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Interviewer: After getting COVID-19, some people can lose their sense of smell or also suffer a condition called parosmia, which is a distortion of smells that can turn once-pleasant odors into unpleasant ones. Not being able to smell or smell accurately can be an inconvenience and not enjoyable, especially if things like fruit, coffee, chicken, and other foods and things in your environment smell like garbage or chemicals like ammonia. But can it impact a person's physical or emotional health?

Dr. Kristine Smith is a rhinologist, which is a nose and sinus expert, at University of Utah Health. Dr. Smith, is a decrease in the ability to smell or an altered sense of smell dangerous?

Dr. Smith: You know, kind of shortest, simple answer is that losing your sense of smell or having a change in your sense of smell is not going to directly cause you harm by not having it, but it does increase your risk of some other potential harmful things. The ones that I try to really emphasize for patients is when your sense of smell comes back wrong, or when it's decreased long term, this does actually put you at an increased risk for experiencing food poisoning over time because you might not be able to tell when something has gone bad in your fridge. And so a really careful attention to the expiry dates on food in your fridge and labeling your leftovers so you know how long they've been there for, or having someone in your home who has a normal sense of smell check them before you eat them is actually really important.

And then similarly, you might not be able to detect smoke or natural gas in your home with your altered sense of smell, and so ensuring that you have up-to-date smoke detectors and natural gas detectors is really important. Even if you have a natural gas stove, potentially getting a handheld natural gas detector can be really important because it might be that you went to light your stove, the lighter didn't work, and then the gas is kind of spewing out of the stove, and you try to relight it, and there's been an accumulation of that gas in your home, which can potentially cause a small explosion. And so it's something I'm very careful to talk to patients about so that they're aware of that potential risk. Barbecues are another area where that can be really problematic.

Similarly, we can see occupational disruptions in our patients that are experiencing parosmia, particularly people that work in the food industry, like chefs, or potentially in other areas like florists or firefighters, who are dependent on their sense of smell to do their job well, and so this can be very impactful for patients.

Outside of those kind of like lifestyle risks that we talked about, changes in your sense of smell actually has the potential to significantly impact your mental health. So your ability to smell, your ability to enjoy food from the flavor that comes from your sense of smell is really important for our well-being long term, and these types of alterations have a really significant impact in the quality of life of our patients.

They do feel very bothered by these symptoms, and they do affect their enjoyment of life on a day-to-day basis. And so having persistent parosmia, having persistent hyposmia can increase your risk potentially for things like anxiety or depression. And I think making sure that our patients are aware of this is really important so that if they start to experience those symptoms, if they start to think that maybe they're being affected by this, we can help to treat those associated issues, those associated anxiety and depression, so that we can mitigate the impact that this is having as much as we can.

Interviewer: I can see how the mental impacts could be very real, especially with I've heard patients reporting that other people in their lives have a hard time understanding what they're going through. Have you experienced that with your patients?

Dr. Smith: Yeah. I would say that's absolutely true. Parosmia, phantosmia, hyposmia are extremely difficult to understand unless you've lived them. And I think most people have had a cold or an upper respiratory tract infection where they've had a weird sense of smell or taste for a short period of time, and they're like, you know, "Nothing tastes good. I don't want to eat while I'm feeling sick." And now imagine if that's what your life is like every day forever. And it can potentially cause real distress when patients can't enjoy things that they normally would enjoy.

So, you know, I personally had COVID-19 in April, and when I was recovering, I actually did have some parosmia phantosmia as I was recovering, and one of the things that I no longer enjoyed was coffee. And I'm a big coffee drinker. I love my morning cup of coffee. And it got to the point where I could not drink my coffee and keep it down because the smell that was associated with it was so terrible. It was making me so nauseated, I couldn't drink it anymore. We had to take all the coffee beans out of our espresso machine and put them away for a while because I just couldn't tolerate them being in the home, and I was really upset about that. I was really bothered about that, and I thought, you know, "This is going to last forever. I'm never going to be able to have a good cup of coffee again." And, you know, fortunately for me, slowly over time that improved, and now I can have my morning cup of coffee again.

But for some patients it's not restricted to one food or to one drink. And it's very bothersome for them. I think it's important that we acknowledge how severely this can impact their life and their day-to-day living because it is a real problem.

Interviewer: And as far as not getting the nutrients that somebody needs because of parosmia, is that a threat? Is that something that maybe somebody should see a dietician about?

Dr. Smith: I think that's a great idea. So if you find that your trigger foods are leading you to eliminate an entire food group from your diet, like meat, this is really going to significantly impact your intake of proteins, of vitamins and minerals, and as you start to restrict your diet using those avoidance measures, you want to make sure that you're still getting a well-rounded diet.

This can be particularly disruptive in an older generation of patients. As you get a little bit older or wiser, one of the things that happens is that your sense of smell starts to diminish naturally over time, and this can be particularly bothersome to patients when it comes to their enjoyment of food. And so if you get an additional disruption to that with COVID-19, it kind of adds a stepwise worsening to that process.

And so one of the reasons that we see folks eating less as they get older and wiser is because their enjoyment of food has decreased in addition to their appetite, and it can be really hard to motivate someone to eat when everything tastes really bland or when it tastes bad. And subsequently, you can have potentially an increased risk of anxiety and depression associated with those things. And so this is something that I think it's important to be mindful of in our older generation so that we can keep an eye out for it and help to manage it as it's becoming a problem.

Interviewer: What would you say to somebody who has parosmia and they're listening to this? What would be the most important message you could give them?

Dr. Smith: Honestly, I think there are two things. The first and most important is that you are definitely not alone. There are so many other patients who are experiencing this. There is a whole growing community of people like you that can help you to kind of get through this stage of your life. It's unfortunately common. We are seeing a lot of it. You are not alone.

The second thing is that it seems to get better. The vast majority of people, you know, 90% plus, within two years of having their COVID-19 infection report that these alterations in their sense of smell go away despite doing nothing about it. And so, for the vast majority of people, it is going to get better with time. It is very slow. We used to think that nerve healing kind of whatever you had one year after the injury, or one year after your episode of COVID-19, was what you were going to be stuck with long term, and we know now that that's not true. It keeps improving two years, three years after you've had the infection, and things seem to slowly get better over time. So don't lose hope. It is very slow. I know that it's hard and it's disruptive, but it does seem to get better for the vast majority of people slowly over time.

Interviewer: You have a deviated septum. Should you get surgery to fix that?

Dr. Marc Error is an ENT at University of Utah Health. And Dr. Error, I'm going to go ahead and throw myself into this. I was in a doctor's office one time and they commented that, "Oh, you've got a deviated septum. Did you break your nose?" And I don't remember ever breaking my nose, but I definitely do notice if I push on one side and try to breathe, it's harder than the other side. Should I come see you and have that fixed?

Dr. Error: A deviated septum can definitely make it more difficult to breathe through one side or the other. The septum is the curtain between the left and the right nostril. And it starts at the very front and travels all the way to the very back of the nose where it ends and opens up into one big cavity. And if that divider is crooked at all, it can block off one nostril or even both if it has an S-shaped deformity to it. So, if you're having trouble breathing through your nose and that bothers you, absolutely, you should have that checked out because that is something that can be repaired and fixed and made so that you can breathe easier through both sides of your nostril.

Interviewer: So that was something I had never considered before. I do notice when I have allergies, so sometimes when I'm having allergies or have a cold, then it's really difficult to breathe through that right nostril. But I don't know, I mean, tell me a little bit about the surgery so I could weigh the pros and the cons. If I was to come into your office and give you the same scenario I just gave you, where would that conversation between us start?

Dr. Error: Well, first of all, we'd really need to assess what's going on completely with the nose. A deviated septum, which is what a septoplasty does and corrects can only be a piece of the puzzle. The nose is a complex organ that has many potential areas that can cause nasal obstruction. And you alluded to the fact that it does change. You know, when you have a cold or when you have allergies, you notice that it's even worse. And this is because there's other structures in the nose that are swelling and causing trouble. Those structures are called turbinates, much like they come from the Latin word turbine that have to do with mixing of air. And these are structures that we all have that are there to humidify air, but over time or if they become irritated, they can get too big and they can block your nose.

So, first of all, we'd really have to assess your nose and say, "What's contributing to your problem? Is it the septum alone? Is it the turbinates?" There's also some cartilages in the nose that can be a little bit weak or floppy. When you breathe in, it creates negative pressure and that can make it so that it's a little bit . . . if those cartilages don't hold the nasal soft tissues open, it can make your nose collapsed. And so these are things that we would take a look at and really assess, why are you having troubles through your nose?

Once we figure that out, the first line treatment for anybody with difficulty breathing through your nose and you included, Scot, would be using a nasal steroid spray regularly. Something like a Flonase or a Rhinocort or fluticasone. There are many that are over-the-counter. These are safe to use long term. They do have some local side effects where they touch or where you put them in the nose, where they can dry out the nasal linings and cause some nasal bleeding. So you have to watch for that, but these ones are safe to use long term.

They work by reducing inflammation in the nose. They don't change the cartilage and the structure of a deviated septum, but they can make it so there's less inflammation and there's more room for air to flow. These take a long time to work, three to four weeks at a minimum to really get the maximum benefit and many people, including myself, if we're to get throwing ourselves into this, I use it pretty regularly because my nose gets plugged, but I can use that and it opens it up enough that I do okay.

But if the nasal steroid spray is inadequate at helping you breathe better through your nose, at that point we'd explore interventions and invasive interventions to help you breathe better, such as a septoplasty or a turbinate reduction or a combination of those procedures to help you open up the nose and breathe better.

Interviewer: So, and my original thought here was, you know, the physician that I saw, this was just a very casual diagnosis, right? So it might not even be accurate, but it looks like you broke your nose. I've noticed that my right nostril seems smaller. I have difficulty breathing. Is that really even a deviated septum is causing that, or is that because I broke my nose and something else is going on?

Dr. Error: No, that is most likely a deviated septum. When you break your nose, you know, we discuss the nose as a complex structure. You know, it's complex three-dimensional structure. And if you break the nasal bones, that frequently will cause influence and may cause a shifting of the septum over to one side or the other.

Kind of a check to see if you have a deviated septum is just as you had mentioned, if one side is more plugged than the other. That usually is a sign that that septum is pushed over. And it tends to be that it's always one side or the other. Like you mentioned, your right side is usually worse than the left side. That's a sign of a deviated septum.

Now, a lot of people will have something where one side is always plugged, but it switches. It goes from right to left. And even if they lay down, they may notice that the side that's closer to the floor, we call it the dependent side swells shut, and if they flip to the other side, the other side swells shut. That's a sign of something else going on in the nose called turbinate hypertrophy or turbinate growth. The turbinates will switch from one side to the other, and those are predominantly treated with, as we discussed, the nasal steroid spray, but there's also procedures that can be done to shrink them down and make them smaller as well.

Interviewer: When somebody is in your office and you've weighed out all these particular options, is there like kind of a final thing that you'd like to say to them to, you know, give them to think about as they consider whether or not the surgery would be for them?

Dr. Error: Well, it really is just based off of, you know, how bad does this bother you? If it's on your mind at all and bothering you at all, you know, it's a week of some discomfort, but it's something that you get benefits for the rest of your life as long as you don't break your nose again. It also can help with some sleep issues if you notice that you're waking up and your nose is plugged. There are people that wake up and they have to get up and walk around until their nose decongest before they can fall back asleep. And so all those things, it can help and just improve your quality of life.

Dr. Miller: Allergies, colds or something else? How do you tell and how do you treat them? That's next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi. I'm here with Dr. Jeremiah Alt. He is an ENT surgeon. That's an ear, nose and throat surgeon. He's a member of the Department of Surgery here at the University of Utah. Jeremiah, how does one tell the difference between an allergic symptoms of nasal discharge versus a common cold or sinusitis? Is there a way to sort of know if you have one or the other?

Dr. Alt: Yeah. That's very difficult. Even very difficult for the physician to figure that out in many cases and requires a thorough history with the patient to figure some of these things out. In general, allergic rhinitis if it's seasonal will occur during the season, where if you have hay fever, you'll get itchy eyes and a runny nose.

Dr. Miller: I always think of hay fever as being itchy.

Dr. Alt: Right.

Dr. Miller: Right? So people are scratching the corners of their eyes and they're blowing and sneezing.

Dr. Alt: Right.

Dr. Miller: The back of the throat is kind of scratchy. Sometimes when I think of the common cold or sinusitis that doesn't feel very itchy. That's [inaudible 00:01:15].

Dr. Alt: Right. So the common cold will have some of the similar symptoms, as there's definitely overlap where you can have increased congestion and nasal blockage. You'd probably be more likely, though, to have some facial pain and pressure. We commonly talk about the loss of smell occurring with sinusitis. But this can also occur with allergies as the inner lining inside your nose is swollen and angry, and inflamed and it can block off some of the ability to smell.

One of the big differences though, is we commonly think of discharge. So if the discharge is yellow or green, this is more signs that this is more severe than just an allergic reaction.

Dr. Miller: More inflammation, more at that issue of infection in the sinus.

Dr. Alt: Correct.

Dr. Miller: So one goes to the store to self-remedy what they would consider to be a fairly short course of this problem. If they have rhinitis, that is the itchy symptoms, what should they be using to treat that problem with? I think most of the medications now are purchased or can be purchased over the counter.

Dr. Alt: Correct. The oral antihistamines are a great option, and they've been used for many years. The second generation are non-sedating, like the Benadryls were that can make people very tired. Although, the second generations can make some people tired.

Dr. Miller: I've taken Benadryl and it works as an antihistamine. But man, does it knock me out. I think it does the same with some people and some people, they don't seem to have that fatigue that I get or that a number of people will get.

Dr. Alt: Correct.

Dr. Miller: Now, I've heard with Claritin, which is an example that comes generic as loratadine, that it's not sedating. But do you think it works as well as something like Benadryl or diphenhydramine?

Dr. Alt: Well, partly it's also what we're targeting. The itchiness, I think, works great. Another great antihistamine is Zyrtec. So if the patient has the itchiness with the runny, drippy nose, what we call clear rhinorrhea, or clear, drippy nose, the Zyrtec is actually quite more drying than let's say the Claritin. So we would push the patient more towards the Zyrtec, which is a more drying medication.

Dr. Miller: This is also listed as a non-sedating antihistamine.

Dr. Alt: Correct. One thing to consider is even if the second generations make you drowsy or feel a little fatigued, you can also take them at night which is an option.

Dr. Miller: So sleep a little better and maybe get a little bit better coverage for the allergic symptoms.

Dr. Alt: Yeah. A third option that's more recent is a topical spray antihistamine. This is not taken by the mouth and you can spray it in the nose. This type of antihistamine, I've never seen it cause drowsiness or fatigue in patients, and you can use it on contact. So if you know you're going outside you can quick spray it in your nose to reduce the antihistamine response that you have for your allergies.

Dr. Miller: So Jeremiah, does that require a prescription or is that available over the counter?

Dr. Alt: That one is still a prescription medication. So you really need to get that from you allergist or your ENT, or your primary care doctor.

Dr. Miller: Now, there's another class of medication used to treat allergic rhinitis as well, and that would be the nasal steroids.

Dr. Alt: Yeah. So the nasal steroids actually have great evidence to be used both for allergic rhinitis and for many of the diseases that we talked about in some of the other podcasts, including chronic rhinosinusitis or reoccurring acute rhinosinusitis, where there's just an overall inflammation inside the sinonasal cavity. This just calms the inside of the nose down. It's a topical steroid. It's sprayed within the nose, usually dosed once or twice a day. What I like to think of it, it addresses the root of the problem.

Dr. Miller: The inflammation.

Dr. Alt: The inflammation, correct. So it really reduces the overall amount of goblet cells in the nose, the inflammatory, or those mediators in the nose and the immune system that are really creating the immune system to start with to create this inflammation.

Dr. Miller: Now, do you think that a patient with allergic rhinitis could also take the antihistamine orally, antihistamine nasal spray, and a topical steroid nasal spray, or should they use them separately? What's your thought on that?

Dr. Alt: It really depends on the patient's response and the overall diagnosis that you've come up with your doctor and your treatment plan. However, commonly we like to use both and we feel like patients get a good response by both blocking with an antihistamine and using a topical nasal steroid like Flonase or Nasonex.

Dr. Miller: Both of which they could get over the counter.

Dr. Alt: Correct.

Dr. Miller: It's possible that they could start their own treatment and then if things weren't going well they could end up seeing their physician.

Dr. Alt: There is a new medication, Dymista, that has actually combined the two together. So you can get it in a single spray, which patients are noting that they've really enjoyed using just one medication instead of two separate.

Dr. Miller: Now, let's say they have the common cold or sinusitis. Do the same medications work?

Dr. Alt: Yes. In general, though, we don't typically use antihistamines for chronic sinusitis unless they have a comorbidity or that's one other disease process that they also have on top of the chronic sinusitis that we want to help control symptomology. So if they have allergies and we want to help control some of that drippy nose, postnasal drip symptoms, we can add on an antihistamine. But, yeah, the steroids are great, as we talked about. It's really disease of inflammation, so that topical nasal steroid is ideal for helping.

Dr. Miller: Would you recommend using an oral, what we call, sympathomimetic, like pseudoephedrine or Sudafed for someone who has the common cold or sinusitis?

Dr. Alt: Those are really two different diseases and two different applications for that. For an acute onset cold or viral rhinosinusitis or bacterial, this can help make the patient feel better. I don't think it really helps get you over the illness quicker. But it can help improve your overall well-being. Now, in sinusitis it can also improve your overall feel of increasing your ability to breathe through your nose.

But this doesn't get at the root of the cause of the disease itself, and we commonly don't like to think of using these long-term in a disease like chronic rhinosinusitis, which is a chronic condition. You'd have to use this over potentially months and years, which we're concerned about the possibility of hypertension.

Dr. Miller: Now, you could also use the same medication as the nasal spray for a few days, I understand.

Dr. Alt: Afrin or over-the-counter oxymetazoline is a great sympathomimetic, which really reduces the overall swelling inside the nose. We commonly like to really counsel the patient that these are great short-term. So these are two to three-day treatment options, and then they really need to consider trying to come off of them.

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updated: February 19, 2019
originally published: December 1, 2015