Management of Viral Upper Respiratory Infection with Loss of Taste
For a patient with viral upper respiratory infection and loss of taste, initiate olfactory training immediately and continue for at least 3-6 months, as this is the primary evidence-based treatment regardless of etiology. 1
Immediate Assessment and Testing
Test for COVID-19 first - Loss of taste/smell occurs in 59-86% of COVID-19 patients and can be the sole presenting symptom in up to 22% of cases. 2, 3 COVID-19 has 98.7% specificity for olfactory dysfunction as a screening criterion. 3
Recognize that most "taste loss" is actually retronasal olfactory loss (flavor perception) rather than true taste dysfunction. 2, 1 This is a critical distinction that affects management.
Understand that traditional nasal symptoms (congestion, rhinorrhea) are often absent with COVID-19-related chemosensory dysfunction, unlike other viral URIs. 2, 3 Don't be falsely reassured by lack of nasal symptoms.
Consider other viral causes including Epstein-Barr virus (infectious mononucleosis), which can also present with loss of taste/smell. 4
Primary Treatment: Olfactory Training
Start olfactory training immediately - This is the only treatment with guideline-level evidence for post-viral taste/smell loss. 1, 3
Protocol: Sniff four strong-smelling substances (traditionally rose, eucalyptus, lemon, clove) for 20 seconds each, twice daily. 1, 3
Duration: Continue for at least 3-6 months minimum, even if improvement occurs earlier. 1, 3
Timing: Begin immediately upon diagnosis; do not wait for spontaneous recovery. 1
Symptomatic Management
Avoid unnecessary medications - There is no evidence supporting intranasal corticosteroids for symptomatic relief from the common cold, though they may be used for acute post-viral rhinosinusitis if symptom reduction is needed. 5
Antipyretics if needed: Use ibuprofen 0.2g orally for fever >38.5°C, every 4-6 hours as needed (maximum 4 times in 24 hours). 5 Temperatures below 38°C are acceptable and may be conducive to antiviral response.
Nutritional counseling: Refer to a registered dietitian for guidance on additional seasoning, avoiding unpleasant foods, and expanding dietary options to maintain adequate nutrition. 1
Expected Recovery Timeline
73% of patients improve within 7-14 days of symptom onset. 2
20% have symptoms persisting beyond 14 days, and some experience permanent dysfunction. 2
Recovery is generally faster and more complete in viral-related cases compared to other etiologies. 6
Follow-Up Schedule
Re-evaluate at 1 month, 3 months, and 6 months after initiating olfactory training. 1
Refer to otolaryngology or specialized smell/taste clinic if no improvement after 3-6 months of olfactory training. 1, 3
Perform objective testing with standardized tools (UPSIT or Sniffin'Sticks) if available, as 98.3% had objective dysfunction even when only 35% self-reported complaints. 2, 3
Critical Pitfalls to Avoid
Don't rely on patient self-report alone - Objective testing reveals much higher rates of dysfunction than subjective complaints. 3
Don't order unnecessary neuroimaging when there is a clear temporal relationship to viral infection. 1
Don't overlook COVID-19 as a potential cause, especially when taste/smell loss is the primary symptom. 1
Address safety concerns related to inability to detect spoiled food or gas leaks. 1
Don't use antibiotics unless secondary bacterial infection is strongly suspected based on clinical criteria. 5