Effectiveness of FESS in Smell Improvement of Sinusitis Patients

Olfactory Function and Olfactory Disorders

The sense of smell is important. This became especially clear to patients with infection-related olfactory loss during the SARS-CoV-2 pandemic. We react, for example, to the body odors of other humans. The sense of smell warns us of danger, and it allows us to perceive flavors when eating and drinking. In essence, this means quality of life. Therefore, anosmia must be taken seriously. Although olfactory receptor neurons are characterized by regenerative capacity, anosmia is relatively common with about 5 % of anosmic people in the general population. Olfactory disorders are classified according to their causes (e. g., infections of the upper respiratory tract, traumatic brain injury, chronic rhinosinusitis, age) with the resulting different therapeutic options and prognoses. Thorough history taking is therefore important. A wide variety of tools are available for diagnosis, ranging from short screening tests and detailed multidimensional test procedures to electrophysiological and imaging methods. Thus, quantitative olfactory disorders are easily assessable and traceable. For qualitative olfactory disorders such as parosmia, however, no objectifying diagnostic procedures are currently available. Therapeutic options for olfactory disorders are limited. Nevertheless, there are effective options consisting of olfactory training as well as various additive drug therapies. The consultation and the competent discussion with the patients are of major importance.

Association of computed tomography scores to psychophysical measures of olfaction: A systematic review and meta-analysis

BACKGROUND

While various sinus computed tomography (CT) scoring systems have been proposed and used in the literature, no single system has been identified as superior. The strength of associations between CT scoring systems and measures of olfaction also remains unclear.

METHODS

A systematic review of PubMed, CINAHL, Scopus, and the Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies that reported both CT scores and measures of olfaction in a cross-sectional manner were included.

RESULTS

A total of 37 studies were eligible for meta-analysis. Of 8035 patients with chronic rhinosinusitis, 55.6% were male patients and 53.2% had chronic rhinosinusitis with nasal polyps. Analysis by meta-regression was performed of Lund-Mackay (LM) versus Smell Identification Test-40 (SIT-40; 12 studies), Brief Smell Identification Test (BSIT; 10 studies), Sniffin' Sticks (SS; 10 studies), and Toyota & Takagi (T&T) olfactometry (four studies). A significant moderate association was found between LM and SIT-40 (R²  = 0.612, p < 0.001) and LM and SS (R²  = 0.612, p < 0.001). An association between LM and BSIT approached significance (R²  = 0.461, p = 0.054). No significant associations were noted between LM and T&T olfactometry and between LM and SS when stratified by nasal polyp status.

CONCLUSION

There is a significant moderate association of current CT scoring systems to SIT-40 and SS. Further research should focus on associations of objective measures of olfaction to CT scores of the nasal cavity, sinuses, and olfactory cleft, as well as other disease markers.

International consensus statement on allergy and rhinology: Olfaction

BACKGROUND

The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).

METHODS

Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.

RESULTS

The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.

CONCLUSION

This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Olfaction: Sensitive indicator of inflammatory burden in chronic rhinosinusitis

BACKGROUND AND OBJECTIVE

Olfactory dysfunction has a high prevalence in chronic rhinosinusitis (CRS) patients and significantly affects quality of life. CRS is recognized as a complex disorder encompassing heterogeneous inflammatory processes in the nose and paranasal sinuses. Olfactory dysfunction in CRS patients is associated with the level of inflammatory mediators and the efficiency of inflammatory control. Learning about the association between CRS-related inflammation and olfactory function will provide clues to the pathogenesis of CRS.

STRUCTURE

The first section of this review describes the assessment of olfactory function using various measures, from ratings to MR based imaging. Then, we discuss the conductive and inflammatory mechanisms related to olfactory dysfunction in CRS: olfaction is associated with certain inflammatory patterns and is potentially a marker of CRS subtype. Finally, we review anti-inflammatory therapies including conservative and surgical approaches, and their effectiveness in olfactory dysfunction in CRS.

CONCLUSION

Assessment of olfactory function should be considered in the clinical evaluation of CRS patients, not only for detecting and quantifying patients' symptom, but also because it appears to be useful to objectively assess the efficacy of CRS treatment over time. In addition, olfaction can be expected to expand the library of CRS phenotypes and endotypes and, hence, pave the way for more precise, tailored treatment options.

Olfactory changes after endoscopic sinus surgery for chronic rhinosinusitis: A meta-analysis

BACKGROUND

Endoscopic sinus surgery (ESS) is an important treatment modality for chronic rhinosinusitis (CRS). However, its effect on olfaction remains controversial.

OBJECTIVE OF REVIEW

To assess the olfactory impact of ESS in patients with CRS.

TYPE OF REVIEW

A meta-analysis.

SEARCH STRATEGY

A systematic literature search in the PubMed, EMBASE and Cochrane Library databases was conducted to identify studies that assessed change in olfaction after ESS in patients with CRS. Search terms were related to paranasal sinus diseases, smell and endoscopy.

EVALUATION METHOD

The extracted data included authors, publication year, study type, age, sex, diagnostic criteria, surgical mode, sample size, follow-up time, olfaction measurement tool and outcome. We analysed the olfactory changes as continuous variables.

RESULTS

Thirty-five studies including 3164 patients with CRS were eligible for the meta-analysis. Among patients having CRS with nasal polyps, olfactory dysfunction improved, as assessed by the Sniffin' Sticks total score (P = .000), Sniffin' Sticks discrimination score (P = .023), Sniffin' Sticks identification score (P = .005), University of Pennsylvania Smell Identification Test (P = .046) and Visual Analogue Scale (P = .000). However, the threshold score of the Sniffin' Sticks test did not improve significantly (P = .361). Olfactory dysfunction did not improve in patients having CRS without nasal polyps according to the University of Pennsylvania Smell Identification Test (P = .404). In non-classified CRS patients, improvement in olfactory dysfunction was observed according to the University of Pennsylvania Smell Identification Test (P = .000), Visual Analogue Scale (P = .001) and Questionnaire of Olfactory Disorders-Negative Statements (P = .001). However, there were no significant improvements according to the Brief Smell Identification Test (P = .325), Sniffin' Sticks threshold score (P = .160) and Sniffin' Sticks identification score (P = .079).

CONCLUSION

Endoscopic sinus surgery may be beneficial for improvement in olfactory conditions in patients with CRS. Further thorough and comprehensive studies need to be conducted.

Clinical practice guidelines for the management of olfactory dysfunction - Secondary publication

OBJECTIVE

To provide an evidence-based recommendation for the management of olfactory dysfunction in accordance with the consensus reached by the Subcommittee of the Japanese Clinical Practice Guideline for olfactory dysfunction in the Japanese Rhinologic Society.

METHODS

Seven clinical questions (CQs) regarding the management of olfactory dysfunction were formulated by the subcommittee of the Japanese Clinical Practice Guideline for olfactory dysfunction. We searched the literature published between April 1990 and September 2014 using PubMed, the Cochrane Library, and Ichushi Web databases. The main search terms were "smell disorder," "olfactory dysfunction," "olfactory loss," "olfactory disturbance," "olfactory impairments," "olfaction disorder," "smell disorder," "anosmia," "cacosmia," and "dysosmia." Based on the results of the literature review and the expert opinion of the Subcommittee, 4 levels of recommendation, from A-strongly recommended to D-not recommended, were adopted for the management of olfactory dysfunction.

RESULTS

Both oral and locally administered corticosteroids have been strongly recommended for patients with olfactory dysfunction due to chronic rhinosinusitis. Nasal steroid spray and antihistamine drugs have been moderately recommended for patients with allergic rhinitis. Although no drugs have been deemed to be truly effective for post-viral olfactory dysfunction by randomized-controlled trials (RCTs) or placebo-controlled trials, olfactory training using odorants has been reported to be effective for improving olfactory function. There is considerable evidence that olfactory testing is useful for differential diagnosis, prediction of disease progression, and early detection of cognitive decline in neurodegenerative diseases.

CONCLUSION

The Clinical Practice Guideline has developed recommendations for the management of various aspects of olfactory dysfunction.

The prevalence of olfactory dysfunction in chronic rhinosinusitis

OBJECTIVES

Many studies have reported that olfactory dysfunction frequently occurs in chronic rhinosinusitis (CRS) populations; however, the prevalence and degree of olfactory loss has not been systematically studied. The aims of this study were to use combined data to report the prevalence of olfactory dysfunction and to calculate weighted averages of olfactory test scores in CRS patients.

DATA SOURCES

A search was conducted in PubMed and Scopus, following the methods of Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines.

REVIEW METHODS

Studies reporting the prevalence of olfactory dysfunction using objective measures or olfactory test scores using validated scales were included.

RESULTS

A total of 47 articles were included in a systematic review and 35 in the pooled data analysis. The prevalence of olfactory dysfunction in chronic rhinosinusitis was found to be 30.0% using the Brief Smell Identification Test, 67.0% using the 40-item Smell Identification Test, and 78.2% using the total Sniffin' Sticks score. Weighted averages ± standard deviation of olfactory test scores were 25.96 ± 7.11 using the 40-item Smell Identification Test, 8.60 ± 2.81 using the Brief Smell Identification Test, 21.96 ± 8.88 using total Sniffin' Sticks score, 5.65 ± 1.51 using Sniffin' Sticks-Threshold, 9.21 ± 4.63 using Sniffin' Sticks-Discrimination, 9.47 ± 3.92 using Sniffin' Sticks-Identification, and 8.90 ± 5.14 using the Questionnaire for Olfactory Disorders-Negative Statements.

CONCLUSIONS

In CRS populations, a significant percentage of patients experience olfactory dysfunction, and mean olfactory scores are within the dysosmic range. Laryngoscope, 2016 127:309-320, 2017.

Olfactory Outcomes after Endoscopic Sinus Surgery for Chronic Rhinosinusitis

Objective

To use combined pre- and postsurgical olfactory outcomes to assess the impact of endoscopic sinus surgery on chronic rhinosinusitis−related olfactory impairment.

Data Sources

CINAHL, Cochrane, OVID, EMBASE, PubMed, and SCOPUS. Each database was searched from inception up to October 2015.

Review Methods

Studies were included that reported subjective or objective olfactory data in chronic rhinosinusitis patients before and after endoscopic sinus surgery.

Results

Thirty-one studies were used in the meta-analysis. Weighted mean differences of olfactory measures demonstrated significant improvement in mixed CRS patients (those with and without polyps) through visual analog scales (−0.83, P = .001), altered taste/smell item on Sinonasal Outcome Test (−1.32, P < .00001), 40-item Smell Identification Test (3.49, P = .0010), and Sniffin’ Sticks identification (0.34, P = .03). Chronic rhinosinusitis mixed patients demonstrated nonsignificant improvements via Sniffin’ Sticks threshold (1.60, P = .16) and Brief Smell Identification Test (0.20, P = .32). When separated, polyp patients and dysosmic patients experienced the highest levels of olfactory improvement. Polyp patients improved by 7.87 ( P = .006) on the 40-item Smell Identification test, 11.54 ( P < .0001) with the Sniffin’ Sticks total score, and 2.57 ( P < .00001) through Sniffin’ Sticks identification. Dysosmic patients improved by 5.75 via the 40-item Smell Identification Test ( P = .0001).

Conclusion

Endoscopic sinus surgery improves nearly all subjective and objective measures of olfaction in chronic rhinosinusitis patients. Patients with nasal polyposis or preoperative olfactory dysfunction improve to a greater degree.

Chronic Rhinosinusitis-Related Smell Loss: Medical And Surgical Treatment Efficacy

Chronic rhinosinusitis (CRS) is an inflammatory disorder of the nasal cavities and paranasal sinuses. Olfactory dysfunction is a common manifestation of CRS and one of its cardinal diagnostic features. A decreased sense of smell can have a profound impact on a CRS patient's quality of life and overall wellbeing. The treatment of CRS-associated olfactory dysfunction includes a wide range of medical interventions, including anti-inflammatory and antibiotic medications, and surgical interventions, including endoscopic sinus and nasal surgery. The evidence and treatment efficacy for these interventions is quite varied. This review provides a summary of the efficacy of the medical and surgical therapeutic options for CRS-associated olfactory dysfunction.

When are we operating for chronic rhinosinusitis? A systematic review of maximal medical therapy protocols prior to endoscopic sinus surgery

BACKGROUND

Endoscopic sinus surgery (ESS) is considered a therapeutic option after failure of maximal medical therapy (MMT) for chronic rhinosinusitis (CRS). There is currently no consensus on the definition of MMT. The objective of this systematic review is to describe the various MMT criteria employed prior to considering ESS.

METHODS

A systematic review was performed using the 2009 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria were adults with CRS based on guideline diagnostic criteria, enrolled to undergo ESS, and study publication within the last 5 years (January 1, 2009, to December 30, 2014). Studies were excluded if the study population included non-CRS indications for ESS. Primary outcome was the MMT criteria employed prior to considering a patient a candidate for ESS. A subgroup analysis was performed based on polyp status.

RESULTS

Of 387 reviewed studies, 21% reported MMT criteria. When reported, criteria included topical nasal corticosteroids (91% of studies) for a mean of 8 ± 8 weeks, oral antibiotics (89%) for 23 ± 8 days, systemic corticosteroids (61%) for 18 ± 12 days, saline irrigations (39%), oral antihistamines (11%), oral mucolytics (10%), and topical/oral decongestants (10%).

CONCLUSION

A minority of studies report MMT criteria used as the indication for ESS. When reported, the majority included an 8-week course of topical intranasal corticosteroids and 3-week course of oral antibiotics. Use of systemic corticosteroids did not differ based on polyp status. Because of variation in current MMT criteria, there is a need to develop standardized indications for ESS that will work to improve the appropriateness of care for patients with.

The effect of radiofrequency turbinoplasty vs two other methods in the management of polypoid changes of the middle turbinate: a randomized trial

BACKGROUND

The aim of this study was to evaluate the effectiveness of middle turbinate radiofrequency (RF) turbinoplasty for the management of the polypoid middle turbinate compared to middle turbinate resection and middle turbinate medialization.

METHODS

The study was performed on 90 patients at a tertiary referral hospital with nasal polyposis resistant to maximal medical treatment. At the time of functional endoscopic sinus surgery (FESS), patients were randomized into 3 groups with respect to the management of the middle turbinate: middle turbinate turbinoplasty by RF; partial resection of the middle turbinate; and medialization of the middle turbinate by scarification to the septum. We evaluated the patients' symptoms according to the 22-item Sino-Nasal Outcome Test (SNOT-22) preoperatively and 1 year after surgery. Additionally, polyp recurrence and complications were compared among the 3 groups.

RESULT

One year after surgery, there was no significant difference in SNOT-22 scores between the groups. However, the RF group had a significantly lower polyp recurrence rate when compared to other groups (p < 0.05).

CONCLUSION

RF middle turbinate turbinoplasty could be considered an alternative to other common approaches, but it needs further long-term studies before widespread usage.