Loss of Smell in the COVID-19 Era: When to Worry

Throughout the pandemic, CHOP’s Division of Otolaryngology – commonly known as Ear, Nose and Throat (ENT) specialists – has received an influx of calls related to children and teens losing their sense of smell, or anosmia. For many, the loss of smell is caused by COVID-19, which while concerning, is usually something that will resolve within six months. For reasons that are not yet understood, some patients’ anosmia will persist for a longer duration. Importantly, a loss of smell can be due to problems unrelated to COVID-19 and may be a sign of a separate and possibly serious condition.

So, how can families tell the difference? By consulting with an otolaryngologist (ENT specialist) to diagnose the issue and recommend next steps.

In most cases, we can offer reassurance. A majority of children who lose their sense of smell from COVID-19 will experience a spontaneous recovery within six months. For others, recovery may take longer, but there are tools that may help speed the process. At this time, we have no evidence that a child’s loss of smell post-COVID-19 will result in permanent disability.

Anosmia from COVID-19 likely occurs from direct infection of the olfactory nerves by SARS-CoV-2, the virus that causes COVID-19. Anosmia commonly occurs early during infection, often with no associated nasal congestion. While smell loss is very common in adults with COVID-19, it fortunately appears to occur less frequently in children. Children with absent sense of smell not associated with COVID-19 should be evaluated by a specialist to consider alternative causes. At CHOP’s Sinus Clinic, these visits sometimes start with a telemedicine appointment for the initial consultation, after which in-person visits can be easily arranged if needed.

Accelerating smell and taste recovery after COVID-19

Many children who’ve contracted COVID-19 experience changes in their sense of smell while the virus is active in their bodies and for some time afterward. Older children are the most likely to notice and verbalize this change. They may say their favorite foods don’t smell the same or taste as good as they used to. As humans, our ability to perceive flavors depends mostly on our sense of smell; when olfaction is altered, taste is affected.

While there are not yet any clinically-approved methods to reactivate a child’s sense of smell after COVID-19, there is evidence that shows olfactory training to be helpful in speeding recovery from smell loss due to other causes.

Olfactory training

Olfactory training – also known as smell training – has been used successfully for years to help patients reengage their sense of smell after viral infections and other ailments. This technique involves consciously sniffing several familiar odors – one at a time for a minute or two – twice a day to stimulate recovery.

Children can help pick scents that are familiar to them, such as cinnamon, orange, ketchup, vanilla, lemon and others. Essential oils can also be used, such as peppermint, eucalyptus and lavender. Other scents that may be familiar but not yet enjoyed – e.g., coffee or onions – may also be used.

Typically, four different fragrances are trialed at a time, though these can be switched out after a few weeks if the child reports no change in their sense of smell. Stronger, smells are recommended during olfactory training.

After consulting with a trained professional, parents can begin olfactory training at home with their child. Parents should encourage children to vary between gentle and deep sniffs of the item before moving on to the next. Encourage the child to imagine and think about the scent while sniffing. For example, if smelling chocolate, encourage the child to envision delicious brownies, or perhaps the child’s favorite cupcakes. The entire experience should take about 10 minutes, twice a day.

The training can reignite the mind-body connection to the items – even if patients don’t realize it at first. For example, a child may smell cinnamon and suddenly have a craving for French toast. While the connection may not seem obvious to the child, parents can observe the links and improvement of symptoms.

Not COVID-related? What else could it be?

If your child loses their sense of smell and there is no history of confirmed or suspected COVID-19, you should observe the child for signs of illness. Are they coughing and sneezing? Do they have congestion and a runny nose? Do they display unusual or unexplained symptoms?

Then, armed with this information, contact your child’s healthcare provider. They will listen to your child’s symptoms and advise whether an in-person or virtual appointment is recommended.

Children with common colds – which can cause congestion, stuffy nose and lack of smell – will typically recover in a few days to two weeks. In most cases, these children can be assessed virtually or in-person by a pediatrician. Recommended treatment typically includes rest and plenty of fluids.

Losing the ability to smell beyond a few days can be an indicator of something more serious. Your child’s pediatrician – with support from an ENT specialist, as needed – can help determine next steps. In some cases, a child with an olfactory deficit will be diagnosed with an infection and may require antibiotics to recover.

In cases where a child’s lack of smell cannot be attributed to today’s usual suspects – i.e., lingering COVID-19 symptoms, a cold or infection – clinicians will begin testing for other possible reasons. CT and MRI scans are common in this circumstance, as is a nasal endoscopy to allow clinicians to look inside the nose for any physical reason for the child’s loss of smell. In some cases, additional testing – including the University of Pennsylvania Smell Identification Test or a Pediatric Smell Wheel for younger children  – may help quantify your child’s smell deficit.

Though rare, nasal obstructions that blocks air flow through the nose may be caused by conditions that require intervention. These include nasal polyps, enlarged adenoids, a deviated nasal septum or tumors. If your child is experiencing pain or bleeding from the nose or nasal area, contact your child’s doctor immediately.

When to seek help

While a child’s loss of their sense of smell is not always a sign of a more serious condition, it can serve as an important warning sign and should be investigated further. Talk to your child’s healthcare provider or contact CHOP’s Division of Otolaryngology at 215-590-3440 or www.chop.edu/ENT.

Mark D. Rizzi, MD, is an attending physician; Jana L. Bradley, MSN, CRNP, CORLN, is a nurse practitioner, both in the Division of Otolaryngology (ENT) at Children’s Hospital of Philadelphia.