Smell disturbance among Saudi COVID-19 Patients

Ahmad S Alroqi1, Leen Othaim Alothaim2, Shoag Jaza Albugami2, Noura Othaim Alothaim3, Almaha A
Alqabbani1, Saud R Alromaih1, Sama Obaid Alharbi2, Fatima Saad Alangari2, Danyah Khalid Saja2, Sarah Saeed
AlMutawa2
1 Department of Otolaryngology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Medical intern, College of Medicine, King Saud University, Riyadh, Saudi Arabia
3 Dental intern, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission 22-Nov-2020

Date of Acceptance 13-Jun-2021
Date of Web Publication 06-Oct-2021

Abstract

Objectives: Recently, COVID-19 was declared a pandemic, and since then, many studies have examined
its symptomatology. In this study, we aimed to focus on Saudi patients with COVID-19 who also
experienced smell dysfunction. We hypothesized that there would be a high percentage of COVID-19
patients with smell dysfunction in the Saudi population. Methodology: A quantitative, observational, cross-
sectional study was carried out in Riyadh, Saudi Arabia in August 2020 and was designed to assess
anosmia and hyposmia in Saudi patients with a positive COVID-19 test. Only Saudi adults with confirmed
COVID-19 were enrolled in the study. We distributed an electronic, self-administered questionnaire through
social media platforms, and personal contact to query the patients who had a positive COVID-19
test. Results: The study included 1005 patients, of whom 63.5% were female. More than three quarters
(76.7%) were between the ages of 18 and 38 years. Most of them (74.1%) were healthy, while some of
them (25%) reported associated comorbidities. Overall, approximately three-quarters (72%) of the
participants developed smell dysfunction during the infection period, with (17.3%) experiencing a partial
loss of smell (hyposmia), and (54%) experiencing a complete loss of smell (anosmia). Conclusions: Our
study revealed that approximately three-quarters (72%) of the participants with COVID-19 developed smell
dysfunction during the infection period, which supports our hypothesis.

Keywords: Anosmia, coronavirus, COVID-19, dysosmia, hyposmia, olfaction, Saudi, smell

dysfunction

How to cite this article:

Alroqi AS, Alothaim LO, Albugami SJ, Alothaim NO, Alqabbani AA, Alromaih SR, Alharbi SO, Alangari FS, Saja DK,
AlMutawa SS. Smell disturbance among Saudi COVID-19 Patients. J Nat Sci Med 2021;4:348-51

How to cite this URL:

Alroqi AS, Alothaim LO, Albugami SJ, Alothaim NO, Alqabbani AA, Alromaih SR, Alharbi SO, Alangari FS, Saja DK,
AlMutawa SS. Smell disturbance among Saudi COVID-19 Patients. J Nat Sci Med [serial online] 2021 [cited 2022
Feb 16];4:348-51. Available from: https://www.jnsmonline.org/text.asp?2021/4/4/348/327593
 Introduction

The outbreak in Saudi Arabia began with one case of a Saudi national who had recently returned from
Iran. The COVID-19 diagnosis was confirmed on March 2, 2020. According to the WHO, the most
common symptoms are fever, dry cough, and dyspnea, and the less common symptoms are sore throat,
loss of taste or smell, diarrhea, and headache. However, several studies have revealed a significant
association between anosmia and COVID-19 in the United States, Europe, South Korea, and Turkey.

One study of 417 patients with laboratory-confirmed COVID-19 across 12 European hospitals found that
change in smell was a common clinical finding in patients who were positive for COVID-19.[1] A study from
Germany has also reported that anosmia was found in more than two-thirds of patients, while Italian and
Swiss doctors have reported similar findings, with many patients displaying ageusia. In addition, data
from South Korea suggest that anosmia is present in 30% of patients who are positive for COVID-19.[2]

Another study in Iran found that 98% of patients experienced some smell dysfunction.[3] Furthermore, a
study in the USA reported that 68% of the patients who tested positive for COVID-19 experienced a loss
of smell compared to 16% who were negative for COVID-19 and concluded that “chemosensory
dysfunction was strongly associated with COVID-19 infection and should be considered when screening
symptoms.”[4]

In contrast to these countries, China has reported that olfactory dysfunction (OD) is an uncommon
symptom. Many other previous studies reported that anosmia manifests in the early stages of the disease
or in less severe COVID-19 disease.[5],[6]In a Korean study, the prevalence was significantly more common
among females, and younger individuals, although two studies found that OD was not related to sex or
age. Another study found that anosmia was more common in COVID-19 disease than in other respiratory
infections. Therefore, anosmia can be a good indicator for COVID-19, and smell testing can be used as a
screening tool.

In this study, we aim to explore the smell dysfunction in Saudi patients confirmed to have COVID-19.

Methodology

A quantitative, observational, and cross-sectional study was designed to assess anosmia and hyposmia
in Saudi patients with confirmed COVID-19 disease. The study was carried out in Riyadh, Saudi Arabia,
in August 2020. The Arabic survey link was distributed after obtaining IRB approval. The study was
approved by the Institutional Review Board Committee in King Saud University College of Medicine Board
Research on research project on 20 July 2020, with Ref. No. E-20-5095. The questionnaire contained 12
questions that assessed the presence of anosmia and hyposmia in patients with confirmed COVID-19 as
well as the onset, duration of their symptoms, the severity of their case, and whether they had any
comorbidities. It also included sociodemographic factors such as age and gender. We distributed an
electronic self-administered questionnaire through social media platforms and personal contact persona
to query patients who had a positive COVID-19 test. A total of 1005 responses were gathered over a 14-
day period from August 6, 2020, to August 20, 2020. After collecting the data using Google Docs, the
data were exported to Microsoft Excel, where coding was performed. We analyzed the data using IBM
SPSS Statistics, version 24 (IBM Corp., Armonk, N.Y., USA).

Only Saudi adults who were confirmed to have COVID-19 were enrolled in the study. Descriptive statistics
(frequencies and percentages) were used to describe the variables. Statistical analyses were carried out
using the Chi-square test and were based on the type of study and outcome variables. A P < 0.05 and a
(95%) confidence interval were used to report the statistical significance and precision of the results.
Regarding ethical considerations, informed consent was obtained, which indicated the purpose of the
study, and the right of the participant to withdraw at any time without any obligation toward the study
team. The authors have no conflicts of interest to declare.

Results

Of the 1005 patients enrolled in the study, 63.5% were female. More than three quarters (76.7%) were
between the ages of 18 and 38. Most of them (74.1%) were healthy, while some of them (25.9%) reported
associated comorbidities [Figure 1]. Overall, approximately, three-quarters (72%) of the participants
developed smell dysfunction during the diagnosis of COVID-19, with 17.3% (24% of those reported smell
dysfunction) experiencing hyposmia, that is, a partial loss of smell, and 54% (76% of those reported smell
dysfunction) experiencing anosmia, that is, a complete loss of smell [Figure 2].

Figure 1: Relation between comorbidities and smell dysfunction

among studied cases

Click here to view

Figure 2: Sense of smell in COVID-19 patients

Click here to view

When comparing female and male patients, female patients showed a significantly higher incidence of
smell dysfunction after being diagnosed with COVID-19 (P < 0.001). Within their respective groups, age
was not significantly correlated with smell dysfunction (P = 0.239) [Table 1]. The presence of comorbidities
was not putting the patients at higher risk of smell dysfunction with the exception of obesity that was
found a protective factor (P = 0.043) [Figure 1]. However, further logistic regression was applied to detect
confounding factors as predictors of loss of smell, in which loss of smell was entered as a dependent
variable, and comorbidities were entered as covariables. The result showed nonsignificant relation
between comorbidities and loss of smell.

Table 1: Demographics and smell dysfunction

Click here to view

In comparing hyposmia and anosmia, patients with anosmia were more likely to notice loss of smell
before the diagnosis of COVID-19 was confirmed (P = 0.001), and patients with hyposmia were more
likely to experience symptoms within a shorter duration of 1 week or less (P = 0.001) [Table 2].

Table 2: Type of smell dysfunction and smell progression

Click here to view

Discussion

In December of 2019, many patients in China presented with fever and respiratory symptoms that were
thought to be a result of pneumonia of unknown origin but were later determined to be symptoms of
infection by a new strain of the coronavirus 2 (SARS-CoV2), and the disease was eventually named
coronavirus disease (COVID-19). This highly contagious disease has been rapidly spreading.

Recently, COVID-19 was declared a pandemic, and many studies have investigated the symptomatology
ever since. In this study, we aimed to focus on Saudi patients with COVID-19 who also experienced smell
dysfunction. We hypothesized that there would be a high percentage of smell dysfunction in the Saudi
population, similar to that previously reported in other populations. Our study indicates that a high
prevalence of smell impairment is associated with COVID-19 infection.

The majority of respondents in this study reported smell impairment, with 54.7% reporting anosmia and
17.3% reporting hyposmia. This is consistent with previous studies.[7],[8],[9],[10] The results showed that half
of the patients with smell impairment noticed impairment before confirmation of a COVID-19 diagnosis. In
addition, 96.1% of the patients who had smell dysfunction due to COVID-19 were not diagnosed with
smell impairment caused by any other disease before the COVID-19 era. This support that smell
impairment manifests in the early stage of COVID-19 as reported in the previous studies.[8],[9],[11]Therefore,
smell dysfunction can be used as a screening tool for early identification of COVID-19 to prevent and
reduce the spread of the disease.[12],[13]

Smell impairments improved in most of our respondents (78%), with half of the cases of smell dysfunction
lasting a week or less, and only 1% of the participants were hospitalized. Literature has reported that
smell impairment occurs in mild COVID-19 cases,[14] but due to the limited number (seven participants in
our data) being hospitalized with smell dysfunction, it is hard to confirm the same finding. Furthermore,
most respondents reporting smell dysfunction were female, and between 18 and 39 years of age, which
was similar to previous studies.[13],[14] A very small proportion of respondents were 65 years or older, as the
survey was primarily distributed through social media, which is not commonly used by this age group.

Regarding comorbidities, most of the patients with smell impairment were healthy, although some of them
reported having comorbidities with the most frequent being obesity followed by hypertension, lower
airway disease, and diabetes mellitus. As smell dysfunction can affect the quality of life, further research
is needed to establish the exact mechanisms of smell dysfunction in COVID-19 patients. The finding of
obesity as a protective factor to have smell dysfunction can be explained by the possibility of having a
confounding variable.

One of the limitations of this study was the distribution of an electronic questionnaire that took place
during the quarantine associated with the COVID-19 pandemic. This affected our results because it was
distributed only to people who had access to social media. It would be preferable to use another method
to target all age groups. Another limitation is that patients themselves determined if they had a partial or
complete loss of smell without undergoing examinations or objective smell testing; such examinations
would help achieve a better understanding of the correlation, and pathogenesis of smell dysfunction in
COVID-19 infection.

Conclusion

COVID-19 is still a new disease with many questions that scientists are racing to answer. In this study, we
sought to determine the prevalence of smell dysfunction in confirmed COVID-19 patients as well as the
importance of this dysfunction. Our results revealed that approximately three-quarters (72%) of the
participants with a confirmed COVID-19 diagnosis developed smell dysfunction during the infection
period, which supports our hypothesis. Therefore, our findings can help in the early diagnosis and
detection of COVID-19 in patients with smell dysfunction as the only symptom. Females were more likely
to experience smell dysfunction than male and participants with obesity experienced smell dysfunction
less than participants with other comorbidities.

Acknowledgment

We would like to thank the ENT Department at King Abdul-Aziz University Hospital, and the research
center at King Saud University in Riyadh, Saudi Arabia, for supporting this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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