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evaluateidiopathicsmelldisorders.However,nonspecificalterationsoccurrelativelyfrequentlyevenin

normosmicsubjects,particularlyinoldage,whichoftenrenderstherelationshipbetweenbiopsyfindings

andfunctionalconditionsinconclusive.

Note

Biopsiesarehighlyvaluableinexperimentalcontexts,butareoflimitedvalueintheevaluationof

olfactorydisordersinindividualpatients.

HowtoEvaluateParosmiaandPhantosmia

The diagnoses “parosmia”and“phantosmia”are solely baseduponthe patient'sreport.

Theymaybe

gradedusingthefollowingsystem:

•Frequencyofoccurrence:daily=1point,otherwise=0points

•Intensity:verystrong=1point,otherwise=0points

•Socialeffects(e.g.,weightloss,significantchangeofhabits):yes=1point,no=0points

Thesumscorerepresentsthedegreeofthedisorder.Findingstosupportthediagnosisofqualitativesmell

disorders are low scores insmellidentificationtests

andsmall OBvolumes compared withpatients

withunimpairedolfaction.

81,82

ThelattermayindicatedecreasednumbersofOBinterneurons,resultingin

reducedlateralinhibition,which,inturn,maygeneratequalitativeolfactorydysfunction.

Note

Objectivemethodstovalidateparosmiaandphantosmiaarelacking.Thesedisordersareestablished

solelybaseduponthepatient'shistory.

AssessmentofTasteFunction

Tastestimuliareprocessedviathreecranialnerves:Thefacialnerve,glossopharyngealnerve,andvagal

nerve.Tastereceptorsarepresentinthemouth,oropharynx,andpharyngealportionoftheepiglottis(and

also in the gut!

). In addition, the vagal nerve contributes sensations of temperature, texture, and

irritation. The brainstem, thalamus, orbitofrontal cortex, and insula are essentially involved in taste

processing. Gustatorysensitivity decreases with age—if less so than olfactory sensitivity—and, as in

olfaction,isgreaterinwomenthanmen.

Afterestablishingthepatient'shistoryandperformingabasicclinicalexamination(seeChapter5),a

specifictastetestisapplied,eithertotheentireoralcavityorinalocalizedfashion,usingbothnatural

and electrical stimulation. Local testing yields more detailed results, permitting, for example, the

detectionoflateralizedtastedisorders,whereaswhole-mouthtestingsimulateseverydaytasteexperience.

Particularlyincasesofdysgeusia(e.g.,bitterormetallictastes),subjectivereportsoftastesensations

arehighlysignificant,asnoquantitativemethodiscurrentlyavailabletoassessthesetypesofdisorders

(Table6.2).

PsychophysicalWhole-mouthTests

Inwhole-mouthtesting, smallamountsoftastesubstances(e.g.,drops or sprays)areapplied.Patients

distributethesampleintheoralcavity,disgorgeitafterafewseconds,andrinsetheirmouthwithwater.

Suprathreshold testing may be performed with so-called taste sprays, using the natural substances

sucrose(1gin10gaqua;sweet),citricacid(0.5gin10gaqua;sour),sodiumchloride(0.75gin10g

aqua;salty),andquininehydrochloride(0.005gin10gaqua;bitter).Thissuprathresholdprocedureisa

simplescreeningtoolthattestsapatient'sabilitytoidentifytastequalities.

Anotherfrequentlyusedmethodisthethreedropstest.

Drops(volume:<0.1mL)ofeitherwateror

atastesolutionareadministeredingroupsofthree,witheachgroupconsistingoftwowaterandonetaste

drop,appliedsuccessivelyinarandomsequence.Thefirstgroupcontainsthelowestconcentrationofthe

tastant.Patientsareaskedtoidentifythetastingdropwithineachgroup.Thetestaimstoassessthetaste

threshold,whichisestablishedastheconcentrationidentifiedthreetimesinarow(forstandardvalues,

pleaseseeref.96).Furthertastetestshavebeensuggested,including“tastetablets,”whichdissolveinthe

oral cavitytoreleasetastesubstances,

orwafers impregnatedwith tastesubstances

;however,these

testsare not commerciallyavailable. Recent developmentsarebased onsoluble material impregnated

withtastant.

Table 6.2Definitionofgustatorydisorders:quantitativedisordersarehighlightedinlightred,andqualitativedisordersindarkred

Diagnosis De scription

Ageusia Totallossofgustatoryfunction

Functionalageusia Significantlyimpairedgustation,includingbothtotallossandminimalresidualperception

Partialageusia Reducedsensitivitytowardonetastequality

Hypogeusia Reducedsensitivity,comparedwithyoung,healthysubjects

Hypergeusia Increasedsensitivity,comparedwithyoung,healthysubjects

Parageusia Abnormalperception,withsensoryinputpresent

Phantogeusia Abnormalperception,withsensoryinputabsent

Note

Anytastetestshouldbeaccompaniedbyabriefsmelltestandviceversa,aspatientsareproneto

mistake aromas for tastesensations, and therefore complainabouttasteproblems insteadofsmell

problems.

PsychophysicalTasteTestsAppliedToSeveralOralSites(LocalTasteTests)

Amonglocaltastetests,thetwo-alternativeforced-choiceprocedureiswidelyused.Patientsareasked

todecidewhichoftwostimuli,presented,forexample,ontheleftandrightside,elicitsatastesensation.

Thismethodmayalsobeusedtoassesstastethresholds.Fig.6.7illustrateslocaltastetests.

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Fig. 6.7a–d Taste tests. (From Hummel T, Welge-Lüssen A. Riech- und Schmeckstorungen: Physiologie, Pathophysiologie und

TherapeutischeAnsatze.Stuttgart:Thieme;2005.)

aLocaltestingwithadequatestimulus:applicationofatastesolutiontoonesideofthetonguewithapipette.

bElectrogustometer“HalleIV,”withstimulatingelectrode,tobeplacedupontongueorpalate.

cTastestrips withsweet,sour,salty,andbittertastesinfourconcentrationseach, tobeplacedupon thetongue's leftorrightside,with the

patientbeingrequiredtoindicatetheperceivedtasteinalist.

dExample ofgustatory-evokedpotentialsafter stimulationwith aceticacidvaporinapatientwithleft-sidedageusia: clearevokedpotential

afterstimulationoftherightside(bottomcurve,witharrowsindicatingpeaks)asopposedtotheleftside(topcurve,noevokedresponse).

LocalTasteTestsUsingAdequateStimuli

Adequatetastestimulimaybeappliedusingeitherliquidtastesolutionsorso-called tastestrips,

100–102

whichconsistofstripsoffilter paperimpregnatedwithtastesubstances. Liquidtastesolutionsmaybe

dabbedonwithcottonswabs,

103

orappliedbymeansofapipette

104

orsoakedpiecesoffilterpaper.

105

Usually, identificationthresholdsofeachgustatory areaareassessedusingincreasingconcentrationsof

tastesubstances.Patientsareinstructedtokeeptheir tongues immobile ina slightlyprotruded position

untiltheyhaveindicatedtheperceivedtastebypointingtotherespectivedescriptoronaboard;afterthat,

theyrinse their mouths with water. The tongue's extended positionduring testing is essential to avoid

distributionofthetastantoutsidethetestedregions;assoonasthetongueismovedintothemouth,tastants

willinevitablyspreadthroughouttheoralcavity,thwartinglocaltesting.

Advantagesofthetastestripsaretheirlongshelf-life,theoptionoflateralizedtesting,andavailability

ofseveralconcentrationsoftastants. Normativedatahavebeenestablished.

106

Theprocedureishighly

reliableandhasbeensuccessfullyusedinseveralclinicalstudies(e.g.,refs.107,108).

Inanothervarietyoftestsquantifyinggustation,intensityestimatesofdifferentconcentrationsoftaste

solutionsareobtainedeitherusingaratingscalerangingfrom“weak”throughto“strong”or,inacross-

modalapproach,bycomparisonwithvariablevolumesofa1,000-Hzsound.

103

Note

Whentastetestingtheanteriortwo-thirds ofthetongue,thetongue mustremainprotrudeduntil the

patienthasindicatedtheperceivedtastequality.

Electrogustometry

Electrogustometry, first introduced inthe 19thcentury, hasbeenestablishedas areliable procedure to

assessgustatoryfunction.

109

Perceptionthresholdsareobtainedbydirectcurrentstimulationwith1.5to

400µAinmonopolar(anodal)orbipolar(coaxial)mode.Itisimportanttocompareleft-andright-sided

function.

Electrogustometryissimpleandprovidesquickevidenceofnervelesions,buttherearealsoseveral

drawbacks: the method does not permit differentiation between taste qualities in gustatory disorders;

accompanying trigeminal sensations may occur at higher stimulus intensities; and correlation between

electricalandchemosensorytastetestingisweak.

110

Nevertheless,electrogustometrymayhaveaspecific

valueinseparatingageusiafromhypogeusia.

111

“Objective”Tests

Recordings of gustatory-evoked potentials are available in very few specialized centers (compare

olfactoryERP).Gustatorystimuliareappliedeithertothewholeoralcavityorinalateralizedfashion.

Atpresent,themethodisprimarilyusedinexperimentalandmedicolegalcontexts.

112

Occasionally,fMRIinresponsetogustatorystimulation(seeabove)maybeperformed,

butitsvalue

asadiagnostictoolinindividualcasesisyettobedemonstrated(Fig.6.5).

Note

Few centers offer “objective” techniques to assess taste disorders, such as gustatory ERPs or

gustatoryfMRI.

AssessmentofMorphologicalChanges

Two methods to assess morphological changes are available: biopsy (e.g., ref. 113) and contact

endoscopy(e.g.,ref.114).In thelatter,thetongue'sepitheliumisdyedwithmethyleneblueand a fiber

opticscopeisplacedonthemucosa,wherecellsarediscernibleat60to150×magnification.Thus,for

example,inpatientswithatransectedchordatympani,fewerandflatterfungiformpapillaearefoundin

theipsilateralepitheliumthan inthecontralateralepithelium

114

(Fig. 6.8). Inaddition,vascular meshes

beneath theepithelium are visible even without dye. Currently, however, this technique is not widely

available.

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Fig.6.8a–dContactendoscopy.(ImagescourtesyofTinoJust,Rostock.)(FromHummelT,Welge-LüssenA.Riech-undSchmeckstorungen:

Physiologie,PathophysiologieundTherapeutischeAnsatze.Stuttgart:Thieme;2005.)

aPartialdyingofthetonguepriortocontactendoscopy.

bArrowindicatesafungiformpapilla(fpap).

cArrowindicatesvasculararchitectureoffpap.

dSurfaceofanfpap(sameregion,dyedwithmethyleneblue);arrowindicatesporeofatastebud.

InvestigationoftheIntranasalTrigeminalSystem

Nostandardizedandclinicallyvalidatedpsychophysicaltestsareavailabletoassessthechemosensory

functionofthe trigeminalnerve.Inexperimentalcontexts,“lateralization”oftrigeminalstimuli

115–118

 is

exploited:Unlikepureolfactorystimuli,nasalsensationssuchastingling,burning,stinging,ortickling—

elicitedinadditiontosmellsbymanyodorantsandmediatedbythetrigeminalnerve—maybelocalized.

Thus, after unilateral presentation of a bimodal olfactory/trigeminal stimulant such as menthol, the

stimulatednostrilcanbe identified,whereasthiswouldbeextremelydifficultwith a specificolfactory

stimulantsuchasvanillin.

115

Inaddition,thresholdassessmentoftrigeminalstimuli,andintensityestimatesin thesuprathreshold

range, may be performed.

119

 Another, experimental, approach aims to record reflexive physiological

effects(e.g.,nasalsecretionorrespiration)inducedbytrigeminalstimulation(overviewinref.120).

“ChemosomatosensoryERP” is also usedtoassess the trigeminalsystem.

121,122

 Typically, odorless

carbon dioxide is chosenas a stimulant which, at concentrationsabove 30%, and at200-millisecond

stimulusduration,elicitsburning, stingingsensations.Possibly, thesetrigeminalERPsmayalsoconvey

prognosticinformationconcerningsmelldisorders

(compareMinovietal2007

123

).Anothermethodof

investigatingthetrigeminalsystemistorecordpotentialsfromtherespiratorymucosa(negativemucosa

potential),

124

asophisticatedtechniquecurrentlyusedonlyinresearch(e.g.,refs.125–127).

Note

Few methods—and these mainly in experimental contexts—are available to assess trigeminal

chemosensoryfunction. However,itmay be assumedthatolfactorydisorders are accompaniedby

reduced trigeminal sensitivity

128

—an important aspect, particularly with respect to medicolegal

evidence(seeChapter18).

SummaryandOutlook

Tothoroughlyevaluatepatients’symptoms,detailed investigationofchemosensoryfunctionisrequired.

The availability of standardized procedures to assess smell and taste seems to be of the utmost

importanceinthedevelopmentofnewstrategiestocurechemosensorydysfunction.

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7SinonasalOlfactoryDisorders

MichaelDamm,RandyM.Leung,RobertC.Kern

Summary

Sinonasalolfactorydysfunctionhasahighprevalenceinthegeneralpopulation.Withintheotorhino

laryngological patient population, sinonasal diseases are responsible for about threequarters of

olfactorydysfunction.Theunderlyingcausesaremostfrequentlyinflammatorydiseasesofthenose

orthe paranasalsinuses(75%), whicharedefinedandcharacterizedinthissection.Itis assumed

thatmostsinonasal diseasesaffecttheolfactoryepitheliumsecondarily. Current informationabout

thepathophysiologyandtreatmentstrategiesofsinonasaldiseasesisincludedinthischapterbecause

improvementinolfactorydysfunctionisusuallyachievedbyimprovementoftheunderlyingdisease.

IntroductionandEpidemiolgy

Rhinitis and rhinosinusitis are broad terms that refer to conditions characterized by inflammation of

mucosaofthenoseand paranasal sinuses, typicallysubdividedonthe basis ofa temporal profile into

acute,recurrentacute,orchronicrhinosinusitis.

1–3

Itisnowwidelyacceptedthatincasesofrhinitis,the

paranasalsinusesarecommonlyaffectedaswell.

However,separatedefinitionsforthedifferententities

exist. Rhinitis is defined according to the consensus report of the International Rhinitis Management

WorkingGroup

 as an inflammation ofthe liningofthe nose, andis characterized by nasal symptoms

including anterior or posterior rhinorrhea, sneezing, nasal blockage, or itching of the nose. These

symptomsoccurontwoormore consecutivedaysformore than1 hour onmostdays.

Considering the

etiology, we can distinguish between infectious and noninfectious, and between inflammatory and

noninflammatory, subtypes of rhinitis (Table 7.1).

 Allergies and acute viral infections of the upper

respiratory tract are the most common causes of rhinitis. Viral rhinitis is the most prevalent disease

affectinghumans.

Allergicrhinitis(AR)isthemostcommonformofnoninfectiousrhinitis,thelifetime

prevalenceofARbeingabove20%.

Severalothernoninfectiousconditionscancausesimilarsymptoms:

hormonal imbalance, physical agents, anatomical anomalies, and the use of certain drugs.

 Olfactory

impairment in rhinitis is usually reversible, but on many occasions the loss of olfaction persists.

Persistentpostviralorpostinfectiousolfactorydysfunctionhasbeenattributedinparticulartoinfluenza-

like infections.

 If it follows one isolated acute infection of the upper respiratory tract, it should be

classed as postviral (postinfectious) olfactory dysfunction rather than rhinitis (see Chapter 8). Other

differentialdiagnosesofrhinitisarecondensedinTable7.2.

Acuterhinosinusitis(ARS)isdescribedasthepresenceofdrainageaccompaniedbynasalobstruction

or facial pain/pressure. ARS is most commonly preceded by a viral upper respiratorytract infection

(URTI);theUSadultpopulationsuffersfromanaverageof2.18URTIsperpersonperyear,ofwhichan

estimated0.5to2%developintoacutebacterialrhinosinusitis.

11,12

ThecriteriaforanARSepisodeshouldincludeatotaldurationofgreaterthan10days,soitcannotto

be confused with a viral respiratory infection, and less than 4 weeks to distinguish it from chronic

rhinosinusitis (CRS). Recurrent acute rhinosinusitis (RARS) is defined by four or more episodes of

bacterialARSperyearwithcompleteresolutionofsymptomsbetweenepisodes—althoughtheliterature

has diagnostic ranges fromtwo to fourper year.CRSis definedas morethan12 weeksofsymptoms

withoutaninterveningsymptom-freeperiod,

andisestimatedtoaffect13%oftheUSpopulation,or32

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