xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

community-based epidemiologic studies. 130–134 Further more, given their potentially obstructive nasal pathology, CRS patients are at risk for false-negative viral PCR results from nasopharyngeal swabs. 2466 Utilizing a combination of nasal and oropharyngeal swabs during PCR screening has been suggested for these patients. 2467 Initial anecdotal reports of healthcare-associated infec tions following rhinological procedures highlighted the potential for viral transmissibility during endoscopic endonasal surgery. 2468 An international registry of oto laryngologists reported 39 suspected healthcare-associated cases of COVID-19 despite wearing N95 masks. 2469 How ever, these cases were self-reported and at risk for sam pling bias. To date, there has been no definitive evi dence that healthcare workers and otolaryngologists are at higher risk for infection. 2470–2473 Regardless, otolaryngol ogy and rhinology societies around the world have recom mended that endonasal surgeries be considered high-risk procedures. 2474 XVI.C Sinonasal Symptomatology Related to COVID-19 Viruses including coronavirus are implicated in both acute and chronic RS, but their role in the pathophysiology of CRS is ambiguous. 2475 While some studies have reported a high rate of viral detection during CRS exacerbations, 1006 others have shown similarly high rates in non-CRS patients, 25 thus a direct association between CRS and viral infection remains unclear. Thus far, there have been no data that links SARS-CoV-2 to increased CRS exacerba tions. Notably, olfactory dysfunction, a cardinal symptom of CRS, has been highlighted as a prevalent symptom of COVID-19. 3,107–110 In these cases, olfactory dysfunction is acute and profound, often heralding other viral symptoms or as the sole manifestation of disease. Unlike anosmia found in CRS, COVID-19-associated olfactory loss presents with no radiographic evidence of olfactory cleft disease or mucosal thickening of the sinuses. 111,112 Importantly, olfactory loss has high diagnostic value as the strongest symptomatic predictor of COVID-19 with potential for early disease screening. 107,113,114 The prevalence of olfactory dysfunction has varied widely between 15% and 96% based on self-reported and quanti tatively measured data. 115–117 The ability to accurately rec ognize one’s olfactory impairment is debated, 115,2476–2479 but self-reported olfactory assessment is valuable for ini tial screenings when psychophysical testing cannot be conducted. 2476 Clinical implications of olfactory dysfunc tion as a prognostic marker for the disease also remain controversial. 2480–2484 Recovery of function appears to be

generally rapid with most patients improving or recovering function within 4 weeks but with 21% to 39% experiencing persistent smell loss. 3,117,2485–2487 Olfactory symptoms often persist despite non-detectable viral loads and resolution of all other symptoms. 2488 In addition to olfactory dysfunction, other chemosen sory modalities including taste and chemesthesis are subjectively reduced with COVID-19. However, it is unknown if the taste disturbances in COVID-19 patients are due to retronasal olfactory dysfunction, with conflict ing results found through psychophysical tests of gustatory function. 2479,2485,2489 Aside from chemosensory dysfunction, there have been few sinonasal symptoms associated with COVID-19. Patient-reported sinonasal symptom severity scores using SNOT-22 found no other symptoms as commonly and sig nificantly impacted as olfactory dysfunction. In fact, nasal obstruction is an uncommon symptom of COVID-19 infec tion and the paucity of nasal congestion with olfactory dysfunction together may serve as predictors for COVID 19. 3,2490,2491 Topical INCS are recommended and maintained even during SARS-CoV-2 infection. 118,119 There is no evidence that INCS are associated with increased infectivity. Some fear discontinuing INCS may not only worsen symptoms but increase viral shedding due to coughing and sneez ing. High volume nasal steroids are particularly efficacious in the treatment of CRS without necessitating surgical intervention. 2492,2493 One randomized, controlled trial in CRSsNP patients without history of sinus surgery showed greater improvements in SNOT-22 and Lund-Kennedy scores after using mometasone nasal irrigations compared to mometasone nasal spray for 8 weeks. 2492 These results suggest there is a role for prolonged high volume nasal steroid irrigations in this pandemic environment for those concerned about proceeding with surgery. The utility and appropriateness of oral steroids remains controversial in the context of COVID-19, as its effects on COVID-19 lung injury are debated, 120 though more recent studies have shown improvement in COVID-19 mortality rate. 121 Preliminary data have suggested that low concentra tions of povidone-iodine (PVP-1) at 0.45% to 1.0% may be considered as a topical therapy for CRS and reduc tion of viral spread, 2494–2497 with effective virucidal activ ity against SARS-CoV-2 in vitro . 2498 PVP-1 rinses were XVI.D Medical Treatment of CRS in the Setting of COVID-19 Pandemic The COVID-19 pandemic has necessitated flexibility in our treatment algorithms for CRS as guided by patient prefer ence and concerns for viral transmission.

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