Will Using A Steroid-Based Nasal Spray Increase My COVID-19 Risk?

The Centers for Disease Control and Prevention considers those who are actively being treated with high-dose corticosteroids to be immunocompromised. Most nasal sprays for allergies do not fall into this category. Consult your primary care physician regarding the specific medication you are taking.

Allergy sufferers are hyperaware of every cough, sneeze, and sniffle entering the height of this allergy season. Those with allergies are not only concerned with distinguishing their allergy symptoms from the novel coronavirus that causes COVID-19, but many are now worried that the medications they take to manage their symptoms might put them at increased risk.

Steroid-based nasal sprays have come under particular scrutiny because the active ingredient—corticosteroids—can reduce the strength of the body’s immune system, which is concerning during a pandemic. Fortunately, nasal spray users need not worry. Anthony Del Signore, MD, PharmD, Director of Rhinology and Endoscopic Skull Base Surgery at Mount Sinai Downtown-Union Square, explains why allergy sufferers should keep using their medications.

Should I stop using my steroid-based nasal spray?

If patients are getting the relief that they usually receive from taking these medications, I typically say to continue using them. Often, symptoms of nasal drainage, nasal obstruction, or sinus infections will increase if you come off of the medications.

It is also important to remember that with topical intranasal sprays, as well as topical nasal rinses with steroids in them, the absorption of the steroid is quite low. And, there is conflicting evidence as to whether or not steroids taken this way will actually cause any decreased defense against the virus.

A lot of the data and recommendations that we’re getting is for systemic steroids, which are steroids taken by mouth or administered intravenously. That’s where we are seeing the decrease in the immune system.

As a result, I am staying away from prescribing oral steroids for the time being. But topical nasal sprays, as well as topical rinses, I’m okay with.

I take an allergy pill. Are there steroids in my medication?

We do not typically give oral steroids to patients complaining about the typical symptoms of seasonal allergies. Instead, we recommend nasal rinses/netipot, oral antihistamines, and intranasal antihistamines as well as intranasal steroids, with pretty good effect and results.

Oral steroids are usually reserved for more serious conditions like asthma, lupus, or severe systemic allergic reactions. And, if you have a more serious condition that requires the use of these oral steroids, you have to weigh the risks and the benefits. I would counsel these patients to practice social distancing, good hygiene, and taking other precautions. These preventative measures can often tip the scale so that the benefits outweigh the risk of the steroids.

What should patients do if they are concerned that their medications will decrease their ability to fight off COVID-19?

There’s a lot of information out there, and patients may be having a tough time finding the right answers. If patients have any questions during these tumultuous times, they should consider setting up an in-person or telemedicine appointment to talk with their health care provider. After getting a global view of the patient and seeing what other risk factors they have, proper recommendations can be made that may at least help to put fears at ease at a time that’s very uncertain for many.

Advice on Distance Learning for Individuals with Hearing Loss

According to UNESCO, school closures in response to the COVID-19 pandemic have impacted approximately 1.4 billion students. Children in pre-primary through high school, as well as adults in collegiate and graduate education are now engaged in “distance” or “remote” learning. While this allows education to continue despite school closures, it is not without drawbacks.  Poor audio quality is an impediment for learners at all levels, and can be especially difficult for those with hearing loss. Maura Cosetti, MD, Director of the Ear Institute of New York Eye and Ear Infirmary at Mount Sinai and David Spritzler, MED, Education Specialist at the Ear Institute, share guidance for distant learners with hearing loss.

Guidance for All Distance Learners

As with a classroom setting, individuals with hearing loss have specific needs related to online education. These steps will improve auditory access for all participants in distance learning.

Request that the presenter uses a wearable microphone and is well-lit throughout the lesson.

Using a built-in mic on tablets or computers can produce muffled audio. A wearable microphone doesn’t have to be anything fancy; a Bluetooth headset or the headphones that come free with a phone will significantly improve sound quality.

Additionally, presenters should be well-lit throughout so that students can speech read their mouths.

Ask for a sound check before the lesson and that student microphones are muted throughout the lesson.

A sound check will ensure that the audio is working on both ends. Teachers or presenters can do this by asking each student a different open-ended question, such as, “What’s the last movie you saw?”

Also, having other learners mute their microphones prevents students from talking over each other and introducing distracting background noise to the lesson. Teachers can have students use a signal, such as waving or holding a thumbs up, when they want to speak.

Reduce background noise. 

Turn off music, TV, and loud appliances and be sure to close windows and doors. If your child must share space with other people during lessons, ask everyone to try to be as quiet as possible.

Let the teacher know when you cannot hear.

Adults are likely to know when they are having trouble hearing, and what to do about it.  However, children are often unaware that they are not hearing well and may be shy about speaking up when there is a problem.  Help your child learn to identify problems by encouraging them to ask themselves if they understand what is being said and to let an adult know if they cannot.

Guidance for Children Who Are Distance Learning

Children with hearing loss have additional challenges regarding distance learning. Parents and guardians should adhere to the following tips to ensure that their child has the best experience while distance learning.

Ask for hearing assistive technology from your child’s school.

Ask your child’s school to send home their hearing assistive technology. This equipment, commonly referred to as “FM”, is usually used to improve the signal-to-noise ratio in the classroom, but it can also be used to connect the audio output from a laptop or tablet directly to a child’s hearing aids or cochlear implants, greatly improving sound quality. Some hearing devices can also connect via Bluetooth, ask your child’s audiologist.

Check your child’s hearing equipment.

Make sure your child’s hearing equipment has been freshly charged and that replacement batteries are on hand.

Additionally, do daily “listening checks”: while standing behind your child, ask them to repeat various letter sounds (could try the “Ling” sounds) in random order, then answer open-ended questions.

Request accommodations from the teacher.

Ask that teachers use captioning for videos and that they send presentations and other materials in advance. This will allow you to “pre-teach” new words and familiarize your child with new content.

Also, get in touch with your child’s teacher of the deaf and educational audiologist. They can help troubleshoot problems as they arise and can provide support to you and your child.

Make sure your child takes a break.

Listening through technology is hard work! Give your child plenty of time to rest in between lessons.

Even in the best of times, children with hearing loss have to work harder than their peers to learn, and commonly experience “listening fatigue” from the increased expenditure of energy. Distance learning is proving to be much more challenging than regular school for all students, and the added stresses of not seeing friends or playing outside make it even harder for kids to pay attention and learn. Therefore, it’s not reasonable to expect children to do the same work that they would in normal circumstances. In order to learn, children need to be presented with activities that are challenging, but achievable. Stress is counterproductive. If your child is resistant to doing schoolwork or participating in distance learning, discuss ways to adjust expectations with teachers.

How the Loss of Smell and Taste Relates to COVID-19

Cough and fever—followed by potentially life threatening pneumonia—have been the most talked about symptoms of COVID-19. However, as we learn more about the illness, it appears that the initial symptoms can often be associated with the upper respiratory tract or the nose, mouth, throat. In particular, otolaryngologists in South Korea, China, and Italy have noted that a decrease in the sense of smell and taste—medically known as anosmia and dysgeusia respectively—often precedes the other symptoms of COVID-19. Patrick Colley, MD, rhinologist and skull base surgeon within the Division of Rhinology and Skull Base Surgery at New York Eye and Ear Infirmary of Mount Sinai, answers frequently asked questions about this discovery.

Are these symptoms common among COVID-19 patients?

Observations from physicians in Germany noted that two out of three patients in that country who were COVID-19 positive experienced a loss of smell and taste. In other countries where a larger number of patients were tested for COVID-19, they noted that 30 percent of patients that tested positive for the virus had loss of smell and taste as the major presenting symptom. This means that somewhere between 30 to 60 percent of patients infected with the illness will experience these symptoms. For this reason, The American Academy of Otolaryngology has recommended—in the absence of other respiratory diseases such as allergic rhinitis, acute sinusitis or chronic rhinosinusitis—that a loss of smell and taste should alert physicians to the possibility of COVID-19 infection and warrant serious consideration for self-isolation and testing.

Is this an early or late symptom of COVID-19 infection?

Based on the data that is currently available from other countries with COVID-19 outbreaks, it appears that the loss of smell and taste associated with this virus is an early sign of infection. This means that many individuals will experience these symptoms prior to showing the signs of fever, cough, or shortness of breath more commonly associated with COVID-19.

How can I tell the difference between a loss of smell due to seasonal allergies and a loss of smell due to COVID-19? What should I do if I have these symptoms?

Patients suffering from allergies can experience decreased senses of smell and taste, but will usually have nasal congestion, a runny nose with predominantly clear liquid, and sneezing. They also frequently note itchy eyes, nose or throat. This is very different from the cough, fever, and shortness of breath that is typically seen in COVID-19 patients.

If you experience sudden loss of smell and taste in the absence of recent head trauma, allergic rhinitis, or sinusitis; observe strict self-isolation protocols and contact your primary care doctor, otolaryngologist, or a COVID-19 hotline to discuss the appropriate next steps of care.

How long will the loss of smell and taste last? Will patients fully regain their senses after recovering from COVID-19?

When associated with a viral upper respiratory tract infection, the senses of smell and taste can be expected to return to normal in three weeks to three months. The time course is dependent on whether the virus damaged any nerves in the nasal cavity.  

It is unknown at this time how many patients will recover their sense of smell and taste completely after COVID-19. In other upper respiratory tract infections, the recovery rate is 90 to 95 percent by three months after the infection has resolved. Older patients and patients with underlying medical problems tend to have a lower recovery rate. We are assuming a similar recovery rate for COVID-19, but it is too early to provide any accurate data at this time.

How is the loss of smell and taste associated with COVID-19 treated? How can I be evaluated for a decreased sense of smell or taste?

The primary treatment of loss of smell and taste associated with COVID-19 is to treat the viral infection itself. Proper rest, self-care, and monitoring of symptoms are important for ensuring the best outcomes in patients infected with this virus. The loss of senses is only a symptom of this infection and will often resolve after the infection has resolved.

Individuals experiencing a decreased sense of smell or taste in addition to a cough, fever, or shortness of breath should contact their primary care doctor or a COVID-19 hotline (NY/NJ/CT). If this is the only symptom you are experiencing, schedule an appointment with an ear, nose, and throat specialist. Physicians at Mount Sinai’s Department of Otolaryngology are available for telemedicine consults.

Patrick M. Colley, MD

Patrick M. Colley, MD

Assistant Professor, Department of Otolaryngology and Division of Rhinology and Skull Base Surgery, New York Eye and Infirmary of Mount Sinai

What Causes the Loss of Smell and Taste?

The sense of smell stems from small olfactory nerve fibers that are found in the superior portion of the nose. These nerve fibers connect through small holes in the skull directly to the first cranial nerve inside the brain. Air that flows through the nose deposits smell particles in the superior portion of the nose where these nerves can detect smell.

This is the same mechanism that is used to taste the majority of the foods that you eat. The taste receptors, or taste buds, that are found in the mouth only detect salty, sweet, bitter, sour, and umami flavors. The remaining flavors are detected by air flow from your mouth back into your nose where they come in contact with the same olfactory nerve fibers. These nerve fibers in the nose are actually where you taste garlic, onions, herbs, and many other flavors commonly used while cooking.

The decreased sense of smell and taste that is often seen in upper respiratory tract infections such as COVID-19 can either be due to nasal congestion causing decreased air flow through the nose and obstruction of the nerve fibers. It may also be caused by a viral infection of the nerve fibers themselves, causing them to stop functioning or die.

Could Your Sore Throat Be Caused by Acid Reflux?

Have you had a cough, tickle in the throat, itchy throat, or raspy voice that will not go away despite not having a cold or feeling sick? Is excess mucus causing you to clear your throat so often that it is annoying and, at times, embarrassing?  Many who suffer from these symptoms are treated by doctors and urgent care physicians with allergy medications, nasal sprays, decongestants, and even antibiotics. Despite this, symptoms do not get better. Often these symptoms are not caused by allergies, a sinus infection, or a cold, but by laryngopharyngeal reflux (LPR). Also called airway reflux, reflux laryngitis, or atypical reflux, LPR is one of the most common diseases of the 21st century. Unlike gastroesophageal reflux disease (GERD), which primarily affects the esophagus, LPR will affect the larynx and pharynx—your voice production system.  Lissette Giraud, MD, provides insight into and answers common questions about this widespread condition.  

What causes LPR?

It is commonly accepted that this condition is caused by reflux of acid or bile. GERD symptoms like heartburn are not typical of the condition but may appear. The most common symptoms of LPR are hoarseness, sore throat, excess mucus in the throat, persistent cough, asthma-like, symptoms (wheezing, chest tightness, and difficulty breathing), postnasal drip, sensation of a lump in the throat, difficulties swallowing, and ear pain. However, LPR presents differently in each person.

When should I see a doctor?

If you have a sore throat, painful swallowing, cough, difficulty swallowing, or hoarseness for 10-14 days, you should seek medical attention, preferably from an ENT.

What is the treatment for LPR?

Treatment will vary in accordance with the severity of symptoms. It can be as simple as making changes to your diet, like avoiding spicy foods, tomatoes, chocolate, caffeine, citrus beverages or foods, and alcohol.

Other solutions include:

  • Avoiding large meals
  • Eating three hours or more prior to going to bed
  • Elevating the head eight inches when sleeping
  • Smoking cessation
  • Losing weight if you are overweight

Your doctor may also recommend a medication to reduce acid production in the stomach, like Zantac or Pepcid, for a few weeks or longer.Stronger medications may be recommended if diet and life style changes have not worked.

Do I need any tests like CT scans, X-rays, or MRI’s to diagnose LPR?

The diagnosis of LPR is mostly based on symptoms and an office procedure called flexible laryngoscopy—an endoscopic exam of the voice box and throat performed by an ENT—and response to treatment. In some cases an upper endoscopy examination to evaluate the stomach and esophagus for inflammation, ulcers, or any abnormal lesion may be recommended. More advanced tests like pH testing and esophageal manometry are less frequently recommended and are typically done for difficult cases.

What are the complications from untreated LPR?

If LPR is left untreated, patients may experience vocal cord lesions like polyps or granulomas, chronic laryngitis, or asthma.

If you or a loved one suffers from the above symptoms, visit an ENT doctor, who will be prepared to do a complete evaluation and determine if you have LPR and recommend treatment.

Photo of Lissette GiraudLissette Giraud, MD, is a board certified otolaryngologist at New York Eye and Ear Infirmary of Mount Sinai and Mount Sinai Doctors Tribeca with more than 15 years of experience. She treats both pediatric and adult patients with an emphasis in management of sinus disease/surgery, laryngopharyngeal reflux, thyroid surgery, dizziness, and ear diseases. Dr. Giraud is fluent in English and Spanish.

What's the difference between LPR and GERD?

Both LPR and GERD are caused by acid reflux. GERD, the more well known condition, occurs when stomach acid backs up into the esophagus. Patients with this condition may experience nausea and heartburn. LPR occurs when stomach acid reaches the back of the throat or, in some cases, the nasal passage.

Frequently, primary care physicians correctly make the diagnosis of LPR. Patients may be reluctant to start treatment since the typical “acid reflux” symptoms—like heartburn, belching, and regurgitation of acid contents—are not present. Additionally, when patients see a gastroenterologist after a referral by their primary care provider or otolaryngologist (ear, nose, and throat physician, also known as ENT), they are frequently told they do not have “acid reflux.” This confuses many patients and creates further frustration.

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What Causes High Levels of Calcium in the Blood?

Though many people take calcium supplements and eat calcium-rich foods, elevated calcium levels can be too much of a good thing.  Mike Yao, MD, Associate Professor of Otolaryngology, explains how your high calcium levels might actually be signs of hyperparathyroidism.

Many of the body’s organs need calcium to be at a specific level to function properly. Calcium levels that are too high or too low can affect the function of the muscles, bones, heart, and brain.

Blood calcium levels are often too high due to abnormal growth of one of the parathyroid glands, a condition called hyperparathyroidism.  The effects of high calcium levels can dramatically decrease your quality of life.  For example, elevated calcium levels can worsen the quality of sleep and  increase anxiety, depression, fatigue, and bone pain. High calcium levels can also decrease concentration, learning, and memory.

Fortunately, high calcium due to hyperparathyroidism is easily treatable with minor surgery.

How do I know if my high calcium level is due to hyperparathyroidism?

A simple blood test to check your parathyroid and calcium levels will confirm a diagnosis. Only hyperparathyroidism will cause the calcium and parathyroid blood levels to be elevated at the same time. Calcium testing is often a part of routine yearly blood tests for adults.  High calcium levels are suspicious for this disease and should lead to further testing for hyperparathyroidism.

What can be done if I am diagnosed with hyperparathyroidism?

Hyperparathyroidism is caused by the abnormal growth of one or more of the parathyroid glands. In approximately 85 percent of cases, only one gland is abnormal. Minor surgery to remove the abnormal gland cures the disease.  This short, outpatient procedure is completed in less than an hour through a one-inch long incision in the neck.  If there is more than one abnormal gland, all abnormal glands are removed through the same incision. Typically, the surgery is not very painful. More than half of our patients do not take any pain medication and most return to work within a week.

Is there a medication I can take instead of undergoing surgery?

Patients reluctant to undergo surgery often ask about alternatives. However, surgery is the only treatment for primary hyperparathyroidism; there is no medication which eliminates the condition. Some endocrinologists will prescribe cinacalcet—a calcium reducer—to lower the calcium level in patients with hyperparathyroidism who are reluctant to have surgery. Yet, for most patients, cinacalcet causes existing problems to worsen. If prescribed, the drug needs to be taken forever to maintain the lower calcium level, and makes patients susceptible to bone loss and osteoporosis. For primary hyperparathyroidism, it may be safer to do nothing than to take cinacalcet. However, the drug can be useful for secondary hyperparathyroidism, a parathyroid disease that only happens in patients with kidney failure.

Mike Yao, MD, is a board certified, fellowship-trained head and neck surgeon at Mount Sinai’s Head and Neck Institute and Center for Thyroid and Parathyroid Diseases. He treats all stages of thyroid diseases and cancers of the head and neck. His practices are located at The Mount Sinai Hospital, Mount Sinai Queens, and Mount Sinai Doctors Westchester.

What is the parathyroid?

The parathyroid are four small glands located behind the thyroid in the neck. These glands are essential in regulating calcium levels throughout your body. Calcium is an essential mineral. It is important for strong bones, teeth, and muscle function.

 

What to Do If Your Voice Is Hoarse

Dysphonia, or hoarseness, affects approximately one-third of people under the age of 65 during their lifetime. This climbs to nearly 80 percent for high vocal users—like teachers and singers—and those over the age of 65. Symptoms of dysphonia include vocal fatigue, pitch changes, voice breaks, unintended volume changes, increased vocal effort, and decreased quality.

Hoarseness can range from temporary voice changes caused by a viral infection to a severe disability that makes basic communication difficult.

If you are seeking medical care for hoarseness, you doctor can now consult the updated Clinical Practice Guideline: Hoarseness (Dysphonia). Recently released by The American Academy for Otolaryngology-Head and Neck Surgery, the Clinical Practice Guideline details how your doctor can best treat this often irritating condition.

Matthew C. Mori, MD, Assistant Professor of Otolaryngology-Head and Neck Surgery at the Icahn School of Medicine at Mount Sinai and a laryngologist at the Grabscheid Voice and Swallowing Center, offers answers to some of the most frequently asked questions.

When should I see a health care provider about my hoarseness?

According to the recent Clinical Practice Guideline: Hoarseness (Dysphonia), you should see a health care provider if:

  • Your hoarseness does not go away or get better in 7-10 days. (It’s especially important to see a doctor if you are a smoker.)
  • You do not have a cold or flu
  • You are coughing up blood
  • You have difficulty swallowing
  • You feel or see a lump in your neck
  • Your loss of, or the severe changes in, your voice last longer than a few days
  • You experience pain when speaking or swallowing
  • Your voice change comes with uneasy breathing
  • Your hoarseness makes your work hard to do
  • You are a vocal performer (singer, teacher, public speaker) and cannot do your job

Do I need antibiotics, steroids, or imaging (such as an X-ray, CT scan, MRI)?

Maybe. However, except for some special cases, you will not need medications or imaging before a specialist looks at your vocal cords or larynx. The Clinical Guidelines recommend against these routine treatments prior to examination of the larynx. However, after an in-office laryngoscopy (examination of the larynx or vocal cords), one or more of these treatments may be prescribed. Acute hoarseness is often caused by laryngitis from a viral infection, making antibiotics ineffective. Additionally, corticosteroids should be avoided unless indicated due to the risk of rare, but serious, adverse effects.

What is voice therapy?

Voice therapy is a well-established program to treat many causes of hoarseness. It involves a trained speech language pathologist guiding you through voice and physical tasks as well as behavioral changes to help you shape healthy vocal behavior and attain the best possible voice. Voice therapy is the first-line therapy for behavior-related vocal lesions like vocal nodules and polyps. With few exceptions, it is covered under insurance.

Do I need surgery to treat my hoarseness?

This depends on the cause of the hoarseness. Lifestyle changes and voice therapy may be enough. But some patients may need surgery to improve the voice due to benign vocal cord lesions—like cysts or polyps—which have not responded to more conservative treatments. Also, if there is a paralysis of the vocal cord, or a form of muscular weakness known as paresis, an injection or implant may be required. If there is a possibility of a malignancy or cancer, surgery or an in-office biopsy would be required to make a diagnosis.

Is it better to wait to see if my hoarseness goes away on its own?

If your voice has not improved after 7-10 days, you should be evaluated by a health care provider. With any problem of the vocal cords, the earlier you start treatment the better.

If your hoarseness persists for more than four weeks, you should be seen by an otolaryngologist, also known as an ear, nose, and throat (ENT) surgeon.

Matthew C. Mori MD is an Assistant Professor of Otolaryngology at the Icahn School of Medicine at Mount Sinai. He is a board certified and fellowship trained surgeon, and a laryngologist at the Grabscheid Voice and Swallowing Center of Mount Sinai. Dr. Mori specializes in the diagnosis and treatment of airway, voice, and swallowing disorders while treating the full gamut of ear, nose, and throat disease.

Avoiding Dysphonia

Preventative measures should be taken to avoid hoarseness, especially for high vocal users. Try the following to avoid the irritating disorder:

  • Drink water daily. Dehydration is bad for you and your vocal chords.
  • If you are in dry, arid conditions, try using an indoor humidifier.
  • Be sure to rest your voice to avoid over-straining.
  • Avoid smoking and second-hand smoke which can irritate your airway.
  • Minimize excessive throat clearing or coughing.
  • Limit drying beverages like alcohol and caffeine.

For additional tips on preventative measures that can be taken to reduce hoarseness, consult this chart from the Clinical Practice Guideline.

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