Borish, Annals of Allergy, Asthma & Immunology, Oct 2026: a simple rule for a hard decision.
💊 The test: if a short systemic steroid course restores smell, the olfactory epithelium can still respond — type 2 inflammation is injuring it, but reversibly — and chronic type 2 therapy is warranted.
If it does not, pharmacologic restoration is unlikely.
Olfactory training may still help (4 odors, twice daily, at least 3 months), but repeated steroid bursts will not change the answer.
The data support taking smell seriously: on dupilumab, anosmia fell from ~75% at baseline to 24-30% in SINUS-24/52, and ~50% of CRSwNP patients get meaningful smell improvement after sinus surgery.
🏥 Stewardship: operate first, says the editorial. FESS plus medical therapy can give long-term remission and creates access for irrigant therapy. Biologics shrink polyps only ~50%, at 3-4x the yearly cost (FESS ~$13,532 vs dupilumab ~$46,376/year) — reserve them for early recurrence, except in severe asthma, where an early biologic treats both airways.
🔍 And frequent "acute sinusitis" usually means underlying CRS — evaluate for that first, not immunodeficiency.
Bottom line: one short steroid course, one question — did smell come back?
Reference:
Borish L. Ann Allergy Asthma Immunol. 2026;137(4):409-410.
https://www.annallergy.org/article/S1081-1206(26)00361-3/fulltext