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Development and Validation of a Novel At-home Smell Assessment

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can an olfactory dysfunction be assessed via commonly available household items?

Findings  In this diagnostic study of 115 adults with self-reported olfactory dysfunction, 2 shorter, patient-reported assessments using common household items were easy to use and had high accuracy when detecting olfactory dysfunction.

Meaning  These findings suggest that these novel assessments can be used by people seeking to test their sense of smell and by health care professionals to detect olfactory dysfunction.


Importance  Current tools for diagnosis of olfactory dysfunction (OD) are costly, time-consuming, and often require clinician administration.

Objective  To develop and validate a simple screening assessment for OD using common household items.

Design, Setting, and Participants  This fully virtual diagnostic study included adults with self-reported OD from any cause throughout the US. Data were collected from December 2020 to April 2021 and analyzed from May 2021 to July 2021.

Main Outcomes and Measures  Participants with self-reported olfactory dysfunction took a survey assessing smell perception of 45 household items and completed the Clinical Global Impression–Severity (CGI-S) smell questionnaire, the University of Pennsylvania Smell Identification Test (UPSIT), and the 36-item Short Form Survey (SF-36). Psychometric and clinimetric analyses were used to consolidate 45 household items into 2 short Novel Anosmia Screening at Leisure (NASAL) assessments, NASAL-7 (range, 0-14; lower score indicating greater anosmia) and NASAL-3 (range, 0-6; lower score indicating greater anosmia).

Results  A total of 115 participants were included in the study, with a median (range) age of 42 (19-70) years, 92 (80%) women, and 97 (84%) White individuals. There was a moderate correlation between the UPSIT and NASAL-7 scores and NASAL-3 scores (NASAL-7: ρ = 0.484; NASAL-3: ρ = 0.404). Both NASAL-7 and NASAL-3 had moderate accuracy in identifying participants with anosmia as defined by UPSIT (NASAL-7 area under the receiver operating curve [AUC], 0.706; 95% CI, 0.551-0.862; NASAL-3 AUC, 0.658; 95% CI, 0.503-0.814). Scoring 7 or less on the NASAL-7 had 70% (95% CI, 48%-86%) sensitivity and 53% (95% CI, 43%-63%) specificity in discriminating participants with anosmia from participants without. Scoring 2 or less on the NASAL-3 had 57% (95% CI, 36%-76%) sensitivity and 78% (95% CI, 69%-85%) specificity in discriminating participants with anosmia from participants without. There was moderate agreement between UPSIT-defined OD categories and those defined by NASAL-7 (weighted κ = 0.496; 95% CI, 0.343-0.649) and those defined by NASAL-3 (weighted κ = 0.365; 95% CI, 0.187-0.543). The agreement with self-reported severity of olfactory dysfunction as measured by CGI-S and the NASAL-7 and NASAL-3 was moderate, with a weighted κ of 0.590 (95% CI, 0.474-0.707) for the NASAL-7 and 0.597 (95% CI, 0.481-0.712) for the NASAL-3.

Conclusion and Relevance  The findings of this diagnostic study suggest that NASAL-7 and NASAL-3, inexpensive and brief patient-reported assessments, can be used to identify individuals with OD. As the burden of COVID-19–associated OD increases, these assessments may prove beneficial as screening and diagnostic tools. Future work will explore whether the NASAL assessments are sensitive to change and how much of a change is clinically important.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: November 15, 2021.

Published Online: January 13, 2022. doi:10.1001/jamaoto.2021.3994

Corresponding Author: Jay F. Piccirillo, MD, Clinical Outcomes Research Office, Department of Otolaryngology–Head & Neck Surgery, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Campus Box 8115, St Louis, MO 63110 (

Author Contributions: Ms Gupta and Dr Kallogjeri had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gupta, Kallogjeri, Smith, Khan, Piccirillo.

Acquisition, analysis, or interpretation of data: Gupta, Kallogjeri, Farrell, Lee, Piccirillo.

Drafting of the manuscript: Gupta.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gupta, Kallogjeri, Smith, Khan.

Obtained funding: Piccirillo.

Administrative, technical, or material support: Gupta, Lee, Piccirillo.

Supervision: Gupta, Farrell, Lee, Piccirillo.

Conflict of Interest Disclosures: Dr Kallogjeri reported owning stock in Potentia Metrics and receiving personal fees for serving as a statistics editor for JAMA Otolaryngology–Head & Neck Surgery outside the submitted work. Dr Piccirillo reported receiving royalty payments for Sino-Nasal Outcome Test, licensed by Washington University. Dr Piccirillo also received fees for serving as the Editor of JAMA Otolaryngology–Head & Neck Surgery. No other disclosures were reported.

Funding/Support: Research reported in this publication was supported by grant T32DC000022 from the Development of Clinician/Researchers in Academic ENT of the National Institute of Deafness and Other Communication Disorders (Ms Gupta, Mr Smith, and Dr Lee) and grant TL1TR002344 from the National Center For Advancing Translational Sciences of the National Institutes of Health (Mr Khan). Recruitment for this study was supported by ResearchMatch and the Recruitment Enhancement Core (Volunteers for Health). ResearchMatch is a national health volunteer registry that was created by several academic institutions and supported by the National Institutes of Health as part of the Clinical Translational Science Award program. ResearchMatch has a large population of volunteers who have consented to be contacted by researchers about health studies for which they may be eligible. The Recruitment Enhancement Core in the Regulatory Support Center of the Institute of Clinical and Translational Sciences, Washington University School of Medicine, is supported by grant UL1TR002345 from the National Center For Advancing Translational Sciences of the National Institutes of Health. Recruitment was also supported by the group AbScent, led by Chrissi Kelly.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Drs Kallogjeri and Piccirillo are Statistics Editor and Editor, respectively, of JAMA Otolaryngology–Head & Neck Surgery, but they were not involved in any of the decisions regarding review of the manuscript or its acceptance. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: Thanks to Amber Perrin, BS, and Zach Jaeger, BS, of the Washington University School of Medicine for their support throughout this project. Ms Perrin received additional compensation.

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