Q. Thanks for coming back to speak with us again, Simon. For those who have not seen your previous interview, can you tell us about yourself?
A. I’m a consultant Rhinologist (Nose Specialist) at the Royal National Throat, Nose and Ear Hospital in London. I studied Medicine at the University of Cape Town and trained in ENT surgery in the North London region. I have a research interest in smell and sinus disorders as well as the genetic disease Hereditary Haemorrhagic Telangiectasia and am pursuing a PhD examining a strange theory of the function of the olfactory receptor called the vibrational hypothesis. Although we have always seen patients with olfactory disorders at the RNTNEH, we are in the process of piloting a specialist smell clinic at the RNTNEH, which is something we’ve had very positive feedback on at the moment.
Q. Today’s questions on the subject of chronic rhinosinusitis and polyps. We have quite a few members to the FB group who will be interested. I wonder if you could start by telling us a bit more about what they are and how they form?
A. CRS is "chronic rhinosinusitis" - a long-standing inflammation of the nose and sinuses. This is the catch-all term we use for inflammatory disease of the nose and the sinuses, and is divided into two subgroups - with and without polyposis (the tendency to make nasal polyps) called CRSwNP and CRSsNP respectively.
CRS is currently diagnosed by set of symptoms (two or more of nasal blockage, discharge, facial pain or pressure, reduction of smell, with at least one of the symptoms being blockage or discharge) combined with characteristic findings on endoscopic examination or CT of the nose. These have to be present for over 12 weeks to be called chronic rhinosinusitis.
There are probably several other smaller groups in the two big diagnostic categories. For instance, someone with CRS with nasal polyposis (CRSwNP), aka polyps, might also have an aspirin allergy and asthma, a disease known as Samter’s or Widal’s triad. We refer to these as endotypes and some of the most exciting current research into CRS is looking closer at the sub-types of this disease.
Q. How does it affect sense of smell? What is actually going on inside the nose for this to happen?
A. Chronic rhinosinusitis with and without polyposis causes smell loss at the obstructive level. The nerves and brain, what I call the "underlying sense of smell" are normal but the smell molecules can’t get to the nerve endings to stimulate the receptors there to start the smell process, they are blocked by the swelling or the polyps in the nose. There may also be a problem with the thick mucus which is produced in these disease states not transmitting the molecules easily to their destinations.
Q. Does a patient with smell dyfunction as a result of polyps have any chance of regaining their sense of smell? Do you expect to have patients with polyps who experience parosmia?
A. The good thing about obstructive causes of smell loss, is that if you remove the blockage, the sense of smell is still there. In some cases it is possible to improve the sense of smell by reshaping the nose with an operation, something my colleague at the RNTNEH, Peter Andrews, is investigating. For those with polyps, removing the polyps, either with medical or surgical therapy, can improve the sense of smell.
I would not expect people with CRSwNP to have true parosmia but there can be superinfections or other reasons for having cacosmia, a persistent bad smell.
Q. What about treatment?
Medical therapies for CRSwNP are directed at reducing the inflammation causing the disease. Up until the last decade, these have been steroid based, either taken in the nose or by mouth. Topical therapy in the nose is safest, as the modern nasal steroids don’t get into the body and can’t affect anything else, but often the polyps are not fully controlled at these doses. Systemic steroids such as prednisolone tablets are usually very effective and reducing polyps and improving the sense of smell but have significant side effects if taken for too long.
Surgical removal of the polyps is usually better in controlling them in the long term, but is not usually a permanent cure. Also, improving the sense of smell with surgery is never guaranteed, in fact surgery itself can cause scarring in the smell area of the nose and can make things worse.
There is a new class of medical treatment becoming available for CRSwNP called monoclonal antibody therapy, one type of which we are currently testing at the Royal National Throat, Nose and Ear Hospital. These are antibodies like those our immune systems make to destroy bacteria, but aimed at parts of the malfunctioning inflammatory system which are over-active in this disease. This blocks the signals of inflammation which start the swelling and polyp formation and may have significant role to play in the future management of CRSwNP, with good disease control and fewer side effects.
Q. Can you recommend a good self-care regime?
A. One thing that everyone should be doing is nasal saline douching, a simple salt-water wash in the nose twice a day can be a very effective. Evidence is that nasal washing is about 50% as effective as any other treatment in CRS, with very few side-effects. I think that smell training may also be helpful in obstructive causes of smell loss.
Q. Do you have any advice for CRS sufferers?
A. It is important to be diagnosed and to start effective long-term management. An- and hyp-osmia is a real concern for a lot of patients with CRS and it is important to communicate that to your surgeon. Unfortunately the sense of smell has been undervalued in the past and we are still left with a fight to make some doctors take it seriously. I believe we are at the start of a revolution in the understanding and management of these conditions. Watch this space!