Changes in Sense of Smell

 

This guideline applies to adults aged 16 years and over.

 

Introduction

• Anosmia: loss or lack of sense of smell, typically associated with loss of taste.
• Hyposmia: reduced sense of smell.
• Cacosmia: presence of unpleasant smells.
• Parosmia: related to abnormal/phantom smells, often occurs during the long recovery phase after anosmia.
• Phantosmia: phenomenon of phantom smells (typically burning paper, smoke, unpleasant smells).

 

Red Flag Features

Nasal malignancy should be excluded in the context of new onset, persistent and/or rapidly progressive:

• Unilateral facial pain and/or swelling
• Unilateral epistaxis or crusting with nasal obstruction – simple epistaxis is typically unilateral
• Clear watery nasal discharge (CSF leak presents like a dripping tap)
• Bulging eye associated with visual disturbance, painful eye movements and/or double vision
• Dental changes e.g. loosening of upper teeth
• Altered sense of smell

Brain tumour / space-occupying lesion:

• Signs of raised intracranial pressure i.e. headache, vomiting, papilloedema

Not an exhaustive list.

 

Management Optimisation

In the absence of red flag features, adequate medical management prior to referral includes:

• Smoking cessation, if appropriate.
• Treat underlying cause – if sinus disease, polyps, consider intranasal steroids.
• Smell training – performed daily for 2-3 months. Charities such as Fifth Senseand AbScenthave tools to guide patients through the process.

 

Advice and Guidance

Refer any suspected nasal malignancy via ENT Advice and Guidance – the consultant will consider the clinical information and advise regarding appropriate prioritisation and urgency of referral.

ENT Advice and Guidance is also available if:

• diagnostic uncertainty
• patient falls outside of referral criteria

 

Referral

Fast Track Suspected Brain Cancer

• Progressive, sub-acute loss of central neurological function.
• Suspected space occupying lesion.

Refer via Suspected Cancer Brain Referral Form.

 

Fast Track Suspected Cancer Plymouth Neuro-Oncology MDT

• Tumour of brain/CNS, skull base, pituitary or spine.

Refer via Suspected Cancer Plymouth Neuro-Oncology MDT Referral Form.

 

Routine Adult ENT referral

• Persistent abnormal sense of smell which has failed to respond to conservative measures and/or an adequate trial of medical management.

MRI scanning is indicated for complete anosmia with no intranasal pathology after assessment in a secondary care clinic.

 

Supporting Information and References

ENT UK - Anosmia

AbScent – smell training

Fifth Sense – smell training

 

Page Review Information

Review date	20/06/2024
Next review date	20/06/2026
GP speciality lead	Dr Laura Vines
Contributors	Ms Aileen Lambert, Consultant ENT Surgeon Mr Neil Tan, Consultant ENT Surgeon