When a patient walked into Dr. Angela Cheung鈥檚 clinic and said the place smelled like chicken noodle soup, she knew it wasn鈥檛 possible, as food was forbidden. The patient had what is known as phantosmia, a condition where the individual smells an odor that does not exist.
Early in the pandemic, losing one鈥檚 sense of smell and taste was among the more widely reported symptoms of COVID-19. While many patients regained these senses within weeks, others took months.
For some, recovering their sense of smell has been a much more challenging journey than losing it: coffee now smells like rotten vegetables and food now smells rancid, like raw sewage, smoke, or is sickly sweet and sour.
The scent of fragrant flowers might now be burnt rubber.
These patients have what is known as parosmia, a condition where their sense of smell is distorted. Even for those with phantosmia, the olfactory hallucination is often not as pleasant as chicken soup, but instead, is a constant smell of something foul, like garbage, experts say.
鈥淚t doesn鈥檛 even smell like coffee. Usually over time things subside a bit, especially if we treat it,鈥 Cheung, a senior scientist with the University Health Network and Sinai Health System and a leading expert on long COVID, told CTVNews.ca in an interview.
鈥淏ut there are some people with very debilitating and awful symptoms. So everything smells rotten, they can't eat, everything makes it nauseating.鈥
Dr. Marc Tewfik, a surgeon and an associate professor of otolaryngology with McGill University Health Centre, told CTVNews.ca that in most cases, the smells are extremely unpleasant and for those with phantosmia, it can be constant.
He described it as being similar to phantom limb syndrome, a common sensation experienced by amputees where they feel something in a limb that is no longer there. And unlike how we may 鈥済et used to鈥 a smell after being in a room for a certain period of time, the scent does not dissipate over time for those with phantosmia, Tewfik said.
in Nature鈥檚 Communications Medicine found that specific highly odour-active molecules may be the cause for most cases of parosmia and why it triggers disgust.
鈥淚t becomes very, very difficult for patients to deal with and certainly, I鈥檝e seen a few patients get to the point where they have suicidal thoughts,鈥 he said, adding that doctors need to look out for these types of situations. has found links between parosmia and phantosmia and patients with severe depression.
鈥淲hen it鈥檚 a really unpleasant smell, it鈥檚 really nauseous. And it鈥檚 unrelenting. After days, weeks, months, it just becomes an overriding element of their existence and it becomes very hard for them.鈥
The good news, he says, is that most of these problems do evolve over time and get better.
For specialists in this field, these olfactory distortions are not unique nor specific to COVID-19. While not necessarily widely or commonly discussed, parosmia and phantosmia are conditions that can be experienced by those with neurological conditions, like dementia, Alzheimer鈥檚, Parkinson鈥檚, and Huntington鈥檚 diseases. Those undergoing cancer treatments like radiation and chemotherapy can also get it. Environmental exposures to smoke and chemicals may also cause damage to the nerve and surface cells. , and other viral infections, can all trigger these olfactory changes. But prior to the pandemic, doctors did not routinely test for viruses, for example.
鈥淏ecause of the scale of COVID, obviously we鈥檙e seeing a lot more of that,鈥 Cheung said.
There has been comparatively little conducted on this particular phenomenon as it relates to COVID-19, with so far suggesting that between eight and 23 per cent of patients experience some kind of change to their sense of smell and taste three months after recovery, says Cheung. Her team鈥檚 research netted slightly higher percentages.
The British Medical Journal (BMJ) said in an article that parosmia is a common condition following the loss of smell associated with COVID-19, often occurring on average about three months after initial infection. The article added that many patients reported feeling that their symptoms have been trivialized by health-care providers. called persistent parosmia caused by COVID-19 an emerging symptom that was worth highlighting more in literature in order to increase awareness.
found about a third of patients who recovered from COVID-19 had persistent issues with altered smell and tastes, while found that for about five per cent of patients, olfactory dysfunction was still present after six months.
Research suggests that the loss of smell and taste is less common with the Omicron variant, but Cheung says she still sees patients reporting this issue, though perhaps a little bit less than before. She attributes the shift to vaccinations, noting that those who became infected only after being vaccinated and then boosted appeared to have fewer issues with lingering symptoms, with some data showing that the odds ratio of getting long COVID is a third among those who are vaccinated.
Experts believe what happens is that there is an injury to the olfactory zone of the nose as a result of inflammation caused by COVID-19. It is generally not a direct injury to the actual olfactory nerve, but to the lining of the cells around those nerves or the epithelium at the mucosal surface. There are hundreds of receptors that send messages to our brains to help identify different scents. When there is an injury, those messages are not being sent correctly. Most people would lose their sense of smell altogether, known as anosmia, or the senses would be reduced, known as hyposmia, but would recover without any abnormal changes.
鈥淲e think that maybe in a smaller percentage of patients, there may be actual damage to the olfactory nerve,鈥 said Tewfik.
鈥淲hen that happens, then sometimes when the nerve recovers or regenerates itself, you can have faulty connections that happen鈥e think it鈥檚 actually a sign of recovery. It means that the nerves are starting to recover, but it can go through this phase where the sensations are altered.鈥
Cheung explains that during recovery, the nerves are not registering correctly in the brain.
In in the peer-reviewed journal Foods, 84 per cent of patients with smell distortions described the smells as unpleasant or gag-inducing, with coffee, onions, and meat among the worst triggering food items. Researchers said that these items have many molecules in common that generate distortions and have similar formation pathways. Milder cooking processes that do not involve roasting, frying, grilling, or baking, may help mitigate some of the distortions, they suggested.
鈥淐offee, onions, garlic, fried foods, eggs, and (in a non-vegetarian lifestyle) meat constitute a major part of a typical weekly diet, certainly in western cultures, and it is clear how distortions and sense of disgust in these key items could have a serious impact on diet and nutrition,鈥 the authors wrote.
While most patients improve over time 鈥 Tewfik says about three to six months for parosmia 鈥 some have very persistent symptoms.
鈥淩arely, we do see some patients where it really goes a long time, like over one or two years, but those are luckily a very small minority,鈥 he said.
Experts say patients can retrain their sense of smell and taste, though the success rate varies. Retraining involves being exposed to scents they are already familiar with, such as something sweet and fruity versus something more pungent like garlic or onion, and training the brain to recognize and register the smell correctly. Patients are exposed to the different smells for 15 seconds, twice a day, for example.
鈥淚t鈥檚 like retraining the olfactory system, like teaching people how to walk again after they have had an injury,鈥 Cheung said. 鈥淏ut nerves are not quick to regenerate. It takes time.鈥
Patients are asked to try and imagine and remember the original scent as they smell an item, Tewfik added.
suggested a combination of a course of a corticosteroid drug, smell training, and nasal irrigation for three months to help with phantosmia.
鈥淚t鈥檚 a very slow process, it鈥檚 not something that usually has an effect immediately,鈥 he added.
鈥淭he reason that it seems to work is because there are stem cells in the nasal cavity that can regenerate olfactory nerves and it鈥檚 one of the only places - if not the only place - in the body where stem cells can regenerate nerve cells, so that鈥檚 really unique to the nose.鈥
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