Evaluation of medical and/or surgical treatment of anosmia/hyposmia in association with inflammatory disease of the upper airway

University dissertation from Stockholm : Karolinska Institutet, Department of Clinical Neuroscience, Occupational Therapy and Elderly Care Research (NEUROTEC)

Abstract: Background: There is a lack of evidence-based, prospective studies in treatment of nasal polyposis. The correlations between symptoms, polyp scores and computed tomography (CT) scans have not been studied sufficiently. Little, if any, sense of smell is common in nasal inflammatory disease. It is clinically well-known that the quality of life deteriorates when one starts to lose the sense of smell. Aims: I & III. To compare the effects of medical treatment and combined surgical / medical treatment on olfaction, polyp scores and symptoms in patients with nasal polyposis and evaluate CT scans as a method for comparing these effects. II. To compare the effects on olfaction of topical glucocorticoid treatment and placebo given for six months in addition to oral glucocorticoids for 10 days, in patients with anosmia / hyposmia. IV. To study the effects of loss of smell on the patient s quality of life and the coping strategies used. Methods: I & III. Thirty-two patients with nasal polyposis were randomized to unilateral endoscopic sinus surgery after pretreatment with oral prednisolone for 10 days and nasal budesonide bilaterally for one month. Postoperatively, they were given nasal steroids (budesonide) bilaterally for one year. During this period, they were assessed with nasal endoscopy, symptom scores and olfactory thresholds. CT-scans of the sinuses, performed before and one year after operation, were evaluated using the Lund staging system. II. The study was randomized, double-blind and placebo-controlled. The criterion for inclusion in the blinded phase was an improvement of at least two steps in the butanol odour threshold test, after open treatment for 10 days with oral and nasal corticosteroids. Forty patients were included. Twenty of them were randomized to treatment with fluticasone propionate, 10 to placebo and 10 others served as controls. The topical treatment was continued for 6 months. IV. Seventy-two patients with anosmia (46%) or hyposmia (54%) filled in the validated Multi-clinic Smell and Taste Questionnaire, the validated General Well-being Schedule (GWBS) and answered other questions shown to be of good validity. Results: I. The combination of local and oral steroids, improved the sense of smell, but surgery had no additional effect. Symptom scores became significantly better with medical treatment alone and surgery had additional beneficial effects on nasal obstruction and secretions as well as polyp scores. III. From before to one year after surgery, we found a significant improvement in the CT total scores, osteomeatal complex (OMC) and the maxillary sinus scores, on the operated side, but not on the unoperated side. II. The three groups showed a similar improvement in their sense of smell after the initial 10-day treatment with combined oral and nasal corticosteroids. Patients who continued the local treatment maintained their improvement at the same level during the study whether or not they had been given nasal corticosteroids or placebo. We found no significant differences between the treatment groups. IV. Several negative effects were common, i.e., risks associated with the loss of smell, interference with daily routines and deterioration in well being. Physical health, financial security, profession, partnership, friendships, emotional stability and leisure also seemed to be negatively affected and GWBS scores showed a reduction in psychological well being. The patients became more aware of the importance of olfaction after its loss, and adopted several types of problem- and emotion-focused coping strategies. Conclusions: I. Medical treatment seems to be sufficient for the treatment of most symptoms of nasal polyposis. When hyposmia is the main symptom no additional benefit seems to be gained from surgical treatment. If nasal obstruction is the chief problem after steroid treatment, surgical treatment is indicated. Selection of those who will benefit from surgery should be based on the patient s symptoms and not on the physician s polyp score. III. CT of the sinuses shows long-lasting improvement in the total and CT scores of the OMC after combined surgical and corticosteroid treatment, as compared to medical treatment alone. II. In patients with anosmia/hyposmia partly caused by local inflammation, no further improvement in the olfactory threshold is achieved by continuing to use a topical intranasal glucocorticoid after an initial combined topical and systemic glucocorticoid treatment. IV. We found that the loss of smell had substantial adverse effects on the quality of life and that high priority should be given to its diagnosis and treatment. Moreover, a combination of problem- and emotion-focused coping strategies may be suggested to patients who have recently lost their sense of smell.

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