable outcome. However, the rate of improvement on TDI score reduces over time.

A Comparative Analysis of the Incidence, Severity and Duration of Smell and Taste Loss in COVID-19 Cases Versus Non-COVID-19 Cases: A Longitudinal Cohort Study

The COVID-19 pandemic has highlighted the relevance of olfactory and gustatory disorders. However, these symptoms can also be caused by various other factors. In this study we aimed to compare the incidence, severity and duration between COVID-19 related and non-COVID-19 related smell and taste disorders. We conducted a longitudinal cohort study using data from the Dutch biobank Lifelines, which includes over 167,000 participants. The data were collected using 27 questionnaires distributed between March 2020 and May 2022. Descriptive data and the incidence of smell and taste loss in both groups were calculated. To visualize the proportion of severity rates of symptoms, a heatmap was created. A survival analysis was conducted and presented in a reversed Kaplan-Meier curve to show the probability of having persistent smell loss in both groups. The study included 235,722 participants. The incidence of smell loss was higher in the COVID-19 positive group, when compared to the COVID-19 negative group. We found varying degrees of symptom severity in COVID-19 positive cases, ranging from mild to severe, while non-COVID-19 related cases mostly reported mild symptoms. The survival outcome for smell and taste loss was 0.12 (SE 0.03, 95% CI 0.07-0.21) in COVID-19 related cases, and was 0.17 (SE 0.03, 95% CI 0.12-0.24) in cases related to other causes. This study reveals a higher incidence and severity of smell and taste loss in individuals with COVID-19 compared to non-COVID-19 related cases. However, non-COVID-19 related smell and taste loss tend to have a longer duration.

Systemic and Local Medical or Surgical Therapies for Ear, Nose and/or Throat Manifestations in ANCA-Associated Vasculitis: A Systematic Literature Review

BACKGROUND

Ear, nose and throat (ENT) manifestations are common in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), yet how to treat these manifestations remains controversial. Therefore, we systematically reviewed the literature on the efficacy of therapies on ENT manifestations in AAV.

METHODS

A systematic review was conducted in accordance with the PRISMA guidelines, searching Medline, Embase and Cochrane libraries, including clinical studies between January 2005 and January 2022, in adults with AAV and ENT involvement, reporting on the effects of local and systemic therapy. The critical appraisal was performed using tools provided by the Cochrane Library and the level of evidence (LoE) was scored according to the Oxford Centre for Evidence-based Medicine.

RESULTS

After screening 5609 identified studies, 136 full-text articles were assessed. Finally, 31 articles were included for critical appraisal and data-extraction. Nearly all studies (n = 29) were retrospective and scored low on LoE. The included studies evaluated local interventions (n = 11), glucocorticoids combined with conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) (n = 8), rituximab (n = 6), or mepolizumab (n = 6). Due to heterogeneity across studies meta-analysis was not performed. Four studies on mepolizumab for sinonasal symptoms (n = 92) showed response in 33-100% and relapse in 35%. Local therapy for subglottic stenosis was effective in 80-100% of patients in 11 studies (n = 157), but relapses were common (up to 83%). In five studies, hearing improvement was observed in 56-100%, with better outcomes when glucocorticoids were combined with csDMARDs compared to glucocorticoids only.

CONCLUSION

Response rates of ENT manifestations varied widely in studies and relapses were observed frequently. Heterogeneity among studies impaired comparison.

Hearing Results, Quality of Life, Patient Satisfaction, and Postoperative Complications of Day-case Versus Inpatient Stapes Surgery for Otosclerosis in Adults: A Randomized Controlled Trial

Objective

To investigate the effect of day-case stapes surgery on hearing results, quality of life, patient satisfaction, and complications rates, compared with inpatient stapes surgery.

Study Design

A single-center, nonblinded, randomized controlled trial in a tertiary referral center.

Methods

One hundred twelve adult patients planned for primary or revision stapes surgery were randomly assigned to either the day-case or inpatient treatment group. The effect on hearing outcomes (primarily), hearing benefits, quality of life, patient satisfaction, postoperative complications, and causes of crossover or readmission (secondarily) were assessed using auditory evaluations, questionnaires, and patients' charts over a follow-up period of 1 year.

Results

Audiometric measurements and postoperative success rates were not different between the inpatient and day-case group. There were no statistically significant differences between both groups regarding the overall quality of life (QoL) (HUI3), disease-specific QoL (GHSI), change in postoperative health status (GBI), and postoperative complications rate. We found a high patient satisfaction toward the day-case approach. Six patients allocated to the inpatient group requested same-day discharge. Of the day-case patients, there was a crossover rate to inpatient care of 38% (20 patients), mainly due to postoperative nausea and vomiting (25%), vertigo (20%), or dizziness (40%).

Conclusion

We found no significant differences in outcomes of audiometric measurements, QoL, patient satisfaction and postoperative complications following day-case, and inpatient stapes surgery. Therefore, stapes surgery in a day-case setting seems to be a feasible approach in terms of postoperative outcome, safety, and desirability when taking patient selection and surgical planning into account. Besides this, the familiarity with a day-case approach of both patient and the surgical team, will increase the acceptance and feasibility of day-case stapes surgery.

Prednisolone does not improve olfactory function after COVID-19: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Prednisolone has been suggested as a treatment for olfactory disorders after COVID-19, but evidence is scarce. Hence, we aimed to determine the efficacy of a short oral prednisolone treatment on patients with persistent olfactory disorders after COVID-19.

METHODS

We performed a randomized, double-blind, placebo-controlled, single-centered trial in the Netherlands. Patients were included if they were > 18 years old and if they had persistent (> 4 weeks) olfactory disorders within 12 weeks after a confirmed COVID-19 test. The treatment group received oral prednisolone 40 mg once daily for 10 days and the placebo group received matching placebo. In addition, all patients performed olfactory training. The primary outcome was the objective olfactory function on Sniffin' Sticks Test (SST) 12 weeks after the start of treatment, measured in Threshold-Discrimination-Identification (TDI) score. Secondary outcomes were objective gustatory function assessed by the Taste Strip Test (TST) and subjective self-reported outcomes on questionnaires about olfactory, gustatory and trigeminal function, quality of life, and nasal symptoms. The CONSORT 2010 guideline was performed.

RESULTS

Between November 2021 and February 2022, we included 115 eligible patients, randomly assigned to the treatment (n = 58) or placebo group (n = 57). No difference in olfactory function between groups was obtained after 12 weeks. Median TDI score on SST was 26.8 (IQR 23.6-29.3) in the placebo group and 28.8 (IQR 24.0-30.9) in the prednisolone group, with a median difference of 2.0 (95% CI 0.75 to 1.5). There was similar improvement on olfactory function in both groups after 12 weeks. Furthermore, on secondary outcomes, we obtained no differences between groups.

CONCLUSIONS

This trial shows that prednisolone does not improve olfactory function after COVID-19. Therefore, we recommend not prescribing prednisolone for patients with persistent olfactory disorders after COVID-19.

TRIAL REGISTRATION

This trial is registered on the ISRCTN registry with trial ID ISRCTN70794078.

COCOS trial: COrticosteroids for COVID-19-induced loss of Smell-protocol for a single-centred, double-blind, randomised, placebo-controlled trial

INTRODUCTION

Hyposmia and anosmia are common in COVID-19. Most patients regain normal smell within 4 weeks, but severe loss of smell persists roughly in 20% after 2 months and may last up to a year or longer. These persistent smell disorders greatly influence daily life. It is hypothesised that COVID-19 induces inflammation around the olfactory nerve and in the olfactory pathway, leading to smell disorders. Corticosteroids might reduce this local inflammatory response and improve smell.

METHODS AND ANALYSIS

We will conduct a single-centre, randomised, placebo-controlled trial to determine the efficacy of a short high-dose treatment of oral prednisolone for persistent loss of smell after COVID-19 in the early phase. We will include 116 patients with persistent (>4 weeks) loss of smell within 12 weeks of COVID-19 diagnosis, based on a positive PCR/antigen test. One group receives 40 mg of prednisolone for 10 days and the other group receives matching placebo treatment. In addition, all patients will perform smell training for 12 weeks. The primary outcome is objective olfactory function measured by means of sniffin' sticks test. Secondary outcomes are objective gustatory function by means of taste strips test and subjective taste and smell ability, trigeminal sensations, quality of life and nasal symptoms, measured by three questionnaires. These outcomes will be measured at inclusion before treatment and 12 weeks later.

ETHICS AND DISSEMINATION

The Institutional Review Board of the University Medical Center Utrecht approved the research protocol (21-635/G-D, October 2021). The trial results will be shared in peer-reviewed medical journals and scientific conferences.

TRIAL REGISTRATION NUMBER

NL9635. EUCTR2021-004021-71-NL.

[A toddler with complicated otorrhea]

A 4-year-old boy was diagnosed with intracranial abscess following adequately treated otorrhea and mastoiditis. This is an uncommon finding. He underwent mastoidectomy with drainage of the abscess. In cases where patients clinically deteriorate during treatment for otorrhea and mastoiditis, further examination using CT-scan is recommended.

Admission Rates Following Day-Case Major Otologic Surgery: A Systematic Review

OBJECTIVE

To assess whether day-case major otologic ear surgery is a safe and feasible alternative to inpatient surgery, while maintaining equal complication rates, and to identify causes of admission after day-case surgery.

DATA SOURCES

PubMed, Embase, and Cochrane.

REVIEW METHODS

A systematic search was conducted. Studies reporting original data on the effect of day-case ear surgery on admission rate, patient satisfaction, and/or postoperative complications were included. Risk of bias of the selected articles was assessed using criteria based on the Cochrane Collaboration's tool for assessing risk of bias.

RESULTS

A total of 1,734 unique studies were retrieved of which 35 articles discussing 34 studies were eligible for data extraction. The admission rates ranged from 0% to 88% following day-case endaural surgery, 0% to 13% following day-case stapes surgery, 0% to 82% following day-case mastoid surgery, and 0% to 15% following day-case cochlear implant surgery. Patient and parent satisfaction regarding day-case surgery ranged from 67% to 99%. Five studies comparing day-case and inpatient otologic surgery showed no difference in hearing outcome, postoperative complications, or patient satisfaction.

CONCLUSION

The highest pooled admission rate was seen following day-case mastoid surgery. Studies comparing day-case and inpatient care suggest hearing results and postoperative complication rates in day-case otologic surgery are similar to inpatient otologic surgery in both children and adults. Therefore, day-case major otologic surgery seems to be a safe and feasible alternative to inpatient surgery for both children and adults.

Diagnosis of Sweet's syndrome in otolaryngology

Sweet's syndrome (acute febrile neutrophilic dermatosis) consists of acute onset of painful cutaneous erythematous lesions, mostly found in the upper extremities followed by the head and neck region, particularly in patients with underlying malignancies. We describe the case of a woman in her mid-30s, who was treated for acute myeloid leukaemia and presented with a severe painful and progressive erythematous lesion of the retroauricular skin. Clinical features, laboratory tests, blood cultures and histological biopsy yielded a diagnosis of Sweet's syndrome. The treatment consisted of oral and topical corticosteroids and her signs and symptoms resolved within 1 week. Although Sweet's syndrome is uncommon, awareness among otolaryngologists is crucial to ensure a prompt diagnosis, cure and referral to an oncologist (if not already involved) for patients with Sweet's syndrome in the head and neck area.

Diagnostic accuracy of fetal MRI to detect cleft palate: a meta-analysis

This systematic review aims to determine the diagnostic accuracy of fetal MRI for detecting cleft palate in fetuses at risk for orofacial clefts. Pubmed, Embase, and CINAHL were searched systematically. A diagnostic study was included if it performed MRI (index test) and postnatal examination (reference test) in fetuses at risk for orofacial clefts. Methodological quality was assessed using the QUADAS-2. A meta-analysis was performed with a random-effects model, calculating the pooled sensitivity, specificity, and area under the curve. The search resulted in eight studies (334 fetuses) to be included: four prospective and four retrospective studies. The applicability concern was low. There was, however, a risk of selection and information bias. All studies showed that MRI well predicted the chance of cleft palate. The sensitivity results were homogeneous, but heterogeneity was assumed regarding the specificity estimate (Cochrane's Q test: p = 0.00). The pooled sensitivity was 0.97 (95% CI 0.93-0.99); the pooled specificity was 0.94 (0.89-0.97). The area under the curve was 0.98 (95% CI 0.98-0.99).Conclusion: This meta-analysis shows that MRI has an excellent sensitivity and good to excellent specificity for diagnosing cleft palate in fetuses at risk for orofacial clefts. Future research should assess applicability for clinical care.What is Known:• Using ultrasound for prenatal detection of cleft palate leads to misdiagnosis frequently.• MRI could potentially improve the prenatal detection rate of cleft palate.What is New:• Eight studies describe the diagnostic accuracy of MRI for detecting cleft palate.• Combined results show excellent sensitivity and good to excellent specificity.

A 1,470 nm diode laser in stapedotomy: Mechanical, thermal, and acoustic effects

BACKGROUND AND OBJECTIVES

Multiple laser systems have been investigated for their use in stapes surgery in patients with otosclerosis. The diode 1,470 nm laser used in this study is an attractive laser system because it is easily transported and relatively inexpensive in use. This wavelength has relative high absorption in water. This study aimed to investigate the mechanical, thermal, and acoustic effects of the diode 1,470 nm laser on a stapes in an inner ear model.

MATERIALS AND METHODS

Experiments were performed in an inner ear model including fresh frozen human stapes. High-speed imaging with frame rates up to 2,000 frames per second (f/s) was used to visualize the effects in the vestibule during fenestration of the footplate. A special high-speed color Schlieren technique was used to study thermal effects. The sound produced by perforation was recorded by a hydrophone. Single pulse settings of the diode 1,470 nm laser were 100 ms, 3 W.

RESULTS

Diode 1,470 nm laser fenestration showed mechanical effects with small vapor bubbles and pressure waves pushed into the vestibule. Thermal imaging visualized an increase temperature underneath the stapes footplate. Acoustic effects were limited, but larger sounds levels were reached when vaporization bubbles arise and explode in the vestibule.

CONCLUSION

The diode 1,470 nm laser highly absorbs in perilymph and is capable of forming a clear fenestration in the stapes. An overlapping laser pulse will increase the risk of vapor bubbles, pressure waves, and heating the vestibule. As long as we do not know the possible damage of these effects to the inner ear function, it seems advisable to use the laser with less potential harm. Lasers Surg. Med. 49:619-624, 2017. © 2017 Wiley Periodicals, Inc.

Day-case stapes surgery: Day-case versus inpatient stapes surgery for otosclerosis: a randomized controlled trial

Background

Otosclerosis is characterized by bony deposits in the otic capsule, resulting in stapes fixation and progressive hearing loss. It can be treated effectively by surgically removing (part of) the stapes and replacing it with a prosthesis. Increasingly, stapes surgery is performed as a day-case procedure. The major drive towards day-case surgery has been out of economic considerations. However, it is also increasingly an explicit patient request and leads to shorter waiting times for surgery, a reduced risk of infection and most likely positively influences the patient’s quality of life as a result of rapid discharge and rehabilitation. Even though stapes surgery seems well suited to a day-case approach, given the low complication rates and early recovery, evidence is scarce and of low quality.

Methods and design

A single-center unblinded randomized controlled trial was designed to (primarily) investigate the effect of hearing outcomes of day-case stapes surgery compared to inpatient stapes surgery and (secondarily) investigate the effect of both methods on quality of life, tinnitus, vertigo and cost-effectiveness. One hundred and twelve adult otosclerosis patients who are eligible for stapes surgery will be randomly assigned to either the day-case or inpatient treatment group. The primary and secondary outcome measures will be assessed using pure-tone audiometry (at approximately 2 months and 1 year follow-up), questionnaires (at 3 months and 1 year follow-up) and costs diaries (weekly the first month after which once a month until 1 year follow-up).

Discussion/conclusion

This trial allows for a comparison between day-case and inpatient stapes surgery to investigate the hypothesis that day-case stapes surgery is associated with a higher quality of life and higher cost-effectiveness, while maintaining equal hearing results, compared to inpatient stapes surgery.

Trial registration

Netherlands Trial Register (www.trialregister.nl): NTR4133, registration date 21^st August 2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s12901-016-0024-6) contains supplementary material, which is available to authorized users.

Comparison of KTP, Thulium, and CO2 laser in stapedotomy using specialized visualization techniques: thermal effects

High-speed thermal imaging enables visualization of heating of the vestibule during laser-assisted stapedotomy, comparing KTP, CO2, and Thulium laser light. Perforation of the stapes footplate with laser bears the risk of heating of the inner ear fluids. The amount of heating depends on absorption of the laser light and subsequent tissue ablation. The ablation of the footplate is driven by strong water absorption for the CO2 and Thulium laser. For the KTP laser wavelength, ablation is driven by carbonization of the footplate and it might penetrate deep into the inner ear without absorption in water. The thermal effects were visualized in an inner ear model, using two new techniques: (1) high-speed Schlieren imaging shows relative dynamic changes of temperatures up to 2 ms resolution in the perilymph. (2) Thermo imaging provides absolute temperature measurements around the footplate up to 40 ms resolution. The high-speed Schlieren imaging showed minimal heating using the KTP laser. Both CO2 and Thulium laser showed heating below the footplate. Thulium laser wavelength generated heating up to 0.6 mm depth. This was confirmed with thermal imaging, showing a rise of temperature of 4.7 (±3.5) °C for KTP and 9.4 (±6.9) for Thulium in the area of 2 mm below the footplate. For stapedotomy, the Thulium and CO2 laser show more extended thermal effects compared to KTP. High-speed Schlieren imaging and thermal imaging are complimentary techniques to study lasers thermal effects in tissue.

Early clerkships

BACKGROUND

Early clinical experience is being introduced in innovative, vertically integrated undergraduate medical curricula. While in many cases, this early clinical experience is limited to the presence of patients during lectures, in Utrecht students gain 'hands on' experience of daily clinical practice during 6-week clerkships. We studied students' and teachers' opinions of these full clerkships in the third year of a medical course.

METHODS

All 238 clinical teachers and 89 students involved in the 2003/2004 third year clerkships of the new Utrecht medical curriculum were asked to fill in a 16-item questionnaire about background knowledge, clinical skills, communication skills, and readiness for clerkships. Answers were given on a 5-point Likert scale. Response was 61%.

RESULTS

Both students and clinical teachers answered all statements positively (score > 3.00), although some statements were awarded higher scores by students than teachers. In conclusion, students and teachers appear to appreciate clerkships early in the curriculum.

CONCLUSIONS

Less background knowledge and a lower age than is usual for the more traditional (later) clerkships do not appear to hinder successful completion of an early clerkship. Indeed, early clerkships have several advantages, such as early observation of the future profession, increased motivation for further study, contextual learning, and improvement of clinical skills.