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Management of Loss of Sense of Smell (Anosmia) Associated with COVID-19 (SARS-CoV-2 Infection)

 
Jarrett Walsh MD PhD Scott Graham MD  Henry Hoffman MD MS (11-07-2020)

Anosmia/dysgeusia is one of the earliest signatures of COVID-19 (Wagner 2020)

Evaluation

  • Examination
    • Flexible nasal endoscopy to rule out other soruces of olfactory dysfunction (i.e. polyps)
    • Administration of smell identificaiton test (sniffn' sticks or UPSIT)
  • Imaging
    • Consider if concerned for co-morbid sinus disease (patients with nasal polyps can also get COVID)
    • MRI likely deferred unless neurological concerns (patients with COVID can also have strokes with other neruological complications)

Treatment

  • Olfactory retraining (see: Turner 2020)
  • Topical steroid irrigations
  • Possible vitamin A and omega 3 supplements (still limited data see: Whitcroft 2020)
  • Oral steroids may have limited value (see: Whitcroft 2019)

Prognosis

  • While data is still being collected on this particular disesase sequelae, one study showed that no patient remained anosmic though up to one third of cases had some residual dysfunction at 6 to 8 weeks of symptom onset (Moein 2020).

Modified Sample Evaluation and Management:

Clinic Note:

The endoscopic exam shows some nasal dryness and a deviated septum to the left.  .
 
University of Pennsylvania smell identification test shows a score of 16 out of 40 consistent with microsomia.
 
He is here today for a new complaint and that is decreased smell and taste following a COVID infection earlier this year.  Formal testing confirms decrease in his sense of smell.  Public health concerns were addressed (see: CDC recommendations) .  Because of the tight association between the patient's onset of symptoms and COVID testing as well as detection of COVID antibodies we would plan no further testing at present. 
 
We specifically addressed this with the patient and at present would not plan an MRI scan or other blood test.  We will start him on budesonide rinse today.  We reviewed the off label nature of this.  We will also start him on olfactory retraining.  We will place him on a course of prednisone prescribed as a taper.  He has no contraindication to short-term prednisone use. 
 
We reviewed the spectrum of risk associated with short-term prednisone use ranging from stomach ulcers and bleeding stomach ulcers with at risk reduced by concomitant antacid consumption all the way through the avascular femoral head necrosis explained his death the top part of the hip bone.  We will plan to see him for routine follow-up in 8 weeks. 
 

References:

 
Meng X, Deng Y, Dai Z, Meng Z. COVID-19 and anosmia: A review based on up-to-date knowledge. Am J Otolaryngol. 2020 Sep-Oct;41(5):102581. doi: 10.1016/j.amjoto.2020.102581. Epub 2020 Jun 2. PMID: 32563019; PMCID: PMC7265845.
 
Gözen ED, Aliyeva C, Tevetoğlu F, Karaali R, Balkan İİ, Yener HM, Özdoğan HA. Evaluation of Olfactory Function With Objective Tests in COVID-19-Positive Patients: A Cross-Sectional Study. Ear Nose Throat J. 2020 Nov 25:145561320975510. doi: 10.1177/0145561320975510. Epub ahead of print. PMID: 33236918; PMCID: PMC7689254.
 
Moein ST, Hashemian SM, Tabarsi P, Doty RL. Prevalence and reversibility of smell dysfunction measured psychophysically in a cohort of COVID-19 patients. Int Forum Allergy Rhinol. 2020 Aug 6:10.1002/alr.22680. doi: 10.1002/alr.22680. Epub ahead of print. PMID: 32761796; PMCID: PMC7436559.
 
Wagner T, Shweta F, Murugadoss K, Awasthi S, Venkatakrishnan AJ, Bade S, Puranik A, Kang M, Pickering BW, O'Horo JC, Bauer PR, Razonable RR, Vergidis P, Temesgen Z, Rizza S, Mahmood M, Wilson WR, Challener D, Anand P, Liebers M, Doctor Z, Silvert E, Solomon H, Anand A, Barve R, Gores G, Williams AW, Morice WG 2nd, Halamka J, Badley A, Soundararajan V. Augmented curation of clinical notes from a massive EHR system reveals symptoms of impending COVID-19 diagnosis. Elife. 2020 Jul 7;9:e58227. doi: 10.7554/eLife.58227. PMID: 32633720; PMCID: PMC7410498.
 
Whitcroft KL, Hummel T. Olfactory Dysfunction in COVID-19: Diagnosis and Management. JAMA. 2020 Jun 23;323(24):2512-2514. doi: 10.1001/jama.2020.8391. PMID: 32432682.
 
Whitcroft KL, Hummel T. Clinical Diagnosis and Current Management Strategies for Olfactory Dysfunction: A Review. JAMA Otolaryngol Head Neck Surg. 2019;145(9):846–853. doi:10.1001/jamaoto.2019.1728
 
Turner JH. Olfactory training: what is the evidence? Int Forum Allergy Rhinol. 2020 Nov;10(11):1199-1200. doi: 10.1002/alr.22681. Epub 2020 Sep 3. PMID: 32776673.
 
Patel ZM, Wise SK, DelGaudio JM. Randomized Controlled Trial Demonstrating Cost-Effective Method of Olfactory Training in Clinical Practice: Essential Oils at Uncontrolled Concentration. Laryngoscope Investig Otolaryngol. 2017 Feb 2;2(2):53-56. doi: 10.1002/lio2.62. PMID: 28894822; PMCID: PMC5527365.