Loss of smell and COVID-19

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I wanted to post this infographic our practice made to help visually summarize the phenomenon of loss of smell that has been associated with COVID-19.

  • There is rapidly accumulating anecdotal evidence that anosmia (loss of smell) with resultant dysgeusia, (loss of taste) are frequently reported symptoms associated with the COVID-19 pandemic. 
  • Additionally, the limited evidence warns of these patients having no other warning symptoms for COVID-19. These patients are concerning since they may be otherwise asymptomatic spreaders. 
  • Our recommendation: There is no current official recommendation, however, my colleagues and I 1have been engaged in continuous discussions with the Academy as well as Otolaryngologists around the country. While we might previously have recommended oral steroids for an acute loss of taste or smell, due to the reports of steroids exacerbating the pulmonary effects of COVID-19 our opinion at this time would be avoiding oral steroids for ansomia or dysgeusia and considering or ruling out COVID-19 in any patient presenting with these symptoms.  
  • Be aware that COVID-19 has also been associated with sinusitis, rhinorrhea, and nasal congestion, however these are less common (<10% in available literature)

To better understand the role that anosmia is playing in this infection, the AAO-HNS has set up a de-identified reporting tool for patients with these symptoms. I would encourage any clinicians that treats or sees patients with loss of smell and COVID-19 to consider adding them to the registry to help further study this phenomenon. The link can be found below:

https://www.entnet.org/content/reporting-tool-patients-anosmia-related-covid-19

The initial data from this tool has been reported here . Out of 273 entries to the database, 73% of subjects were noted to have loss of smell prior to COVID-19 diagnosis and it was the initial symptom of COVID-19 in 26.6% of patients. There was some improvement noted in 27% of patients with an average improvement time of 7.2 days and 85% of the patients who improved, did so within 10 days. This is still anecdotal data and it is too early to make any serious conclusions, but in these rapidly changing times, this is the best we currently have. 

Online ENT Visits During COVID-19

At the 2019 Academy of Otolaryngology meeting, Dr. John Kokesh, Dr. David Cognetti, Dr. Davy Cohen, and I presented a panel titled “Telemedicine, practical tips for your implementation into your daily practice.”

To help physicians and ENTs seeking to quickly adopt telemedicine into their practice, I have posted my slides from this panel below. The slides describe the currently available tools for telemedicine and discuss the pros/cons of different platforms, as well as cost and use cases. *I have added an additional slide into this presentation relating to recent changes made by HHS during the COVID-19 crisis.**the academy has graciously made the video of the full talk available to everyone on YouTube. The link is also below! It can also be found for members at The AAO-HNS website under the 2019 annual meeting webcast.

If you are a provider trying to increase access for your patients during this uncertain time, please feel free to reach out to me directly with any questions about this talk or telemedicine in general. 

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YouTube: Telemedicine: Practical Tips for Implementation into your daily practice

What can an ENT do via an online or telemedical or telehealth visit?

What can an ENT do via an online or telemedical or telehealth visit?

While everyone understands the utility of seeing a psychiatrist or a primary care physician via video chat, it can be hard to see how a specialist visit can be done online. Still, my experience and the available evidence suggests it can be really helpful. Additionally, currently during the coronavirus pandemic, the American Academy of Otolaryngology Head and Neck Surgery is recommending all providers limit patient care to urgent and emergent in-person visits. 

To begin, I would argue that most of the diagnosis for any medical specialty comes from the doctor actively listening to the patient’s story and symptoms and asking poignant questions. 

Furthermore, most experienced physicians have a sort of ‘spider sense’ about who is sick and worrisome, and whose symptoms can be monitored for a bit longer. Video chat allows us to determine this by actually seeing the patient face-to-face. 

In ENT, through the use of video, we can examine a lot of the facial anatomy. 

Things we can do:

-a decent cranial nerve exam 

-evaluate any swelling or skin lesions 

-check eye/neck/tongue/facial muscle movements 

-assess bleeding

-with the use of a camera flash or flashlight, you can actually get a decent oral cavity exam

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(This isn’t as good as an exam with a tongue blade, but it certainly allows visualization!)

-with some software, the patient or a family member can even transmit an ear exam of anterior nose exam if they purchase a device like the firefly otoscope 

Together, all of this information can provide an ENT with a good sense of how to begin treating a patient. More importantly, it can help an ENT to determine whether a patient needs to be seen in the office or not. 

What can’t be done online? (Why an ENT may ultimately want to schedule an in-person visit)

The beauty of online visits is that it helps to determine who may need to be seen in-person at an office. 

For some symptoms, we will need to perform a hands-on exam at our office to ensure we are not missing anything concerning (like an infection or cancer). 

Often, your doctor may want to use a microscope or endoscope to examine a patient more closely. We call this ‘endoscopy,’ and it is typically quick and pain-free. It allows us to examine internal regions of the body or regions of the body that cannot be adequately observed with the naked eye. When making certain diagnoses, this type of in-person observation can provide vital information. 

I have included some endoscopy images below to give a sense of how much detail and anatomy we can observe with a physical exam in the office. 

(Above: on the viewers left a normal eardrum, on the viewers right a septal spur in the nose)

Should a patient be seen online or in person? The beauty is a patient doesn’t necessarily need to decide. Many ENTs are now offering online visits as a screening method. Depending on the results of your online or telehealth visit, your doctor may or may not ask you to come into the office. 

 

How are telemedicine or telehealth or online visits billed?

In light of the current national crisis, Medicare and many national insurers have begun covering telemedical visits for patients through insurance.

Patients with insurance should check first with their insurers, but generally can expect that telemedical visits will be covered in the same manner that in-person visits were covered. This does mean, however, that a patient may be responsible for a copay depending on a specific health plan’s deductible. Alternatively, many providers are offering flat-rate cash fees for telemedical appointments that bypass insurance completely. 

Can I FaceTime with My Doctor?

The short answer is yes! For now.

In light of the current coronavirus crisis, the US department of Health and Human services has allowed patients and doctors to connect over a select group of encrypted services like Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype.

Prior to the current coronavirus pandemic, doctors were required to use a secure encrypted video chat service to discuss a patient’s health issues. All video chats were required to meet HIPAA compliance, which is a set of standards for health information security. The policies were changed for coronavirus, however, so that patients could safely practice social distancing while still remaining connected to their doctors and able to have their everyday health concerns tended to.

You can find the full policy, as updated for coronavirus, here.

Below is an excerpt from the HHS Policy.

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Can an ENT help differentiate coronavirus from a sinus infection?

While I always recommend patients coordinate care with their primary physicians, ENTs are specialists of the upper airway, which is where COVID-19 often presents itself. In light of long wait times at urgent care centers and primary offices, some ENT’s are willing to help perform coronavirus screening via online visits.

Indeed, many symptoms of a sinus infection mimic those of coronavirus. Both a sinus infection and coronavirus can lead to symptoms of cough, runny nose, fever, and fatigue. An ENT may be able to help differentiate between the two or suggest potential treatment options depending on your symptoms, or help determine when coronavirus testing may be needed.

One interesting symptom of the coronavirus is that there are emerging reports (that have not been fully verified) of a loss of taste or smell associated with the virus. In general, most patients with loss of taste or smell will be referred to an ENT, so many ENTs are already treating or seeing coronavirus patients. I recommend you call your ENT’s office first to discuss, and this would be a perfect question for a telemedical or telehealth visit.

Currently, there are no at-home testing options for COVID-19, however, in the next few weeks, there may be at-home test kits available.

What is a telemedical or telehealth visit?

Manan on Iphone

 

In the past few days, I’ve been asked a lot about telemedicine by many of my family members/mother’s friends (I love you mom!). To help clarify, in the next few posts, I am going to help answer some really basic questions on telemedicine.

First up: What is a telemedical or telehealth visit or online visit?

A telemedical or telehealth or online visit is a way for patients to connect to their healthcare providers virtually, without stepping foot into a doctor’s office. 

Often this involves using a smartphone with a camera, or a laptop with a camera, to connect a patient with a physician to allow for a video chat, but it can also mean a simple telephone call with your provider.

What are the benefits of a telemedical or telehealth visit?

Telemedical or telehealth visits allow patients to have continued access to care from the comfort of their home. During this changing time, it allows access to your provider without risking exposure to coronavirus. 

There are other benefits for patients though:

  1. You save on travel time. The visit can be done from anywhere. (Seeing your doctor in your bathroom however, might be awakened for all. Patients may want to keep their surroundings in mind.) 
  1. No need to wait in an office waiting room. 
  1. These visits are always more cost effective then an urgent care; for most plans they can be billed through insurance. 
  1. Can help determine whether or how urgently you need to be seen in person.

Do I need software or a special application?

This depends on what software your healthcare provider is using for the telemedical or telehealth visit. Some telemedical software does require you to download an application, and this is usually easily done through your smartphone’s application store. Other telemedical software does not require you to download anything new.

Finally, in light of the current coronavirus emergency, the department of Health and Human Services is allowing providers to use some popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, or Skype.