Management of Loss of Taste and Smell
Start olfactory training immediately and continue for at least 3-6 months, as this is the primary evidence-based treatment for persistent chemosensory dysfunction. 1
Immediate Assessment Steps
COVID-19 Testing
- Perform COVID-19 testing in all patients with sudden-onset taste/smell loss, as this is a hallmark symptom occurring in 59-86% of COVID-19 patients 2, 1
- Loss of taste/smell can be the sole presenting symptom in 11.9-22% of cases, often without typical nasal congestion or rhinorrhea 2
- Healthcare workers and close-contact workers require immediate testing and isolation due to comparable viral loads between symptomatic and minimally symptomatic individuals 2
Objective Testing
- Use validated psychophysical testing (UPSIT or Sniffin' Sticks) rather than relying on patient self-assessment, as objective testing reveals dysfunction in 98.3% of patients even when only 35% report symptoms 2, 1
- Perform rigid nasal endoscopy to differentiate between conductive (obstructive) and sensorineural causes 1
Primary Treatment Protocol
Olfactory Training (First-Line)
- Begin olfactory training immediately upon diagnosis 1
- Continue training for a minimum of 3-6 months, as this is the only treatment with moderate-strength evidence 1
- Direct patients to validated resources like www.fifthsense.org.uk for proper technique 3, 1
Dietary Management
- Refer to a registered dietitian for counseling on flavor enhancement, additional seasoning, and expanding dietary options 1, 4
- This addresses the practical impact on nutrition and quality of life, particularly important as loss of taste/smell can lead to malnutrition and unintended weight loss 5
Expected Recovery Timeline
Natural History
- 73% of COVID-19 patients recover within 7-14 days 2
- Recovery occurs in 44-73% of patients within the first month overall 1
- 20% have symptoms persisting beyond 14 days, with some developing permanent dysfunction 2
- Recovery is inversely correlated with severity, duration of loss, age, smoking, and male sex 5
Follow-Up Schedule
Structured Monitoring
- Re-evaluate at 1 month, 3 months, and 6 months after initiating treatment 1, 4
- Repeat objective psychophysical testing at each visit to document changes 1
- Refer to an otolaryngologist or specialized smell/taste clinic if no improvement after 3-6 months of olfactory training 1, 4
Treatment of Underlying Causes
Sinonasal Disease
- Treat any identified sinonasal inflammatory disease with appropriate medical or surgical management 1, 4
- The most common causes of olfactory dysfunction include allergic rhinitis, chronic rhinosinusitis, and upper respiratory infection 5
Medication Review
- Review and discontinue offending medications when possible, as drugs are common causes of taste dysfunction 6
Advanced Imaging Considerations
When to Order Imaging
- Order CT and MRI of skull base and brain only when psychophysical testing severity does not correlate with endoscopic findings 1
- This raises suspicion for occult sinonasal or skull base tumor 1
- Avoid unnecessary neuroimaging when there is a clear temporal relationship to viral infection 4
Safety Counseling
Important Patient Education
- Counsel patients about inability to detect spoiled food or gas leaks 4
- Address potential psychological repercussions including lowered self-esteem and mental health issues 7
- Provide strong emotional and family support, consider support groups and cognitive behavioral therapy 7
Common Pitfalls to Avoid
- Do not rely on patient self-assessment - patients are commonly unaware of their impairment severity and cannot accurately distinguish between smell and taste dysfunction 1, 5
- Do not overlook COVID-19 as a potential cause, especially when taste/smell loss is the primary or isolated symptom 4
- Do not delay olfactory training - begin immediately rather than waiting to see if spontaneous recovery occurs 1
- Remember that most "taste loss" actually reflects loss of retronasal olfaction (flavor perception) rather than true taste dysfunction 2, 1