Dr. Vinay. S. Bhat
Otolaryngology (E.N.T)
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
I was diagnosed with chronic sinusitis last week. I have a very weak sense of smell and taste, tinnitus, post-nasal drip, and congestion. My sense of smell is also getting weaker for the last five days. Can chronic sinusitis permanently damage my sense of smell at this time? Or can it be reversed? I have used nasal sprays, antibiotics, and Prednisone to no avail. This has lasted nine weeks.
Hello,
Welcome to icliniq.com.
Chronic rhinosinusitis is a chronic inflammation of the nose and sinuses where there will be significant dysfunction in sinus physiology. This causes swelling of the nose tissues leading to symptoms such as nasal congestion, nasal discharge, post nasal drip and heaviness of head. Decreased sense of smell or loss of sense of smell is also one of the symptoms of chronic rhinosinusitis. Disturbance in sense of smell in chronic rhinosinusitis is usually due to mechanical obstruction to the passage of air to the nerves which carry the sense of smell rather than actual injury to the nerves. Usually, there will be recovery of sense of smell and may take a few months with treatment for rhinosinusitis. You may need to take better antibiotics such as Clarithromycin for a week, along with a repeat course of steroids. Nasal washes with saline mixed with steroid respules are also useful in reducing the swelling and improving the sense of smell. I can say that permanent loss of sense of smell is very unlikely in chronic rhinosinusitis. Treatment of rhinosinusitis either by medicines or surgery usually brings back the sense of smell.
Investigations to be done
Treatment plan
Patient's Query
Thank you doctor,
So far, I have taken 300 mg Clindamycin for two weeks and Prednisolone taper 25 mg for 14 days. I use nasal sprays two times a day and do saline rinses. None of these have worked. I have an ENT consultation in two weeks time and I am trying to get a CT scan done. I have spoken to numerous doctors about this, and they concur with what you are saying. However, I did speak with an ENT specialist who has told me that loss of smell is caused by obstruction but also inflammation which affects the olfactory mucosa. This could do permanent damage over time. This is why I am so worried about this. What is your opinion regarding that? My sense of smell has been weakened for almost three months and I am afraid it will not recover. Another doctor told mentha olfactory receptors are dormant right now but the sense of smell will likely return at a later time. Is there any truth to what the ENT has told me?
Hello,
Welcome back to icliniq.com.
Chances of permanent loss of sense of smell can occur in nasal polyposis but not in chronic rhinosinusitis. Chances of recovery are high. Till now I have not seen anyone with chronic rhinosinusitis having permanent loss of sense of smell. Probably you will recover with the present treatment itself. You need to get a CT scan to confirm chronic rhinosinusitis and MRI (magnetic resonance imaging) for the evaluation of olfactory nerve fibers and related structures.
Patient's Query
Thank you doctor,
Can nasal polyps develop in the sinuses in nine weeks? I have yet to be diagnosed and there is a possibility that I do have polyps. Since I have a loss of smell and taste, is not this highly indicative of nasal polyps? A few doctors I have spoken too said they do not believe I do have polyps. However, one doctor said she may have seen a polyp up high in the left nostril but later said she cannot be too sure because of all the swelling. She used an otoscope.
Hello,
Welcome back to icliniq.com.
Nasal polyps cannot be diagnosed by direct nose examination. You need to get a test known as diagnostic nasal endoscopy. It will show the polyps if at all there are any. CT scan alone may not diagnose polyps but when combined with diagnostic nasal endoscopy we can confirm it and also can comment about the extent of polyps and possibility of it blocking the olfactory nerves.
Patient's Query
Thank you doctor,
Sometimes my sense of smell improves a bit. It seems to get stronger, then weaker. Is this possible with nasal polyps? Additionally, in every other acute infection I have had, my sense of smell has disappeared but still returned. I have also experienced a few hours where it does go back to normal. Also, if indeed it is polyps, should the Prednisone have had an effect on them? I took 25 mg for 14 days. There was no effect at all. I am just throwing questions out there. What do you think? In course I will have the CT scan completed soon I hope.
Hello,
Welcome back to icliniq.com.
In acute infections, loss of sense of smell is purely because of mechanical obstruction and once you take medicines such as decongestants you sense of smell comes back. It is a good sign of your sense of smell is coming back once in a while. It means that nerve endings are still functional and with appropriate diagnosis and treatment they should improve. Not all polyps respond to steroids. Some polyps are steroid resistant especially once in the olfactory area. CT scan probably would give a lot of information.
Patient's Query
Hello doctor,
Thank you for the reply, You are a wealth of information doctor. I appreciate your answers. I have a few more questions. To give you more context, I have been diagnosed with chronic sinusitis. In the past, I had many acute infections for which I took antibiotics. These always stopped the infections, however for three to four weeks after, I would have a weak sense of smell. This would usually clear up. This time, I started an acute infection which had remained ever since. I still have a weak sense of smell and taste, pressure in the sinuses, ear pain, post nasal drip, coughing, and congestion. The doctors who have examined me at the hospital confirm there is a lot of swelling in the nose. I have been prescribed two weeks of low dose antibiotics and prednisone. But this has done nothing. 1. The doctor told me chronic sinusitis can last four to six months. Is he correct? 2. Sometimes my sense of smell restores to normal for an instant ornament dew minutes. Is this a sign I dont have polyps? 3. If I do not have polyps but just CRS do I run a high risk for developing them? 4. My sense of smell and taste has been weaker this past week. Why is this happening? Should I be concerned? 5. My sense of smell still work but very difficult sometimes. Is this because of the congestion? It seems like the odors cant get in properly. Thank you so much for your guidance.
Hi,
Welcome back to icliniq.com.
Very clearly you have all the symptoms of chronic rhinosinusitis with acute exacerbationw every few months. During acute exacerbations of chronic rhinosinusitis you will develop symptoms such as nose block, headache, cough, post nasal discharge and loss of sense of smell. 1. Chronic rhinosinusitis by definition lasts for more than 12 weeks and acute exacerbations generally last for less than 12 weeks. What you have now is a recovery stage of a acute exacerbation, where rest of acute symptoms have gone except for olfactory dysfunction which is also a symptom of chronic rhinosinusitis. 2. Our nasal airway is a dynamic structure and every few hours there is change in nasal airway resistance on each side of nasal cavity. So during periods of lesser airway resistance your sense of smell is coming back because of larger airway opening the olfactory area. 3. CRS (chronic rhinosinusistis) with polyposis and CRS (chronic rhinosinusistis) without polyposis are different conditions. Since you have been diagnosed with CRS(chronic rhinosinusistis) without polyposis in the past the chances of developing CRS (chronic rhinosinusistis) with polyposis is unlikely but not impossible. 4. Sense of smell and taste are inter related and its expected to have taste dysfunction when you have smell dysfunction. 5. Confirmation of cause for olfactory dysfunction in your case at this stage definitely requires a CT (computed tomography) scan and diagnostic nasal endoscopy as medicines have not worked.
Patient's Query
Hello doctor.
Thank you for the reply, I have very little discharge from my nose and when I do it is clear or white. However, I have a very bad cough and post nasal drip. When I cough up the mucus it is always yellow-greenish. I noticed this today after coughing into a tissue. This has also happened before. I have been tested for allergies but do not have any airborne allergies. Just penicillin. I have an appoinment for taking CT scan at the hospital. I have been assured that my doctor will review the scan right away. Strangely, I am able to smell a little bit more today for some reason. Are you able to explain why this could be? Thank you for your answers to these questions. I really appreciate it.
Hi,
Welcome back to ciliniq.com,
In CRS (chronic rhinosinusitis) excessive mucous produced always flows back to the throat as opening of our paranasal sinuses are directed backwards. So apart from some nose congestion and block we do not see any mucous coming out of front of nose. Mucous coming out of post nasal drip infects the throat frequently and its very common to see chronic cough with yellowish sputum in many of patients with CRS (chronic rhinosinusitis). Acute exacerbations of CRS (chronic rhinosinusitis) eventually resolves with or without treatment, since you have already taken treatment probably now your airway is improving and smell sensation is coming back.
Patient's Query
Hi doctor,
Thank you for your help. The past two days my post nasal drip and cough have disappeared which I believe is a good sign. I still have a very weak sense of smell and also a weak sense of taste. I am concerned that I many have developed nasal polyps during the past week although my doctor assures me this is not very likely. I have also been sleeping more than usual which is a good thing too. Although I am congested, it does seem to have been improving a little bit during the last week or so. I do have a CT scan booked, which is only in a few days' time. Do you think based on everything I have told you that this is a simple case of CRS without polyps? My doctor seems to think it is. Is it possible to have a weaker sense of smell and taste with chronic sinusitis without nasal polyps? Thank you.
Hi,
Welcome back to icliniq.com.
It is good to know that you are recovering from many of the symptoms of acute exacerbation of CRS (chronic rhinosinusitis). Relief from post nasal drip and cough is a good sign. Loss of Sense of smell probably will be the last symptom to recover as olfactory nerve endings are situated in the roof of the nose and slightest oedema (swelling) in that area can physically block it. Generally CRS (chronic rhinosinusitis) with polyposis patients will have significant nose block and nasal congestion with some symptoms of allergy such as sneezing and watering. Since you do not have any of these symptoms now or earlier it is a unlikely diagnosis. I think it is CRS (chronic rhinosinusitis) without nasal polyposis with mucosal thickening and oedema at the olfactory area which probably is blocking the air entry to thay area. You have to know that CT (computed tomography) cannot differentiate between polyps and mucosal thickening. So in report they may label it as polyps. In such situation doing a nasal endoscopy will be helpful.
Patient's Query
Hi doctor,
Thank you for the reply. I do not have any sneezing or allergies. I have simple congestion and oedema is likely. I can still smell and taste although it is very weakened. When I eat, I can taste maybe 10 percent of it. My sense of smell is weak too. Maybe 20 percent. I am just looking forward to feeling better. As an ENT specialist, what can I expect on my first consult? By then, the ENT will have the CT results. Is this first approached medically. Thank you.
Hi,
Welcome back to icliniq.com.
Probably your ENT (ear, nose and throat specialist) after seeing CT (computed tomography) results will advise a diagnostic nasal endoscopy. It is a simple OPD (outpatient department) procedure where detailed view inside the nose is seen. If there is any oedema or swelling is seen then probably you will advised to use steroid nasal sprays for few months. If there are any polyps you may be asked a repeat steroid tablets for few days. Usually surgery is reserved only for extensive polyposis or resistant rhinosinusitis.
Patient's Query
Hi doctor,
Thank you for the reply. In continuation to the previous consult, I recently had an acute infection of my sinuses 12 weeks ago. Antibiotics eradicated the infection but I still had swelling in the nasal cavity. I got a referral to an ENT specialist who examined me last week. He reviewed my CT scan and said I have a slightly deviated septum; what he termed an "S septum." He said my frontal and sphenoid sinuses are 100 percent clear. He said I have very slight mucosal thickening in the maxillary sinuses but swelling no more than someone with a cold. Both maxillary sinuses have a bit of mucus. He then did a nasal endoscopy and said I do not have nasal polyps and there is only mild inflammation. He said that my left nostril is narrow and that a turbinate is swollen and touching the septum. I can still feel it inside that nostril. He said surgery is not required for this issue and to continue for six weeks with nasal saline rinses and the nasal corticosteroid. Questions, 1. My question is that should this therapy reduce swelling and the size of the turbinate? 2. What do you think is rationale is? Thank you.
Hi,
Welcome back to icliniq.com.
Your CT (computed tomography) scan and diagnostic nasal endoscopy clearly suggests that there is no nasal polyp and chronic rhinosinusitis. You are just in the recovery stage of acute rhinosinusitis and you are taking little longer than expected to recover. Steroid nasal sprays are the medicines which can reduce swelling in the nasal mucosa and turbinates and they are the best choice of medicines at this stage. What your doctor has advised is absolutely correct.
Patient's Query
Hi doctor,
Thank you for your response. 1) Is use of nasal corticosteroids effective in decreasing hypertrophy in the inferior turbinates? My ENT has asked me to continue for six weeks and has prescribed three months of the steroid spray. Eventually, he says I will be able to stop using them, but my concern is that it isnt always effective. 2) Is it true these sprays should reduce the turbinate or is surgery always required? My ENT did not say I need surgery for this, but of course, after reading online, I have found some literature that says that medical management of turbinate hypertrophy is not usually effective. Thank you for your insight.
Hi,
Welcome back to icliniq.com.
1. Corticosteroid nasal sprays can reduce hypertrophy of inferior turbinate in most instances and it is the only available option for medical treatment. Within two to three months of use your doctor will be able to tell you if it is working or not. 2. Inferior turbinate hypertrophy is of two types one is bone hypertrophy which cannot be treated by any medicines and mucosal hypertrophy which can be treated by sprays. Most of the times hypertrophy in a case of acute rhinosinusitis is mucousal so chances of sprays working is very high. Surgery is very rarely required.
Patient's Query
Hi doctor,
Thank you so much for your reply. I know this might be a difficult question to answer, but generally how long does it take nasal corticosteroids to reduce edema in the turbinates? I know this is individualized to each patient, however, in your experience when should I start to notice an improvement if treatment is working? I can thankfully still breathe through both nostrils but I am still quite congested. Secondly, there are times throughout the day when both nostrils seem to open for a bit although not fully. Is this normal? Finally, my ENT has recommended that I move from two sprays in each nostril twice a day to two sprays in each nostril once a day. My pharmacist seems to disagree and insists that twice a day application is more appropriate. Why would my ENT suggest to lower the dosage and what is your view on this? Do you agree with the ENT or pharmacist in this case and why? Thank you for all your help.
Hi,
Welcome back to ciliniq.com.
1. Nasal sprays in general take a month for initial response and within three months there should be significant reduction in symptoms as well as swelling inside the nose. 2. There is a normal physiological process known as nasal cycle which occurs inside our nose. There will alternating change in nasal resistance of each nasal cavity every few hours. It is a nature's way of giving rest to one side of nasal cavity while other works. This results in intermittent blocking sensation in each nostril. In normal individuals it may not be very obvious but in person with pre existing nose issue it becomes very obvious. 3. Dosage of spray depends on the content of the spray. Mometasone nasal spray dosage is two puffs two times daily in each nostril, Fluticasone Propionate spray one puff two times daily in each nostril, Fluticoasone Furoate spray dosage is one puff two times daily for initial fifteen days then one puff once daily in each nostril.
Patient's Query
Hi doctor,
Thank you for all your valuable answers. Finally, just a couple of final questions. 1. This condition is very similar to feeling like being at the beginning or end of a bad cold. While I can breathe through my nose is it still quite stuffy. I have noticed that there are periods throughout the day where both nostrils seem to open up a lot more. I have noticed sometimes it feels like air is flowing higher in the nose but then it changes and either one or the other nostril feels more stuffed that the other. Can turbinate hypertrophy cause permanent damage to my sense of smell? I have looked online and cannot find any information regarding this except that it is simply an obstructive condition and that air has more difficult reaching the olfactory nerves. I can smell, however, it seems a little weaker, similar to a cold. Also, I have noticed that my sense of smell seems better than my sense of taste. Sometimes its difficult to taste certain foods. 2. Luckily, it seems to be slowly improving the past couple of days. As I understand it, turbinate hypertrophy is due to inflammation in the nose. My ENT has told me I have very mild inflammation in my nose when he examined me last week and no polyps, however, could this low level inflammation lead to polyposis? If so, should I be concerned? My ENT said it would be unlikely since I do not have allergies and he does not believe I have chronic sinusitis (no pus, damage, post-nasal drip, discharge, active infection) but rather I have had a very bad case of sinusitis, for whatever reason, has set into subacute sinusitis. 3. Finally, you mentioned that using nasal sprays to reduce mucosal hypertrophy in the turbinate is usually effective if it is only the mucosal layer affected. In other words, if the bony part was swollen it would not help. Would my ENT have been able to see on the CT scan and nasal endoscopy that it is indeed only the mucosal layer affected? In other words, if the bone was affected and he saw this would he have probably suggested surgery? As it stands, he said surgery is not necessary in my case. This leads me to believe that he doesn't think the bone is involved; only the mucosal layer. Thank you very much for your learned answers and all the best.
Hi,
Welcome back to icliniq.com.
1. You are absolutely right about recovery from very bad cold. Acute rhinosinusitis is nothing but routine cold and headache. In your case you had a very severe one probably with a resistant bacteria with significant involvement of all the sinuses. This may be the reason for delay in recovery but as per your symptoms you are recovering well but slowly. 2. Acute rhinosinusitis is not a cause for nasal polyposis. Nasal polyposis is a chronic condition which occurs only in individuals who are susceptible. Since all your tests include CT (computed tomography) scan and endoscopy are normal there is no chance of development of polyposis in future too (it would have occured already if your were susceptible). 3. CT (computed tomography) would have clearly shown bony hypertrophy if there was any. Your ENT (ear, nose, throat specialist) would have informed you about bony hypertrophy of inferior turbinate and would have given guarded prognosis with sprays. He seems to be confident about nasal sprays. I think there is no need for any surgery and mucosal hypertrophy will be taken care by spray itself.
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Otolaryngology (E.N.T)
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