Editor’s note: Due to the COVID-19 pandemic, the 2021 Triological Society Combined Sections Meeting was held virtually on Jan. 29-30. The physical distance didn’t stop otolaryngologists in every specialty area from discussing the latest treatments, techniques, and issues in otolaryngology research and clinical practice.
New but limited data have emerged suggesting that oral steroids with olfactory training may be a safe and effective treatment for loss of smell due to COVID-19 but, as with much of the evidence surrounding otolaryngology issues that have arisen during the pandemic, more work is needed to know for sure whether this is a sound strategy.
This combination approach, attempted in a pilot trial of just 27 patients, was part of a panel discussion on the evidence that’s available to help guide clinicians on airway issues and problems with taste and smell. “With this very rapid onset of a completely novel virus, there has been an equal need for a rapid acquisition of symptom and treatment knowledge,” said moderator Jennifer Lavin, MD, MS, an assistant professor of otolaryngology at the Ann & Robert H. Lurie Children’s Hospital of Chicago.
In the pilot study of steroids and olfactory training, patients who had been diagnosed with COVID-19 and then had persistent olfactory dysfunction were randomized 1:2 to either oral steroids plus the training, or to olfactory training alone. The combination therapy improved patients’ olfactory scores above the threshold for minimal clinical importance for subjective improvement of smell. No significant increase in olfactory function was seen in patients performing olfactory training alone (Eur Arch Otorhinolaryngol. 2021:9:1-5).
“This study suggests that oral steroids and olfactory training may be safe, effective, and helpful, but it highlights the crucial need for future investigation with larger cohorts,” said Stephanie Shintani Smith, MD, MS, assistant professor of otolaryngology–head and neck surgery at the Northwestern University Feinberg School of Medicine in Chicago.
Still, she noted, the use of steroids for olfactory dysfunction is highly controversial, with many arguments both for and against it. For acute loss of smell, the CDC does not recommend any type of steroid use; for persistent loss of smell, the recommendations are less clear. The good news, however, Dr. Smith said, is that the literature reports that in up to 90% of patients with olfactory dysfunction, the condition improves or resolves over time.
It’s tempting to presume that if you do lose your taste and smell you might have a milder course of illness. —Allen Seiden, MD
Allen Seiden, MD, professor of otolaryngology–head and neck surgery at the University of Cincinnati in Ohio, pointed to several studies suggesting that patients with a milder form of COVID-19 are more likely to have problems with taste and smell. In one meta-analysis of 18 studies and about 3,600 patients, olfactory loss was reported in 67% of mild or moderate cases, and in 31% of severe cases (Eur Arch Otorhinolaryngol. 2021;278:247-255).
“It’s tempting to presume that if you do lose your taste and smell you might have a milder course of illness,” Dr. Seiden said. “But critics would say that if you’re hospitalized, you’re obviously much sicker and so you’re less focused on taste and smell issues.”
Nevertheless, he said, studies do point to the importance of a loss of taste and smell as an indicator of COVID-19 infection. In one study of 180 patients, olfactory loss was the initial symptom in a little less than half of the cases, and, surprisingly, it was the only symptom in 19% of cases (ibid). “We just don’t see that in typical respiratory viral infections,” Dr. Seiden said.
The other distinguishing feature of post-COVID olfactory loss is the potential for rapid recovery. “We still need to do a lot more objective testing in these patients to get a better handle on the true incidence and true pattern of recovery,” Dr. Seiden said. “And, of course, long-term follow-up will be instrumental in that regard.”
Ramon Franco, MD, medical director of the Voice and Speech Laboratory at Massachusetts Eye and Ear in Boston, said the literature shows that complaints about voice are the most common laryngeal complication stemming from COVID-19 infection, followed by breathing and swallowing. A study on cases with laryngeal complications found that 65% were intubated for 22 days, using a 7.5 endotracheal tube (Laryngoscope Investig Otolaryngol. 2020;5:1117-1124).
“That’s how you can tell laryngologists weren’t involved in the intubation process, because we wouldn’t use such a huge tube,” Dr. Franco said. And 65% of patients had been proned, or turned from face up to face down, to help with breathing. About 94% had abnormalities of the glottis, and about 44% had abnormalities of the trachea; the most common stroboscopy finding was wave movement diminution. Unilateral vocal fold immobility was present in 40% of cases, he said.
“It shouldn’t come as a surprise that it’s only the patients who are intubated who have problems with vocal fold immobility and stenosis,” said Dr. Franco. All of the patients who were proned had glottic pathology, he said. “It may have to do with the fact that when the patients are proned, the tube is essentially moving around and could be causing a lot of damage.”
A published review of 59 protocols for tracheostomy during the pandemic (25 in the U.S. and 34 more that are international) could offer lessons for refinement of these challenging procedures, said Dr. Franco. Ninety-one percent recommended a minimum of 14 days of ventilation beforehand. Thirty-two protocols included contraindications to tracheotomy, with 14 listing unstable respiratory or cardiac status and seven listing a positive SARS-CoV-2 test. Seventy-eight percent recommended repeat testing before tracheotomy. As for the approach, 27% recommended open tracheotomy, 33% percutaneous, and 40% either one, with 89% having a preference for a negative-pressure room for the procedure (Otolaryngol Head Neck Surg [published online ahead of print November 3, 2020]).
In addition, more than half recommended minimizing the staff in the room, with the most experienced staff recommended to encourage excellent communication, Dr. Franco said. All of the protocols called for wearing at least an N95 mask; 49% called for powered air-purifying respirators. Eighty-four percent called for full paralysis to minimize aerosol generation.
A study out of Spain measuring airborne particulates during tracheotomy for critically ill patients with COVID-19 found that there were about three times the particulates generated during the opening of the trachea than at the start of the procedure and about four times more than at the procedure’s end (Travel Med Infect Dis. 2021;39:101948). “Clearly,” Dr. Franco said, “that’s the time to have minimal staff in the room and be very careful.”
Thomas R. Collins is a freelance medical writer based in Florida.