I am an Assistant Professor in Otolaryngology (ENT) at Drexel University College of Medicine, and I specialize in disorders of the nose and sinuses. I recently developed a mobile app to help track and study the relationship between COVID-19 infect...

Is is bad for you to pick your nose and eat it, or is it just a social convention that that is considered gross?

Haha, I anticipate this will be the top question asked today. The bad things that happen from chronic nose pickers are nosebleeds, especially if you have other factors going on (like being on blood thinners, or have high blood pressure). The worst I have seen are patients developing ulcers along their septum from OCD-related nose picking, which are pretty bad. Eating the actual contents, however, is probably harmless. Bon appétit!

Ok perhaps a silly question then here. I am probably one of those people. I used to get nosebleeds once a week growing up. I also have a deviated septum that I would love to get fixed some day.

But I wonder when I see posts like this, how do people avoid picking their noses? I literally cannot breathe out of my nostrils if they have not been picked for over a few hours. They just get completely blocked. Blowing my nose only rarely gets enough out and often causes havoc with my equilibrium.

What is the alternative?

Daily saline nasal rinses (like Neilmed, or a netipot) can be very beneficial for you to help with keep the nose clean and to flush out things that can cause you to experience irritation. Of course, since you have an area of the septum that is bent and likely getting directly hit by your nasal airflow, that area will naturally dry out, crack, bleed, or cause increased crusting. Depending on the severity, surgery may be the only thing to fix your problem for good.

How do you treat an ulcer in the nose? I would think it would be difficult to do so.

Depending on the cause of the ulcer, in most cases you need to first stop causing trauma to it (to allow it to heal). Then usually recommend saline rinses to keep the nose clean, and to apply antibiotic ointment to their nose regularly.

Some people who eat their boogers say that it's kind of like a vaccine - do you agree?

I will say with certainty that eating your boogers will not vaccinate you against any sort of infectious disease.

Will every case of Covid involve a loss of smell or taste to some degree?

Not necessarily. The current research estimates that anywhere from 40-60% of all COVID cases will experience some sort of loss of taste and/or smell.

Is the loss of senses a permanent loss, or temporary?

Usually temporary, most people recover within a month of experiencing the changes to their smell.

Is the anosmia and phantosmia originating from an intracranial hypertension point or something else?

I'm only a medical student, so Dr. Unsal could give a better answer than me. However, I've written two papers on the neurocognitive effects of COVID-19. While I don't think the exact mechanism is known yet, it is not due to intracranial hypertension. You'd see global cognitive dysfunction with intracranial hypertension, rather than anosmia.

It's more likely that the symptom is peripherally driven, such that the smell "signal" never reaches the brain. This could be caused by inflammation of sensory epithelium restricting airflow to the olfactory cleft. Or, if the smell does reach the sensory neurons, it's possible that damage to the supporting cells (which express ACE2 and TMRSS2, a receptor and enzyme that allow SARS-CoV-2 entry into a cell) can reduce signal transmission to the brain. I'd be happy if Dr. Unsal expanded on this and/or corrected anything I have gotten wrong.

From what we know so far, it appears that the smell changes are most likely peripheral like CharmCityMD mentioned. Great explanation!

This may be a silly question, especially when the numbers are THAT high, but have they ruled out zinc supplements as a factor in the smell and taste loss?

I know that zinc supplements can cause this as well and too much can even cause permanent smell and taste loss. Given that people were actually injecting bleach to avoid coronavirus, are we certain none of the smell and taste loss is from excessive zinc usage?

I know that zinc nasal sprays have been shown to cause issues with smell loss. It is certainly possible that too much zinc supplementation can also also do the same. The dose at which that happens though, I am not sure. We don't really know how many people are taking zinc and how much. My app actually does ask about zinc, so this is one thing I am interested in also finding out. However, people have been taking zinc for colds for a long time now, since there is some evidence it can help shorten colds and those people have not experienced crazy rates of smell/taste loss. That tells us that the explosion of anosmia cases we are seeing are more likely directly related to COVID infection.

A few years ago, I took part in a flu vaccine trial which involved being quarantined and tested multiple times each day. I do not know if I had the vaccine, or a placebo. I also do not know if I was infected with a flu or not, as it was a double blind experiment. I didn't ever feel terribly ill during it, but I did loose my sense of smell after it. I put it down to the swabs going into my nasal cavity and assumed it would recover. At first, I kept smelling a chemical smell, like petrol, no matter where I was. Then, all sense of smell disappeared.

Fast forward to 2020, in February, my niece had a very persistent cough, which a lot of my family caught. I ended up catching it and was knocked off my feet for about 2 weeks with a horrible cough, fever and tiredness. I suspect it may had been covid-19, but wasn't ever tested. However, since recovering, my sense of smell has returned better than ever. I'm very happy, being able to smell again makes such a huge difference. But I'm curious if you think these events are related? Or if you can help explain why my smell was absent for almost 2 years before coming back stronger than before?

Many thanks for your work, by the way.

That is an interesting story for sure. It is hard for me to tell if if the two are related. Smell loss can be caused from so many different things. It can be related to other medical conditions you may have, if you were generally "stuffy" with a clogged nose, if there was an environmental factor involved (like allergies), or if you had any deficiencies in vitamins or other nutrients. All I can say is that 2 years is a long time with smell loss, so I am happy to hear you are back to normal again!

Does the medical community really think children under 10 “rarely spread the virus”?

If so, what are the specific proposed anatomical and/or physiological mechanisms for this?

Is it purely due to smaller lung volumes? Shorter stature putting their noses closer to the ground? I have heard someone guess that maybe there are fewer ACE2 receptors in the nasal mucosa in children, but I’m fairly certain that was just a guess.

So that is still a big question, and one that we don't have a definitive answer to yet. Yes, what you've stated is a potential theory. Younger children appear to produce fewer ACE2 receptors, making it more difficult for the virus to infect cells. Additionally, the lower lung volumes of children cause less viral particles to spread into the air.

Additionally, another theory is that young children appear to be developing more inflammatory-like conditions toward the coronavirus, as compared to young adults and adults whom present with the typical peumonia/cough. So although children may still get the disease, they are less likely to spread it because they are not producing as many virus containing respiratory droplets.

Edit: To answer your first question, there is growing evidence that children under the age of 10 are indeed less vulnerable. Like with many other infectious diseases, it would make sense if they are less able to become infected, they are less likely to spread it to others. How much less, however, is still widely unknown.

That all makes sense, but I still think children spread germs very effectively eg. putting things in their mouths and wiping snot on surfaces.

Absolutely true. There is definitely a behavioral factor with young children that also increases their ability to spread it more effectively (less likely to keep their masks on, less likely to keep their hands clean, etc). This is one of the big anxieties parents and teachers have with reopening schools back up.

Can small children be asymptomatic carriers of the virus?

It is possible, we just don't know enough yet about the rate of asymptomatic carriers of young children since they have clearly been less impacted by COVID as compared to adults.

Why does is always seem like one of my nostrils are clogged?

It could be lots of things! But the most common is because you may have a bend in the wall of your nose that causes one side to become much more narrowed then the other. I would recommend for you to see an ENT to take a look inside with a camera to figure out what the real problem is.

Back in April I couldn't smell OR taste anything. I was okay with the anosmia because it didn't really disrupt my daily activities, but the lack of taste was misery. Why are they connected and happen altogether?

So much of our smell is connected to our taste. Taste primarily consists of 4 senses: bitter, sweet, sour, and salty. In fact, one of the major questions we need ask our patients is there is deficit to one of these sensations, in order to determine if they are just experiencing an isolated smell or taste issue. Odors and aromas comprise much of the other sensation of "taste" we experience.

The most common cause for smell loss is called a conductive anosmia, where the odor particles cannot enter into the nose (from a stuffy nose, or cold). These types of smell loss goes away once the obstruction in the nose resolves. When it comes to neural damage of the olfactory (smell nerve) fibers, this can occur from just having a rough cold that injures the nerve. Many times it can resolve, but in others it may persist for months or even become permanent. However, just because you had it once and it resolved, doesn't necessarily mean that it will happen again.

My friend had Covid back in late March and her smell and taste are still not fully recovered. Is there any info on how long it might take for her sense of smell and taste to return (if ever)?

So it sounds like your friend is one of those atypical cases that does not recover within a month. Because COVID is so new, it is difficult to tell you exactly how long it will last. The longest I have see thus far is about 3 months. Since his/her smell loss is under 2 years time, there is a still good chance of recovery. However, in general, your friend should see an ENT to make sure there aren't any other causes for the smell and taste issues.

Do you ask children to try and pronounce your field of study for fun at family gatherings?

I am pretty sure even most adults cannot pronounce it! Although, Otolaryngology does make for a great scrabble word at family gatherings.

I had a friend lose his sense of smell after a head injury. Do you know of any science that says it could come back? What if I hit him in exactly the same spot on the same day in the same place like a teen movie?

Trauma can be a cause of nerve related smell loss. The science (that I am aware) dictates that time since the smell loss is one of the biggest determinants of whether it will come back again. After a couple years, it is unlikely to come back to normal. But it also depends on the severity of the head injury and any other medical problems your friend has. Unfortunately, repeated injury to the same "spot" will not reverse the damage already done.

Is neuroplasticity at all related to the senses? I know stroke patient’s brains “rewire” but I imagine this is a hardware vs software situation.

Yes, neuroplasticity can be related to the senses. Working areas of the brain will try to compensate for other injured areas. Your brain is constantly seeking efficiency.

For some reason everytime I go to pick my daughter up from daycare I sneeze as soon as I step in the building. It's the only time I sneeze all day but I'm sure the screener is starting to wonder if I am infected with something because it happens every time I see her.

Is this somehow related to the temperature change, stepping into an Air Contitioned building after a long walk in the sun? I have some mild seasonal allergies (eyes) but haven't really been sneezing from them other than this.

There is a phenomenon called vasomotor rhinitis that results in nasal irritation, stuffy nose, and even sneezing that can occur from certain temperatures and humidity in the air around us. For example, this occurs in many of us when we are outdoors in the winter time and get runny/stuffy noses. However, the degree and sensitivity of the reaction is pretty variable amongst individuals.

However, like you've mentioned, it could be that your nose is sensitive to certain odors or particles floating around in the daycare. It is difficult to say for sure given this is something that only happens to you in that particular setting.

Have you prescribed Dupixent to any of your patients with chronic rhino sinusitis with polyps? I’ve had 3 sinus surgeries, and was hopeless without taste and smell, but this shot seems like it cleared it up pretty well. Off topic, but just wanted your opinion on the med.

Yes I have! Dupixent is a great option for patients with recurrent chronic rhinosinusitis with polyp disease. Biologics, like dupixent, target the exact molecules causing the cascade of inflammation in your body that produce polyps and therefore can be extremely effective if diagnosed appropriately. The only downside is the cost, and the fact that you need to get injections twice a month, indefinitely. Also, once you stop the medication, the polyps tend to come back.

Would Dupixent help polyps caused by AERD? I've never heard of it.

My colleagues at Jefferson University are actually studying this right now. There is preliminary data to suggest that it may help with AERD as well.

My mom is addicted to nasal spray

Her sinuses are blocked as normal, and she has to spray every couple hours to open them up.

I have been pleading with her to get over her addiction and quit the sprays, she understands and agrees with me on principle but is too afraid to “suffer” with a stuffed nose.

My question is, how long do you reckon it will take the sinuses to get back to the normal physiological state of being open regularly if she quits cold turkey?

Im hoping if i can give her an actual concrete number of days that it will take to get to normal, i might convince her to quit.

Yeah, this is unfortunately a story I hear all too often. Its not your mom's fault, but there aren't good warnings about certain types of nasal sprays that easily available over the counter. Usually, it takes about a month or so for the nose to return to normal although some damage can be permanent depending on how long she has been using them. Usually I prescribe my patients with other kinds of sprays to try to help keep decongested during the rebound time so I would recommend she seek out help from an ENT to best ease her back to normal. Additionally, if there is an anatomic problem that is causing her to be blocked up, it can be addressed surgically so she won't have the urge to use it any longer.

Tonsil stones!! Is there something I’m eating that’s making them worse? Is the only way to prevent them by getting my tonsils removed?

Tonsil stones are a consequence of your anatomy, unfortunately. As we age, the structure of the tonsils can change and the problem may eventually disappear. Gargling salt water daily can also certainly help to keep the tonsils clean. For my patients that are really suffering though, I usually recommend to get them taken out.

Thank you for this thread. I am on day 14 of symptoms from a positive COVID test. I lost my ability to smell on day 3 and lost my ability to taste that same day. I have recovered about 80% of my ability to taste, but my smell is only just now beginning to return.

I have taken to smell training, however smelling essential oils has given me a nasty headache. I was able to distinguish between smells and they were not distorted as some have experienced. The smell was weak and I needed it to be quite close to my nose to smell, but it was there.

Is the headache a good sign that I will recover my ability to smell in full? Or my ability to taste? I do not want to develop the metallic or distorted rotten smell/taste, but is there anyway to know if that will occur? And finally, why does distortion of smell and taste occur?

I am glad to hear that your smell is 80% better! Most people should recover within a month's time, so it sounds like you should be on your way to recovery. Beyond just "smell" we also have pain sensors in our nose that react to the more noxious elements in the odors we breathe. These tend not to be affected by COVID. Sometimes, those things can give us headaches so I'm curious if that is causing your problem. Headaches themselves however, are not suggested to be an indication that your smell is returning.

There are two main theories on why the distortion of smell occurs. Studies examining COVID patients with MRI scans suggest that the virus directly affects the olfactory nerve bulb, as direct disruption of the smell fibers cause this area to light up on brain scans. Other reports suggest the loss of smell may be conductive (meaning, the odors are not getting to the smell parts of the nose). This can be from disruption or damage to the tissues that surround the nerves, thereby blocking odors from reaching the nerve endings. Because of these conflicting theories, the exact cause of injury is still widely unknown and one of the reasons why I started this project!

I don't know if my sense of smell is back to 80%, just sense of taste. I know they are interconnected so I'm hoping that your response provides some semblance of a full recovery for me since my taste is near normal.

I downloaded your app so that I can contribute to your research to help others like myself.

Thank you for your support! Best wishes.

Hi Dr. Unsal!

This isn’t related to COVID in the slightest, but I have congenital anosmia.

Whenever I go for regular checkups (in my 20s) I always forget to mention my anosmia, because it’s such a normal part of my life that I never think of it when going through my medical history. Is this something I should really try to make sure my primary physician knows about me, or would it not make much practical difference?

Also, I’ve always wanted to visit an ENT doc to find out whether my condition is due to the lack of development of olfactory bulbs, or epithilium present in the nose. Do you think this would be a fruitful endeavor if it isn’t otherwise impacting my life? Or should I only visit a specialist if there is a problem?

Sorry for so many questions, thanks for your time!

Thanks for your question. I think it is important to let your primary care doctor know, because congenital anosmia can be related to other disease processes or syndromes (like Kallmann Syndrome). Even if you have no other medical problems now, if you were to experience anything odd with your health in the future, having that piece of information is always important to know for physicians when coming up with a differential diagnosis. If it isn't otherwise impacting your life and if you've had this since birth, I can't imagine that it will have much of an impact on your life. However, it would be good to discover why the condition occurred for the same reason I mentioned before.

I'm a chronic sufferer of empty nose syndrome due to an overzealous UPPP treatment for sleep apnea. I've often heard some in the medical community don't believe it actually exists. Have you ever dealt with any ENS cases and are you aware of any up and coming potential treatments?

Yes, ENS is a real problem and because it is not completely understood, there can be some in the medical community that are easy to dismiss it. The main studies investigating the problem find that there may be problem with the way air travels through the nose, and is typically related to the size and shape of the inferior turbinates that sit near the floor of the nose. One experimental treatment includes grafting or bulking up the size of these turbinates to increase the resistance in the nose, as well as to alter the flow of air.

That is amazing! Nice work! Drexel is one of my top choices for a Path A program, do my first question is: how do you like it there, and Philly in general?

Secondly: I have struggled with constant phlegm into the back of my throat. It's always thickened and very difficult to clear and I struggle to breathe well (even though I'm breathing just fine). I've struggled with this since I was very young, and I'm now 31F. I've seen a handful of otolaryngologists, but they seemed to just wave it off. It does interfere with my daily life, is embarrassing when I'm trying to clear it in public and I think also contributes to the headaches I get.

Surgery was performed on my sinuses, turbinates, and deviated septum, but that just made things worse and left me with a $30k+ bill. So, I get a little hesitant to pursue things further. I am also diagnosed with Lupus and Sjogrens Syndrome.

Do you have any general thoughts on the cause of this, and further recommendations? Or how to choose a good otolaryngologist?

Thank you, and keep up the excellent work!

Great! I love Philly. For me, it hits the sweet spot of being in a big city with lots of things to do without the crazy hustle bustle and noisiness of other cities like NYC. And if you miss that, NYC is only 2 hours or so away. It is also a little more affordable living-wise compared other big cities. Lastly, my experience with the people that live here has been great, people here are really friendly.

I am sorry to hear of your issues. When we think about "throat phlegm", it is generally caused by two main things: Constant drainage from the nose (from things like allergies or chronic sinus inflammation), or as result of reflux. The throat will make mucous to neutralize the acids coming from your stomach, and this is usually a significant cause of the problem in many people. Given your autoimmune history, your mucous may also be thickening up because of the reduced salivation. Make sure you stay plenty hydrated!

Choosing a good otolaryngologist would be the same for finding any good doctor. Find someone that listens your problems carefully, is willing to educate you on disease processes/management strategies, and of course, genuinely cares about your ailments. Best wishes!

In your field of doctorolgy, is there a more painful diagnostic procedure than the nasalpharynx swab? I got a COVID-19 test and they used tried and true "pull your brain out through your nose with a q-tip" technique. I'm having trouble imagining something more painful that's done regularly.

Sometimes the nasal swab is done inappropriately, and those performing the procedure can jam it up into one of your nasal turbinates which is pretty painful. The floor of the nose actually tilts downward, so you need to aim the swab down to get the right angle to get to the nasopharynx. Thats what we try to teach others, at least. But, yeah either way, not a very pleasant experience.

Sometimes in the office we do biopsies in the mouth or throat, or put cameras down people's nose and throat which can be very uncomfortable unfortunately. But, that's price we gotta pay to figure out a diagnosis.

Why use your app as opposed to MyData Helps app for COVID data?

My app is specifically geared toward ear nose and throat symptoms, so I've tailored the questions to help me best target smell related issues. Beyond that, my app also has a section where people can actually track their symptom scores over time, so you can use it to see your progress over several days, weeks, to months.

Do you know of any studies that indicate what would be the optimal amount of nasal hair for maintaining health, warding off infections? Does this optimum vary by gender/age/etc...?

Not that I know of. Your nose hairs are primarily there to filter out large particles, and are just one of many parts of you nose and immune system that help ward off infections.

Sometimes my right nostril is dominant and vice versa for the left nostril,sometimes it balances? I want it to be balance all day is there a solution?

This is a physiologic phemonenon called the "nasal cycle" that occurs every 3-6 hours, whereby one side of the nose will get "stuffier" and then go to the other side. If you happen to have narrowing on one side more than the other (like from a deviated nasal septum, which is the wall that separates your right and left side), you may feel that one side ends up becoming more dominant.

If you are having quality of life issues from breathing only from one side, the safest thing you can start doing is using nasal saline rinses daily, and then visit your local ENT to look inside to diagnose your specific problem.

Do we really need to use distilled or sterilized water for nasal saline rinses? Thanks!

Yes, use clean water. Well water needs to be boiled. City tap water is usually safe because its chlorinated, but if you have any question about it spend the 80-90 cents on a gallon of distilled water, or just boil it before using.

Thank you for your reply, I'm not having issue however the brain functions better when breathing is in balance I want it to be like that most time, do you think breathing yoga exercise (pranayam) would help?

Sure! As a doctor, I am all about recommending healthy activities to patients that make them feel better in any way. Much of the way we experience breathing is so subjective, so what may work for you may not work for others. It can never hurt to try.

Hi Doc! Thanks for doing this! Can chronic sinus related issues cause nausea and dizziness? After laying down for more than 5 or 6 hours, when I get back up, sometimes I get nauseous, dizzy, and some vertigo. By accident, I discovered that taking allergy medicine helped immensely. More specifically a combination of Chlorpheniramine (antihistamine) and Phenylephrine (decongestant). Does this make any kind of sense?

More background info: Sometimes my ears feel like they need to pop when I'm just sitting on my couch or around my house, at least once a day. I've never had an ear infection that I'm aware of nor have I had chronic sinus issues. I do get seasonal allergies. Thanks again!

It is possible since a lot of those things are connected. Eustachian tube dysfunction is very common in people with chronic sinus issues and allergies. This is a tube that connects your middle ear to your nose. When the function of it is impaired, you can get lots of pressure building up like when you go on an airplane. The primary thing is to get the nose issue treated first and see how things go. Once you start treatment for that, then see if the other symptoms slowly resolve. If not, it can warrant more questions/workup. Good luck!

Wouldn't you say that classifying anosmia with covid is a little bit misleading? Aren't there any stronger associations with our nose and sinuses that we can detect other than anosmia? I ask because I myself have anosmia occasionally due to allergies or a small cold, so I could imagine many others have the same effects. I just would think it can lead to a lot of fear and worry if people have covid. But obviously thats what you are trying to find out!

Yes, you are absolutely correct. In the study, we ask lots of questions about all the other covid symptoms and if they have been tested. We are also trying to study the people that were positive so we can get a glimpse of what their experience was like. However, if people are reporting severe smell loss in conjunction with things like cough/fever, studies have already shown that the anosmia is more likely from a coronavirus infection.

Am I understanding that you're saying, during the pandemic, a COVID-19 infection is the most common cause for anosmia. I know several people who has anosmia before COVID-19 even emerged (from flu or allergies), and several who've had anosmia during the pandemic, but did not have COVID-19 when tested.

Do you mean, there are studies that show, the majority of people with anosmia and cough or fever during the pandemic have COVID-19, or that COVID-19 is the most common single cause of these symptoms during the pandemic?

And related, if someone has anosmia without cough or fever, is this a common symptom of COVID-19 infection?

Based on the numbers out there, if you have anosmia, cough, and fever you most likely have COVID until proven otherwise. Before COVID, this type of sudden onset anosmia was much less prevalent in the general population. Because anosmia occurs in 40-60% of people with COVID, for now, we have to ask if it is COVID-related. Can it be something else? Sure, exactly for the reasons you mentioned. There is never 100% in medicine.

Despite this, it is definitely much more rare to have only COVID-related anosmia without any of the other cough or fever symptoms.

I have this issue with my right ear. It's so weird I'm not even sure how to describe it. It's like it pops in and out periodically, sometimes while eating, sometimes while doing nothing. It doesn't hurt, but it makes noises sound different (like I can hear my blood flowing and my breathing gets very loud - it's somewhat similar to pressure build up do to elevation change, but not exactly). I believe it's tympani tensor syndrome, but I don't know. When I read about that it doesn't really seem to match the sounds I'm hearing. How could I get this diagnosed when it doesn't happen all the time? How can we describe sounds no one else can hear? And how do you diagnose things based on people's terrible descriptions of what they feel/hear?

Sounds like some sort of Eustachian tube dysfunction. Just because physicians can't hear/experience what your are feeling, we can still treat it! I would go see your local ENT so they can start you on some medications to see if they can reduce the frequency of your symptoms.

I’ve had post nasal drip for about 6 mths - I often get it following a cold for a solid few weeks. I wake up feeling mucous in the back of my throat (though my sinuses are completely clear) and I cough throughout the day because of it. It also sometimes triggers my gag reflex which is lots of fun. What kind of treatment would you recommend? I’ve tried irrigation, allergy meds etc. I recently read that it may not be post nasal drip at all but related to lungs or ‘silent’ acid reflux or something - just wondering your opinion before I approach a specialist.

Yes, the culprit may be related to silent acid reflux. Make sure you dont eat anything 2-3 hours before bed, cut out any smoking/drinking (if applicable), and chew a few tums before you go to sleep. Unfortunately if the problem is severe, you may need some stronger medications.

Are there cases in which congenital anosmia can be reversed in adults? I have a friend who can only "smell" chemical like smells, such as vinegar, acetone, chopped garlic etc.

Not that I know of. Those smells you referenced also stimulate the pain sensory nerves from the trigeminal nerve (cranial nerve 5). There are certain odors that do this, and is actually one of the ways we test people to see if they are lying about their smell loss.

So sometimes, when I swallow there’s this weird “click“ on the left front side of my throat, next to my larynx, it only happens when have my head positioned certain ways, what is that?

Not sure. Many times we hear clicks in our ears when we swallow, which is the sound of our eustachian tubes opening up briefly. It could just be the sound of your larynx moving up and down within the soft tissues of your neck when you swallow, but that would be purely a guess at best.

Any advice for an M1 who wants to get involved in some ENT research? Who should I reach out to? Also is it okay if I do general surgery research or do ENT programs want to see ENT research? Thanks!

Any research is good research! ENT research is obviously preferred because that's within the specialty. But, no one will hold it against you for having publications in other fields. If you only focus on non-ENT research throughout med school though, you may get asked why. My advice is to seek out your school's ENT program, and start making connections within the department. If not, seek out a nearby program that does and start reaching out to people in the department to see how you can get involved. You got nothing to lose by dropping cold emails, and everything to gain. Good luck!

Hello there. Is Empty Nose Syndrome an actual physiological issue, or is it psychosomatics?

It is a real issue, and can drive patients miserable. Unfortunately it is a difficult problem to fix, so the goal is to try and avoid it from happening in the first place.

Thank you for this AMA and for your work in this area. Dysosmia is a super-interesting phenomenon! Unfortunately, it has been with me since Spring 2019. Forgive the (long) length of this post, but I want to share as much as is possible, in case it is helpful to others, too.

Background: I am a 60-year old white female vegetarian bicyclist in good health, 5' tall and 107 pounds. I had enjoyed a very keen sense of smell and memory for fragrance throughout my life (easily duplicating complex spice combinations from food years later, for example.) I also now know that my visual and emotional memory had strong associations with odors as well.)

I have taken 3-6-9 oil since 1998, a multivitamin and some vitamin d--all in moderate doses, and probiotics since 2016, post-surgery for carpal tunner and IV antibiotics. As I approached menopause in my mid-50s, I put on weight by eating too much "healthy food," the same kinds of which I had eaten my whole adult life (organic oils, fruits, veggies, and nuts, with limited dairy.) In April 2018, I switched to a low fat, higher-protein diet with a good deal of Greek yogurt--and lost 29 pounds over 11 months. Symptoms of dysnomia started in Spring 2019.

I first became aware of smell changes after my hubby and I returned to our rental house in Massachusetts after having been away for a week. (Throughout 30+ years of marriage, I was the one who had a better sense of smell.) We walked in and he found the smell of mildew/mold to be overwhelming--I smelled nothing. We had the landlord deal with the issue and thought no more of it, but I continued to have unusual perceptions or absence of smell. At first, everything smelled like plain Greek yogurt--I thought I was just tired of it. I noticed that ginger--which I ate every day--was also gone. Then summer basil was dull, and peppermint smelled like horseradish. Floral scents stayed mostly intact--roses, jasmine--and citrus was evidently still satisfying because my husband noted that I started putting lime on just about every savory dish.)

By the end of the summer, we knew that we were going to leave Massachusetts, and I hoped that this was just a temporary reaction to the mold. We traveled throughout New England and the mid-Atlantic in the fall, and South Carolina in the winter. I noticed the absence of perception of nearly every common bark/woodsy scent, with continued disgust of dairy fats. I lost alliums and citrus faded. I started researching and found "Fifth Sense, in the UK," and read about loss related to Parkinson's' s/Alzheimers, tumors, and viruses. Then I moved back to my home in the Poconos, just as COVID-19 hit.

During the fall/winter, I interacted with my doctor of 30 years, a homeopathic MD/internist in the greater Philly area. We tried several remedies with no change. I realized that I probably needed to see an ENT, and just then, COVID-19-related anosmia entered the picture. Next, the Poconos locked down. And so, I waited...

Reflecting on the situation, in the new COVID-19 context, previous information came to memory:

1. In Massachusetts, I worked as a grants officer in a small college. I had few contacts with students, but there was one Chinese student who I was kind to (he needed an envelope, and randomly walked into my office looking for one. When he learned that my daughter had studied in China, he visited often.) In January 2019, just as the semester started, and he had just returned from China, he came to see me, sick, and coughed all over my office.
2. My hubby also had interaction with the Chinese student because he worked in the college library--and again, the student knew of our daughter. My hubby became very ill in the spring, high fever and weakness for 5 days.

Could we have had COVID-19 as early as spring 2019?

I started participating in Project Baseline in May 2020 and had a swab 5/30/2020 with Negative results. I went to see the ENT about 4 weeks ago. A nasal endoscopy found no anomalies--"healthy, no masses..." and I am scheduled for an MRI.

Just before I went to the ENT, I read something about how probiotics may not be a catch-all solution, how determining the right ones is an individual unknown, and how gut bacteria and CNS are related. So I stopped it just before the appointment.

I also reported back to my homeopath that my sinuses were healthy. Three weeks ago, I took one dose of camphora 200c, and I started having glimpses of smell. I took a second dose 2 weeks ago, and a third two days ago. I continue to have glimpses of odor--the woods after rain, for example.

So that is my story. The ending is not clear, but I am giving it another few weeks before I go for the MRI.

All the best, and thanks again.

I just realized that I did not ask anything. What do you think is going on?

Thank you for your story. Yes, we believe that COVID was likely spreading around the USA in January. It is certainly possible that you have had it, however, because antibodies have not been shown to last more than 2-3 months, it would be difficult to know now if that was the case. Also, the majority of smell loss so far appears to be temporary, usually returning within a month. However, smell loss can still be caused from other viral respiratory infections. I think the MRI is a good idea considering everything else about your workup has been "normal"

Generally speaking, smell loss within 2 years of duration has a chance to improve and can return back to normal. If the smell loss has persisted for more that that, it is less likely to come back. One relatively safe supplement you can try that has been shown to improve nerve related smell loss is called alpha-lipoic acid, taken at 600mg per day. Since I cannot give you medical advice on this platform, I would make sure you ok this with your doctor first, of course, before deciding to take it. Best of luck!

Hey Doc, they asked about January 2019 and not January 2020. Just letting you know! I actually have the same question. Something that seemed quite similar to covid circulated around my university in November/December of 2019. It was highly contagious and nearly the entire staff caught it along with myself and other students.

I am at West Chester University.

Oh I am sorry, I misread that trying to keep up with the questions. Unless new information pops up in the future, it is highly unlikely that you were exposed to COVID back in January in 2019. However, as I mentioned, lots of respiratory viruses can cause anosmia so there is always a chance it could have been something else.

Will the antibodies generated by the vaccines also only last 2-3 months? Or is there something different about the way antibodies are generated by vaccines that would cause them to last longer than that? Perhaps the concentration of antibodies generated?

The vaccines will likely be a different story in order to find ways to trigger your immune system to build a more robust immune response. I don't see how it would be feasible to force everyone to get vaccinated every 3 months. One of the major areas of vaccine research is to stimulate a strong T-cell response, which would allow for memory T-cells to develop so that the vaccine can hopefully last longer. Some vaccines may also require "booster" shots to help bolster a stronger immune response. There are 100-150 candidates out there so we will have to wait and see.

I get super duper bad hayfever. I even tried prescription antihistamines and I was still blocked up, so what's up with that?

Antihistamines work decently for most people, but they are treatment after you're already clogged up. I would also recommend using nasal saline rinses daily to wash out the pollen/allergens in your nose. The less of the stuff thats in your nose bothering you, the better you should feel.

Hello! It's great to hear that work is being done in this area, and see other people suffering from loss of smell and taste.

My mom and cousin both lost their smell and taste back in late March. My mom says that she can taste sugar and salt now, and she can smell really strong scents (tuna, heavy perfume). Is there anything else she can do to help develop her senses back? She was taking zinc for a while but apparently too much can damage your nerves as well.

I'm also curious how the "smell nerves" can be damaged and how they recover - can you explain this science a little more?

Cranial nerve I (the olfactory nerve) from the brain comes near a certain part of your nose and forms the bulb from which tiny fingers exit through the base of the skull (cribriform plate). These nerves fibers become part of the olfactory epithelium, or lining, which not only contains nerve receptors but also lots of other cell types and form microscopic layers. Some of the cells function as a support system that can help repair the nerve or maintain the nerve. Others provide a protective layer and mucous to help with catching the odors molecules floating by.

So, if any parts of these components become damaged, you can end up with nerve-related smell loss. However, it all depends how severe the damage is and where it is. The olfactory epithelium has the ability to regenerate where as the portion inside the brain or skull can not.

I've lived most of my life with having such a poor sense of smell (stick me at the dump and it doesn't bother me), but I can't fathom losing my sense of taste. What is stuff tasting like if you lose your sense of taste whether due to COVID or other reasons?

If you lose primarily your smell, food will taste very bland, and you'll be limited to only sensing things like the foods saltiness, bitterness, sourness, or sugar-content. If you lose your sense of taste, you will loss some or all 4 of those sensations in varying combinations.

My fiancé is an ENT resident and I find the field fascinating. She also received personal letter from Dr. Sataloff and I hope they can collaborate at some point.

1. Is there a spectrum of olfactory senses - akin to taste where you can differentiate between sweet, savory, and bitter - that is impacted COVID sooner than others? For example, if you gradually lose your sense of smell because of COVID, will you stop smelling fruits before you stop smell coffee? Is anosmia of a certain scent an early indicator of COVID?

2. I think I have the aptly names ACHOO syndrome. I’ve asked a neurosurgeon and several (general) ENTs what causes it My guess is that my trigeminal nerves are somewhat mixed. Any insight from a rhinologist?

Awesome! Dr. Sataloff is a very close colleague of mine and great doc!

1. Great question. No studies that I am aware of have addressed this. I think we will never have a true answer because of the variability of how each person is affected by COVID. In order to study that, we would have to have healthy people take objective smell tests regularly and then monitor exactly which scents become problematic if/when they catch COVID. Also, what you are describing are people that experience gradual smell loss. For many people, the smell loss can be complete and sudden, so it is even hard for them to determine what they were and weren't able to smell.
2. ACHOO is a very interesting syndrome. I personally have never treated anyone with this particular issue. There is a genetic factor involved that was published in the NEJM showing that it is transmitted in an autosomal dominant factor. Some people suggest that it is caused from a hypersensitivity of the ophthalmic branch of the trigeminal nerve leading to an increased likelihood of sneezing. One study even shows that it was associated with deviated septum. My knowledge on the topic beyond that, however, is limited.

I have a 3 part question:

I have AERD/Samter’s and have been isolating myself at home since March because COVID feels like it would be a death sentence for me. I also started Dupixent in March and it’s been a life changer after 19 years of anosmia and 3 FESS.

Is it true that those with AERD/Samter’s are considered high risk?

Am I at an even higher risk of complications and hospitalization because of Dupixent?

Will I have to continue isolating myself until most of the population is vaccinated against COVID because I can’t have a live vaccine while on Dupixent?

Thank you!

These are some good questions that unfortunately we still do not know much about. There is no data on COVID patients taking biologics. If you have a large asthma component to your AERD, so far I haven't seen evidence that shows asthmatics are at a higher risk, however more COVID positive patients in the USA also have asthma compared to China and Europe.

At the end of the day, it is a risk benefit scenario. People with severe asthma are more at risk landing in a hospital from an asthma attack when compared to COVID, so we know the risk is worth it in those cases. Biologics are considered immunosuppressants, so there is a chance you may be at a higher risk. Again, there is no data to support that yet so please take that with a grain of salt.

Most likely, you will need to stop Dupixent for a set period of time before you can receive the COVID vaccination. Yes, live vaccinations are not recommended for patients on biologic therapies.

I recently discovered that taping my mouth shut at night with 3M Micropore tape has enhanced my quality of sleep, as well as eliminating any dry mouth or sore throat I may have had in the past. My question to you is what leads some people to be mouth breathers while others breathe through their nose normally?

When people lay down, blood tends to pool in the nose and can cause nasal and turbinate swelling. If you have a deviated septum, or some other anatomic issue causing narrowing in the nose, it will become worse at night when you sleep. Your body will want to adjust to breathing that is most comfortable for you, which causes people to mouth breathe.

I had an operation for polyps and regained my sense of smell for a few months. It’s since gone away as my polyps are back, I suspect, though nowhere near as bad as before. Will I ever smell again? Is there any way to permanently get rid of polyps? It was so nice having a sense of smell again :(

Yes, you likely have a conductive anosmia, meaning the polyps are physically blocking the odor molecules from reaching your smell nerves. Once the polyps are gone, the smell returns. However, polyps usually recur, so you need to be on a strict management strategy to help keep them at bay. There are tons of treatment options, so you will have to see your local ENT to figure out how best help you with your particular situation.

There was a recent article in Cell Reports:

De Boeck et al. show that lactobacilli are decreased in patients with chronic rhinosinusitis and enriched in healthy controls. They isolate one strain adapted to the nasopharyngeal mucosa that shows beneficial probiotic effects and safety in the form of a nasal spray in healthy volunteers.

What do you think of this research? I was wondering if it might be helpful for my wife - she has developed a persistent turbinate swelling since she took a broad spectrum anaerobic antibiotic. My thinking is that the antibiotic may have killed off her nasal microbiome.

Yeah I agree with it. It is well known that the normal flora of the nose is an important part of keeping things healthy inside the nose and sinuses. However, if it's just turbinate swelling, it maybe something else in the environment that she is breathing that is making her feel stuffed up. Taking probiotics won't hurt, but I would also recommend using saline irrigations regularly to remove any sort of environmental factor that may be causing the problem.

Hello professor! I'm a 25 yo male, regular smoker. Recently I was having trouble breathing while laying down on my side. But one drop of oxymetazoline cured it,for the time being. Should I be worried? Given the pandemic situation prevailing outside what precautions should I take?

If it's trouble with your nasal breathing that improved with oxymetazoline, you probably have a deviated septum. You tend to sleep on the side that it is deviated, as blood will pool more on that side and you will maximize the breathing from the other side. The best you can do is what the CDC recommends: use a mask when around others, wash your hands often, use social distancing, and etc. Also, you should really try to quit smoking!

i downloaded your app. its almost been two weeks now since i started to show symptoms. i dont have many symptoms now besides headaches, fatigue, difficulty sleeping, and complete loss of smell. when i first started having symptoms it felt just like really bad allergies. i really want my smell to return as soon as possible because it is really taking a toll on me mentally. every day i go around my house trying to smell different things. sometimes i think i can smell something for a split second then when i go to sniff it again nothing. so i guess my question is how long do you think this will last?

Most people that we've see through the app and also in the published research should experience a resolution of their loss of smell for within a month. In MOST cases the smell loss is temporary. However, we are seeing some outliers where the longest recorded case from the app was 3 months until complete resolution.

oh my god that is terrible news! how am i going to live life not being able to smell? i am a chef and i wont be able to properly do my job if that happens...i am worried even more now that the extra unemployment benefits are supposedly cutting off at the end of the month and now i literally cant go to work because i have covid....i was reading an article yesterday about what they are calling the "long haulers" experiencing symptoms for months...even more scary is the neurological problems people are experiencing that not many people are talking about

I am so sorry to hear that. I would still remain hopefully however! Your smell loss is not technically considered permanent until has been about 2 years, after which it is less likely to come back completely. I would advise seeing your local ENT so you can start treatment with supplements and smell training exercises.