Diagnosis and Treatment ofDiagnosis and Treatment ofOlfactory DysfunctionOlfactory Dysfunction

포천중문의대포천중문의대이비인후과학교실이비인후과학교실교수 홍 석 찬교수 홍 석 찬

Physiologic or Anatomic Causes of Physiologic or Anatomic Causes of Olfactory DysfunctionOlfactory Dysfunction

-Hyperosmia-Hyperosmia

hunger, nausea, obesity, hunger, nausea, obesity,

occupational, environmental,occupational, environmental,

nasal cycle, gendernasal cycle, gender

-Hyposmia-Hyposmia

satiety, menstrual cycle, agingsatiety, menstrual cycle, aging

Causes of Intranasal ObstructionCauses of Intranasal Obstruction

-Transport loss-Transport loss

polyps, olfactory gliomas, meningiomaspolyps, olfactory gliomas, meningiomas

intranasal tumors (esthesioneuroblastoma,intranasal tumors (esthesioneuroblastoma,

squamous cell carcinoma, etc.) squamous cell carcinoma, etc.)

rhinosinusitis, atrophic rhinitisrhinosinusitis, atrophic rhinitis

deviated nasal septumdeviated nasal septum

adenoid hypertrophyadenoid hypertrophy

granulomas, nasopharyngeal ca.granulomas, nasopharyngeal ca.

Systemic Causes of RhinitisSystemic Causes of Rhinitisand Olfactory Dysfunctionand Olfactory Dysfunction

Viral rhinitis (herpes simplex, influenza, hepatitis viruseViral rhinitis (herpes simplex, influenza, hepatitis viruses)s)

Allergic rhinitisAllergic rhinitis

Vasomotor rhinitisVasomotor rhinitis

Drugs, chemicalsDrugs, chemicals

PregnancyPregnancy

Chemical pollutantsChemical pollutants

Industrial dustsIndustrial dusts

Neurologic Causes of Olfactory DysNeurologic Causes of Olfactory Dysfunctionfunction

Head traumaHead trauma

Vascular insufficiencyVascular insufficiency

InfectionsInfections

Intracranial tumors (frontal lobe tumors)Intracranial tumors (frontal lobe tumors)

Multiple sclerosisMultiple sclerosis

Neurodegenerative diseasesNeurodegenerative diseases

(Parkinson’s disease, Alzheimer’s disease)(Parkinson’s disease, Alzheimer’s disease)

Temporal lesions (hippocampal uncus)Temporal lesions (hippocampal uncus)

Endocrine and Nutritional Causes of Endocrine and Nutritional Causes of Olfactory DysfunctionOlfactory Dysfunction

-Endocrine disorders-Endocrine disorders

Addison’s disease, Cushing’s syndrome,Addison’s disease, Cushing’s syndrome,

hypothyroidism, Turner’s syndrome,hypothyroidism, Turner’s syndrome,

Kallmann’s syndrome, diabetes mellitusKallmann’s syndrome, diabetes mellitus

-Nutritional causes-Nutritional causes

vitamin A deficiency, Korsakoff’s syndrome, renal failvitamin A deficiency, Korsakoff’s syndrome, renal failure, cirrhosis, Whipple’s disease, cystic fibrosisure, cirrhosis, Whipple’s disease, cystic fibrosis

Miscellaneous CausesMiscellaneous Causes

1. Surgery (intranasal and sinus surgery,1. Surgery (intranasal and sinus surgery,

craniofacial resection, laryngectomy)craniofacial resection, laryngectomy)

2. Radiation (NPC patients with radiotherapy) 2. Radiation (NPC patients with radiotherapy)

3. Psychogenic causes3. Psychogenic causes

hysteriahysteria

schizophreniaschizophrenia

Drugs affecting olfactionDrugs affecting olfaction

Amebicides, antihelmintics, anesthetics,Amebicides, antihelmintics, anesthetics,

anticholesteremics, anticoagulants, anticholesteremics, anticoagulants,

antihistamines, antimicrobial agents,antihistamines, antimicrobial agents,

antiproliferatives, antirheumatics, opiates,antiproliferatives, antirheumatics, opiates,

antiseptics, antithyroid agents, diuretics,antiseptics, antithyroid agents, diuretics,

antihypertensives, hypoglycemic drugs,antihypertensives, hypoglycemic drugs,

psychopharmacologics, vasodilators,psychopharmacologics, vasodilators,

sympathomimetics, muscle relaxants, etc.sympathomimetics, muscle relaxants, etc.

Diagnostic EvaluationDiagnostic Evaluation

1. Thorough history taking1. Thorough history taking

2. Physical examination2. Physical examination

3. Radiologic study3. Radiologic study

4. Olfactory function test4. Olfactory function test

5. Additional laboratory evaluation5. Additional laboratory evaluation

6. Biopsy of olfactory neuroepithelium6. Biopsy of olfactory neuroepithelium

Thorough History TakingThorough History Taking

1. Slow vs. abrupt progression1. Slow vs. abrupt progression

2. Long-term vs. intermittent loss2. Long-term vs. intermittent loss

3. Coincident nasal symptoms3. Coincident nasal symptoms

4. Attendant neurologic dysfunction4. Attendant neurologic dysfunction

5. Histories of sinonasal inflammation5. Histories of sinonasal inflammation

6. Occupational, nutritional problem6. Occupational, nutritional problem

7. Previous surgery, radiation exposure7. Previous surgery, radiation exposure

8. Use of alcohol, tobacco, and drugs8. Use of alcohol, tobacco, and drugs

Physical ExaminationPhysical Examination

1. Nasal endoscopy1. Nasal endoscopy

2. Head and neck examination2. Head and neck examination

-ear-ear

-eye-eye

-oral mucosa-oral mucosa

-neck examination-neck examination

3. Neurologic examination3. Neurologic examination

Radiologic StudyRadiologic Study

1. Computed tomography (CT)1. Computed tomography (CT)

2. Magnetic resonance imaging (MRI)2. Magnetic resonance imaging (MRI)

3. Functional MRI (fMRI)3. Functional MRI (fMRI)

4. PET (Positron emission tomography)4. PET (Positron emission tomography)

5. MSI (Magnetic source imaging)5. MSI (Magnetic source imaging)

Olfactory Function TestsOlfactory Function Tests

1. Threshold detection test1. Threshold detection test

-Sniff or squeeze bottles filled with-Sniff or squeeze bottles filled with

various concentrations of an aqueousvarious concentrations of an aqueous

solution of an odorant such as butanol,solution of an odorant such as butanol,

phenylethyl alocohol, or acetone are used.phenylethyl alocohol, or acetone are used.

-ascending staircase method-ascending staircase method

2. Odor discrimination test2. Odor discrimination test

-Whether two odors are same or different-Whether two odors are same or different

is determined ; hit and false-alarm rateis determined ; hit and false-alarm rate

-The odd stimulus is chosen from a set of-The odd stimulus is chosen from a set of

stimuli that are identical.stimuli that are identical.

-odor confusion matrix-odor confusion matrix

3. Odor identification test3. Odor identification test -UPSIT (University of Pennsylvania-UPSIT (University of Pennsylvania Smell Identification Test), CC-SITSmell Identification Test), CC-SIT -CCCRC test (Connecticut Chemosensory -CCCRC test (Connecticut Chemosensory Clinical Research Center test)Clinical Research Center test) -T & T Olfactometer-T & T Olfactometer -Sniffin’Sticks test, KVSS test-Sniffin’Sticks test, KVSS test -Le Nez du Vin test-Le Nez du Vin test

4. Electrophysiologic tests4. Electrophysiologic tests

-EOG (Electro-olfactogram)-EOG (Electro-olfactogram)

-OEP (Olfactory evoked potential)-OEP (Olfactory evoked potential)

-MEG (Magnetoencephalography)-MEG (Magnetoencephalography)

-CNV (Contingent Negative Variation)-CNV (Contingent Negative Variation)

Additional Laboratory EvaluationAdditional Laboratory Evaluation

1. Endocrine function tests (thyroid and adrenal)1. Endocrine function tests (thyroid and adrenal)

2. Allergic evaluation, nasal cytology2. Allergic evaluation, nasal cytology

3. Serum glucose3. Serum glucose

4. Complete blood count, ESR4. Complete blood count, ESR

5. Renal function tests5. Renal function tests

6. CSF examination6. CSF examination

7. Autoimmune studies (autoantibodies) 7. Autoimmune studies (autoantibodies)

Biopsy of Olfactory NeuroepitheliuBiopsy of Olfactory Neuroepitheliumm

1. Additional information regarding the1. Additional information regarding the

status of the receptor cells can be given.status of the receptor cells can be given.

2. Information is enhanced with the use of2. Information is enhanced with the use of

immunohistochemical or electron immunohistochemical or electron

microscopic techniques.microscopic techniques.

3. Biopsies should be obtained from more 3. Biopsies should be obtained from more

than one site and probably only on one side.than one site and probably only on one side.

Treatment of Treatment of Olfactory DysfunctionOlfactory Dysfunction

1. Medical therapy1. Medical therapy

-for allergic rhinitis,-for allergic rhinitis,

topical or systemic corticosteroidtopical or systemic corticosteroid

cromolyncromolyn

immunotherapyimmunotherapy

-for bacterial infections,-for bacterial infections,

systemic antibioticssystemic antibiotics

-for patients with nasal polyps,-for patients with nasal polyps, oral corticosteroidsoral corticosteroids (continued treatment with the possibility(continued treatment with the possibility of long-term side effects) of long-term side effects) -For olfactory impairment by non-sinonasal-For olfactory impairment by non-sinonasal origin, systemic steroid can be applied origin, systemic steroid can be applied with some side effects (Yang KH, 2000).with some side effects (Yang KH, 2000).

-for hypothyroidism,-for hypothyroidism,

appropriate thyroid treamentappropriate thyroid treament

-for Whipple’s disease,-for Whipple’s disease,

responds well to vitamin A therapyresponds well to vitamin A therapy

-for phantosmia,-for phantosmia,

cocainization of the olf. neuroepitheliumcocainization of the olf. neuroepithelium

or localized excision of the neuroepitheliumor localized excision of the neuroepithelium

2. Surgical intervention2. Surgical intervention

-FESS for chronic sinusitis or nasal polyposis-FESS for chronic sinusitis or nasal polyposis

-septoplasty for deviated nasal septum-septoplasty for deviated nasal septum

-craniotomy and resection of the olfactory-craniotomy and resection of the olfactory

bulbs for paroxysmal dysosmia followingbulbs for paroxysmal dysosmia following

head injuryhead injury

-polypectomy and maintenance on oral steroids,-polypectomy and maintenance on oral steroids,

improvement of olfactory functionimprovement of olfactory function

-FESS and long-term topical steroids,-FESS and long-term topical steroids,

significant improvement in olfactionsignificant improvement in olfaction

-Local injection of dexamethasone acetate-Local injection of dexamethasone acetate

suspension into the nasal mucosasuspension into the nasal mucosa

(Fukazawa K, et al., 1999)(Fukazawa K, et al., 1999)

3.Miscellaneous treatment3.Miscellaneous treatment

-Zinc sulfate -Zinc sulfate

-Vitamin A and beta carotene-Vitamin A and beta carotene

-Phosphodiesterase inhibitors-Phosphodiesterase inhibitors

(theophylline and methyl xanthines)(theophylline and methyl xanthines)

-Supplementation of glutamate or aspartate-Supplementation of glutamate or aspartate

-Caroverine (NMDA antagonist)-Caroverine (NMDA antagonist)

-Auricular acupuncture stimulation-Auricular acupuncture stimulation

( Tanaka O, Mukaino Y, 1999)( Tanaka O, Mukaino Y, 1999)

-Nasal airflow-inducing maneuver-Nasal airflow-inducing maneuver

(“polite yawning”) in laryngectomee(“polite yawning”) in laryngectomee

( Hilgers FJ, et al., 2000)( Hilgers FJ, et al., 2000)

ReferencesReferences

Kimmelman CP. Disorders of taste and smell.Kimmelman CP. Disorders of taste and smell.

A self-instructional package. AAO-HNS. 1996.A self-instructional package. AAO-HNS. 1996.

Chemosensory Bioresponses in Man II. Abstracts.Chemosensory Bioresponses in Man II. Abstracts.

Chemical Senses 25: 781-801, 2000.Chemical Senses 25: 781-801, 2000.

Kettenmann B. Multiple olfactory activity in theKettenmann B. Multiple olfactory activity in the

human neocortex identified by magnetic sourcehuman neocortex identified by magnetic source

imaging. Chemical Senses 22: 493-502, 1997.imaging. Chemical Senses 22: 493-502, 1997.