Regarding Use of Topical Steroids in Patients With COVID-19–Associated Olfactory Loss—Reply | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
[Skip to Navigation]
Sign In
Views 2,209
Citations 0
Comment & Response
November 19, 2020

Regarding Use of Topical Steroids in Patients With COVID-19–Associated Olfactory Loss—Reply

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
JAMA Otolaryngol Head Neck Surg. 2021;147(1):110-111. doi:10.1001/jamaoto.2020.4276

In Reply I thank Dr Patel for her contribution to my recent Invited Commentary, “Treatment Recommendations for Persistent Smell and Taste Dysfunction following COVID-19—the Coming Deluge.”1 A thoughtful analysis of available evidence is essential in determining appropriate treatment recommendations in any context, and her voice is welcome as we refine care pathways for patients with persistent olfactory dysfunction following coronavirus disease 2019 (COVID-19).

There is an ongoing need for additional high-quality studies evaluating the use of topical corticosteroid sprays and/or irrigations for the treatment of postviral olfactory dysfunction (PVOD). Although the findings introduced by Dr Patel and members of her esteemed research team represent 2 of the higher-quality studies adding evidence to this debate, they are limited by study designs that include patients with olfactory dysfunction not related to viral illness. This potential source of confounding is significant because less than 50% of enrolled participants in their randomized clinical trial had a postviral etiology associated with their symptoms.2 Among this subgroup of 62 patients, only 20 (32%) showed clinical improvement. In addition, the distribution of these patients between the budesonide and control groups is unclear. Although this in no way diminishes the importance of their findings among patients with olfactory dysfunction not related to chronic rhinosinusitis (CRS), further study and nested analysis is needed to tease out outcomes among unique etiologies of olfactory dysfunction, including PVOD.

The consideration of topical corticosteroid sprays for PVOD in the setting of COVID-19 is an ongoing and welcome debate with expert recommendations both for and against their routine use.3,4 Factors considered when recommending these sprays include their relative safety, low cost, efficacy in olfactory dysfunction related to CRS and the available evidence supporting the use of these same medications in topical irrigations. It is also important to note the emergence of an exhalation corticosteroid delivery system with improved sinonasal penetration vs traditional sprays.5 Although the current lack of evidence supporting corticosteroid sprays in PVOD must be acknowledged,6 it is my belief that future studies with increased power and the use of emerging devices with improved sinonasal distribution have the potential to demonstrate benefit, especially when used with olfactory training. It is for these reasons that I recommend both topical corticosteroids (with discussion of sprays vs irrigations) and olfactory training to patients with persistent PVOD.

Back to top
Article Information

Corresponding Author: Joshua M. Levy, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, Emory University School of Medicine, 550 Peachtree St NE, MOT Building, Ste 1135, Atlanta, GA 30308 (Joshua.Levy2@emory.edu).

Published Online: November 19, 2020. doi:10.1001/jamaoto.2020.4276

Conflict of Interest Disclosures: None reported.

References
1.
Levy  JM.  Treatment recommendations for persistent smell and taste dysfunction following COVID-19—the coming deluge.   JAMA Otolaryngol Head Neck Surg. Published online July 2, 2020. doi:10.1001/jamaoto.2020.1378PubMedGoogle Scholar
2.
Nguyen  TP, Patel  ZM.  Budesonide irrigation with olfactory training improves outcomes compared with olfactory training alone in patients with olfactory loss.   Int Forum Allergy Rhinol. 2018;8(9):977-981. doi:10.1002/alr.22140PubMedGoogle ScholarCrossref
3.
Whitcroft  KL, Hummel  T.  Olfactory dysfunction in COVID-19: diagnosis and management.   JAMA. 2020;323(24):2512-2514. doi:10.1001/jama.2020.8391PubMedGoogle ScholarCrossref
4.
Walker  A, Pottinger  G, Scott  A, Hopkins  C.  Anosmia and loss of smell in the era of covid-19.   BMJ. 2020;370:m2808. doi:10.1136/bmj.m2808PubMedGoogle ScholarCrossref
5.
Sher  MR, Steven  GC, Romett  JL,  et al.  EXHANCE-3: a cohort study of the exhalation delivery system with fluticasone for chronic sinusitis with or without nasal polyps.   Rhinology. 2020;58(1):25-35.PubMedGoogle Scholar
6.
Yan  CH, Overdevest  JB, Patel  ZM.  Therapeutic use of steroids in non-chronic rhinosinusitis olfactory dysfunction: a systematic evidence-based review with recommendations.   Int Forum Allergy Rhinol. 2019;9(2):165-176. doi:10.1002/alr.22240PubMedGoogle ScholarCrossref
Limit 200 characters
Limit 25 characters
Conflicts of Interest Disclosure

Identify all potential conflicts of interest that might be relevant to your comment.

Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.

Err on the side of full disclosure.

If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.

Not all submitted comments are published. Please see our commenting policy for details.

Limit 140 characters
Limit 3600 characters or approximately 600 words
    ×