Objectives We set out to create Consensus Guidelines, based on current evidence and relative risks of adverse effects and the costs of different treatments, that reflect the views of the British Rhinological Society (BRS) Council on where the use of biologics should be positioned within treatment pathways for CRSwNP, specifically in the setting of the National Health Service (NHS). Methods An expert panel of 16 members was assembled. A review of the literature and evidence synthesis was undertaken and circulated to the panel We used the RAND/UCLA methodology with a multi-step process to make recommendations on the use of biologics. Setting and participants N/A Results Recommendations were made, based on underlying disease severity, prior treatments and co-morbidities. A group of patients for whom biologics were considered an appropriate treatment option for CRSwNP was defined. Conclusions Although biologics are not currently available for the treatment of CRSwNP, the BRS Council have defined a group of patients who have higher rates of ‘failure’ with current treatment pathways, higher resource use and are more likely to suffer with uncontrolled symptoms. We would urge NICE to consider approval of biologics for such indications without applying further restrictions on use.

Objectives The primary aim of the study is to provide recommendations for the investigation and management of patients with new onset anosmia during the COVID-19 pandemic Design After undertaking a literature review, we used the RAND/UCLA methodology with a multi-step process to reach consensus about treatment options, onward referral imaging. Setting and participants An expert panel consistent of 15 members was assembled. A literature review was undertaken prior to the study and evidence was summarised for the panellists. Main outcome measures The panel undertook a process of ranking and classifying appropriateness of different investigations and treatment options for new onset anosmia during the COVID-19 pandemic. Using a 9-point Likert scale, panellists scored whether a treatment was: Not recommended, optional, or recommended. Consensus was achieved when more than 70% of responses fell into the category defined by the mean. Results Consensus was reached on the majority of statements after 2 rounds of ranking. Disagreement meant no recommendation was made regarding one treatment, using Vitamin A Drops. Alpha lipoic acid was not recommended, olfactory training was recommended for all patients with persistent anosmia of more than 2 weeks duration, and oral steroids, steroid rinses and omega 3 supplements may be considered on an individual basis. Recommendations have been made regarding the need for referral and investigation have been made. Conclusion This study identified the appropriateness of olfactory training, different medical treatment options, referral guidelines and imaging for patients with COVID-19 related anosmia. The guideline may evolve as our experience of COVID-19 develops.

IntroductionBackground and rationaleSmell is the forgotten sense; even when facing a problem with their sense of smell, patients often struggle to get recognition, let alone diagnosis or treatment from healthcare professionals. Olfactory disorders are as common as profound hearing loss and blindness affecting an estimated 5% of the population1. Common causes of olfactory disorders include chronic rhinosinusitis, post-viral olfactory loss and post-traumatic olfactory loss2 as well as it being present in the majority of cases of Parkinson’s disease and common in Alzheimer’s disease. We are now also witnessing the rise of sudden onset anosmia as a marker of Covid-19 coronavirus infection3-9. It remains to be seen how many new cases of lasting olfactory loss will arise from those afflicted by the pandemic.Recent population studies have now identified anosmia as an independent risk factor for shortened longevity, even after controlling for dementia and cardiovascular disease10-13. It is not clear why this is so but may suggest that the olfactory system acts as a barometer of environmental impact on the central nervous system as a whole. As this phenomenon has been observed in several countries it clearly demonstrates that olfactory disorders deserve to receive greater attention than they currently do.Taste is often thought to be lost by those affected by olfactory disorders due to the misperception of retronasal olfaction as a “taste” sensation. In reality only a small percentage of people reporting a problem with their sense of smell or taste experience a true gustatory disorder, but due to this common misperception alongside the need to be representative of all patients with chemosensory disorders, it is always important to encapsulate both senses within any work of this kind.Fifth Sense, the UK charity for people affected by smell and taste disorders, was founded in 2012 when authors DB and CP met and agreed on the need for patient advocacy to tackle the unmet needs of patients affected by olfactory disorders. Since then, with the help of a growing membership, we have been able to characterise the significant impact of olfactory disorders on those affected14,15 and we have also become aware of the frustrations many members in their dealings with the medical profession and getting their sensory loss taken seriously15-17. In 2019, Fifth Sense was awarded a National Lottery Grant for £238,815 to enable it to develop and grow its work, including the establishment of a network of patient support hubs.ObjectivesFollowing on from the above, this study aimed to characterise the details of the difficulties faced by patients with olfactory disorders in accessing healthcare as a patient and public co-production18. This will help us jointly address these issues through the work of the National Lottery Grant in 2020-2023.