With COVID-19 cases rising as the winter approaches, otolaryngologists—who may come in close contact with these patients—might have heightened concerns. This season is already the busiest time of year due to more patients with allergies and sinus infections and those wanting to meet annual insurance deductibles. Despite recent announcements by Pfizer and Moderna regarding effective vaccines, wide distribution will take time. With practices operating at full capacity, what should otolaryngologists know about treating COVID-19, and how can they protect themselves during this demanding time? The best approach is to recognize the unique symptoms of COVID-19, keep yourself and your staff vigilant about safety protocols, and treat the additional COVID-19 symptoms as they come to your attention.
Spotting the Differences
First, it’s important that otolaryngologists be able to quickly discern between COVID-19 and regular sinus infections or upper respiratory tract infections. This can be challenging because they share some of the same symptoms, including cough, fever, and nasal symptoms (i.e., congestion and mucus production), said Ahmad R. Sedaghat, MD, PhD, director of the division of rhinology, allergy, and anterior skull base surgery at the University of Cincinnati College of Medicine in Ohio.
But COVID-19 and sinus and respiratory tract infections also have some differences. Because COVID-19 is a viral infection, patients may experience more severe body aches, lethargy, and fatigue compared to a bacterial sinus infection, Dr. Sedaghat said. “While sinus infections and upper respiratory tract infections may also cause temporary olfactory dysfunction, the prevalence with which it occurs in COVID-19 patients seems to be much higher, such that sudden anosmia should be a trigger to test for COVID-19.”
COVID-19 has also been associated with smell loss in more than 50% of affected patients, although it’s often transient. “The disruption of these processes can be very difficult to manage,” said Zara M. Patel, MD, associate professor and director of endoscopic skull base surgery in the department of otolaryngology–head and neck surgery at Stanford University School of Medicine in Stanford, Calif. “Smell and taste play significant roles in defense mechanisms, such as detecting smoke in a home or avoiding spoiled food. They also pervade every aspect of socialization.”
It’s unclear whether loss of smell results from viral-induced olfactory nerve damage, mucosal edema and blockage of the nasal cavity/olfactory fossa, or both. In one study, anosmia onset was approximately four days after infection and lasted about nine days; 98% of patients recovered their sense of smell within 28 days (Am J Otolaryngol. 2020;41:102581). “It’s too early to know whether COVID-19 causes persistent olfactory dysfunction in a subset of patients,” said Caitlin McLean, MD, assistant professor and director of rhinology and allergy in the department of otolaryngology–head and neck surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia.
Given the statistics, a physician could easily attribute a loss of smell to COVID-19. However, Richard L. Doty, MS, PhD, professor and director of the University of Pennsylvania Smell and Taste Center at Perelman School of Medicine in Philadelphia, cautions against ruling out the possibility that anosmia could result from other health conditions, such as a tumor or vitamin deficiency, although COVID-19 dysfunction comes on rapidly. Jacqueline Jones, MD, otorhinolaryngologist and clinical associate professor of otolaryngology at Weill Cornell Medical College in New York City, concurred, noting that olfactory dysfunction could also result from chronic sinusitis or nasal polyps.
In addition to losing olfactory functions, Dr. Jones has also seen patients with additional aberrations of taste and smell. Coffee is one of the most common foods that many individuals can no longer tolerate, an effect that can be extremely upsetting to those who perceive it to be essential to their daily routine. Mint is another flavor that many patients can no longer abide—simply smelling something minty like toothpaste can be nauseating.
Moreover, some studies seem to show that some patients experience a loss of smell without noticing it (Int Forum Allergy Rhinol. 2020;10:944-950; Head Neck. 2020;42:1560-1569). “This is particularly important since the sense of smell is critical to one’s ability to detect dangerous substances such as a gas leak or spoiled food,” said Dr. Sedaghat.
Facial pain and pressure, dental pain, and purulent discharge tend to be more common symptoms of sinus infections, said Paul Schalch Lepe, MD, clinical assistant professor in the division of otolaryngology–head and neck surgery at UC San Diego Health in California.
Ease of spread, illness severity, and duration of contagiousness also differ between COVID-19 and sinus and respiratory tract infections, and COVID-19 has a high rate of transmission via airborne droplets. Flu symptoms typically appear within one to four days, while patients with COVID-19 may not exhibit symptoms for seven to 14 days, said Dr. Jones, meaning patients with COVID-19 can be infectious somewhat longer than people with the flu before symptoms develop. Most patients are infectious for 24 hours prior to developing the flu, while patients with COVID-19 can be infectious for three to five days before symptoms appear.
In comparison, there’s less variability in how sinus infections present, said Dr. Schalch Lepe. Sinus infections that are bacterial in origin aren’t as easily transmitted, and patients have consistent symptoms, so these patients are easily identifiable.
Another key difference between COVID-19 and an upper respiratory infection or sinus infection is that a large number of people with COVID-19 are asymptomatic, while another subset of patients progress to critical condition or even death, said Dr. McLean. Most people with an upper respiratory infection or acute sinus infection experience limited symptoms for a short duration and make a full recovery.
Men, minorities, older adults, or adults with pre-existing conditions such as obesity, heart disease, and type 2 diabetes are more vulnerable to severe illness from COVID-19 than the rest of the population, Dr. McLean added. These groups aren’t necessarily more susceptible to other upper respiratory tract or sinus infections, however.
Having COVID-19 can also result in potential neurologic manifestations. “Other cranial nerves are at risk for neuropathy in a small percentage of patients, along with multiple other potential neurologic effects,” Dr. Patel said. In a recent paper, she discussed the increased incidence of cranial neuropathies in patients with post-viral olfactory loss (JAMA Otolaryngol Head Neck Surg. 2020;146:465-470). “This may indicate some inherent vulnerability of particular patients to nerve injury or decreased ability for nerve recovery via this mechanism.”
There are also reports of tinnitus and sensorineural hearing loss after COVID-19 infection. The cases reported thus far seem to occur in patients who are generally sicker, admitted to the hospital, and occasionally enter an intensive care setting, Dr. Schalch Lepe said. Patients often realize they have severe tinnitus and/or hearing loss after discharge, and subsequently seek care from an otolaryngologist—including audiologic evaluation.
While sinus infections and upper respiratory tract infections may also cause temporary olfactory dysfunction, the prevalence with which it occurs in COVID-19 patients seems to be much higher. —Ahmad R. Sedaghat, MD, PhD
The reason for hearing loss is unknown, Dr. Schalch Lepe said, but it’s likely related to general inflammation of the central nervous system, because some of these cases have had associated findings of encephalitis and meningitis. A possible confounding factor is that some patients might be treated with multiple intravenous medications, some of which could be toxic to the inner ear. Currently, there is no evidence-based treatment for hearing loss caused by COVID-19.
It’s important to employ safety protocols before a patient even arrives at a practice. “All patients should be screened when making an appointment, and any patients with symptoms consistent with COVID-19 should be seen by a physician via telehealth before being seen in person,” Dr. Jones said. All patients should come to an appointment alone; if the patient is elderly or a child, they should have only one caregiver present.
To limit exposure to an infectious patient, Stella Lee, MD, associate professor of otolaryngology–head and neck surgery at the University of Pittsburgh Medical Center, said hospitals and clinics should continue current protocols: Have checkpoints where anyone who enters has their temperature taken and is asked about COVID-19 symptoms or recent contact with someone who tested positive.
Waiting room volume should continue to be kept to a minimum. Leave extra time for new patients, and insist that they complete registration materials online prior to arrival. If a patient reports an acute olfactory disturbance—a characteristic sign of COVID-19 that can occur independently or with other symptoms—consider recommending that the patient be tested for COVID-19 and self-isolate.
As has been well publicized, otolaryngologists should wear PPE, including an N95 mask, glasses or goggles, and a face shield and gloves when interacting with every patient. Maintaining proper hand hygiene and physical distancing are fundamental.
Dr. Lee uses pledgets instead of aerosolized sprays to administer topical decongestants and a local anesthetic prior to nasal endoscopy. She asks patients to keep their mask over their mouth during a procedure and have tissues in hand in case they have to sneeze.
Staff should be trained in proper disinfection and cleaning of all rooms and scopes between patients, Dr. Jones said. If possible, install disinfecting systems that sanitize the office. Consider placing fans in exam and waiting rooms to increase air circulation.
Other options include using HEPA filters in exam rooms to help increase air changes per hour to improve ventilation and clearance of viral particles or using air purifiers that can decontaminate aerosols generated during otolaryngic exams.
It’s also worth stating that practices should stay vigilant with precautions. “Unfortunately, the pandemic hasn’t gone away,” said Dr. Patel. “Although fatigue can set in when wearing masks and face shields, and practicing within these new restrictions can feel tedious, it’s important to ensure that practices aren’t the source of infection.”
Treating most COVID-19 nasal symptoms is similar to treatment for symptoms from other causes, although there have been some new advances. Dr. Lee and colleagues are currently investigating the use of a 1% betadine nasal spray and oropharyngeal gargle for COVID-19 patients to mitigate infection and potentially shorten illness duration and severity. Patients self-administer the spray into each side of their nose and then gargle with the medication in the oropharyngeal cavity. “If proven effective in mitigating viral load in infected patients, topical betadine as an outpatient treatment method early in a patient’s disease course may help decrease transmission of COVID-19,” he said.
In a study of 100 COVID-19 patients, Dr. Doty found that two-thirds of those who received an objective smell test fully regained their smell function in six to eight weeks, although a few recovered spontaneously in a few weeks (Int Forum Allergy Rhinol. 2020;10:1127-1135). “Recovery likely depends upon the severity of the viral impact,” he said. All patients were tested after treatments for COVID-19 and were in the process of leaving the hospital to go home.
Although fatigue can set in when wearing masks and face shields, and practicing within these new restrictions can feel tedious, it’s important to ensure that practices aren’t the source of infection. —Zara M. Patel, MD
While sense of smell returned completely in approximately 70% of Dr. Sedaghat’s patients, with most of the remainder having at least some recovery, some took weeks or months to achieve this result. With continued follow-up, he expects the number of patients with complete recovery to increase.
No literature has been published to date that supports any methodology for treating patients with anosmia caused by COVID-19. However, some otolaryngologists are conducting clinical trials to evaluate certain methodologies. Another option is to recommend treatment based on one’s experience with other complications from viral infections, Dr. Jones said.
For example, Dr. Jones advises patients take 2,000 mg of omega-3 per day, in addition to olfactory training, to aid in the recovery process after having COVID-19. A current study is investigating the use of 1,000 mg of omega-3 fatty acid twice daily to treat the effects of anosmia and parosmia associated with COVID-19 (https://clinicaltrials.gov/ct2/show/NCT04495816). In addition, she encourages patients to take zinc, as well as vitamins D and C, all common natural treatments for upper respiratory infections.
Dr. Jones also recommends starting olfactory training—which should include citrus, mint, floral, and spicy smells—as soon as a patient can tolerate it. Dr. Jones’ patients sniff essential oils on a paper towel twice daily. If a smell is too noxious, she’ll advise them to stop for two to three weeks and then try to reintroduce it.
Dr. Lee is also a proponent of olfactory training to aid with recovery of smell loss after viral inflammation by spurring nerve regeneration. She advises patients to sniff four scents, including lemon, cloves, eucalyptus, and rose, as essential oils in glass vials. They should breathe normally and imagine what a lemon smells and tastes like, for example, to train themselves to recover that scent. Patients should switch odors every three months.
Steroids may be another treatment option; however, conflicting evidence surrounds their use. Therefore, it may be prudent to avoid using oral and/or topical corticosteroids to treat acute smell loss in a patient with active COVID-19, Dr. McLean said. Recommendations are less clear for patients with persistent smell loss who have completely recovered from COVID-19. “Use caution when prescribing corticosteroids until data is available about efficacy and risks specific to the COVID-19 population,” she said.
As the winter sets in, arm yourself with the best safety and treatment protocols as the COVID-19 pandemic rages onward. Although the medical community still has much to learn about this virus, give it your best by relying on what is known and staying abreast of new developments.
Karen Appold is a freelance medical writer based in Pennsylvania.