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19 Taste Testing: Purpose, Procedure, Interpretation
251
A person’s sense of taste might be affected by their genes. An inherited feature is
the capacity to detect the bitter avor of phenylthiourea and other molecules containing a -N-C=group. Caffeine, potassium chloride (KCl), and saccharin are all
seen as more bitter by phenylthiourea tasters, according to studies. The inability to
taste is a severe symptom of type I familial dysautonomia (Riley–Day syndrome) [18].
Taste sensitivity can be impaired by injuries to the central nervous system or
peripheral nerves, such as in multiple sclerosis, facial paralysis, or thalamic or uncal
lesions.
Diseases such as lichen planus, aglycogeusia, Sjögren syndrome, renal failure
with uremia and dialysis, erythema multiforme, geographic tongue, and cirrhosis
can all have an impact on a person’s sense of taste [18].
19.4.1 Taste Dysfunction
Due to the redundancy in taste neuroanatomy, ageusia is uncommon, although dysgeusia and hypogeusia are more common [20]. Dysgeusia and hypogeusia can
occur when there is a problem with the salivary glands, carrier proteins, or taste
receptors [1], all of which are necessary for normal gustatory function.
• Infectious and Inammatory Causes
• Dysgeusia and hypogeusia can be caused by infections and inammatory disor-
ders everywhere in the oropharynx, including the teeth, larynx, throat, tongue,
taste buds, and salivary glands [1].
• Infectious causes [1]:
– Dysgeusia may be caused by gingivitis, oropharyngeal candidiasis (thrush),
or dental caries. Oropharyngeal infections can impair Gustatory function,
reducing the blood supply to the tongue and taste buds. In addition, genetic
polymorphisms in taste receptor proteins, which alter taste sensitivity and
preferences for sweet tastes, may predispose individuals to developing dental
caries by causing an increase in sugary food consumption [24].
– In the context of inuenza-like diseases, hypogeusia and dysgeusia can occur,
possibly due to taste pore rupture and inammatory cell inltration into the
lamina propria [25].
– Ageusia and anosmia are often the rst signs of coronavirus disease 2019
(COVID-19) in patients, appearing either before or after the beginning of
other symptoms [26–30]. Sixty-three to eighty-ve percent of patients experience taste and smell disturbances, with most experiencing symptoms within
4days after becoming unwell [31–34].
• Inammatory causes:
• Hypogeusia and dysgeusia can be caused by inammation of the salivary glands,
as seen in Sjögren’s syndrome, other autoimmune illnesses, or systemic radioio-
dine therapy [35, 36]. Additionally, xerostomia (dry mouth) may boost the dan-
ger of tooth decay [37].
252
R. Öcal et al.
• If the tongue is inamed (glossitis), the taste pores that allow tastants to reach the
taste buds may close. Atrophic glossitis, where many or all of the lingual papillae
and taste buds are lost, can be brought back to health by taking vitamin B-12
supplements [1].
• Direct harm to taste cells and damage to taste buds and salivary glands [38] can
result from radiation therapy (or accidental exposure to ionizing radiation) to the
head and neck, leading to impaired taste. Oropharyngeal infections, made more
likely by reduced saliva production, can further diminish gustatory function [39].
Radiation dosage to the tongue signicantly correlates with the severity of taste
impairment. Since taste cells are constantly regenerated, taste impairment
improves over time once radiation therapy is nished [38].
• Hypogeusia and dysgeusia can be caused by acid reux, specically laryngopha-
ryngeal reux [40–42], which can alter one’s taste preferences and sensitiv-
ity [43].
• Direct tastant activity, effects on saliva, taste receptor cells, peripheral neurons,
the central nervous system (CNS), and zinc levels, among other unknown prod-
ucts [1, 2], are just some of the processes by which medications might alter
gustatory function.
• Drugs
• Some drugs that may cause adverse reactions in the sense of taste include [1]:
• Treatments for dysgeusia include the following:
– ACE inhibitors, ARBs, dipyridamole, nitroglycerin, vandetanib, and
vismodegib
– Acetazolamide and methylphenidate for bitter dysgeusia
– Drugs such as allopurinol, baclofen, beta-lactam antibiotics (such amoxicil-
lin and cephalexin), clarithromycin, metronidazole, ethambutol, urazepam,
interferon-gamma, levamisole, lithium, tetracycline, tocainide, and intrave-
nous lidocaine have been shown to alleviate symptoms of metallic dysgeusia.
– Hypogeusia (to one or more tastants) or ageusia—angiotensin-converting
enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), amiloride,
amphotericin B, amrinone, bleomycin, carbamazepine, carboplatin, cisplatin,
chlorhexidine mouth rinse, dicyclomine, diltiazem.
– Chemical, toxic, and metal exposure often result in dysgeusia and phantogeu-
sia; ageusia is unusual [1].
• Exposure to chemicals, toxins, and metals—Exposure to chemicals, toxins,
and metals typically causes dysgeusia and phantogeusia; ageusia is rare [1].
– Taste bud morphology [44] and peripheral and central nervous system (CNS)
signal transmission [45] can be altered by acute exposure to organophosphates, leading to impaired gustatory function. Ingesting contaminated air,
water, or food exposes taste buds to pesticides.
– Mercury, copper, zinc, chromium, arsenic, and lead are only some of the met-
als and metalloids that have been linked to altered taste. All seven adults
reported a sweet metallic taste in a case series of occupational acute lead
poisoning [46]. In addition to respiratory and systemic problems [47], a sweet,
19 Taste Testing: Purpose, Procedure, Interpretation
253
metallic taste is a dening feature of metal-fume fever (occupational exposure
to zinc oxide fumes in brass and steel foundry workers and welders).
– Short-term dysgeusia has been linked to acute solvent exposure [48, 49].
Due to the redundancy of the nerves involved in taste function, cases of complete
ageusia caused by nerve injury are sporadic; similarly, chances of profound hypogeusia in the absence of substantial central neurologic impairment are equally
uncommon. For instance, patients with a history of head trauma were shown to have
a prevalence of 19% for dysgeusia but just 2% for total loss of taste [50].
However, mild hypogeusia is more common in the presence of nerve injury and
is associated with regionalized loss of taste. For instance, the anterior two-thirds of
the tongue on the affected side can be affected by taste loss or dysgeusia if the
chorda tympani nerve is injured [51]. Third, molar extractions are associated with
chorda tympani and lingual nerve risks [52, 53]. The lingual branch of the glossopharyngeal nerve [54] can be injured during bronchoscopy, laryngoscopy, or tonsillectomy, leading to impaired taste.
Zinc deciency is linked to dysgeusia and hypogeusia [55, 56], and vitamin B-12
deciency can impair taste function by inducing atrophic glossitis. Patients with
taste disturbances at risk for zinc deciency should have their zinc levels checked
[57], including those with malnutrition, malabsorption, Crohn’s disease, chronic
liver disease, diabetes mellitus, sickle cell disease, and end-stage kidney disease.
Dysgeusia has been linked to several metabolic and endocrine problems, such as
early onset polycystic kidney disease (ESKD), hypothyroidism, and diabetes mellitus (types I and II) [45].
Multiple factors contribute to the taste changes seen in ESKD [58, 59]. Fewer
fungiform taste buds have been linked to ESKD [60], and hemodialysis patients
with ESKD have lower saliva production and a different saliva composition [61].
Zinc deciency may also occur in hemodialysis patients [62].
• Dysgeusia and hypogeusia are the most common taste impairments in diabetic
patients, but other states exist. Patients with diabetes may experience hypogeusia to
sweet taste, characterized by an elevated taste threshold for sweet avors relative to
healthy controls [63]. Dysgeusia may also be inuenced by diabetic neuropathy [64].
• Dysgeusia may be related to hypothyroidism. In a cohort of 18 people with
untreated primary hypothyroidism, for instance, more than 80% were found to
show hypogeusia to one or more taste stimuli [65], even though only 50% of
those people believed their sense of taste was impaired or altered. Multiple factors, including changes in saliva production, mucous membrane, and taste bud
shape, likely contribute to taste disruption in hypothyroidism. However, the taste
disturbance disappears if thyroid function is restored to normal [66].
Multiple sclerosis [67, 68], Parkinson’s disease [69], and Alzheimer’s disease
[70] have all been linked to hypogeusia or dysgeusia as a symptom of their respective diseases.
254
R. Öcal et al.
Unknown in origin, burning mouth syndrome (BMS) primarily affects post-
menopausal women and is characterized by chronic, uctuating, burning intraoral
discomfort without external evidence of inammation [71, 72]. The exact pathophysiologic process is unclear, but it is thought to be related to peripheral and central nervous system dysfunction.
19.4.2 COVID-19
The 2019 coronavirus illness (COVID-19) is characterized by anosmia and dysgeusia. Anosmia, hyposmia, and dysgeusia should raise suspicion of COVID-19 infection, according to the American Academy of Otolaryngology-Head and Neck
Surgery (AAO-HNS) [73–75]. This is especially true in patients who do not have
other respiratory diseases, such as allergic rhinitis, acute rhinosinusitis, or chronic
rhinosinusitis. After exposure to the COVID-19 virus (i.e., severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2)), the CDC has added “new loss of taste or
smell” to the list of symptoms that may appear 2–14days later [76]. The WHO has
included the inability to detect odors or avors in the list of less common symptoms
associated with COVID-19 [77].
In a study of 103 individuals with COVID-19, Speth etal. [78] showed that olfac-
tory impairment was present in 61.2% of cases, with onset at median infection day
3. Loss of taste correlated strongly with the severity of olfactory impairment.
Patients also reported signicantly worse shortness of breath when they had olfactory impairment. Researchers also discovered that olfactory impairment was more
common in women [78] and decreased with age.
Aziz et al. [79] conducted a literature review and found that over 50% of
COVID-19 patients have impaired taste sense using pooled analysis; however, the
frequency may be signicantly more signicant due to underreporting [79].
19.5 Taste Disorder Diagnosis
A taste or smell disorder can be diagnosed with a complete history and physical
examination. Pay close attention to a patient’s history of URIs, nasal or sinus pathology, trauma, other medical issues, and drugs [18].
Sinus CT scans should be ordered if the patient’s history and physical examina-
tion do not t a typical prole. Without central nervous system symptoms or an
abnormal neurologic examination, an intracranial mass such as meningioma is
unlikely to cause olfactory loss. A brain MRI is usually only advised when the history is complicated or additional neurologic symptoms or signs are present (for
instance, a 50-year-old woman with a taste phantom that has persisted for 6months).
A typical laboratory panel is not indicated, although tests can be ordered to assess
for allergies, diabetes, thyroid issues, kidney and liver health, hormone imbalances,
and nutritional deciencies. Biopsy of the olfactory epithelium is primarily
employed as a research tool [18].
19 Taste Testing: Purpose, Procedure, Interpretation
255
19.6 Taste Evaluation intheClinic
Taste disorder evaluation has yet to progress as far as olfactory disorder evaluation.
Specically, thresholds of detection or recognition must be determined. Since only
ve primary taste sensations and only four of them are evaluated [18], there is no
analogous strategy to odor identication tests.
The threshold evaluation is affected by the tongue’s ability to produce saliva and by
the size of the stimulated tongue area. Therefore, the results of such examinations tend
to vary widely. There is no guarantee that a change in suprathreshold taste intensity
will correlate with a shift in threshold detection. The extent of gustatory function or
impairment cannot be determined only through taste threshold testing. After radiation
therapy, a patient’s recognition thresholds for the four taste attributes may return to
normal, but the reported tastes may still be substantially diminished in magnitude [18].
19.6.1 Predicting theThreshold
It is possible to acquire a set of 16 taste strips (Burghart, Messtechnik, Germany)
that have already been impregnated with four different taste qualities (sweet, sour,
salty, and bitter) at four different concentrations. Sweet (0.4g/mL sucrose), sour
(0.3g/mL citric acid), salty (0.2g/mL sodium chloride), bitter (0.006g/mL quinine
hydrochloride), and umami (0.025g/mL sodium chloride). There are published normative values [18] for these tapes.
19.6.2 Magnitude Matching
In suprathreshold testing, the patient’s reactions to tastes with intensities beyond the
threshold are evaluated. Magnitude matching [18] is a psychophysical technique to
quantify this characteristic.
Numbers have been used in other studies of suprathreshold tastes, but a direct
comparison between people is impossible. There is no psychological signicance to
round numbers such as 10 or 100 [18].
In contrast, the process [18] of magnitude matching makes use of one normal
sensory modality (hearing) to compensate for a decit in another modality (taste).
For the magnitude matching job, we supply a range of salt, sugar, acid, and alka-
line tones (1000Hz) and a range of sodium chloride, sucrose, citric acid, and quinine hydrochloric acid concentrations. While listening to the tones through
headphones, the patient drinks each solution and attempts to expectorate it. The
individual gives subjective ratings of stimulus intensity. By comparing the data to
loudness functions, we can see that taste disorders manifest as subdued psychophysical responses. That is, in contrast to people without hypogeusia, those who
suffer from this condition tend to equate higher concentrations of tastes with lower
tones. The principal drawbacks of this testing method are that it requires normal
hearing to function and is highly time-consuming to administer and interpret [18].
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R. Öcal et al.
19.6.3 Spatial Test
The ability to taste in different parts of the mouth and tongue can be evaluated with
a spatial test. Damage to any of the three major nerves that supply the gustatory
system [18]—the glossopharyngeal nerve, the vagus nerve, and the chorda tympani
branch of the facial nerve—or their ganglia can result in a disturbance of taste that
can be assessed only by examining the anatomic areas supplied by those nerves.
Four pieces of standard-sized lter paper are saturated with high concentrations
of the four fundamental avors to conduct the tests. The sheets are distributed randomly throughout all eight tongue segments and both sides of the soft palate.
Patients then used the same scale as in the whole-mouth assessment [18] to rate the
intensity and quality of the avor.
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Part III
Symptoms and Signs Related with Upper and
Lower Respiratory Tract Diseases