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Ear Nose and Throat Manifestations of COVID-19



Prof Guri Sandhu

Having started in Wuhan in China in December 2019, the Coronavirus Disease 2019 (COVID-19), dramatically spread all over the world, crossing all countries’ borders, such that the World Health Organization confirmed it as a pandemic disease on March 2020.


The early variants of this virus caused mainly lower respiratory tract symptoms, such as fever, cough, shortness of breath, and chest tightness that could progress rapidly to acute respiratory distress syndrome, requiring hospitalisation and in some cases ventilatory support. In the most severe cases lives have been lost to the disease.


ENT symptoms of COVID-19 include nasal congestion, headache, sore throat and altered or loss of smell and taste sense. Some patients become aware of enlarged tonsils and palpable glands in the neck (lymph nodes).


Loss of the sense of smell (anosmia) has a significant impact on quality of life. Most of what we perceive as taste is in fact attributable to the sense of smell, as taste perception in the mouth is actually very basic. The organ of smell (olfactory apparatus) sits in the roof of the nasal cavity. Loss of smell can follow head injuries where this olfactory apparatus is damaged, or in patients where airflow to this area is restricted due to nasal congestion, sinusitis or nasal polyps. Viral infections, such as those causing the ‘common cold’ or ‘flu’, have long been recognised as causes of prolonged loss of the sense of smell, which can persist even after recovery from the original illness. Loss of smell after these viral illnesses has been estimated to occur in around 10% of patients, whereas, estimates for COVID-19 related anosmia range from 30-85% of sufferers. Many patients report smell distortion (parosmia) and taste distortion (dysgeusia) as the primary presentation or during the recovery phase of anosmia. Loss of sense of smell is now recognised as a symptom of COVID-19 by the World Health Organisation.


Loss of one of our principle senses can bring anxiety, but sufferers should be encouraged by the fact that nearly 50% of patients show recovery within four weeks. In other patients recovery can be slower and take 6-18months, however, it is not yet known how many patients will have a permanent deficit.


There is some evidence that in the early phase of loss of smell, related to COVID-19, a course of oral steroids may help with recovery. These need to be prescribed by a doctor after a formal examination, and taking into account the individual’s risks and benefits of such a treatment. There is some weak evidence to support the use of omega 3 supplements in smell loss and these can be obtained without prescription. 


Smell training has been shown to help recovery and is recommended for anyone with symptoms of anosmia or parosmia that last for more than two weeks. Smell retraining kits are available on the internet. Alternatively you can make use of pleasant odours that you find round the house. The aim is to repeatedly stimulate the nerves of smell.


Reports of ear problems related to COVID-19 include hearing loss, tinnitus (noise perceived without an external source) and balance disturbance. There are only a small number of such reports in the literature and the incidence is probably no higher than from other viral illnesses. 


COVID-19 infection is associated with inflammation of the nose and throat. As a result it is not unusual for suffers to report nasal symptoms such as blocked and runny nose and sneezing especially with the Omicron variant. The majority of patients also report a sore throat and associated swallowing and voice problems. Most of these symptoms subside with recovery from the illness. 


The small subset of COVID-19 patients who have been treated on, and survived ventilation on the Intensive Care Unit (ICU), have a high risk of damage to their voice, swallowing or airway, as well as damage to the lungs and other organs. Recovery from these insults may take much longer to resolve or require assessment and management by appropriate specialists. These survivors from the ICU almost all report voice problems and examination of the larynx will often reveal damage to the vocal cords, and sometimes vocal cord weakness. 10-15% of these patients will have narrowing of the airways at or below the level of the vocal cords (airway stenosis), causing breathing difficulties, and often swallowing problems as well. These symptoms need to be assessed and managed in a specialist ENT clinic