my name is a boss. Anwar that I'm one of the general E. N. T. S. Here at pacific head and neck um I'm excited to be here. Thank you all for coming. I think we'll get the we'll get everything started with I think a very relevant topic in today's day and age and that's olfactory dysfunction in covid 19 which I think you know we as E. M. T. S. Are seeing pretty frequently but I'm sure as being seen a lot more commonly in primary care offices. Um No financial disclosures. So just an overview what what I'll be talking about. Um First I'll be going over the incidence and duration of covid 19. Associated olfactory dysfunction. Um I'll quickly go over the path of physiology of covid 19 associated olfactory loss. And then the bulk of my talk will be about the evaluation and treatment options available to to these patients. So um you know in terms of the incidents of olfactory symptoms, Most covid 19 infections at least at the beginning of the pandemic resulted in at least transient olfactory dysfunction. And olfactory dysfunction is uh you know defined as high pas mia which is a decreased sense of smell and as mia which is an absence of smell and parasomnia which is a distortion in your sense of smell. And so um in a in an article back in 2021. Around this time a year ago, a meta analysis showed olfactory dysfunction was present in 48% of patients with covid 19 Interestingly 45% of them subjectively reported it. But when we tested these patients, um actually 72% were objectively measured to have some olfactory dysfunction. So some of these patients aren't even aware that they have some olfactory loss. Um that study also interestingly showed a female preponderance 61% but fortunately smell and taste. This function has become less common among the more recent variants, including omicron. We've been seeing less and less of it and with, you know, patients that have been infected with the more, more recent Covid 19. 1 study looking at um 486 omicron cases found only 8.3% of patients had olfactory dysfunction and we're not exactly sure why. You know, there's a there's less incidents of olfactory dysfunction, but it might be due to previous infections or vaccinations. Um It could also be due to the fact that the variant might be having a milder inflammatory reaction at the olfactory epithelium. So in terms of the duration of olfactory symptoms, um fortunately it tends to be relatively short lived in most patients. Um And asthma related to covid 19 typically has a duration of 8 to 9 days and 85% of patients will recover their sense of smell within six months And 96% of patients within one year, according to one study. Um In 2021. So it is about the, you know, 5 to 10% of patients though, that will have uh olfactory dysfunction longer than six months and those are the patients you know that we see in our office very frequently um The intensity and duration of the olfactory dysfunction is highly variable and appears to be dependent on the capacity and rate of regeneration of the olfactory neural epithelium. So um in terms of the path of physiology, you know covid 19 related anosmia likely is related to intra nasal inoculation of the virus into the olfactory neural circuitry. Um This is a schematic of the olfactory epithelium. So the olfactory epithelium sits in the in the back of the nasal cavity. Kind of towards the top. And um sorry uh what this shows is um the olfactory epithelium has tiny little Celia that are um kind of emitted from the epithelium. And this is where the odorant molecules molecules attached and they deliver that information through these olfactory axons or neurons and that's where it hits the olfactory bulb and then is sent via the my first cranial nerve to the brain. Um So the mechanism of entry into the into the cns is a little bit unclear but what we what we think is happening is that actually the virus is getting into the supporting cells. So not the actual axons but the supporting cells called the suspect tacular cells and once it enters these supporting cells it ends up destroying them. And and without these supporting cells the olfactory neurons you know deteriorate and that's where we get the olfactory dysfunction. So why does this matter? Well, olfactory dysfunction is really, you know, it's a disability. It can be dangerous. Um you know, people can't smell their spoiled food. You know, if there's a fire in their in their house or their apartment, they can't they can't smell the smoke. If there's a gas leak, they can't smell it. So that this is relevant in that terms. But I think, you know, more practically speaking, it can definitely lead to depression. You know, it's something that we see in the office a lot olfactory loss is associated with depression and there are neuro anatomist connections between the old factory and limbic system. So whenever I see a patient with long term um olfactory loss, I do like to acknowledge that, you know that it can cause depression, I'd like to acknowledge their feelings. Some people are even a little bit embarrassed to feel a little bit depressed about this, but it's a it's a true thing that happens to some of these patients and so, you know, we're trying our best to help them out there. Um in terms of causes, you know, the most common causes tend to be um inflammation within the nose. So that's things like rhinitis, whether it's allergic or non allergic sinusitis. Um there's also post traumatic and post surgical, a lot of endo nasal skull base surgeries can cause at least temporary smell loss. There's neo plastic reasons that can lead to smell loss. There's certain tumors that can occur near the olfactory epithelium like olfactory neuroblastoma and many ngoma that can cause smell loss. Um neuro inflammatory um you know, olfactory dysfunction can be one of the earliest signs of Alzheimer's disease. So that's something to be aware of. But at the same time olfactory dysfunction can be a normal part of aging. So um it's something that we see in a lot of older patients, there are even congenital reasons to have olfactory loss. One of them is Kallman syndrome, where the olfactory bulb just doesn't develop um appropriately. And then you know the talk that I'm gonna be giving is mostly focusing on post viral anosmia and you know there's many different viruses that can cause anosmia. Um and so much of the research is pre covid related um when we talk about and always be and and treatment for it. But certain viruses can lead to and as many including influenza rhinovirus and um coronavirus that isn't even covid related. So when when we evaluate these patients um uh you know the history is the most important. We like to see if there's um any other reason that the patient could have in Bosnia. Aside from covid 19 whether it's allergies or neurologic symptoms. Um and and then we do like to decide for that from there. You know, we we um we do in our examination in the primary care setting, anterior rhine Oscar p um it can be very effective, you know, even if you don't have a nasal speculum just putting an odor scope with a step speculum into the nose. Can give you a good evaluation of the turbine, it's the middle me a tous and can get get you signs of allergies or polyps or or you know pure talent drainage. That could be an indication of sinusitis in our office. Um You know, we have the advantage of nasal endoscopy where we can take a deeper look in the nose. We can kind of look directly at the olfactory epithelium um and see if there's any, you know mass is nasal polyps that might be leading to the obstruction of those odorant molecules. And then we also have objective smell testing which is basically like a scratch and sniff. They smell a series of different odors and we graded and see kind of find out how severe their losses and that gives us a good way of you know, determining their progress when we're treating them. Um imaging is always a question when people come in with um with hypothermia and as mia. Um it's definitely, you know, we typically don't need it in post viral olfactory dysfunction. Um You know sometimes we will consider a ct scan, especially if there's evidence or or were suspicious about chronic rhinosinusitis or other mucosal inflammatory components. Um And then sometimes MRI's we we we think about getting that if we suspect a mass on our nasal endoscopy or the patient has other neurologic symptoms that might be correlated with epilepsy or multiple sclerosis and things like that. Um So just a quick general guideline for primary care physicians um when they see patients with covid 19 related and as mia um you know, first evaluate for other neurologic symptoms. Um As I was mentioning, you know, um epilepsy seizures, multiple sclerosis, things like that. Um You know, evaluate for that first and then and then, you know, I think in general if the loss of smell is less than three months without any other real nasal symptoms, um I think it's okay to consider treatment in your own practice and and we'll go over the treatment in a second if the loss is more than three months. I think at that point, that's when we it's good to send it over to to us and we can take a better look in the nose and see if there's any other things that might be causing that smell loss. Um smell loss greater than six weeks with other nasal symptoms. You know, if they have pure land drainage, they have signs of sinusitis or allergies. Um You can send them over to us, obviously you can send them over to us whenever you want. But this is just a general guideline. So just just now going into the treatment that just a treatment overview here um You know, you want to treat any concomitant rhinitis, rhinitis or sinusitis symptoms and that usually involves you know nasal sprays or anti histamines. Um But the mainstay of treatment tends to be all factory training, which I'll talk about in a second. Um Some type of nasal steroids and typically it's buddhist tonight irrigation have been shown to be beneficial. Uh And then I'll also talk about some other options that aren't as proven. But um you know there is some research maybe that supports them. And this includes oral steroids, steroid, nasal sprays and certain supplements. So uh olfactory training is really the most important thing when it comes to post viral um in as mia. And so this is something that um you know, I give to all my patients with an as mia. It's low risk basically what you do is there's there are these kits that you can buy online and they come with Um four essential oils. Those are rose lemon, eucalyptus and clove. And what we tell our patients to do is take a deep slow inhale for 15-20 seconds. Then they take a 15-32nd break and then move on to the next odorant. They do this twice daily and they and they really just focus on the memory of that odor. Um And this isn't you know, not a quick fix. It's it's at least six months. I usually don't see patients back for at least 3 to 6 months after I start them on this. Um And so setting that expectation I think is important. And basically what we think is happening is that it's slowly kind of regenerating the neuropathy liam and and the axons within the olfactory nerve. Um So you know, it might sound like hocus pocus but really there are several studies including three randomized controlled trials that show a benefit to olfactory training. Um and you know, it's definitely better outcomes in patients who um have had the high pas mia for less than one year. And so that's the reason, you know, I think even at the first visit someone comes in complaining about about hi paz mia just start them on on on olfactory training. There's really no downside to it aside from maybe a little bit of time. Um and it's really probably one of the only thing that's been shown in multiple randomized controlled trials to be effective. Um There's always a question about oral steroids and whether that's beneficial in post covid related Hi paz mia. You know, there hasn't been any randomized controlled trials that have been done to evaluate oral steroids and patients with post viral hypoglycemia. Um and the studies that are out there are kind of typically case series or smaller patient patient populations and there's really no good evidence to support routine use of oral steroids in post covid hypothermia, there might be a little bit of data to support giving steroids very early in the disease process. So maybe within the first 1 to 2 weeks if you catch it. But there's always a downside of steroids and you know like I said, 85 90% of patients will eventually recover their sense of smell. So um you know, there's always a risk benefit analysis if you do catch it early. But typically if it's a week or two out then I don't think steroids, oral steroids are necessary. Topical nasal steroids. On the other hand, I think do play a role in post covid hypothermia. Um The the only nasal spray and there's a specific nasal spray that's been actually studied in post covid and asthma is mormonism fury, which is Nasonex. And in this study they took Nasonex plus olfactory training and complain and compared that to nasal saline with olfactory training. And it was a randomized controlled trial with 77 patients. And what they found was that the Nasonex group had two times more patients return to normal sense of smell um at four weeks. So um that type of nasal steroid I think is reasonable. Um And then the other thing that's been shown also to be helpful but this is not in covid related patients yet. Um I know they're doing some studies but is buddhist in irrigation and that's where you take like a neti pot or or a sinus rinse and put a put a steroid into that um and kind of flush your nostrils. And the hope is that it kind of gets deeper into the nose and in towards the olfactory epithelium and has an effect in that in that way. So there is a randomized controlled trial again not covid but it is post viral anosmia. And they compared the destiny irrigation plus olfactory training with and they compared that to saline irrigation um with olfactory training. They had six months follow up in 100 and 22 patients and there was a 27% improvement in the saline group alone. But there was a 44% improvement in the B destiny group and that did reach clinical significance. So um what I usually say is that your destiny and I think I prefer that only because it's kind of a deeper action gets deeper into there. And if for some reason they don't like to use steroid irrigation or they don't like um irrigation then I'll then I'll mention the names next to them. Um Some other therapies that just aren't really supported by that much research but I think something to consider um you know in covid 19 there's a higher level of TNF alpha in the olfactory epithelium. And so there's some supplements that have been shown to decrease levels of TNF alpha in various inflammatory in syndromes. Not covid specifically. So this includes omega three fatty acids, vitamin C. D. And E. Um So I'll talk about that in a second. The other one is intra nasal Theophile in nasal spray. Uh Theophile in is a chemical or a compound that increases C. A. M. P. And C. GMP. Which you know increasing this within the within the olfactory epithelium helps to increase the production of olfactory receptor selves. So there is some data it's it's pretty limited that shows that this can help some patients with just high pas mia in general. Again it's not post covid related but there is actually an ongoing clinical trial right now that's uh comparing inter nasal theophilus nasal spray um in post covid related patients comparing it to nasal saline. So that should come out in the next couple of years. But going back to Omega three fatty acids. Um You know there is some data here but it's mostly in post surgical patients. So there was a randomized controlled trial with 87 patients after endoscopic skull base surgery. And as I mentioned a lot of a lot of times these patients will have transient and rarely permanent smell loss. And in this randomized trial they compared postoperative saline rinses versus uh saline rinses plus omega three fatty acids. So 1000 mg B. I. D. And what they found is that the saline rinse only group 26.8% of the patients continue to have clinically significant smell loss at six months of follow up. Whereas the saline rinse plus the omega three group 93.5% of them um returned to baseline smell in three months only. So uh they got back to their baseline pretty quickly and you know omega three fatty acids again are are low risk. So I do think um at least offering it to patients is reasonable. So this is my kind of practical approach to post covid 19 hypothermia. Um Of course treat any rhinitis or sinusitis symptoms whether it's with nasal sprays or antibiotics if needed. Um Olfactory training definitely start this early. It's data showing that it's better if you started early. Um then it's either be destiny irrigation or Mamata zone nasal spray. Um Plus or minus omega three fatty acids as I mentioned. Um I think it's important to reassure patients with you know, especially those that are depressed. Um And then you have to set reasonable expectations. This isn't going to be something that works in a in a few days or even a few weeks or months. A lot of the data is you know six months, eight months, one year. So it's going to take them some time and as long as they are consistent with a lot of the data showing a benefit. And so after that I usually follow up in 3-4 months to assess how they're doing so. Just in summary many cases of covid 19 are associated with transient smell loss although it is less common in the more recent variants. Um About 5 to 10% of patients will develop long term olfactory dysfunction. Um Annual factory training should be initiated in all patients be decimated irrigation or momenta zone, nasal spray should be considered. Um And then consider an E. N. T. Referral if the smell loss is longer than three months or if there are any other concerning nasal symptoms or if there are any questions at all. Thank you. Any questions. Yeah so we tell them to either get a Neti pot or in like a Neil med sinus rinse. They fill that with either distilled water filtered water. Like usual they dump into this. Oh sorry the question was um in terms of the buddhist innit irrigation what exactly do we tell patients on how to use it and what's the proper way to use it. So yeah basically you take the Neti pot or the Neil med sinus rinse, fill it up with normally like you do with either filtered or distilled water um You dump in the salt packet like it comes with and then we give them basically a compounded Capsule or an ampule of Buddhist. Tonight it's usually .6 mg to 1.0 mg. And we just tell them to open that up and dump it into the saline irrigation and shake it up and then uh you know flush their nostril one side um half the bottle on one side, half the ball on the other side. And we tell them to do it twice a day. Typically the compound. Um You can prescribe it but you just have to prescribe it to a compounding pharmacy. Yeah. Yeah. Oh, at one time they used to talk about zinc to zinc do anything um zinc in research, like randomized control trials, There isn't much there to support it. Um But I think zinc is a reasonable thing to try because it's relatively low risk and it's anti inflammatory. Um But you know, there's not like research to back it. Mhm. So doctor um or if you had a patient with post traumatic olfactory dysfunction, uh not just post surgical, but let's say closed head trauma, whiplash with potential sharing. Would you treat them the same way as the post surgical patients? I think those patients it's a lot less likely that they're going to regain their smell function because there's been, you know, an an atomic severance of their olfactory bulb and their neural epithelium. So I think in general treating them the same way is reasonable. But I would set their expectations maybe a little bit lower. Yeah, that's the same question. Would you treat, let's say you see a patient comes in and acutely with trauma and loss of smell, would you put them on a steroid or something to reduce demote or anything or is there does that occur that much? Yeah, I think if it was a cute, like if I if they came in within a week or so, I think I would start um oral steroids in them um to give them the best shot at, you know, getting back their their smell function. Yeah, but I would also do the other stuff that I mentioned. Yeah. So two quick questions. So one when you say steroids, um what type of steroids? It's I typically use predniSONE and I, you know, when when we do this, if we give it um I'll give it like a good dose. So start off with like 50 or 60 mg and then start that for a few days and then taper down from there. Okay, so we're not, we're just just to clarify for the audience, we're talking a pretty significant dose of steroids for usually about a week or two, tape or not. Not a medical pack, especially if you're trying to recover from a acute anosmia. Um And then the second question is um taste is also associated very much so with smell function. Um Has there been any uh evidence to suggest that there's anything to do to help patients who have taste disturbance following covid or um in in recent literature, is that still something that's ongoing? It's still something that's ongoing. I think a lot of it there's they're kind of correlated smell and taste. So a lot of it is if you get there, if you if you focus on their smell, which is I think a little bit easier to focus on. And there's research behind it. A lot of those patients will get their taste function back. Um Taste is a tough one. I will say that. So one of the pieces that has a great talk uh for compliance. When you look at the studies uh the results reflect that the patients are compensated so they are compliant. Um So how do we get patients to be compliant with olfactory retraining and visual analog stimulation for six months? And what I tell them physiologically is the factory system is a very unique system. There it is one of the two reservoirs of neurogenesis stem cells. So in the olfactory bulb nature put neuro epithelial cells to regenerate smell. And that regeneration is possible if you continue to ping it and I tell them listen you can get your smell back if you do this visual analog retraining. And as dr Abbas said you have a patient put a rose in front of them and then they smelled the rose. And they're looking at the rose and they're they're pinging the memory of what arose smells like by looking at it while they're stimulating chemically the olfactory same thing with the lemon. I have them put a lemon in front of them and have them stare at the lemon while they're actually smelling the smell. Um So in that you tell them it is possible but you have to do it. I can't tell you how many patients will come back. Yeah. I tried it for a couple of weeks. It didn't work. And then what's next? Well keep doing it for six months. But that's uh that's, but if we compensated them they do it.