With COVID-19 cases rising as the winter approaches, otolaryngologists—who may come in close contact with these patients—might have heightened concerns. This season is already the busiest time of year due to more patients with allergies and sinus infections and those wanting to meet annual insurance deductibles. Despite recent announcements by Pfizer and Moderna regarding effective vaccines, wide distribution will take time. With practices operating at full capacity, what should otolaryngologists know about treating COVID-19, and how can they protect themselves during this demanding time? The best approach is to recognize the unique symptoms of COVID-19, keep yourself and your staff vigilant about safety protocols, and treat the additional COVID-19 symptoms as they come to your attention.
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December 2020Spotting the Differences
First, it’s important that otolaryngologists be able to quickly discern between COVID-19 and regular sinus infections or upper respiratory tract infections. This can be challenging because they share some of the same symptoms, including cough, fever, and nasal symptoms (i.e., congestion and mucus production), said Ahmad R. Sedaghat, MD, PhD, director of the division of rhinology, allergy, and anterior skull base surgery at the University of Cincinnati College of Medicine in Ohio.
But COVID-19 and sinus and respiratory tract infections also have some differences. Because COVID-19 is a viral infection, patients may experience more severe body aches, lethargy, and fatigue compared to a bacterial sinus infection, Dr. Sedaghat said. “While sinus infections and upper respiratory tract infections may also cause temporary olfactory dysfunction, the prevalence with which it occurs in COVID-19 patients seems to be much higher, such that sudden anosmia should be a trigger to test for COVID-19.”
COVID-19 has also been associated with smell loss in more than 50% of affected patients, although it’s often transient. “The disruption of these processes can be very difficult to manage,” said Zara M. Patel, MD, associate professor and director of endoscopic skull base surgery in the department of otolaryngology–head and neck surgery at Stanford University School of Medicine in Stanford, Calif. “Smell and taste play significant roles in defense mechanisms, such as detecting smoke in a home or avoiding spoiled food. They also pervade every aspect of socialization.”
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It’s unclear whether loss of smell results from viral-induced olfactory nerve damage, mucosal edema and blockage of the nasal cavity/olfactory fossa, or both. In one study, anosmia onset was approximately four days after infection and lasted about nine days; 98% of patients recovered their sense of smell within 28 days (Am J Otolaryngol. 2020;41:102581). “It’s too early to know whether COVID-19 causes persistent olfactory dysfunction in a subset of patients,” said Caitlin McLean, MD, assistant professor and director of rhinology and allergy in the department of otolaryngology–head and neck surgery at the Lewis Katz School of Medicine at Temple University in Philadelphia.
Given the statistics, a physician could easily attribute a loss of smell to COVID-19. However, Richard L. Doty, MS, PhD, professor and director of the University of Pennsylvania Smell and Taste Center at Perelman School of Medicine in Philadelphia, cautions against ruling out the possibility that anosmia could result from other health conditions, such as a tumor or vitamin deficiency, although COVID-19 dysfunction comes on rapidly. Jacqueline Jones, MD, otorhinolaryngologist and clinical associate professor of otolaryngology at Weill Cornell Medical College in New York City, concurred, noting that olfactory dysfunction could also result from chronic sinusitis or nasal polyps.
In addition to losing olfactory functions, Dr. Jones has also seen patients with additional aberrations of taste and smell. Coffee is one of the most common foods that many individuals can no longer tolerate, an effect that can be extremely upsetting to those who perceive it to be essential to their daily routine. Mint is another flavor that many patients can no longer abide—simply smelling something minty like toothpaste can be nauseating.
Moreover, some studies seem to show that some patients experience a loss of smell without noticing it (Int Forum Allergy Rhinol. 2020;10:944-950; Head Neck. 2020;42:1560-1569). “This is particularly important since the sense of smell is critical to one’s ability to detect dangerous substances such as a gas leak or spoiled food,” said Dr. Sedaghat.
Facial pain and pressure, dental pain, and purulent discharge tend to be more common symptoms of sinus infections, said Paul Schalch Lepe, MD, clinical assistant professor in the division of otolaryngology–head and neck surgery at UC San Diego Health in California.
Ease of spread, illness severity, and duration of contagiousness also differ between COVID-19 and sinus and respiratory tract infections, and COVID-19 has a high rate of transmission via airborne droplets. Flu symptoms typically appear within one to four days, while patients with COVID-19 may not exhibit symptoms for seven to 14 days, said Dr. Jones, meaning patients with COVID-19 can be infectious somewhat longer than people with the flu before symptoms develop. Most patients are infectious for 24 hours prior to developing the flu, while patients with COVID-19 can be infectious for three to five days before symptoms appear.
In comparison, there’s less variability in how sinus infections present, said Dr. Schalch Lepe. Sinus infections that are bacterial in origin aren’t as easily transmitted, and patients have consistent symptoms, so these patients are easily identifiable.
Another key difference between COVID-19 and an upper respiratory infection or sinus infection is that a large number of people with COVID-19 are asymptomatic, while another subset of patients progress to critical condition or even death, said Dr. McLean. Most people with an upper respiratory infection or acute sinus infection experience limited symptoms for a short duration and make a full recovery.
Men, minorities, older adults, or adults with pre-existing conditions such as obesity, heart disease, and type 2 diabetes are more vulnerable to severe illness from COVID-19 than the rest of the population, Dr. McLean added. These groups aren’t necessarily more susceptible to other upper respiratory tract or sinus infections, however.
Having COVID-19 can also result in potential neurologic manifestations. “Other cranial nerves are at risk for neuropathy in a small percentage of patients, along with multiple other potential neurologic effects,” Dr. Patel said. In a recent paper, she discussed the increased incidence of cranial neuropathies in patients with post-viral olfactory loss (JAMA Otolaryngol Head Neck Surg. 2020;146:465-470). “This may indicate some inherent vulnerability of particular patients to nerve injury or decreased ability for nerve recovery via this mechanism.”
There are also reports of tinnitus and sensorineural hearing loss after COVID-19 infection. The cases reported thus far seem to occur in patients who are generally sicker, admitted to the hospital, and occasionally enter an intensive care setting, Dr. Schalch Lepe said. Patients often realize they have severe tinnitus and/or hearing loss after discharge, and subsequently seek care from an otolaryngologist—including audiologic evaluation.