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eConsult Clinical Question

Patient presents with prior COVID diagnosis. She still has a decreased sense of smell. Are there any recommendations to help with this or should she be recommended for further evaluation?

eConsult Response

If the loss of sense of smell (hyposmia) occurred with rapid or immediate onset during a test-confirmed COVID-19 infection, then additional testing is not required. If the onset is less certain, occurring gradually over weeks or months, or occurring weeks after the known COVID-19 infection, then a brain magnetic resonance imaging (MRI) with and without contrast is appropriate to help evaluate for rare contributors such as anterior skull base tumors.

As for treatment options, the two best treatments include moisturizing sprays (nasal saline sprays/rinses) and Smell Retraining Therapy (SRT). SRT has been used for many years but has become more common during the COVID-19 pandemic. It consists of using vials of known chemicals (usually essential oils from a health food store) and sniffing them a few times per day for several months. This helps to reinforce the neurologic pathways that help people identify common smells, odors, and tastes. The most common categories include rose, lemon, clove, and eucalyptus oils. Detailed information on SRT is available from most Otolaryngology/ENT clinics, or online at abscent.org or at fifthsense.org.uk.

For timeline or prognosis, hyposmia recovery after COVID-19 remains highly variable. Most patients recover either completely or nearly-completely. This often occurs within the first 1-3 months, but many people see slow gradual recovery over 6-12 months. Spontaneous recovery after 12 months is possible but rare. A small but significant percentage of patients will not ever fully recover. There are not any medications currently known to improve or enhance this recovery, however (many different medications are being studied but no clear winners thus far). Patients with diminished sense of smell need to be cautious about closely checking the expiration dates on foods, especially meat or dairy products, and need to strongly consider installing natural gas leak detectors (similar to smoke detectors), as they might not notice the smell of a gas leak if it were to occur.

These real-life examples have some limitations. Given the evolving recommendations and guidance on COVID-19 care, these cases should not be considered complete or definitive and may not reflect the most up-to-date guidance.