The COVANOS trial - insight into post-COVID olfactory dysfunction and the role of smell training

BACKGROUND

Olfactory dysfunction is a cardinal symptom of COVID-19 infection, however, studies assessing long-term olfactory dysfunction are limited and no randomised-controlled trials (RCTs) of early olfactory training have been conducted.

METHODOLOGY

We conducted a prospective, multi-centre study consisting of baseline psychophysical measurements of smell and taste function. Eligible participants were further recruited into a 12-week RCT of olfactory training versus control (safety information). Patient-reported outcomes were measured using an electronic survey and BSIT at baseline and 12 weeks. An additional 1-year follow-up was open to all participants.

RESULTS

218 individuals with a sudden loss of sense of smell of at least 4-weeks were recruited. Psychophysical smell loss was observed in only 32.1%; 63 participants were recruited into the RCT. The absolute difference in BSIT improvement after 12 weeks was 0.45 higher in the intervention arm. 76 participants completed 1-year follow-up; 10/19 (52.6%) of participants with an abnormal baseline BSIT test scored below the normal threshold at 1-year, and 24/29 (82.8%) had persistent parosmia.

CONCLUSIONS

Early olfactory training may be helpful, although our findings are inconclusive. Notably, a number of individuals who completed the 1-year assessment had persistent smell loss and parosmia at 1-year. As such, both should be considered important entities of long-Covid and further studies to improve management are highly warranted.

Optimising trial outcomes and patient retention for the MACRO trial for chronic rhinosinusitis

BACKGROUND

This study aimed to evaluate current subjective and objective outcome assessments for the MACRO (defining best Management for Adults with Chronic RhinOsinusitis) Trial which compares antibiotics, placebo and sinus surgery. This was to identify any redundant assessments and to include patient perspectives to determine acceptability for confirmation in the trial.

METHODS

Adults CRS patients meeting the provisional eligibility criteria for the MACRO trial were recruited to this mixed-method study at 2 sites. Correlations between the objective outcome measures and SNOT-22 scores were evaluated. Selected participants took part in a semi-structured telephone interview to explore their experiences and views of undergoing outcome measures.

RESULTS

Seventy patients (37% male) were recruited, 36 had CRS without nasal polyps, 34 had CRS with nasal polyps. There was a weak inverse correlation between the SNOT-22 â€Blockage†ratings and Peak Nasal Inspiratory Flow readings, a moderate inverse correlation between the SNOT-22 â€Smell†ratings and Sniffin’ Sticks scores, but no significant correlation between the SNOT-22 and Saccharin test results. The participants’ experience of the trial visit was positive with an acceptable duration of trial visit. Most proposed outcome measures were valued by participants with the exception of the Saccharin test.

DISCUSSION

The Sniffin’ Sticks test and PNIF correlate with their respective component SNOT-22 scores but are considered important by patients; PNIF is simple, cheap test to perform. The Saccharin test will be removed as participants did not value it and was not highly rated in parallel work on a core outcome set for CRS.

Unilateral visual loss resulting from orbital encroachment of an ethmoidal juvenile trabecular ossifying fibroma

Ossifying fibromas are mainly found in the mandible and maxilla. Reports of them arising in the ethmoid sinuses and orbits are rare. We present a case of an otherwise healthy 20-year-old man with gradual onset of right visual disturbance signified by right relative afferent pupillary defect due to a large unilateral ossifying fibroma arising from the ethmoid sinus compressing the medial half of the right orbit. We emphasise the multidisciplinary combined endoscopic endonasal and external approach to ensure a successful debulking of the fibroma.

ENT in the context of global health

Global health is a fashionable term frequently used in the twenty-first century's news that is rarely understood by ear, nose and throat (ENT) professionals. Communicable diseases such as HIV, tuberculosis and malaria have been in the headlines of global health for decades. Despite the recent public health concerns about noncommunicable diseases, including ENT disorders, these disorders still receive little attention on the global health stage. Despite the 'benign' nature and a large number of patients affected at a given time, noncommunicable diseases were found to account for 60% of international mortality in 2008. More specifically to ENT, disabling hearing impairment has been found to be the most common disability globally. Therefore, it is now critical for otolaryngologists worldwide to get involved in the overlooked ENT global issues. This article discusses the main challenges faced by the ENT community in the developing world and proposes what can be done to help.

Will we ever cure nasal polyps?

BACKGROUND

Nasal polyposis is a benign hyperplastic growth of nasal mucosa. There is a paucity of evidence on the prevalence and incidence of nasal polyposis. Although nasal polyps can be asymptomatic, they can cause a spectrum of nasal problems including nasal obstruction, rhinorrhoea, nasal congestion, anosmia resulting in ageusia. Nasal polyps are mostly associated with chronic rhinosinusitis, The current management of chronic rhinosinusitis with nasal polyps is controversial and is not curative.

METHODS

A Medline search was conducted, using the keywords 'rhinosinusitis', 'sinusitis', 'classification' and ''aetiology.

FINDINGS

The current treatment of nasal polyposis in chronic rhinosinusitis with nasal polyps is still challenging. Emerging research through endotypes profiling aims to better understand the complexities of this heterogeneous disease to personalise treatment and provide a cure. Randomised controlled trials aim to provide robust evidence for current management options.

Wooden spatula sinusitis following maxillary expansion surgery

Sinusitis is a recognised rare complication of palatine expansion procedures and is usually caused by the presence of an oroantral fistula. We report the first case of unilateral sinusitis as a result of a retained foreign body (a wooden spatula) following a surgically assisted rapid palatine expansion procedure.

Isolation and expansion of cytomegalovirus-specific cytotoxic T lymphocytes to clinical scale from a single blood draw using dendritic cells and HLA-tetramers

Cytomegalovirus (CMV) reactivation in immunocompromised recipients of allogeneic stem cell transplantation is a cause of morbidity and mortality from viral pneumonitis. Antiviral drugs given to reactivating patients have reduced the mortality from CMV but have toxic side effects and do not always prevent late CMV disease. Cellular immunotherapy to prevent CMV disease is less toxic and could provide prolonged protection. However, a practical approach to generating sufficient quantities of CMV-specific cytotoxic T cells (CTLs) is required. This study describes a system for generating sufficient CMV-specific CTLs for adoptive immunotherapy of HLA-A*0201 bone marrow transplant recipients from 200 mL donor blood. Donor monocytes are used to generate dendritic cells (DCs) in medium with autologous plasma, interleukin 4, granulocyte-macrophage colony-stimulating factor, and CD40 ligand. The DCs are pulsed with the immunodominant HLA-A*0201-restricted CMV peptide pp65(495-503), and incubated with donor T cells. These cultures are restimulated twice with peptide-pulsed lymphoblastoid cell lines (LCLs) or CD40-ligated B cells and purified with phycoerythrin (PE)-labeled pp65(495-503)/HLA-A*0201 tetramers by flow sorting, or with anti-PE paramagnetic beads. The pure tetramer-positive population is then rapidly expanded to obtain sufficient cells for clinical immunotherapy. The expanded CTLs are more than 80% pure, of memory phenotype, with a Tc1 cytokine profile. They efficiently kill CMV-infected fibroblasts and express the integrin VLA-4, suggesting that the CTLs could cross endothelial barriers. This technique is reproducible and could be used for generating CMV-specific CTLs to prevent CMV disease after allogeneic blood and marrow transplantation. (Blood. 2001;98:505-512)