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.
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.
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.
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.
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.
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.
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?
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 .
My ENT has said I have mild or mild to moderate disease. I've reacted well to medications. I guess I must wait for the smell to come back
Yes , I would suggest the same. Hope you recover completely . Best regards .
Do you think I have a good chance to recover smell?
Yes Mr.Nathan , I do think you should recover , as and when the nasal inflammation subsides. You have made steady progress as well.
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?
Yes , it is quite difficult to get the steroid nasal douche to reach that area. However , if there is persistent Reccurrent chronic frontal recess inflammation , you may need an endoscopic Draf 2b/3 surgical procedure subject to radiological findings . And once the procedure is done , the nasal douche reaches easily. However , the indication would be strictly based on clinical follow-up , findings and radiological findings .
My ENT said that there is no need for surgery that he can see with the CT scan and endoscopy. He said I have a mildly deviated septum, but aside from this, no issues
Great . So that would be the recommendation. Periodical clinical reviews , endoscopy whenever warranted and when ever indicated a CT would be the guide regarding prognostication .
Are most of your patients able to control all their symptoms with medication alone? I'm sorry to be a bother doctor but you're really helping me
Most of the patients do well with medications alone - Steroid nasal Sprays , however , if they continue to need budesonide nasal douches / washes/ oral steroids and if there is radiological evidence of persisting disease even after 3 months, with clinical symptoms of sinusitis - headache / post nasal drip , I do recommend relevant endoscopic surgery to address the recalcitrant Sinus disease ( not responding to what is called as maximal medical therapy ). The idea of surgical intervention in such situations is 1) to get rid of resistant disease 2) Facillitate steroid nasal washes / spray to reach narrow areas in the nasal airway , which would otherwise , not be exposed to / receive / come in contact with ,topical medications.
3 months? Oh dear, I've been symptomatic for 24 months now. I have been using Budesonide rinses for almost a year. I am responding to this treatment however. My ENT told me to be very careful not to swallow much of it but it should be safe for long term use
I didn’t mean to raise any alarm. As long as you are under review by a reasonably experienced ENT , it should be fine . There are regional differences in clinical practice in different parts of the world. If there were to be any major concerns , I’m sure your ENT would have raised them. So , I would suggest , a doctor assessing / examining you clinically , endoscopically and radiologically would be in a better position to make a decision regarding course of treatment : conservative medical vs surgical therapy . Please do not get too anxious. I am quite sure you are in good hands . You have made a lot of progress from where you started off , 2 years back . That is very promising.
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?
Your ENT is absolutely right . Even CRS can just get aggravated with something as simple as a common cold . I am sure your doctor would keep you under close monitoring both clinically and radiologically ( from time to time ). To answer your question about permanent damage , all I can say is , there is no evidence of permanent damage yet. If not , you would not be getting your sense of smell back from time to time .
Is permanent damage inevitable in chronic sinusitis without polyps?
It would be hard to predict the same . Any sense organ remains at risk of damage when there is Reccurrent long term inflammation. However , as I mentioned before , the fact that you get your smell sense back in between suggests , there is no permanent damage yet.
Will there be times when there will be no inflammation in CRSsNP? Do you find that some of your older patients with CRSsNP suffer some type of permanent loss as years go by?
The decision for surgical intervention is always made after considering the contributing factors to the disease as well as RISK vs BENEFIT. However that decision is taken by the clinician after discussion with a patient, and if there in no improvement with medical management and if there is residual disease on radiology. I wouldn’t opine along those lines , if you were not regaining your smell sense from time to time . In my opinion , surgical management may be considered , keeping in mind the morbidity you are facing , and having undergone maximal medical therapy for 24 months . However you will need to make that decision after considering , the risks , surgery poses.
Yes. I heard that surgery can cause permanent loss of smell. However, it is important to note I have been using Budesonide rinses for 12 months only and have had a good reaction. Hopefully, smell will return and stay. It increases and has done so for the past week everyday although it doesn't last long. Is it fair to assume that inflammation can be eradicated fully in my case? I know this is only a guess but being I have had a good response, is it possible? Is inflammation forever in chronic sinusitis or does it go away for periods?
It’s basically a time based decision making , when I have patients with permanent damage , there is really nothing , I can offer surgically or medically . To answer your first question - periods of inflammation vs no inflammation depends on what we can identify as contributing factors . Residual persistent hidden sinus disease would definitely be one of them .
Have you encountered many of your patients who have suffered permanent damage to their sense of smell with chronic sinusitis without polyps?
There are only two scenarios - 1) Patients who are under follow-up and don’t respond to medical line of treatment and a decision for surgery is taken . So naturally they done have any damage . 2) Patients who have been on treatment at multiple geographical locations and present with permanent damage . I really have not had patients developing permanent damage , while under follow up with me , because , as I mentioned , we intervene earlier , if there is no improvement with medical line of treatment .
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
Sure , all those are definitely positive signs of improvement .
Perhaps I should keep taking my budesonide rinses. I have another 5 months given to me by my ENT and then reevaluate then. Hopefully my smell will have returned by then. Does this seem reasonable? With another 4 or 5 months pose major risk for permanent damage provided my sense of smell doesn't get any worse?
Definitely worth the wait , as you mentioned , you have made steady progress in terms of regression of sinusitis symptoms . As your ENT is reviewing you, that should be fine. If the issue can be resolved medically , that would definitely be the better option. You can always make a joint decision regarding future course of management options after 4-5 months , if there is no resolution. Wishing you the very best , Mr.Nathan .
What would be a sign of permanent damage to the sense of smell in your opinion?
Sorry for the late reply. The sign of permanent damage would be worsening/ deteriorating smell sensation which does not improve periodically .
Can the sense of smell deteriorate when other symptoms are gone?
As I mentioned , there may be periodic deterioration and improvement in the smell sense dependent on local / regional inflammation . However , if there is absolutely no improvement periodically , that can indicate towards either persistent inflammation or permanent damage .
When my sense of smell comes back, will it always deteriorate and come back or should it stabilize and remain strong?
It should remain strong once the inflammatory process in the area is fully controlled , which you mentioned has been making steady progress. So once the inflammation has completely subsided , the sense of smell can be expected to remain strong. As we discussed , a final opinion can only be made at the end of the surveillance period over the next 4-5 months during which , you would be continuing the budesonide washes. After that final review , a decision regarding further plan of management can be taken. Till then , you will have to be patient with probable waxing and waning in symptoms . Best regards
If chronic sinusitis recurs a for me, will it last 2 years again? Does it usually last as long as the first time?
That is a good question. We would definitely deal with a reccurrent disease with surgical intervention.
Should I be concerned doctor that for the past couple of days that all major symptoms are gone except weak smell? Is this a sign of permanent damage or will it still take some time for the sense of smell to come back to normal in your experience?
Not really , anybody can have sinusitis due to several contributing inflammatory factors. However if not resolving with medical management , will need surgical intervention depending on the anatomical factors attributed.
Have you had a lot of patients who have been able to control inflammation in their maxiallary sinuses and some in their ethmoid sinuses but are unable to control a little bit of inflammation in the ethmoid sinuses? I'm becoming concerned that I won't be able to get rid of this remaining amount. There is not pain, but a very faint strange feeling in the ethmoids. Like it isn't 100 percent normal. Maybe 90 percent normal. If I stay really, really still, there is a faint throbbing in the ethmoid sinuses in the frontal recess. It doesn't hurt. It's hard to explain. Should I be able to eridicate this remaining amount?
Hello Mr.Nathan. Yes I do come across a good number of patients who have persistent inflammation in their Ethmoids and Frontal sinuses that may not respond well to medical therapy ( they may respond temporarily however they come back with symptoms and radiological evidence of persistent disease ) In such situations , we recommend endoscopic sinus surgery to open up their sinuses in order to 1) clear their irreversibly damaged mucous lining and more importantly 2) To provide access to medicated nasal douches / washes. Hence in patients with persistent symptoms and radiological evidence of disease - we recommend surgery.
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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