What workup is needed for an 85-year-old male with a 1-month history of reduced taste and smell?

Diagnostic Workup for Reduced Taste and Smell in an 85-Year-Old Male

COVID-19 testing should be the first step in the workup for an 85-year-old male with a 1-month history of reduced taste and smell, followed by a comprehensive nasal endoscopy and MRI if symptoms persist without clear cause. 1

Initial Evaluation

COVID-19 Assessment

• Perform COVID-19 testing immediately, as anosmia/hyposmia is a well-documented presenting symptom of SARS-CoV-2 infection, particularly important in elderly patients 1
• Note that in elderly patients, anosmia can present early in COVID-19 disease and may be associated with higher mortality risk (as documented in an 85-year-old male who died 6 days after presentation with anosmia) 1

Clinical Examination

• Perform a focused examination of:
  • Nasal passages (looking for polyps, inflammation, obstruction)
  • Oral cavity (checking for infections, dental issues)
  • Oropharynx
  • Neurological assessment focusing on cranial nerves I, VII, IX, and X 2

Standardized Assessment

• Conduct objective smell testing using validated tests such as:
  • University of Pennsylvania Smell Identification Test (UPSIT)
  • Sniffin' Sticks 3, 4
• These tests help differentiate between:
  • Anosmia (complete loss)
  • Hyposmia (partial loss)
  • Specific taste deficits (sweet, bitter, sour, salty, umami) 2

Advanced Diagnostic Testing

Nasal Endoscopy

• Indicated to evaluate for:
  • Inflammatory conditions
  • Nasal polyps
  • Sinonasal tumors
  • Structural abnormalities 1, 3

Imaging Studies

• MRI of orbits, face, and neck with contrast is the preferred imaging modality for:

  • Direct visualization of olfactory bulbs and tracts
  • Assessment of brain structures involved in olfaction
  • Ruling out tumors affecting the cribriform plate 3

• CT of maxillofacial area should be considered if:

  • Sinonasal inflammatory disease is suspected
  • Bony anatomy evaluation is needed
  • Rhinosinusitis with nasal polyposis is suspected 3

Specific Considerations for Elderly Patients

• Age-related decline in smell and taste is common but should be a diagnosis of exclusion 5
• Medication review is essential as many drugs can interfere with smell and taste 6
• Consider nutritional assessment, as smell and taste disorders in the elderly can lead to:
  • Poor appetite
  • Inappropriate food choices
  • Decreased energy consumption
  • Impaired protein and micronutrient status 7

Common Etiologies to Consider

1. Inflammatory conditions:

   • Chronic rhinosinusitis (with or without polyps)
   • Allergic rhinitis 2

2. Infectious causes:

   • COVID-19 (highest priority given current evidence) 1
   • Upper respiratory infections
   • Oral infections 6

3. Neurological disorders:

   • Neurodegenerative diseases (Parkinson's, cognitive impairments)
   • Head trauma history 2

4. Structural abnormalities:

   • Nasal polyps
   • Sinonasal tumors 3

5. Medication-induced:

   • Review all current medications 6

Prognosis

• Up to 50% of patients with olfactory dysfunction improve over time
• Poorer prognosis is associated with:
  • Longer duration of symptoms
  • Greater severity of loss
  • Advanced age
  • Smoking history
  • Male sex 2

Remember that approximately 95% of perceived "taste" disorders are actually caused by impairment of smell rather than primary gustatory loss 2. This distinction is important when determining the diagnostic approach and potential treatment options.