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1.
Curr Opin Allergy Clin Immunol ; 21(1): 8-15, 2021 02 01.
Article in English | MEDLINE | ID: covidwho-2326975

ABSTRACT

PURPOSE OF REVIEW: Coronavirus disease 2019 (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has quickly become a great public health hazard globally. Nasal epithelial cells are an important site for SARS-CoV-2 infection and replication. The purpose of this review is to summarize recent findings on the endotypes of chronic rhinosinusitis with nasal polyps (CRSwNP) and the potential impact of SARS-CoV-2 infection. RECENT FINDINGS: Endotypes of CRSwNP are characterized by type 1, type 2 and type 3 inflammation according to patterns of inflammatory cells and the cytokines expressed in nasal tissue. Nasal epithelial cells show the highest expression of angiotensin-converting enzyme 2 (ACE2), the receptor for attachment and entry of SARS-CoV-2 into host cells, among all investigated cells in the respiratory tree. SARS-CoV-2 infection likely leads to increased activation of T-helper-1 (Th1) cell responses. Recent studies further suggest that ACE2 may be upregulated by type 1 and downregulated by type 2 inflammatory cytokines in nasal epithelial cells. SUMMARY: Expression of ACE2 in nasal epithelial cells is influenced by inflammatory endotypes of CRSwNP. Type 1 inflammation in nasal tissue may increase the risk of SARS-CoV-2 infection by upregulating ACE2 expression. However, clinical association between CRSwNP and COVID-19 is still unclear.


Subject(s)
COVID-19/epidemiology , Nasal Polyps/epidemiology , Rhinitis/epidemiology , SARS-CoV-2/physiology , Sinusitis/epidemiology , Angiotensin-Converting Enzyme 2/metabolism , COVID-19/immunology , COVID-19/virology , Comorbidity , Goblet Cells/immunology , Humans , Inflammation/immunology , Nasal Polyps/immunology , Rhinitis/immunology , Risk Factors , Sinusitis/immunology , Virus Internalization
2.
Otolaryngol Pol ; 77(1): 1-5, 2022 Nov 24.
Article in English | MEDLINE | ID: covidwho-2326462

ABSTRACT

BACKGROUND: Acute rhinosinusitis (ARS) is a common and well-defined disorder, primarily of viral aetiology, with rhinovirus and coronavirus accounting for more than 50% of viral ARS. The fight with COVID-19 pandemic resulted in an increased availability viral testing, which in turn allowed testing for presence of SARS-Cov-2 in all patients presenting common cold (or ARS) symptoms. The aim of this study was to assess the clinical characteristics of acute rhinosinusitis in patients diagnosed with COVID-19. METHODOLOGY/PRINCIPAL: This study is a post-hoc analysis. Patients symptoms were evaluated using a structured questionnaire twice: directly after a positive SARS-Cov-2 result and 7-12 days following the first evaluation. Subjects were asked about presence of nasal and systemic symptoms as well as headache. RESULTS: A total of 130 COVID-19 symptomatic patients were recruited into the study, 58 (45%) patients met EPOS2020 diagnostic criteria for ARS. Of all ARS patients, 72% presented with rhinorrhoea, 69% with pain perceived over paranasal sinuses, 62% with nasal congestion, 52% with cough, 45% with olfactory dysfunction, 38% with fever, 33% with facial pressure and in 22% pain was exacerbated by sinus palpation. CONCLUSIONS: Half of COVID-19 subjects has ARS. The course of SARS-Cov-2 ARS does not seem to differ significantly from ARS of other aetiologies. Since ARS in the course of COVID-19 seems to meet the definition of ARS proposed by EPOS 2020, we hypothesize that substances validated for ARS treatment, such as intranasal corticosteroids could be effective in SARS-Cov-2 ARS.


Subject(s)
COVID-19 , Sinusitis , Humans , COVID-19/complications , COVID-19/diagnosis , SARS-CoV-2 , Longitudinal Studies , Pandemics , Sinusitis/diagnosis , Sinusitis/epidemiology , Acute Disease , Pain
3.
J Allergy Clin Immunol Pract ; 11(1): 43-50, 2023 01.
Article in English | MEDLINE | ID: covidwho-2300642

ABSTRACT

The field of chronic rhinosinusitis (CRS) is constantly evolving. In the past 10 years, key advancements in basic and translational research as well as clinical studies have improved our understanding and management of CRS. Notably, treatment options have expanded to include novel therapeutic drugs, devices, and surgical techniques. Assessments of patient symptoms and their impact on quality of life have become more standardized. Progress has also been made in both determining the true prevalence of CRS and recognizing comorbidities that can impact CRS severity. Practice guidelines have also shifted from expert opinion to more data-driven analyses. This review highlights major clinical advancements made in the field of CRS over the past 10 years as well as identifies current gaps in knowledge that can form the basis for new areas of study over the next decade.


Subject(s)
Nasal Polyps , Rhinitis , Sinusitis , Humans , Rhinitis/epidemiology , Rhinitis/therapy , Rhinitis/diagnosis , Quality of Life , Nasal Polyps/epidemiology , Sinusitis/diagnosis , Sinusitis/epidemiology , Sinusitis/therapy , Comorbidity , Chronic Disease
4.
Pediatr Infect Dis J ; 42(5): 412-417, 2023 05 01.
Article in English | MEDLINE | ID: covidwho-2262495

ABSTRACT

OBJECTIVE: To study national pediatric acute rhinosinusitis (ARS) burden fluctuations before and during the first 2 coronavirus-19 (COVID) years, characterized by alternating lockdown and relaxation periods, the introduction of COVID vaccines, and the emergence of nonalpha COVID variants. METHODS: This was a cross-sectional, population-based study covering the 3 pre-COVID years and the first 2 COVID years from a big database of the largest Israeli Health Maintenance Organization. For comparison purposes, we explored ARS burden trends with those of urinary tract infection (UTI), which is unrelated to viral diseases. We identified children <15 years presenting with ARS and UTI episodes and categorized them according to their age and presentation date. The average ARS and UTI episodes of the 3 pre-COVID years were used to calculate the incidence rate ratios (IRRs) of the 2 COVID years, analyzed separately. Seasonal variations were explored. RESULTS: We identified 44,483 ARS and 121,263 UTI episodes. There was a substantial reduction in ARS episodes during the COVID years (IRR 0.36, 95% CI: 0.24-0.56, P < 0.001). Although UTI episode rates also decreased during COVID (IRR 0.79, 95% CI: 0.72-0.86, P < 0.001), the reduction in ARS burden was 3-fold higher. The dominant pediatric ARS age group was between 5 and 15 years. The largest decrease in ARS burden was during the first COVID year. ARS episode distribution showed a seasonal fluctuation, with a peak during the summer months during the COVID years. CONCLUSIONS: Pediatric ARS burden decreased during the first 2 COVID years. Episode distribution was noted to be year-round.


Subject(s)
COVID-19 , Sinusitis , Urinary Tract Infections , Child , Humans , Child, Preschool , Adolescent , Cross-Sectional Studies , Pandemics , COVID-19/epidemiology , Communicable Disease Control , SARS-CoV-2 , Sinusitis/epidemiology , Urinary Tract Infections/epidemiology , Acute Disease , Retrospective Studies
5.
J Assoc Physicians India ; 70(11): 11-12, 2022 Nov.
Article in English | MEDLINE | ID: covidwho-2254783

ABSTRACT

OBJECTIVE: Invasive fungal sinusitis is an invasive disease associated with high mortality of up to 60%. There is a well-documented increase in rhino-orbital-cerebral fungal co-infection in COVID-19 patients. Our study aimed to determine the factors that lead to the development, the natural history of progression and the therapeutic interventions done for this grave complication. METHODS: Patients admitted in general medicine ward in King Edward Memorial (KEM) Hospital, Mumbai were included. Patient's history and examination findings were noted. Advised Investigations- imaging studies like CT scan, MRI done were noted down. Operative procedures like functional endoscopic sinus surgery (FESS), abscess drainage, dental extraction, were performed at the hospital and details were taken. Fungal cultures, sugar monitoring, liver function test, renal function test, complete blood counts, ECGs, chest X-rays, and amphotericin charting were also done.. RESULTS: On retrospective analysis of the presenting patient's records, we found that all patients had received steroids for COVID-19 treatment and had co-morbidities, especially diabetes mellitus. Prolonged hospitalization further exposes the patient to various multi-resistant bacteria making them prone to various secondary infections. CONCLUSIONS: It is of paramount importance that physicians know the associated risk factors, mentioned in our study, that may lead to invasive fungal co-infection in COVID-19 patients, and to regularly examine the patient for any developing signs so appropriate diagnosis and treatment can be initiated as early as possible. It is an unrelenting disease process that requires the utmost care, and our case series provides an in depth look of four such cases for future reference.


Subject(s)
COVID-19 , Coinfection , Diabetes Mellitus , Sinusitis , Humans , Retrospective Studies , COVID-19 Drug Treatment , COVID-19/complications , Sinusitis/complications , Sinusitis/epidemiology , Sinusitis/diagnosis , Diabetes Mellitus/drug therapy
6.
Int J Environ Res Public Health ; 19(20)2022 Oct 12.
Article in English | MEDLINE | ID: covidwho-2266514

ABSTRACT

This study aimed to investigate the change in the incidence and variance of otorhinolaryngologic diseases during the coronavirus disease 19 (COVID-19) pandemic. The entire Korean population (~50 million) was evaluated for the monthly incidence of 11 common otorhinolaryngologic diseases of upper respiratory infection (URI), influenza, acute tonsillitis, peritonsillar abscess, retropharyngeal and parapharyngeal abscess, acute laryngitis and bronchitis, stomatitis and related lesions, acute sinusitis, rhinitis, otitis media, and dizziness from January 2018 through March 2021 using the International Classification of Disease (ICD)-10 codes with the data of the Korea National Health Insurance Service. The differences in the mean incidence of 11 common otorhinolaryngologic diseases before and during COVID-19 were compared using the Mann-Whitney U test. The differences in the variance of incidence before and during COVID-19 were compared using Levene's test. The incidence of all 11 otorhinolaryngologic diseases was lower during COVID-19 than before COVID-19 (all p < 0.05). The variations in disease incidence by season were lower during COVID-19 than before COVID-19 for infectious diseases, including URI, influenza, acute tonsillitis, peritonsillar abscess, retropharyngeal and parapharyngeal abscess, acute laryngitis and bronchitis, acute sinusitis, and otitis media (all p < 0.05), while it was not in noninfectious diseases, including stomatitis, rhinitis, and dizziness. As expected, the incidences of all otorhinolalryngolgic diseases were decreased. Additionally, we found that seasonal variations in infectious diseases disappeared during the COVID-19 pandemic, while noninfectious diseases did not.


Subject(s)
Bronchitis , COVID-19 , Influenza, Human , Laryngitis , Noncommunicable Diseases , Otitis Media , Peritonsillar Abscess , Respiratory Tract Infections , Retropharyngeal Abscess , Rhinitis , Sinusitis , Stomatitis , Humans , COVID-19/epidemiology , Incidence , Rhinitis/epidemiology , Retropharyngeal Abscess/epidemiology , Pandemics , Laryngitis/epidemiology , Influenza, Human/epidemiology , Noncommunicable Diseases/epidemiology , Dizziness , Peritonsillar Abscess/epidemiology , Sinusitis/epidemiology , Respiratory Tract Infections/epidemiology , Otitis Media/epidemiology , Bronchitis/epidemiology , Stomatitis/epidemiology
7.
J Assoc Physicians India ; 70(11): 11-12, 2022 Nov.
Article in English | MEDLINE | ID: covidwho-2202485

ABSTRACT

OBJECTIVE: Invasive fungal sinusitis is an invasive disease associated with high mortality of up to 60%. There is a well-documented increase in rhino-orbital-cerebral fungal co-infection in COVID-19 patients. Our study aimed to determine the factors that lead to the development, the natural history of progression and the therapeutic interventions done for this grave complication. METHODS: Patients admitted in general medicine ward in King Edward Memorial (KEM) Hospital, Mumbai were included. Patient's history and examination findings were noted. Advised Investigations- imaging studies like CT scan, MRI done were noted down. Operative procedures like functional endoscopic sinus surgery (FESS), abscess drainage, dental extraction, were performed at the hospital and details were taken. Fungal cultures, sugar monitoring, liver function test, renal function test, complete blood counts, ECGs, chest X-rays, and amphotericin charting were also done.. RESULTS: On retrospective analysis of the presenting patient's records, we found that all patients had received steroids for COVID-19 treatment and had co-morbidities, especially diabetes mellitus. Prolonged hospitalization further exposes the patient to various multi-resistant bacteria making them prone to various secondary infections. CONCLUSIONS: It is of paramount importance that physicians know the associated risk factors, mentioned in our study, that may lead to invasive fungal co-infection in COVID-19 patients, and to regularly examine the patient for any developing signs so appropriate diagnosis and treatment can be initiated as early as possible. It is an unrelenting disease process that requires the utmost care, and our case series provides an in depth look of four such cases for future reference.


Subject(s)
COVID-19 , Coinfection , Diabetes Mellitus , Sinusitis , Humans , Retrospective Studies , COVID-19 Drug Treatment , COVID-19/complications , Sinusitis/complications , Sinusitis/epidemiology , Sinusitis/diagnosis , Diabetes Mellitus/drug therapy
8.
J Allergy Clin Immunol Pract ; 10(6): 1423-1432, 2022 06.
Article in English | MEDLINE | ID: covidwho-1747846

ABSTRACT

The COVID-19 pandemic has raised awareness about olfactory dysfunction, although a loss of smell was present in the general population before COVID-19. Chronic rhinosinusitis (CRS) is a common upper airway chronic inflammatory disease that is also one of the most common causes of olfactory dysfunction. It can be classified into different phenotypes (ie, with and without nasal polyps) and endotypes (ie, type 2 and non-type 2 inflammation). However, scientific information regarding CRS within the context of COVID-19 is still scarce. This review focuses on (1) the potential effects of severe acute respiratory syndrome coronavirus 2 infection on CRS symptoms, including a loss of smell, and comorbidities; (2) the pathophysiologic mechanisms involved in the olfactory dysfunction; (3) CRS diagnosis in the context of COVID-19, including telemedicine; (4) the protective hypothesis of CRS in COVID-19; and (5) the efficacy and safety of therapeutic options for CRS within the context of COVID-19.


Subject(s)
COVID-19 , Nasal Polyps , Olfaction Disorders , Rhinitis , Sinusitis , Anosmia , Chronic Disease , Humans , Nasal Polyps/complications , Nasal Polyps/epidemiology , Nasal Polyps/therapy , Olfaction Disorders/epidemiology , Pandemics , Rhinitis/epidemiology , Rhinitis/etiology , Rhinitis/therapy , Sinusitis/epidemiology , Sinusitis/etiology , Sinusitis/therapy
9.
Laryngoscope ; 131(12): 2652-2658, 2021 12.
Article in English | MEDLINE | ID: covidwho-1233217

ABSTRACT

OBJECTIVES: Occurrence of invasive fungal respiratory superinfections in patients with COVID-19 has gained increasing attention in the latest studies. Yet, description of acute invasive fungal sinusitis with its management in those patients is still scarce. This study aims to describe this recently increasing clinical entity in relation to COVID-19 patients. STUDY DESIGN: Longitudinal prospective study. METHODS: Prospective longitudinal study included patients diagnosed with acute invasive fungal rhinosinusitis after a recent COVID-19 infection. Antifungal agents given included amphotericin B, voriconazole, and/or posaconazole. Surgical treatment was restricted to patients with PCR negative results for COVID-19. Endoscopic, open, and combined approaches were utilized to eradicate infection. Follow-up for survived patients was maintained regularly for the first postoperative month. RESULTS: A total of 36 patients with a mean age of 52.92 ± 11.30 years old were included. Most common associated disease was diabetes mellitus (27.8%). Mycological analysis revealed infection with Mucor and Aspergillus species in 77.8% and 30.6% of patients, respectively. Sino-nasal, orbital, cerebral, and palatine involvement was found in 100%, 80.6%, 27.8%, and 33.3% of patients, respectively. The most common reported symptoms and signs are facial pain (75%), facial numbness (66.7%), ophthalmoplegia, and visual loss (63.9%). All patients were treated simultaneously by surgical debridement with antifungal medications except for two patients with PCR-positive swab for COVID-19. These two patients received antifungal therapy alone. Overall survival rate was 63.89% (23/36). CONCLUSION: Clinical suspicion of acute invasive fungal sinusitis among COVID-19 patients and early management with antifungal therapy and surgical debridement is essential for better outcomes and higher survival. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2652-2658, 2021.


Subject(s)
COVID-19/microbiology , Invasive Fungal Infections/epidemiology , Rhinitis/epidemiology , SARS-CoV-2 , Sinusitis/epidemiology , Acute Disease , Adult , Antifungal Agents/therapeutic use , Debridement , Female , Humans , Invasive Fungal Infections/microbiology , Invasive Fungal Infections/therapy , Longitudinal Studies , Male , Middle Aged , Prospective Studies , Rhinitis/microbiology , Rhinitis/therapy , Sinusitis/microbiology , Sinusitis/therapy
10.
Am J Otolaryngol ; 42(6): 103080, 2021.
Article in English | MEDLINE | ID: covidwho-1230345

ABSTRACT

BACKGROUND: Acute invasive fungal rhinosinusitis (AIFRS) is aggressive morbidity affecting immunocompromised patients. Coronavirus disease 2019 (COVID-19) may allow secondary fungal disease through a propensity to cause respiratory infection by affecting the immune system leading to dysregulation and reduced numbers of T lymphocytes, CD4+T, and CD8+T cells, altering the innate immunity. The aim of this study is to evaluate the incidence of acute invasive fungal rhinosinusitis (AIFRS) in COVID-19 patients. METHODOLOGY: Data for acute invasive rhinosinusitis was obtained from the Otorhinolaryngology departments at our tertiary hospital at the period from January 2017 to December 2020. Then the risk factors of comorbid diseases and fungal types between post-COVID-19 and non-COVID-19 groups regarding the incidence of AIFRS are compared. RESULTS: Consequently, the incidence of AIFRS showed a more significant difference (P < 0.05) in post-COVID-19 patients than in non-COVID-19 especially in immunocompromised patients, diabetic, renal, and liver dysfunction patients as well as patients with risk factors of AIFRS. The most common organisms affecting patients with AIFRS are Rhizopus oryzae, Aspergillus fumigatus, and Absidia mucor. CONCLUSIONS: The incidence of AIFRS is markedly prominent in post-COVID-19 patients than in those of non-COVID-19, especially in immunocompromised, diabetic, renal, and liver dysfunction patients and patients with risk factors for rhinosinusitis.


Subject(s)
COVID-19/epidemiology , COVID-19/immunology , Disease Outbreaks , Invasive Fungal Infections , Rhinitis/epidemiology , Rhinitis/microbiology , Sinusitis/epidemiology , Sinusitis/microbiology , Absidia , Acute Disease , Aged , Aspergillus fumigatus , CD4-Positive T-Lymphocytes/immunology , CD8-Positive T-Lymphocytes/immunology , Female , Humans , Immunity, Innate/immunology , Immunocompromised Host/immunology , Incidence , Magnetic Resonance Imaging , Male , Middle Aged , Rhinitis/diagnostic imaging , Rhinitis/immunology , Rhizopus oryzae , Risk Factors , Sinusitis/diagnostic imaging , Sinusitis/immunology , Tomography, X-Ray Computed , Young Adult
11.
In Vivo ; 35(3): 1409-1417, 2021.
Article in English | MEDLINE | ID: covidwho-1207958

ABSTRACT

The nasal epithelium expressing enriched angiotensin-converting enzyme II (ACE2), the key cell entry receptor of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), could serve as the first barrier to protect the airway from viral infection. Recent studies have demonstrated that higher viral loads were detected in the nasal cavity than the pharynx in coronavirus disease 2019 (COVID-19) patients, and otolaryngologists should carefully consider infection prevention in clinical practice for the treatment of nasal conditions. Moreover, several studies have indicated that anosmia is one of the clinical characteristics of COVID-19, but the precise prevalence and mechanism remain unclear. Thus far, comorbidity of allergic rhinitis and chronic rhinosinusitis do not seem to be a major risk factor for severe COVID-19. However, we should develop strategies in clinical practice for treatment of nasal diseases during the pandemic. In this article, we reviewed current evidence of the relationship between COVID-19 and nasal conditions, such as COVID-19-related olfactory dysfunction, allergic rhinitis, and chronic rhinosinusitis.


Subject(s)
COVID-19 , Rhinitis, Allergic , Sinusitis , Humans , Pandemics , Peptidyl-Dipeptidase A , Rhinitis, Allergic/epidemiology , SARS-CoV-2 , Sinusitis/epidemiology , Sinusitis/therapy
12.
Otolaryngol Head Neck Surg ; 165(5): 609-610, 2021 11.
Article in English | MEDLINE | ID: covidwho-1125962

ABSTRACT

With the onset of the COVID-19 pandemic, social distancing guidelines have reshaped the way that we live our lives. Perhaps the most common and strictly adopted measure has been mask wearing. Mask wearing, whether it be cloth, surgical, or N95, has quickly become the new norm in the ongoing struggle against this pandemic and has been proven to be effective in curbing its high infection rate. There has, however, been growing opposition to these policies by a substantial part of the general population who claims that masks are ineffective and can worsen breathing. To some, the choice to use or not use a mask has morphed into a point of political contention, rather than a choice rooted in concerns for public health. This commentary attempts to investigate the validity of these claims and explore how clinicians can encourage the usage of masks despite the fears and confusion against them.


Subject(s)
COVID-19 , Sinusitis , Humans , Masks , Pandemics , SARS-CoV-2 , Sinusitis/epidemiology
14.
Ann Allergy Asthma Immunol ; 125(4): 481-483, 2020 10.
Article in English | MEDLINE | ID: covidwho-716534
15.
Int Forum Allergy Rhinol ; 10(8): 944-950, 2020 08.
Article in English | MEDLINE | ID: covidwho-72528

ABSTRACT

BACKGROUND: Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), is responsible for the largest pandemic since the 1918 influenza A virus subtype H1N1 influenza outbreak. The symptoms presently recognized by the World Health Organization are cough, fever, tiredness, and difficulty breathing. Patient-reported smell and taste loss has been associated with COVID-19 infection, yet no empirical olfactory testing on a cohort of COVID-19 patients has been performed. METHODS: The University of Pennsylvania Smell Identification Test (UPSIT), a well-validated 40-odorant test, was administered to 60 confirmed COVID-19 inpatients and 60 age- and sex-matched controls to assess the magnitude and frequency of their olfactory dysfunction. A mixed effects analysis of variance determined whether meaningful differences in test scores existed between the 2 groups and if the test scores were differentially influenced by sex. RESULTS: Fifty-nine (98%) of the 60 patients exhibited some smell dysfunction (mean [95% CI] UPSIT score: 20.98 [19.47, 22.48]; controls: 34.10 [33.31, 34.88]; p < 0.0001). Thirty-five of the 60 patients (58%) were either anosmic (15/60; 25%) or severely microsmic (20/60; 33%); 16 exhibited moderate microsmia (16/60; 27%), 8 mild microsmia (8/60; 13%), and 1 normosmia (1/60; 2%). Deficits were evident for all 40 UPSIT odorants. No meaningful relationships between the test scores and sex, disease severity, or comorbidities were found. CONCLUSION: Quantitative smell testing demonstrates that decreased smell function, but not always anosmia, is a major marker for SARS-CoV-2 infection and suggests the possibility that smell testing may help, in some cases, to identify COVID-19 patients in need of early treatment or quarantine.


Subject(s)
Betacoronavirus/isolation & purification , Coronavirus Infections , Olfaction Disorders , Pandemics , Pneumonia, Viral , Rhinitis , Sino-Nasal Outcome Test , Sinusitis , Adult , COVID-19 , Chronic Disease , Coronavirus Infections/diagnosis , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Differential Threshold , Female , Humans , Male , Middle Aged , Odorants , Olfaction Disorders/diagnosis , Olfaction Disorders/etiology , Olfactory Perception , Pennsylvania/epidemiology , Pneumonia, Viral/diagnosis , Pneumonia, Viral/epidemiology , Pneumonia, Viral/physiopathology , Reproducibility of Results , Rhinitis/diagnosis , Rhinitis/epidemiology , Risk Factors , SARS-CoV-2 , Sinusitis/diagnosis , Sinusitis/epidemiology , Smell
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