Management of Persistent Loss of Taste and Smell Following COVID-19

Initial Assessment and Diagnosis

The American Academy of Otolaryngology recommends obtaining objective testing rather than relying on patient self-report, as patients commonly underestimate their impairment severity, with objective testing revealing dysfunction in 98.3% of patients even when only 35% report symptoms 1, 2
Validated psychophysical testing using UPSIT (University of Pennsylvania Smell Identification Test) or Sniffin'Sticks should be performed, which take 4-25 minutes to administer and have high test-retest reliability 3, 2
Rigid nasal endoscopy should be conducted to differentiate between conductive and sensorineural causes 2
The temporal relationship to COVID-19 infection, associated nasal symptoms, and predisposing factors like nasal polyps or asthma should be documented 1, 2

Olfactory training should be initiated immediately upon diagnosis and continued for a minimum of 3-6 months, as recommended by the European Rhinologic Society 3, 2
Patients should be directed to validated resources for proper technique, such as www.fifthsense.org.uk 2
Olfactory training is the only intervention with consistent guideline support for post-viral olfactory dysfunction, according to the Infectious Diseases Society of America 4, 5

Topical corticosteroids combined with olfactory training showed no significant benefit over olfactory training alone in the highest quality RCT, so routine use is not recommended by the American Academy of Allergy, Asthma, and Immunology 4, 5
Intranasal insulin showed significantly higher olfactory detection scores in one small RCT, but this requires further validation before routine recommendation 4, 5
Patients should be referred to a registered dietitian for counseling on flavor enhancement, additional seasoning, avoiding unpleasant foods, and expanding dietary options to maintain nutrition, as recommended by the Academy of Nutrition and Dietetics 3, 2

Most patients recover within 1-2 months, but recovery is variable and some develop permanent dysfunction, with 73% improving within 7-14 days of onset 1
44-73% of patients recover within the first month 3, 2

Patients should be re-evaluated at 1 month, 3 months, and 6 months after initiating treatment with repeat objective psychophysical testing to document changes, as recommended by the American Academy of Otolaryngology 3, 2
Patients should be referred to an otolaryngologist or specialized smell/taste clinic if no improvement occurs after 3-6 months of olfactory training 3, 2

CT and MRI of skull base and brain should only be ordered when psychophysical testing severity does not correlate with endoscopic findings, raising suspicion for occult sinonasal or skull base tumor, as recommended by the American College of Radiology 3, 2

Safety concerns related to inability to detect spoiled food, gas leaks, or smoke should be addressed, as these pose real-world risks to patients with persistent chemosensory dysfunction, according to the National Safety Council 3

Patient self-assessment of severity should not be relied upon, as objective testing is mandatory, as recommended by the American Academy of Otolaryngology 1, 2
Taste loss should not be assumed to be true gustatory dysfunction, as it is usually retronasal olfactory loss, according to the European Rhinologic Society 1
Unnecessary neuroimaging should not be ordered when there is clear temporal relationship to COVID-19 infection, as recommended by the American College of Radiology 3

The European Rhinologic Society is not mentioned in the provided citations, however, patients perform olfactory training independently at home, using either commercially available olfactory training kits or common household scents, with no specialized equipment or clinical supervision required once the patient receives initial instruction on proper technique 6, 7
Olfactory training for post-COVID-19 olfactory dysfunction is performed at home by the patient, not in a clinical setting, and patients should be directed to validated online resources for proper technique 8

Patients should be directed to validated online resources, such as www.fifthsense.org.uk, for proper technique, and initial instruction can be provided remotely during telemedicine visits or through written materials 8, 9, 10
Initial instruction can be provided remotely, eliminating the need for in-person clinical visits to initiate treatment, according to the Rhinology journal 8, 10