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A Review of Smell and Taste Dysfunction in COVID-19 Patients

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A Review of Smell and Taste Dysfunction in COVID-19 Patients 19-A reviewCOVID-final_3-PRIMARY.qxd 9/7/20 8:30 PM Page 574 REVIEW ARTICLE A review of smell and taste dysfunction in COVID-19 patients Danny Kit Chung Wong 1, Hardip Singh Gendeh 2, How Kit Thong 1, Sai Guan Lum 2, Balwant Singh Gendeh 3, Aminuddin Saim 1, Salina Husain 2 1Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, KPJ Healthcare University College, Negeri Sembilan, Malaysia, 2Department of Otorhinolaryngology-Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, 3Hospital Pantai Kuala Lumpur, Kuala Lumpur, Malaysia ABSTRACT INTRODUCTION The severe acute respiratory syndrome coronavirus-2 (SARS- Introduction: Multiple anecdotal reports suggest that smell COV-2) or Coronavirus disease 2019 (COVID-19) has infected and taste loss were early subclinical symptoms of COVID-19 more than 5.2 million people with 330,000 over fatalities as patients. The objective of this review was to identify the of May 2020. 1 The outbreak was first detected in Wuhan, incidence of smell and taste dysfunction in COVID-19, China in December 2019 and has rapidly spread globally determine the onset of their symptoms and the risk factors over the last six months. It is transmitted via droplet of anosmia, hyposmia, ageusia or dysgeusia for COVID-19 inhalation through the upper respiratory tract and was infection. declared a global pandemic by the World Health Organization (WHO) on 11th March 2020. Methods: We searched the PubMed and Google Scholar on 15th May 2020, with search terms including SARS-COV-2, The typical general symptoms of COVID-19 are fever, cough, coronavirus, COVID-19, hyposmia, anosmia, ageusia and and shortness of breath. Other symptoms include sore throat, dysgeusia. The articles included were cross sectional nasal congestion, body aches, myalgia, headaches, nausea studies, observational studies and retrospective or and vomiting, diarrhoea and abdominal pain. 2 Anosmia and prospective audits, letters to editor and short ageusia or smell and taste dysfunction are not listed communications that included a study of a cohort of symptoms as part of the screening criteria. patients. Case reports, case-series and interventional studies were excluded. Since being declared a pandemic, there have been anecdotal reports suggesting that smell and taste loss were early Discussion: A total of 16 studies were selected. Incidence of subclinical symptoms of COVID-19. Otorhinolaryngology smell and taste dysfunction was higher in Europe (34 to (ORL) or Ear, Nose and Throat (ENT) societies have alerted 86%), North America (19 to 71%) and the Middle East (36 to physicians to the risk of patients having COVID-19 with 98%) when compared to the Asian cohorts (11 to 15%) in isolated smell or taste dysfunction before the general COVID-19 positive patients. Incidence of smell and taste symptoms occur (i.e. fever, dry cough, fatigue and shortness dysfunction in COVID-19 negative patients was low in of breath). 3 comparison (12 to 27%). Total incidence of smell and taste dysfunction from COVID-19 positive and negative patients In mid-March 2020, the German virologist Professor Hendrick from seven studies was 20% and 10% respectively. Streeck, reported that more than two in three of 200 Symptoms may appear just before, concomitantly, or confirmed COVID-19 patients interviewed in a hospital immediately after the onset of the usual symptoms. Occurs reported loss of smell and taste. 4 France in a press release said predominantly in females. When occurring immediately after anosmia without nasal obstruction is a pathognomonic sign the onset of the usual symptoms, the median time of onset of COVID-19 infection after their interview with 55 COVID-19 was 3.3 to 4.4 days. Symptoms persist for a period of seven patients. 5 Iran showed a dramatic increase in complains of to 14 days. Patients with smell and taste dysfunction were anosmia across multiple regions since the start of the reported to have a six to ten-fold odds of having COVID-19. coronavirus outbreak. 6 Conclusion: Smell and taste dysfunction has a high Although some countries have passed their peak of incidence in Europe, North America, and the Middle East. infections, others such as Brazil, Russia, Peru and Mexico are The incidence was lower in the Asia region. It is a strong risk seeing an increase in cases. 7 According to Professor Claire factor for COVID-19. It may be the only symptom and should Hopkins, the President of the British Rhinological Society be added to the list of symptoms when screening for COVID- (BRS), in the UK, there were a significant number of essential 19. workers who had anosmia or hyposmia but did not meet criteria for a swab test and were forced to go to work. These KEYWORDS: COVID-19; SARS-COV-2; smell; taste; dysfunction people potentially had COVID-19 and their diagnosis could have been missed thus contributing to the spread of disease. 8 This article was accepted: 25 June 2020 Corresponding Author: Hardip Singh Gendeh Email: [email protected] 574 Med J Malaysia Vol 75 No 5 September 2020 19-A reviewCOVID-final_3-PRIMARY.qxd 9/7/20 8:30 PM Page 575 A review of smell and taste dysfunction in COVID-19 patients As a result, this has led to the announcement of BRS on the In all, both searches revealed 630 results and a total of 16 21st March 2020 to call for healthcare professionals to don manuscripts were included in this narrative review tabulated adequate personal protective equipment (PPE) in view of in Table I. The studies comprised of 3 prospective audits, 5 strong evidence of anosmia being a valid symptom for retrospective audits, 6 short communications and 2 pre- COVID-19. 3 Meanwhile in the USA, the Center for Disease prints. 10-25 The studies were published between 25th February Control and Prevention (CDC) in April 2020 added loss of 2020 to 12th May 2020. taste or smell to its list less common symptoms that may arise two to 14 days after exposure to the COVID-19 virus. 9 Anatomy and Physiology of Olfaction Furthermore, many nations have yet to include smell and/or The zone of smell of the classical olfactory system in the nose test disorders as a screening symptom for COVID-19. lies in the olfactory epithelium, located at the roof of the nasal cavity. It covers an area of about 5cm 2 on either side of There were three objectives with the present review. Firstly, it the nose, including superior turbinates, septum and ethmoid was to identify the incidence or frequency of smell and taste bone. The structure of the nose is designed, in part, to direct dysfunction in COVID-19; secondly, to determine the onset of inspired air toward the olfactory epithelium. The the smell and taste dysfunction whether it was before, during neuroepithelium is characterised by the presence of olfactory or after the general symptoms of COVID-19 (i.e., fever, cough, neurons whose axons project through the cribriform plate of shortness of breath) and finally, to determine if smell and the ethmoid bone, and synapse with neurons in the central taste dysfunction is a significant risk factor for COVID-19. olfactory nervous system. The group of axons form an olfactory tract that connects to olfactory bulb on the ventral surface of the frontal lobe. The axons then travel to the olfactory cortex in the inferior and medial temporal lobe. MATERIALS AND METHODS This literature review was narrative in nature. Latest Some project to limbic system and hypothalamus, where manuscripts within the past six months (coinciding with the smells associated with long-term memory and emotional start of COVID-19) on COVID-19 from peer-reviewed journals response. Newer studies revealed a more extensive were included. Searches was conducted using the PubMed distribution of olfactory epithelium that involves the and Google Scholar database on 15th May 2020. anterolateral part of middle turbinate and posterior nasal septum. 26 Search terms used were “SARS-CoV-2 AND hyposmia OR anosmia AND coronavirus” (Search 1) and “SARS-CoV-2 Odorant particles are inhaled through the nose and carried AND ageusia OR dysgeusia AND coronavirus” (Search 2). by the turbulent airflow to the olfactory epithelium superiorly Relevant references from individual articles were retrieved and dissolve into mucous membrane. These odorant and included. molecules are transported by binding proteins to the olfactory receptors within the cell membrane of an olfactory dendrite. The inclusion criteria were cross sectional studies, Binding of the odorants to the specific olfactory receptors observational studies and retrospective or prospective audits, induces graded membrane potential in the olfactory neurons, letters to editor and short communications that included a which transmits signals to the brain. study of a cohort of patients. Case reports, case-series, reviews, and interventional studies were excluded. Both Besides the normal route, some of the odorants reach the published and unpublished (pre-print) materials were olfactory epithelium by ascending through the nasopharynx included. and posterior choanae. This retronasal olfaction has contributed in part to the sensation of flavour during Data from shortlisted papers were divided equally between consumption of food and liquids. 26 This may explain the four researchers, two each for Search 1 and Search 2 reason why taste sensation can be affected when the olfactory respectively who obtained full texts and reviewed the function is impaired. manuscript. Risk bias was minimised by adhering to the objectives of this study. Duplicate articles were removed. A Smell and Taste Dysfunction In COVID-19 second author re-reviewed the full text manuscripts. Olfactory dysfunction presenting as anosmia or hyposmia Significant and relevant results were tabulated based on has an overall prevalence rate of 3 to 20%.
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