Managing smell and taste disorders in primary care

Updated 7 May 2021

Dr Devina Maru - RCGP Clinical Champion

Mr Duncan Boak - Chair, Fifth Sense

Professor Carl Philpott - The Norfolk Smell & Taste Clinic, The Norfolk & Waveney ENT Service; Norwich Medical School, University of East Anglia

Little girl smelling flower

Anosmia (total or partial loss of smell) affects an estimated 5% of the population aged under 60 years old and approximately 20% of those aged over 60 the United Kingdom.

In addition to anosmia, some people experience smell distortions such as parosmia and phantosmia. Ageusia (total or partial loss of taste) is much rarer and often people report losing the ability to taste when it is more likely to be smell loss affecting the ability to detect flavour. It is essential GPs are equipped with the tools and knowledge to manage consultations in relation to anosmia and ageusia and signpost to resources available for support and self-help.

COVID-19, ongoing symptomatic COVID-19 and post-COVID-19 syndrome (Long covid)

Anosmia and ageusia have emerged globally as peculiar tell-tale signs of COVID-19 infection.  About 60% of people with COVID-19 report olfactory disturbance, and around 1 in 4 people with COVID-19 report that loss of smell is the first symptom they experience.

A study by Mennni et al showed that amongst the 2 million participants who reported potential symptoms in a smartphone-based app, the proportion who reported loss of smell and taste was higher in those with a positive result than in those with a negative test. Statistical analysis revealed that loss of smell and taste is a potential predictor of COVID-19 in addition to other, more established, symptoms including high temperature and a new, persistent cough.

Long COVID” is a term being used to describe illness in people who have either recovered from COVID-19 but are still report lasting effects of the infection or have had the usual symptoms for far longer than would be expected.

The updated terminology by NICE, SIGN and the RCGP includes ‘ongoing symptomatic COVID-19’ for signs and symptoms of COVID-19 from 4 weeks up to 12 weeks and ‘post-COVID-19 syndrome’ for signs and symptoms that develop during or following an infection consistent with COVID-19 or continue for more than 12 weeks and are not explained by an alternative diagnosis.

Figures from the UK COVID Symptom Study app, which has more than four million regular users, suggest that a significant number of people report symptoms for a month and between 10% and 20% report complications for longer, of which anosmia and ageusia can be a lasting symptoms.

It is anticipated that GPs will be see an influx of patients with long COVID in addition to new COVID cases, adding to the pressures. GPs must be prepared and have the necessary resources and support to care for patients both physically and emotionally.

Recently a RCGP survey of members (894 KB PDF) revealed that 54% of respondents had patients with loss of taste and smell after 12 weeks.

Psycho-social impact

Anosmia can cause profound psychological and social effects resulting in feelings of physical and social vulnerability. People feel vulnerable to potential hazards from environmental dangers such as spoiled food and gas leaks. Because of the reduced pleasure of eating, some sufferers report a reduction in their appetite with subsequent physical concerns. Emotional negatives experienced by sufferers include embarrassment, sadness, depression, worry and bereavement. Other concerns included personal hygiene, loss of intimacy and the breakdown of personal relationships.

No simple solutions are available for anosmia and ageusia and we are only now starting to slowly comprehend the effects. Even if no reversible cause can be identified, clear information and support can now be provided.

Guidance for management in primary care

Dr Maru has contributed to the suggested systematic approach in the management of post infectious olfactory dysfunction in Primary Care. The paper has been published in the Journal International Forum of Allergy & Rhinology, and was recently cited in the BBC News COVID article highlighting how smell training is recommended for lost sense of smell.

Please see below the systematic proposed approach described in the paper:

  • History Taking: thorough details of the specifics of the impairment. If sudden onset anosmia during the pandemic, SARS-CoV-2 infection is possible and take necessary precautions with swab testing and personal protective equipment if face-to-face contact is needed.
  • Please refer any red flag signs to ENT e.g. neurological impairment, unilateral nasal congestion, persistent headache, weight loss
  • Examination: Full head and neck examination and basic neurological examination
  • Acute symptoms of common cold with PIOD: consider symptomatic relief with decongestants or nasal saline irrigation
  • Persistent PIOD (3 months or more):
    • If unable to perform an objective olfactory assessment via psychophysical tests (for example - sniffin sticks), a visual analogue scale and/or validated questionnaire (eg. an olfactory disorder questionnaire) can enable assessment of olfactory dysfunction on daily life
    • If hyposmia/anosmia is found, olfactory training at home over a 12-week period (please see smell training patient advice box below or consider a short course of steroids in selected patients  (diagnostic – NOT therapeutic)
    • If no improvement – ENT referral
  • Counselling on the hazards of smell disturbances should be undertaken at any opportunity, including advice on labelling food and gas detectors in the home environment. Further help and support can be found through online fora such as the charity Fifth Sense

Smell Training Patient Advice

The advice is not that patients “should sniff odours as often as possible”. The odours for this training include rose, eucalyptus, clove and lemon.

Place each item into a separate bowl/jar or just take the raw material into your hands.

  • Slowly and gently, inhale naturally – sniffing too quickly and deeply is likely to result in you not being able to detect anything
  • Repeat this for 20-30 seconds. 
  • Move on to the next smell and repeat as above
  • Record your experience – any changes or what you notice in your SmellAbility Resources.
  • If no improvement then refer to ENT.

Resources to signpost patients 

Fifth Sense, the charity for people affected by smell and taste disorders, provides support, information and a range of resources to help patients and families, including information on specialist smell and taste and rhinology clinics. Since its inception in 2012, the charity has led the way in supporting people and raising awareness of the impact of these conditions. The need for Fifth Sense’s services has increased significantly this year, and the organisation has launched several initiatives to help beneficiaries.   

The charity’s hugely successful ‘Let’s Talk Smell and Taste’ online conversations provide an opportunity for people to meet others, share experiences and gain mutual support in a safe, friendly environment. The Fifth Sense SmellAbility toolkit provides a range of resources to help people understand their own ability to smell, explore whether they can develop this further using different sources of odour and record any noticeable changes. The Fifth Sense website also contains information on other things people can do to help themselves, such as sinus rinsing.

For more information, visit the Fifth sense website.

Further Research

Fifth Sense is partnering with the James Lind Alliance (part of the National Institute of Health Research) to deliver a Priority Setting Partnership (PSP) for smell and taste disorders. This will give patients, their families and clinicians the opportunity to share their priorities for future research into conditions that have a significant quality of life impact on so many. 

A diverse group of stakeholders including clinicians across ENT, Neurology, Psychology, Primary Care and patient and carer representatives from a range of conditions and causes have come together to form this PSP. We want to find out what matters to patients, carers and clinicians in the field of smell and taste disorders to ensure future clinical research will be relevant, focused and cohesive.

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