In the summer of 2021, Uneeta Palmer was gearing up to bring her three young boys to a humungous birthday celebration in Los Angeles—and then she fell sick. “Right off the bat, I lost my sense of taste,” remembers Palmer, a marketing and communications director from the Dallas area. “I was like, ‘Ooh, this must be COVID.’ But I didn’t freak out. I thought, ‘Man, I’m going to lose some weight because of this.’ I think I was more patient and accepting of the symptoms because I wanted to lose some weight.” Sure enough, she tested positive for COVID and cancelled the trip. After only one or two bad days, she was able to get an antibody infusion that helped her kick most of the symptoms quickly. But her sense of smell and taste did not come back.
As the months went by, Palmer did lose a few pounds, but she also began to stress eat. “That was interesting because I thought, ‘This [food] isn’t even good! I can’t even really taste it.’ I was working off my memory of how things ought to taste and smell, and my habits.” Eventually, her taste came back, more muted than before, yet her sense of smell remained blocked. And she started to feel bereft of simple joys, from her morning coffee ritual that had lost its sparkle, to a lack of inspiration in the kitchen. “I realized that I was having some sadness creep in, because my habitual experiences weren’t the same,” she says. “Imagine walking into a coffee shop and not being able to smell the ground espresso and coffee beans. All those things are part of the caffeination of your experience. [Losing my sense of smell] robbed me of that. I’ve found myself daydreaming about being able to smell coffee again.”
It’s getting close to a year now for Palmer, and smell loss has affected everything from her mothering (“I have to rely on my friends to tell me if my boys are musty”) to her dating life. “I’m recently divorced, and I don’t want to jump into anything,” she explains. “But I’m like, I can’t take this guy seriously because I don’t know his scent. Even when I hug a male friend—and we’re just talking PG here—I can’t fully experience them.” In a way, she’s lost a part of her inner compass. “I’ve recognized how important [smell] is for connection. It may not be for other people, but it is for me. And my body absolutely knows there’s a missing component here that would normally be a part of my consideration.”
When You Can’t Stop and Smell the Flowers
A troubling offshoot of the global pandemic, the prolonged loss of smell (and often its sister sensation, taste) is a sensory handicap that has plagued many people post-COVID—long outlasting the infection itself and baffling physicians and researchers. “As many as 50 percent of people who get COVID can develop chronic smell issues,” says Matthew Kim, MD, an ear, nose, and throat doctor affiliated with Westchester Medical Center Health Network. “I’ve seen a lot of patients over the past two years with persistent smell loss, altered smell, or other smell dysfunction. For most of them, we’ve come up with a treatment plan that aims to maximize their capacity to recover.” Usually, the ability to smell and taste comes back on its own within a few weeks or months, though improvements are slow and gradual and may take up to two years. Some people may not recover completely. And so far, no medications have been shown to restore either post-COVID anosmia (smell loss) or its related disorder, parosmia (distorted smell, in which normal scents are perceived as foul or noxious odors). Yet there is still reason for hope, with at least one evidence-based treatment—olfactory training, a kind of physical therapy for the nose—that can support and perhaps hasten the body’s natural ability to heal.
The reasons for COVID-related smell loss are not well understood, though a few hypotheses have emerged. “[One] theory is that the virus infects and damages the tissue that supports the smell nerve, and, in some cases, can infect and damage the nerve itself,” says Kim. “In rare cases, [the virus] may travel into the brain and affect the downstream tissue that helps us smell.” These insults would explain the sudden and complete “light switch” loss of smell that occurs for many people just after they contract COVID-19. But in order for smell loss to become chronic, a second mechanism may be at work. “The other injury, if we can call it that, is that because those patients have no smell input to their brain anymore, the brain forgets how to process smells,” says Kim. “Even after the nerve has recovered or is back to functioning again, the brain has to remember or relearn how to process that sensory information.”
Complicating the picture, emerging research is shedding new light on the mechanism behind smell loss. In a small study published in May in JAMA Neurology, led by researchers from Johns Hopkins Medicine, evidence suggests that smell loss may be a consequence of inflammation from COVID-19, rather than a direct injury from the virus itself. “The inflammatory reaction that we have to the virus is releasing cytokines, which are inflammatory processes of our own body, which is causing injury to the nerve fibers, the axons, and even some vascular irritation around the nerves,” explains Paul Wright, MD, a neurologist in Poughkeepsie and senior vice president and system chair of the Neurosciences Institute. “So in one sense, our own body plays a significant part of why we lose our sense of smell specifically for this virus.”
Olfactory Training to the Rescue
While our understanding of COVID smell loss is still evolving, there is consensus about how to treat this stubborn condition. It starts with olfactory training or “smell therapy,” the evidence-based rehab program that aims to retrain the smell nerves. Smell therapy is not new—it’s been around for a while to treat smell dysfunction triggered by other causes (nasal polyps, head trauma, pituitary surgery, and even dementia or Alzheimer’s disease can be attended by smell loss). But in the aftermath of COVID-19, more physicians and therapists have had to step up to help patients who are desperate to smell and taste normally again.
“All of a sudden, people can’t smell, so we’re doing smell therapy,” says Wright. “We never learned it in medical school or in [my neurology] specialty training. But it’s worthwhile, because if there’s a disconnect between two electrical circuits, then maybe we can reroute and modify that circuit.” In other words, at the heart of olfactory training is the concept of neuroplasticity—the idea that we can reteach the brain how to interpret smell again.
“It’s possible that the cells in our nose are receiving odors, but the brain is just not making sense of them,” explains Hannah Landon, an occupational therapist (OT) at Northern Dutchess Hospital in Rhinebeck. Landon works one-on-one with patients in olfactory training, providing support with both in-person and telehealth sessions. The personalized process starts with a questionnaire about how smell or taste loss is affecting the person’s quality of life. Next comes a scratch-and-sniff test that gauges their ability to smell the four main scent categories: spicy, fruity, floral, and resinous (or earthy, woodsy types of smells).
After determining which category is most impaired, Landon walks the patient through olfactory training, which involves smelling essential oils with a short, small inhale through the nose. “The idea is to breathe in a way that doesn’t go beyond the nose and into the lungs,” she explains. The exercise also incorporates mindfulness and mental imagery. “If you’re smelling a rose scent, you’re not just waiting to see if you can smell it—you’re actively trying to remember what the rose petals feel like, what a rose it looks like and how it blooms, and maybe a memory associated, like when you got roses,” says Landon. “All of those things add context to your brain.”
Practicing at home for a few minutes daily is key to the process—whether it’s with essential oils or through activities like cooking or baking. Having a goal helps: Landon had one patient who was a landscaper and just wanted to smell fresh-cut grass and flowers again. “We retested him after two weeks and he had already made significant improvement,” she says. Landon notes that most patients come in thinking they can smell nothing at all and are surprised to find they score as high as 60 percent on the first test. “That suggests there’s an unconscious process going on, and then hopefully, the retraining will help to make the connections a bit stronger, so they are conscious connections.”
Getting Creative and Staying Motivated
For Ashley Pugliese, an employee assistance professional and mother of two from Fishkill, loss of smell and taste was one of many long COVID symptoms that dogged her for well over a year after she contracted the virus in February 2020. After an ENT scoped her and found that everything looked okay internally, Pugliese started on olfactory training that involved sniffing essential oils and tasting different fruits. “My kids and I would make a game of it: Sniff this, tell me what it is. They’d cut stuff up and feed it to me [blind], and say, tell me what it is,” she recalls. “You could kind of get, by the texture of things, that memory. If smell and taste work like muscles, you’re [exercising them and] remembering what things smell and taste like.”
As her olfactory capabilities started coming back, Pugliese experienced parosmia, the distorted sense of smell that’s also common post-COVID. “I would ask my husband all the time, ‘Do you smell smoke? Is something on fire? It smells like burning hair,’” she remembers. While unpleasant, parosmia may in fact signal the return of the olfactory sense. (“It’s actually a good prognostic sign that you’re going to make a significant recovery,” says Kim.) Pugliese worked with a neti pot to clear her nasal passages, continued her smell training, and practiced breathing techniques she learned from Westchester Medical Center’s Post-COVID-19 Recovery Program. “Slowly but surely, everything’s returned, which is great,” she says. After losing her sense of smell and taste for 14 or 15 months, she’s living (and smelling and tasting) proof that no one should lose hope.
In addition to smell training, Kim advises patients to try nasal sprays and rinses (with or without steroids); fish oil supplements have also been shown to support the injured smell nerve. Chronic sinus issues and allergies should be treated so they don’t hamper recovery, and smokers should quit, since cigarettes already compromise smell and taste. And while new therapies are being studied to treat smell loss—such as platelet-rich plasma injections—steer clear of treatments that lack sound science. “Waking up” the nose with noxious chemicals like ammonia or bleach can do much more harm than good. Organizations such as AbScent and Smell and Taste Association of North America (STANA) are helpful resources for educational materials, support groups, and advocacy for those suffering from smell or taste dysfunction.
While COVID long-hauler syndrome itself can lead to much more dangerous conditions that impact the heart or lungs, those dealing with smell and taste loss should not feel that their problem is too small to warrant medical attention. “We rely on our senses, whether consciously or subconsciously, to get us through life,” says Wright. “They are there to keep us alive and safe.” To that end, an important aspect of treatment is the safety piece. “We test to make sure that people can identify the odor of smoke, natural gas, and spoiled food,” says Landon. One hack is to label foods in the fridge with the dates they were cooked or opened, being meticulous about tossing items after their use-by dates.
And while losing your sensory abilities can bring on the blues, it’s worthwhile to stay positive and open-minded to unexpected gifts. “I’m actually seeing a health benefit to this, because I’m starting to work out more,” says Palmer, almost a year into her smell-loss ordeal. “I’m more appreciative of all my senses, more aware of my habits, and it’s made me want to take care of myself better. There’s a wellness journey that this has taken me on, too.”
This article appears in June 2022.
