Original Article

American Journal of Rhinology & Allergy

2021, Vol. 35(3) 323–333
A Systematic Review of the ! The Author(s) 2020
Article reuse guidelines:
Neuropathologic Findings of Post-Viral sagepub.com/journals-permissions
DOI: 10.1177/1945892420957853
Olfactory Dysfunction: Implications and journals.sagepub.com/home/ajr

Novel Insight for the COVID-19 Pandemic

Jason C. Lee, MD, PhD1 , Rohit Nallani, MD1 ,

Lauren Cass, MD, MPH1, Vidur Bhalla, MD2,
Alexander G. Chiu, MD1, and Jennifer A. Villwock, MD1

Abstract
Background: Post-viral olfactory dysfunction is a common cause of both short- and long-term smell alteration. The
coronavirus pandemic further highlights the importance of post-viral olfactory dysfunction. Currently, a comprehensive
review of the neural mechanism underpinning post-viral olfactory dysfunction is lacking.
Objectives: To synthesize the existing primary literature related to olfactory dysfunction secondary to viral infection, detail
the underlying pathophysiological mechanisms, highlight relevance for the current COVID-19 pandemic, and identify high
impact areas of future research.
Methods: PubMed and Embase were searched to identify studies reporting primary scientific data on post-viral olfactory
dysfunction. Results were supplemented by manual searches. Studies were categorized into animal and human studies for
final analysis and summary.
Results: A total of 38 animal studies and 7 human studies met inclusion criteria and were analyzed. There was significant
variability in study design, experimental model, and outcome measured. Viral effects on the olfactory system varies signif-
icantly based on viral substrain but generally include damage or alteration in components of the olfactory epithelium and/or
the olfactory bulb.
Conclusions: The mechanism of post-viral olfactory dysfunction is highly complex, virus-dependent, and involves a com-
bination of insults at multiple levels of the olfactory pathway. This will have important implications for future diagnostic and
therapeutic developments for patients infected with COVID-19.

Keywords
anosmia, hyposmia, smell dysfunction, olfactory dysfunction, post-viral olfactory dysfunction, coronavirus, SARS, influenza,
respiratory syncytial virus, herpes simplex virus, neuropathology

Introduction
The pandemic of COVID-19, caused by a novel strain of
coronavirus (SARS-CoV-2), is rapidly spreading global-
ly. In the acute phase, symptoms commonly reported
include fatigue, cough, dyspnea, myalgia, joint pain,
anosmia, dysgeusia, and lack of appetite.1 Mounting evi-
dence suggests that isolated chemosensory dysfunction –
namely hyposmia, anosmia, and dysgeusia – is frequent.2
Recent reports indicate the incidence of anosmia in
COVID-19 positive patients is as high as 80–98%, with
1
Department of Otolaryngology—Head and Neck Surgery, University of
Kansas School of Medicine, Kansas City, Kansas
2
Saint Luke’s Hospital of Kansas City, Kansas City, Missouri
Corresponding Author:
Jason C. Lee, Department of Otolaryngology—Head and Neck Surgery,
University of Kansas School of Medicine, Kansas City, KS 66160, USA.
Email: jlee22@kumc.edu
324
Figure 1. A simplified illustration of the olfactory pathway, from initial odorant binding to signal transduction to higher olfactory cortical
centers.
olfactory dysfunction (OD) being the primary symptom
in nearly 12% of patients.3,4
Anosmia related to viral upper respiratory tract infec-
tion (URI) is not unique to COVID-19. Post-viral olfac-
tory dysfunction (PVOD) has long been recognized as a
major cause of clinically significant olfactory loss,
accounting for up to 40% of the overall incidence in
OD.5,6 Nevertheless, the precise neuropathological
mechanism underpinning PVOD in general is poorly
understood.
The olfactory system is complex, and its organization
consists of distinct structural and functional cellular
components (Figure 1). Briefly, odorants must reach
the olfactory epithelium (OE) and bind to odorant bind-
ing proteins (OBPs). Activation of olfactory receptor
neurons (ORNs) then transmits the resultant signal to
the olfactory bulb (OB). The summation of this signal is
subsequently transduced to higher olfactory cortices and
central sensory areas in the brain, where olfactory proc-
essing becomes increasingly more complex.
Additionally, there are multiple supporting and regener-
ative cells critical to olfactory function that continually
replenish and maintain this system. A viral insult to any
of these interconnected components may potentially
result in OD.
Here, we present a systematic review that summarizes
and synthesizes the current scientific literature on PVOD
from both animal and human studies, with an emphasis
on pathophysiologic mechanisms. Based on the available
data, we propose a novel “Two-Hit Hypothesis” on the
development of PVOD and highlight implications of this
American Journal of Rhinology & Allergy 35(3)
hypothesis for the development and deployment of novel
therapeutics, especially those that may have immediate
relevance during the current COVID-19 pandemic.
Methods
Literature Search
The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines were followed
for this study. We conducted a broad literature search in
PubMed and Embase from inception through January
31st, 2020 for studies reporting primary scientific data
investigating the mechanism of PVOD. The comprehen-
sive search terms used, including Mesh Terms, was the
following: “olfaction disorders”[MeSH Terms] OR
“olfactory dysfunction” OR “olfactory disorder” OR
“anosmia” OR “hyposmia” OR “smell disorder”
OR “olfactory loss” OR “hyposmia” OR “smell”
AND “respiratory tract infections”[MeSH Terms]
OR “Virus” OR “viral” OR “postviral” OR “post-
viral” OR “post-infectious” OR “postinfectious” OR
“URI” OR “URTI” OR “severe acute respiratory syn-
drome” OR “SARS” OR “covid” OR “coronavirus” OR
“influenza” OR “rhinovirus” OR “respiratory syncytial
virus” OR “human metapneumovirus” OR “herpes sim-
plex virus” OR “parainfluenza virus” OR
“cytomegalovirus” OR “Epstein-barr virus” OR
“adenovirus”. Additional searches were conducted for
each aforementioned URI virus type with AND
“olfactory” OR “olfaction” OR “smell”.
Lee et al.
Figure 2. Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flowchart based on our predefined inclusion
and exclusion criteria.
Two authors independently completed the literature
search and reviewed titles and abstracts, eliminating inel-
igible articles. Disagreements in article selection were
discussed in depth, and a third independent reviewer
was involved if a tie-breaking vote was needed.
Figure 2 displays initial studies identified and excluded
studies at different screening points.
Study Selection
Only primary, retrievable scientific literature available in
the English language were included. Only literature
examining viruses that are known to cause acute URI
in humans or are analogous in the experimental species
were included. Many viruses, such as vesicular stomatitis
virus, rabies virus, and poliovirus, are also neurotropic
and may target the olfactory system.7 However, studies
of these viruses were beyond the scope of this review
focusing on viral URI-induced olfactory loss and thus
were excluded.
Overall exclusion criteria for animal studies was as
follows. Studies that examined only viral titers as param-
eters were excluded. In animal studies, experimental
models utilizing viral injection directly into the olfactory
bulb (OB) were excluded as such models contrast with
the natural mode of URI transmission and induce cyto-
toxicity and inflammation beyond what would be
325
expected. Furthermore, studies that did not examine
either the olfactory epithelium (OE) or OB, or their com-
ponent parts, were excluded as pathophysiologic mech-
anisms could not be determined.
Human studies were limited to those assessing PVOD.
Studies that investigate viral detection or serology with-
out further investigation of any mechanistic component
(i.e. anatomical or physiological changes within the
olfactory system) were excluded as well. Studies of sino-
nasal inflammatory disorders or OD secondary to head
trauma were excluded. Additionally, studies examining
prognosis and treatment of PVOD were also excluded
from the formal systematic review. For both animal and
human studies, references within the selected articles
were also reviewed.
Data Extraction
A wide variety of methods were utilized in selected stud-
ies. For animal studies, data extracted included animal
model, type of virus examined, structural olfactory unit
examined, morphological changes, functional cellular
unit examined, involvement of inflammation, activation
of microglia, any role of apoptosis or programmed cell
death, and any olfactory testing employed in the study.
For human studies, data extraction assessed study type,
sample sizes, imaging modality, anatomical site or brain
326
region studied, brief summary of results, olfactory test-
ing used, and any limitations of the study relevant to
understanding the pathophysiology of PVOD.
Results
The systematic search resulted in a total of 45 primary
scientific articles specific to the investigation of PVOD
(Figure 2). A subtotal of 38 animal studies were found
and are summarized. Data from animal studies are listed
and summarized in Table 1. A subtotal of 7 human stud-
ies were identified and are summarized in Table 2.
Animal Studies
There was high variability with respect to methodology
and outcome measured in experimental models of OD
induced by viral infection. Of the 38 animal studies
included in the review, 29 (76.3%) were conducted
using mice or rats, 7 (18.5%) were done using ferrets,
one (2.6%) was done using dogs, and one (2.6%) using
chicken. Of the different type of viruses used, influenza
was the most widely studied, followed by coronavirus,
herpes simplex virus (HSV), parainfluenza virus, cyto-
megalovirus (CMV), and respiratory syncytial virus
(RSV).
In influenza virus, all studies that examined OE dem-
onstrated lesional changes in the OE,19,21–23,29,32,33 with
exception of a non-neurovirulent subtype H3N2.21
Olfactory bulb was examined specifically in 12 studies,
with 9 studies (75%) showing histological evidence of
lesional changes.20,22,23,25–28,31,33 Neural damages in
higher cortical centers were also noted in 9 stud-
ies.19,20,22,23,25–28,33 Damages to various cell types
within the olfactory system were observed, including
ORNs,22,23,27,32,33 supporting cells (SC),19 basal cells
(BC),19 granule cells (GC),22,23,33 and mitral cells
(MC).22–24,33
In coronavirus, none of the studies demonstrated
gross lesioning in the OE.38–40 However, the number or
turnover of ORNs were negatively impacted.37–40 The
OB was specifically examined histologically in 4 studies,
with 3 studies (75%) showing some evidence of lesional
changes.35,38,53 Three studies that investigated higher
cortical centers also noted neuronal changes.35,36,38
In parainfluenza virus, 2 of the 5 studies noted gross
changes in the OE,42,45 while 3 others did not.41,43,44
Notably, no gross changes in the olfactory bulb or
higher cortical centers were demonstrated.42,44,45 The
ORNs were damaged or negatively impacted in all avail-
able studies.41,42,44,45
In HSV, neuronal lesions were identified throughout
the olfactory system, including the OE, OB, as well as
higher cortical centers in all 6 included studies,13–18 with
the exception of a neuro-attenuated L1BR1 substrain.18
American Journal of Rhinology & Allergy 35(3)
Human Studies
Human studies of PVOD also varied widely in method-
ology, outcomes, and approach. At the level of the OE,
viral insult caused variable degeneration and death of
the ORNs on histopathology with biopsy.52 Increase in
olfactory cleft (OC) width and volume was noted to be a
potential risk factor for PVOD.46 Three studies demon-
strated significant reduction in OB volume in patients
with PVOD,48,50,51 and that greater duration of PVOD
led to greater reduction in OB volume.48,51 Finally, one
study showed that metabolic activities of higher olfac-
tory centers were reduced following PVOD.49
Discussion
Our systematic review revealed that PVOD is attributable
to disruption at many levels of the olfactory pathway by
the cumulative effects of direct cell damage, inflamma-
tion, and cytokine effects. Most animal studies demon-
strated that the numbers of ORNs are reduced in the OE
and OB, which is likely the major cause of olfactory dis-
ruption following most types of viral infections.
Importantly, our review also highlighted the fact that tar-
gets of virus-mediated cellular disruption in the olfactory
system are viral substrain dependent. This has significant
implications and emphasizes the need to study and direct
patient care in a highly virus-specific manner following
PVOD. Our review also found that human studies con-
sistently suggest that both peripheral and central olfac-
tory structures are negatively impacted in relation to
structural integrity, volume, or metabolism. Many impor-
tant studies in humans have shown putative viral agents
in PVOD. For instance, high levels of parainfluenza virus
3 have been detected in patients with PVOD.54 However,
direct demonstration of specific pathophysiological
changes within the olfactory system following viral sub-
type insults in humans has yet to be accomplished.
Viral Specific Effects on the Olfactory System
Two important aspects of the influenza virus emerged
during our review: (1) histologic changes in the OE
and OB are relatively small, consisting of small foci of
degeneration, and (2) hemagglutinin plays a critical role
in influenza neurotropism, or the ability to infect certain
neural cells. The OE and OB are consistently affected by
the influenza virus but exhibit only small foci of histo-
logic abnormalities in all included studies. Involvement
of higher cortical centers within the olfactory pathway
appears to be subtype specific.28 Direct comparison of
H5N1 and H1N1 showed that infection with H5N1
resulted in lesion and inflammation of higher cortical
centers with poor animal survival, while H1N1 infection
was strictly limited to the OE.28 Adding to the complex-
ity, different substrains of H5N1 influenza also exhibited
Lee et al. 327

Table 1. Animal Studies.

Virus Model Examined Region Lesioned Site Affected Cell Microglia Inflammation Cytokine Apoptosis
8 8
RSV Mice OE, OB OE
ORNþ/BSþ N/A N/A N/A N/A
Mice9 OE, OB OEþ, OB
ORNþ N/A Yes IL-17C N/A
CMV Mice10 OE OEþ ORNþ/SCþ N/A N/A N/A N/A
Mice11 OE N/A ORNþ/SCþ N/A N/A N/A N/A
Mice12 OE N/A ORNþ/SCþ N/A N/A N/A N/A
HSV Mice13 OB, HCR OBþ, HCRþ MCþ/GCþ Yes Yes TNF-a IFN-c Unchanged
Neuronsþ
Mice14 OB, HCR N/A MCþ N/A Yes N/A N/A
Rats15 OB, HCR OBþ, HCRþ N/A N/A Yes N/A N/A
Mice16 OB, HCR OBþ, HCRþ MCþ/GCþ Activated Yes N/A N/A
Mice17 OE, OB, HCR OBþ, HCRþ MCþ/GCþ N/A Yes N/A N/A
Mice18¥ OE, OB 186 - OEþ/OBþ/HCRþ ORNþ N/A N/A N/A 186 -
L1BR1 - unchangedL1BR1 -
OEþ/OB
/HCR
increased
Influenza Chicken19 OE, OB, HCR OEþ/OB
/HCRþ ORN
/SCþ/BCþ; Activated N/A N/A N/A
Neuronsþ,
glial cellsþ
Ferrets20 OB, HCR OBþ, HCRþ Neuronsþ Activated Yes N/A N/A
Ferrets21¥ OE H5N1 - OEþ N/A N/A Yes N/A N/A
H3N2 - OE

H1N1 - OEþ
Ferrets22 OE, OB, HCR OEþ/OBþ/HCRþ ORNþ/MCþ/GCþ N/A Yes N/A N/A
Ferrets23¥ OE, OB, HCR H5N1 - OEþ ORNþ/MCþ/GCþ Activated Yes N/A N/A
/OBþ/HCRþ
MBCS -
OEþ/OB
/HCR

Mice24 OB, HCR N/A MCþ/Neuronþ Activated N/A N/A Increased
Ferrets25¥ OB, HCR VN1203 - OBþ/HCRþ N/A N/A Yes N/A N/A
HK483 - OBþ/HCRþ
Ferrets26¥ OB, HCR HK486 - OBþ/HCRþ N/A N/A Yes N/A N/A
HK483 - OBþ/HCRþ
Mice27 OB, HCR OBþ/HCRþ ORNþ/Neuronsþ N/A N/A N/A N/A
Mice28¥ OB, HCR HK483 - OBþ/HCRþ HK483 -Neuronsþ N/A Yes N/A N/A
PR8 - Epithelial cells /Glial cells
PR8 -
Epithelial cells
Ferrets29 OE, OB OEþ/OB
N/A N/A Yes TNF-a N/A
IL-6
Mice30 OB N/A Neuron-/Glial cellsþ Activated N/A TNF-a IL1-b N/A
Mice31 OB OBþ N/A N/A N/A TNF-a IL1-b N/A
Mice32 OE, OB OEþ, OB
ORNþ Activated No N/A Increased
Mice Tg33 OE, OB, HCR OEþ, OBþ, HCRþ ORNþ/SC
/MCþ Activated Yes N/A N/A
/TCþ/GCþ
Coronavirus Mice34 OB N/A N/A Activated N/A IFN N/A
Mice35 OB OBþ/HCRþ MCþ N/A Yes N/A N/A
Mice Tg36 OB, HCR OB
/HCRþ N/A N/A No N/A N/A
Mice37 OB OBþ ORNþ N/A N/A N/A Increased
Mice38 OE, OB, HCR OE
/OBþ/HCRþ ORNþ/MCþ/GCþ/TCþ N/A Yes N/A N/A
Mice39 OE, OB OE
/OBþ ORNþ/MCþ/GCþ/TCþ N/A N/A N/A N/A
Mice40 OE OE
ORNþ N/A N/A N/A N/A
Parainfluenza Mice41 OE, OB OE
ORNþ/BCþ N/A No N/A Decreased
Mice42 OE, OB OEþ/OB
ORNþ/MC
/TC
N/A N/A N/A N/A
Dogs43 OE OE
N/A N/A No N/A N/A
Mice44 OE, OB, HCR OE
/OB
/HCR
ORNþ/SCþ N/A No N/A N/A
Mice45 OE, OB OEþ/OB
ORNþ/SC
/MC
/TC
N/A N/A N/A N/A

Abbreviations: OE, olfactory epithelium; OB, olfactory bulb; HCR, higher cortical centers; ORN, olfactory receptor neuron; SC, supporting cell; BS, basal
cell; MC, mitrial cell; GC, granule cell; TC, tufted cell; Neurons, neural cells not otherwise specified in the article; þ, denotes lesion or cell infected cells;

denotes no lesion or uninfected cells; Tg, transgenic; N/A, not applicable; ¥, studies that used multiple viral strains.

variable neurovirulence. H5N1 VN1203 substrain exhib-
ited a rapid and widespread CNS transmission that
resulted in more extensive neuronal death and inflamma-
tory response, while infection with its counterpart H5N1
HK483 showed a much slower spread within the CNS
with less notable cellular damage.25 Interestingly,
mutation of a multi-basic cleavage site within the hem-
agglutinin impaired the ability of H5N1 to spread within
the olfactory system and the CNS.23 These together sug-
gest that hemagglutinin has a critical role in neurotrop-
ism. In general, microglial activation, inflammatory
response, and cytokine production appear to be elevated
328
Table 2. Human Studies.

Anatomical Site
Sample Imaging or Brain Region
Authors Year Study Type Size Modality Studied Results Olfactory Testing
46
Altundag et al. 2020 Retrospective Case– n ¼ 71 CT Scan OC Significantly greater OC width and volume Sniffin Sticks
Control in OD group compared to controls.
No difference in olfactory fossa depth
Wolf et al.47 2018 Cross-sectional n ¼ 21 N/A OC 1117 different proteins detected with 10 Sniffin Sticks
being most abundant
No differences between OD patients and
healthy controls in olfactory cleft
proteome
Yao et al.48 2018 Cross-sectional n ¼ 38 Voxel-based OB/OFC Significant decrease in right OFC and total T&T Olfactometry &
MRI OB volume in PVOD. Significant negative Sniffin Sticks
correlation between right OFC and OB
volume and duration of olfactory loss
Kim et al.49 2012 Cross-sectional n ¼ 18 FDG-PET OFC Significant hypometabolism in olfactory Olfactory Butanol
sensory and integration brain regions in Threshold Test &
PVOD patients compared to controls Olfactory
Regional metabolism in cortical regions Identification Test
inversely correlated with olfactory tests
Rombaux et al.50 2009 Review þ Cross-sectional n ¼ 122 MRI OB Reduced OB volume in all patients Sniffin Sticks
Cohort OB volume significantly correlated with Retronasal Testing
TDI and retronasal scores.
Rombaux et al.51 2006 Retrospective Cohort n ¼ 26 MRI OB/Olfactory OB volume smaller in anosmic patients Sniffin Sticks
Sulcus compared to hyposmia. No difference in
olfactory sulcus depth in hyposmia vs.
anosmia patients. Significant negative
correlation between OB volume and
duration of olfactory loss
Yamagishi et al.52 1994 Cross-sectional n ¼ 70 N/A Olfactory Variable damage to and degeneration of T&T Olfactometry &
Epithelium peripheral ORNs identified on mucosal IV Alinamin Injection
samples Test

Abbreviations: PVOD, post-viral olfactory dysfunction; OC, olfactory cleft; OD, olfactory dysfunction; OFC, orbitofrontal cortex; OB, olfactory bulb; T&T, odor-threshold & identification; TDI, Threshold,
Discrimination, Identification; ORN, Olfactory Receptor Neuron; NSE, neuron-specific enolase.
Lee et al.
following neuroinvasion of influenza, which collectively
may contribute to viral clearance and cell death. A nota-
ble exception is influenza A R404BP which induces min-
imal inflammation in the olfactory system but significant
apoptosis of the ORNs.32
Coronaviruses similarly displayed strain specific dif-
ferences in neurovirulence. For example, SARS-CoV-1
in transgenic mice expressing human angiotensin-
converting enzyme 2 (ACE2) in epithelial cell lines dem-
onstrated a high degree of neurovirulence towards
higher cortical regions in the olfactory pathway while
sparing much of the morphology of the OB.36 This con-
trasts with the highly neurovirulent strain of MHV-JHM
and MHV-OBLV—both of which are murine coronavi-
rus counterpart—that significantly disrupt the OB and
higher cortical regions with resultant cell death.35,38
Consistent with other studies, disruption of the architec-
ture within the OB was shown to lead to olfactory
impairment after coronavirus infection in vivo.53
Parainfluenza virus had unique tropism—or the abil-
ity of specific virus to target and infect different cells—
within the olfactory system. All studies to date have
shown that, regardless of subtypes, the neurovirulence
of parainfluenza is restricted to primary ORNs and their
surrounding cells in the OE and OB. Infectivity or lesion
of higher cortical lesions has yet to be demonstrated. The
component that restricts parainfluenza tropism within
the olfactory system remains elusive. It is also unclear
if viral components are transported to higher cortical
regions. Two studies objectively evaluated olfaction
after parainfluenza infection and found deficits.41,43
Following infection of Sendai virus (murine parain-
fluenza), mice showed increased latency to find buried
food pallet even in a food deprived state.41 ORNs also
showed diminished calcium signaling to odorant bind-
ing, suggesting impairment in depolarization and signal
transduction on a cellular level.41 Interestingly, parain-
fluenza virus also produces minimal morphologic
changes or inflammatory response when compared to
other viruses, such as influenza or herpes. This may
account for the prolonged presence of viral protein
and viral RNA within the OB.41,45
Studies demonstrated high neurovirulence of HSV for
the CNS. In vivo studies of HSV-1 and HSV-2 consis-
tently showed high degree of neuroinvasion within the
olfactory pathway as well as in higher cortical centers,
resulting in encephalitis and cell death.13,15,16 ORNs,
mitral cells, and granule cells have all been shown to
undergo cell death following HSV infection.
Implications for COVID-19
Fortunately, investigation into the pathophysiological
mechanism of SARS-CoV-2-induced OD is already
underway.55–57 As indicated earlier, viral tropism
329
within the olfactory system is important in the patho-
genesis of OD. According to single cell sequencing anal-
ysis of RNA profiles from existing databases, only a
subset of sustentacular cells, horizontal basal cells, and
Bowman’s gland cells co-express the genes encoding the
ACE2 receptor and TMPRSS2 protease, both of which
are essential for SARS-CoV-2 viral entry.55–57
Therefore, SARS-CoV-2 may disrupt homeostasis and
regeneration of ORNs in the OE, leading to clinically
observable OD. Alternatively, SARS-CoV-2 may pro-
duce extensive neuronal damage in higher cortical cen-
ters of the olfactory pathway, like its SARS-CoV-1
counterpart.36
Filling the Knowledge Gap in PVOD
Available animal and human studies demonstrate that
measurable and observable damages to the olfactory
system following viral infection are apparent: reduction
in progenitor cells, cell death of ORNs, damage to sup-
porting cells, deciliation of neuroepithelium, and lesions
of higher olfactory cortical centers. However, most stud-
ies also showed some degree of regeneration and repair
following viral clearance. Notably, the olfactory system
has a remarkable ability to regenerate. For instance,
bilaterally bulbectomized rats have been shown to
retain the ability to smell via newly generated connec-
tions to the forebrain.58 Furthermore, induced chemical
lesion of the OE—by as much as 95%—and the OB in
rats showed little to no impairment of olfactory function
and failed to produce anosmia.53,59,60 Additionally,
anosmia is reported in 65% of patients who survive
herpes encephalitis, which inflicts devastating neuronal
damage in multiple brain areas, including the olfactory
pathway.61 This highlights the remarkable permissibility
of the olfactory pathway to neuronal damage and its
regenerative ability. Finally, normal and subnormal
olfaction in humans has been reported in the absence
of the OB.62,63 Therefore, the mechanism of how viral
insults account for the lack of olfactory perception on a
long-term or even permanent basis remains elusive.
For a previously normosmic individual to become
truly anosmic, the damage would theoretically need to
be quite extensive and long lasting, which does not
appear to be the case based on the available animal lit-
erature. Yet, PVOD is consistently a major cause of
long-term OD despite differences in the mechanism of
initial insults. Furthermore, human studies that broadly
studied PVOD consistently show volumetric changes in
olfactory related brain regions.50,51 Barring complete
disruption of regenerative ability and destruction of
the olfactory pathway, this evidence taken together sug-
gests a convergent mechanism for clinical manifestation
of long-term OD beyond the apparent anatomical
changes. We therefore postulate that the fundamental
330
Figure 3. Natural progression of PVOD. Each phase consists of
distinctive sets of viral insults. Persistence of OD into a long-term,
or permanent, basis requires impairment of synaptic plasticity in
addition to cellular damage.
process of olfactory coding is altered following the initial
viral insult. This is further supported by fMRI studies in
humans that have demonstrated aberrant functional
olfactory connectivity in PVOD patients compared to
that of control subjects.64 The question naturally
arises, then, as to how viral infection alters olfactory
coding. Here, we suggest that synaptic plasticity, or the
ability to strengthen or weaken communications
between neurons, is a potential target of viral disruption.
Two-Hit Hypothesis
We propose a “Two-Hit Hypothesis” which posits that
secondary impairment of synaptic plasticity in combina-
tion with initial viral insults is necessary for the clinical
development of persistent PVOD (Figure 3). Consistent
with our hypothesis, influenza A has been shown to
induce long lasting changes in synaptic plasticity in the
hippocampus even after viral clearance, presumably
through the action of cytokines, activated microglia, as
well as altered gene expression.65 Similarly, RSV infec-
tion has been shown to impair synaptic plasticity even
after viral clearance, leading to cognitive impairment.66
The ability of neurotropic viruses to hijack synaptic plas-
ticity has also been demonstrated in Borna disease virus,
which disrupts synaptic vesicle recycling.67 It is conceiv-
able that most, if not all, neurotropic viruses have the
ability to alter synaptic plasticity through unknown
mechanisms.
The hallmark of synaptic plasticity is activity-induced
or learning-induced modification,68 which may, in part,
explain why olfactory training is an effective therapy for
PVOD.69,70 Interestingly, older individuals appear to be
more susceptible to develop PVOD.71 Age-dependent
changes in synaptic plasticity are also well observed
and may, in part, account for age-related susceptibility
to PVOD.72 Similarly, synaptic plasticity is closely reg-
ulated by hormonal changes,73 which may partly explain
American Journal of Rhinology & Allergy 35(3)
the preponderance of female patients affected by PVOD,
especially in the elderly.50 However, it should be noted
that this novel theory is speculative and further investi-
gation in warranted.
Novel Therapeutic Strategy
Based on the natural clinical history of PVOD (Figure
3), treatment strategy can be categorized into those that
specifically target the acute phase, and those that target
the chronic phase. Arguably, the best form of interven-
tion is to prevent the initial viral entry, which may be
relevant for COVID-19. SARS-CoV utilizes host ACE2
receptors for cell entry.57 Prevention of SARS-CoV-2
viral entry has been demonstrated using specific protease
inhibitors in vivo.56 Given the current COVID-19 pan-
demic, a push towards viral-entry specific research and
intervention may be important in the absence of effective
vaccination. For substrains of viruses that induce inflam-
mation, topical or systemic corticosteroids may prove
useful in the acute phase of PVOD. Viral mediated
induction of cytokines may persist for many months.74
Elevated cytokines such as IFN-c and TNF-a have been
well demonstrated to cause OD in vivo.75,76 Therefore,
selectively targeting these cytokines may provide yet
another avenue for therapy. Cytokine targeted treatment
may however be complicated by their critical function in
viral clearance in the early phase of the infection.74 Stem
cell or gene therapy targeting basal proliferating cells in
the OE or neuroblast precursors in the subventricular
zone to specifically improve regenerative potential of
the OE or OB, respectively, may also prove to be
useful in the future.
However, patients presenting to otolaryngologists are
more likely to fall in the chronic phase category; anos-
mia alone may not lead one to seek treatment immedi-
ately. According to our novel “Two-Hit Hypothesis”,
therapies specifically targeting synaptic plasticity
should be explored. Nevertheless, determining the pre-
cise mechanism by which different viruses detrimentally
affect synaptic plasticity within the olfactory pathway
may open a new frontier in therapeutic options.
Conclusion
The underlying pathophysiological mechanism of PVOD
is complex and virus dependent. A combination of direct
damage to ORNs, impairment in olfactory neuron
regeneration, inflammatory response, cytokine action,
as well as higher cortical damage may account for the
clinical manifestation of PVOD. Permanent or long-term
OD beyond the period of viral clearance and cellular
regeneration likely involves additional alteration in the
olfactory system.
Lee et al.
Acknowledgment
We would like thank Teresa Lee for kindly providing the illus-
trations included in this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Jason C. Lee https://orcid.org/0000-0001-9117-4492
Rohit Nallani https://orcid.org/0000-0001-6313-205X
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