Dr. Ranjit Peter
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 have had symptoms of chronic sinusitis without polyps for 24 months now. My ENT said I had mild to moderate sinusitis. My symptoms were congestion, eustachian tube dysfunction, a weak sense of smell, postnasal drip, and severe pain. I have been using Budesonide rinses twice daily, and all my symptoms are gone except a weak sense of smell and mild eustachian tube dysfunction. I am trying to determine if my sense of smell is permanently damaged or will still take time to come back. Thank you.
Hello,
Welcome to icliniq.com.
Based on your clinical history and response to therapy, we can expect some improvement in the sense of smell. The fact that there is some sense of smell is favorable. However, it would be beneficial to know the status of your sinuses in terms of persistent disease after medical management. Therefore a repeat CT (computed tomography) scan of the paranasal sinuses is needed. If there is evidence of persistent disease, there would be an indication for surgical management to open up the sinuses and facilitate natural drainage. This will directly reduce the inflammatory load from retained secretions in the sinuses. However, it would be necessary to re-evaluate the current status of sinuses before recommending further management. Regards.
Patient's Query
Hello doctor,
Thank you for the reply. My sense of smell increases momentarily. In your clinical experience, have you came across patients who have had permanent damage to the olfactory mucosa with permanent loss of smell? I am trying to determine if my sense of smell is weak due to some remaining disease or it is because of permanent damage. Thanks.
Hello,
Welcome back to icliniq.com
Thank you for the update. That gives a much clearer picture of your clinical status. Yes , you are right . It will most certainly be good to control the remaining disease. We must realise that the sense of smell is dependent on the sensation of the roof of our nasal cavities and the functioning status of the olfactory nerve endings. Based on your clinical background , the residual disease in the ethmoids may be contributing to the loss of smell. I would recommend you to use steroid nasal sprays containing Fluticasone Furoate two puffs in each nostril once daily for three months. Also use Budesonide nasal drops along with it. Take care.
Patient's Query
Thank you doctor,
In my case doctor, I have had a weak sense of smell since my chronic sinusitis started, but I have never lost it completely. When I took Prednisone tablets last year, my sense of smell returned for a few days. Sometimes, my sense of smell improves on its own, but it has never come back to normal without Prednisone. I understand that this is a difficult question to answer without you examining me, but, in your experience, is it possible that my sense of smell will come back? and, if it does not come back, is this because of unchecked disease or permanent damage? Thank you doctor.
Hi,
Welcome back to icliniq.com.
Thank you for your queries. To answer your first question, yes, in my experience, I have come across several patients who have a well-controlled disease without improvement in the sense of smell. However, such patients never report intermittent improvement in sense of smell during the course of medical management for chronic sinusitis without polyps. They would usually have reduced or absent sense of smell from the very early period of their clinical condition. Some people may lose their sense of smell during their course of recurrent bouts of sinusitis and inflammation. With reference to your second query, yes, you do not have allergic rhinitis or nasal allergy as per the workup that you mentioned was done. However, nasal mucosa responds to nasal irritants (even in the absence of an allergic response), for example when anyone gets into a dusty room, the nasal protective reflexes would initiate a sneeze reflex as well as get congested. Sure, I understand your concern. The only reason, I suggested optimism in your particular clinical situation, was because of your periodic experience of regaining your sense of smell or at least some improvement from time to time. The argument against permanent damage depends on the fact that if your olfactory nerve endings were permanently damaged, you would not have any improvement in the sense even with Prednisolone. Very early in our discussion, you mentioned the physician's opinion based on your CT scan findings, about the presence of minimal persistent disease. Based on all the available data, we could conclude that persistent disease or inflammation is contributing to your decreased sense of smell, and removal of that disease or inflammation would probably give you relief. There are certain areas in your paranasal sinuses that may not respond to what we call maximal medical therapy. The next step would be surgical clearance after reconfirming the presence of persistent disease prior to any surgical intervention. Keeping all the above factors in mind, the best option would be to get a physical review at some point in time by a reasonably experienced rhinologist and opine after an endoscopic and radiological examination. To again sum up your query, I would infer that your reduced sense of smell is a result of persistent disease and not due to permanent damage. Best regards.
Patient's Query
My ENT has said all my sinus opening are open. Since our last talk, many of my symptoms are gone. The only remaining symptom is tinnitus and weak sense of smell. There is a mild pressure behind the top of the nose from time to time but no pain. Should this eventually go away with current treatment (Budesonide rinses twice daily)? I spoke with another ENT online who said he believes my sense of smell has suffered permanent damage. However, over the past few days, my sense of smell has gone almost to normal for periods of a few minutes to 20 minutes and then gets weak again. He said that there could be permanent damage since I have so few remaining symptoms but it still fluctuates. What do you think?
Thank you for that update Mr.Nathan. Q1. There is a mild pressure behind the top of the nose from time to time but no pain. Should this eventually go away with current treatment (Budesonide rinses twice daily)? A1. It’s definitely a relief to know that your sinus openings are patent / open . The only thing that I could suggest is to look for persistent hidden disease radiologically by getting a repeat CT scan done. Budesonide rinses twice daily cannot be recommended long term , as steroid absorption would be concern. Q2. However, over the past few days, my sense of smell has gone almost to normal for periods of a few minutes to 20 minutes and then gets weak again. He said that there could be permanent damage since I have so few remaining symptoms but it still fluctuates. What do you think? A2. The fact that you were able to cherish almost near normal sense of smell, even though for a short period of time , indicates there is no permanent damage . There are only two possibilities - i ) the olfactory area in your nose gets roomy and well ventilated periodically and you get your sense of smell back or ii ) there is some kind of nerve fatigue happening after a period of time . Keeping in mind both the possibilities , I would think in favour of the first reasoning , as you do not suffer from any other neurological dysfunction or comorbidity. Therefore , my only last Reccomendation would be to get an MRI Brain if indicated after a detailed clinical examination . However considering the cost , a screening CT scan should rule out any basic hidden disease in sinuses and roof of nose .
Patient's Query
Patient's Query
Yes Mr.Nathan , I do think you should recover , as and when the nasal inflammation subsides. You have made steady progress as well.
Patient's Query
The only remaining place I sense some inflammation is in the frontal sinus recess Is it difficult to get steroid rinse to the olfactory neuroepithelium?
Patient's Query
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Patient's Query
Patient's Query
You are very patient with me. My ENT is very experienced. He offered surgery but said it will be possibly of no help. As you can't tell, weak smell is my biggest worry. It's difficult to taste food and smell faint scents. I've read that controlled CRS should provide either a normal or only slightly impaired sense of smell My sense of smell remains quite impaired although I have had no period since this started where I've lost it completely. It is also more alarming since the vast majority of my symptoms are gone. During my last endoscopy, my ENT said he could find no more evidence of disease, but, he said, there could be remaining disease higher up in the ethmoids which he cannot see. He toldr chronic sinusitis need not be chronic. It can come and go. Some people relapse with a cold. If this is true, and my ethmoids have progressively been improving, providing theres no damage to the olfactory neuroepithelium, should my sense of smell revert to normal and stay there with time? Is 24 months of weak smell a risk for permanent damage in mild or mild to moderate disease?
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Mmm tea doctor. I guess I'm in a sticky situation since I have improved week after week since beginning my budesonide treatment and my sense of smell does improve to almost normal for brief periods. Perhaps it will still take some time to remove the remaining small amount of disease. One can surmise that if medication has been working well to remove inflammation that it still will take some time to eradicate that remaining amount of restore smell. This plus the fact that other symptoms have disappeared or are almost gone including clicking in the ears. Pain and throbbing is gone altogether there only remains some edema
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Do you have a lot of patients without and pain or pressure in their ethmoid sinuses but only have a tiny faint throbbing feeling that is affecting their sense of smell? I have responded very well to medical therapy to this point. Perhaps I must wait a little longer for this little amount to go away?
Most of my patients have pressure or pain as their symptom of persistent disease. Yes you can wait for another 4-5 months ( as discussed earlier ) before making a decision regarding surgical intervention , unless there is worsening of the pressure / pain symptom .
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Otolaryngology (E.N.T)
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