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A 27-year-old White female presents after 2 weeks of minimally invasive rhinoplasty using piezoelectric surgery with dorsal preservation for postoperative follow-up. She complains about the development of an olfactory disorder (dysosmia).

HPI

The patient reports no history of prior olfactory dysfunction. During her postoperative recovery, she received some visitors. She appears healthy and mentions that during the past week, her sense of smell has been compromised after returning to a regular diet a few days after surgery. She tried various strong perfumes to test whether this condition is only limited to certain odors. However, she has partial to complete loss of olfaction. In her reports, she also mentions that dysosmia caused her to lose her appetite. She lost a little weight as a result of her reluctance to eat. The patient believes this condition is associated with changes after her minimally invasive rhinoplasty surgery using a piezoelectric procedure with dorsal preservation.

PMHX/PDHX/medications/allergies/SH/FH

A minimally invasive rhinoplasty using piezoelectric surgery with dorsal preservation technique was performed on the patient 2 weeks earlier without a history of nasal obstruction and respiratory problems before and immediately after surgery. Her COVID-19 reverse transcription polymerase chain reaction (RT-PCR) test result was negative 48 hours before surgery. Head trauma, nerve pathway disease, or nasal congestion from an upper respiratory infection are not present in her medical history. (Severe head traumas or nerve pathway diseases, such as central nervous system infections or tumors, can often affect neurotransmission, leading to altered sensory perception as anosmia.) COVID-19 vaccines have not been administered to the patient. The following medications were prescribed after rhinoplasty, which are not known to interfere with smell:

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  Dexametazom 0.5-mg tablets q8h (#20)

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  Cefalexin 500-mg tablets q6h (#20)

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  Phenylephrine 0.5% spray q8h for 3 day/(#1)

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  Tetracycline 3% ointment q8h (#20)

There is no history of smoking, cocaine, or other drug or medication use. (Chronic cocaine and intranasal steroids, such as fluticasone furoate and mometasone furoate use, can cause damage to the chemoreceptors of the olfactory bulb.) Other known drugs that can cause olfaction disorder are:

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  Antibiotics: amoxicillin, azithromycin, and ciprofloxacin

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  Blood pressure medications: amlodipine and enalapril

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  Statin drugs (cholesterol-lowering drugs): atorvastatin, lovastatin, and pravastatin

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  Thyroid medication: levothyroxine

No history of allergy is reported.

Examination

General. The patient is a healthy, asymptomatic, well-dressed female. She wore a mask outdoors and took safety precautions to prevent COVID-19 during the 2020 pandemic infection. She experiences partial to severe anosmia. Two weeks later, symptoms of dysgeusia also started to appear.

Maxillofacial. The patient does not have lymphadenopathy. Her facial skin is without any lesions or active dermatologic infections or pathology. Her oral mucous membranes are moist. There are no signs of upper respiratory infection (postnasal drip, mucous discharge, or erythema).

Intraoral. No abnormalities or lesions are noted. Oral hygiene is good.

Nasal. The external nasal bones are stable. The nasal mucosa is nonerythematous with normal moisture and an absence of irregular lesions.

Pulmonary. The patient does not exhibit shortness of breath.

Imaging

The patient had no nasal obstruction before surgery.

Two weeks after minimally invasive rhinoplasty using piezoelectric surgery with dorsal preservation, a chest x-ray examination revealed no lung involvement. (A multifocal and bilateral ground glass opacity is usually present in the lower lobes of the lungs along with consolidations that have a peripheral or basal predominance in patients with COVID-19.)

Labs

Forty-eight hours before rhinoplasty, the patient’s RT-PCR test result for COVID-19 was negative. Two weeks after the patient’s complaint, a repeated RT-PCR test was performed because of the suspicion that the patient might have been infected with COVID-19. (No routine laboratory tests are indicated for rhinoplasty in an otherwise healthy patient. However, for patients with a history of clotting disorders or liver and kidney pathology, complete blood count with differential, prothrombin time [PT], partial thromboplastin time, international normalized ratio [INR], sodium, potassium, blood urea nitrogen and creatinine, alanine aminotransferase [ALT], aspartate aminotransferase [AST], and alkaline phosphatase are recommended for screening.)

Before and After photo series of a 27-year-old patient who had minimally invasive rhinoplasty using piezoelectric surgery with dorsal preservation. A, Frontal view. B, Side view. C, Three quarter view. D, Base view.

(From Keyhan SO: minimally invasive rhinoplasty using piezoelectric surgery using preservation technique, 2020, Isfahan)

Assessment

It is usually 5 to 10 days after the onset of the COVID-19 symptoms that the radiographic findings reach their peak severity. There were no abnormalities on the computed tomography scan of the nose and chest radiography after surgery.

The RT-PCR test was repeated 2 weeks after the postoperative visit because other symptoms of COVID-19, especially dysgeusia, had emerged. Positive results were obtained from the repeated PCR test. The patient’s positive PCR test result indicated the presence of COVID-19 infection. A chest radiograph revealed no abnormalities.

A gradual improvement in sense of olfaction was noticed 2 months after surgery. The patient completely recovered her sense of smell after 6 months.

Treatment

It is possible for most people who test positive for COVID-19 with mild to moderate illnesses to recover at home. Supportive treatment can be provided with over-the-counter medications, such as acetaminophen (Tylenol) or ibuprofen (Motrin, Advil) to alleviate symptoms.

Nasal CT scan series before surgery showing no history of nasal obstruction.

(From Keyhan SO: minimally invasive rhinoplasty using piezoelectric surgery using preservation technique, 2020, Isfahan)

The US Food and Drug Administration (FDA) has approved several treatments for COVID-19 infections that have the potential to develop severe symptoms and result in hospitalization or death. In the case of an effective diagnosis, the health care provider should prescribe the medication immediately. Even mild symptoms should be reported to health care providers as soon as possible to determine whether the patient is eligible for treatment.

Treatment must be received immediately after diagnosis and development of symptoms. People who are more prone to get very sick include unvaccinated individuals; older adults (adults older than 50 years old [the risk proportionally increases with age]); and patients with certain medical conditions such as chronic lung disease, heart disease, and immunocompromised status. Vaccination considerably decreases the severity, need for hospitalization, and chance of death from the disease. Yet individuals at high risk (especially those ages 65 years and older and immunocompromised adults) can still benefit from treatment.