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Switzerland
Completelossofolfactorycapability (anosmia)causedby anaccidentandstillpersistingafter2years
leads toa disbursementofaone-timecompensationof15% for loss ofintegrity.Hyposmialeadstoa
compensationof7.5%.SuchdamageeventsmustbereportedtotheSuva(theSwissNationalAccident
InsuranceFund).Ifthepersonaffectedbytheolfactorylossworksinafieldwhereolfactoryfunctionis
essential (e.g., cook, perfumer), an enactment of nonsuitability can be initiated and occupational re-
training started. Recognition and declaration of occupation-related toxic olfactory disorders are also
handledbytheSuvainSwitzerland.
Austria
Completelossofolfactorycapability(anosmia)causedbyanaccidentandstillpersistingafter2yearsis
considered to amount to a reduction in earning capacity of 10% and is compensated accordingly. A
completeanosmiaamountsto10%,andhyposmiato5%.
Qualitative olfactory disorders (parosmia) as a sole symptom are not recognized in the German
assessment regulations based on thelack of quantification,or the impossibility for a clear diagnosis.
However,ifaquantifiablelimitationofolfactoryorgustatorycapabilityexistsandsymptomsofparosmia
are characterized, this fact can be integrated into the assessment. The decisive question is, however,
whethertheparosmiahasarelevantadverseeffectonthepersonatissue(e.g.,lossofappetite,weight
loss,etc.).
Owing to the special regenerative ability of the olfactory senses, a spontaneous remission or an
improvement should always be taken into consideration. If the onset of the symptoms is recent, the
possibility of remissionshould be mentionedinthe expertopinion,andreassessment suggestedindue
course(e.g.,after2years).Thishardlyeverarisesincasesofwork-relatedolfactorydisorderthathave
developedoveranumberofyears,butaspontaneousremissionmustalwaysbeconsideredinthecaseof
asudden occurrencesuch as an accident.Thoughthe possibilityofaremissiondecreases with time,a
fixedperiodoftimeafterwhichaspontaneousremissionisimpossiblecannotbedefined.
In advisory issues, certain questions regarding olfactory and gustatory disorders come up quite
frequently. These include assessments for the supposed existence of an occupational disease caused
mainly by chronic exposure to toxic substances such as organic solvents or smokes (e.g., welding
smokes). A set of documented cases already exists where a work-related olfactory disorder was
acknowledgedoutside thelistofoccupationaldisorders,formerly § 551,Chapter 2, Federal Insurance
Code(RVO),atpresent§9,Chapter2,CSL.
Furthermore, expertopinionsmay be provided withincivil law,particularlyfortraumaticolfactory
disorders caused by accidents due to an outside source (e.g., traffic accidents resulting in traumatic
anosmia). Expert opinions may also be required in liability suits regarding olfactory disorders
supposedlycausedduringmedicalinterventions(usuallysurgicalinterventionsonthenasalcavityorthe
paranasalsinuses).
UnitedStatesofAmerica
Whileawardsforlossofvision,lossofhearing,andlossoflimbsseemtoberelativelystandardinthe
courts, the awards for loss of smell vary widely. Awards in California vary between $250,000 and
$750,000.
RecommendationoftheGermanTaskForce
The Olfactology and Gustology Task Force of the German Society of Otolaryngology (Deutsche
Gesellschaftfür Hals-Nasen-Ohrenheilkunde) haspublishedrecommendationsregarding theassessment
ofolfactorydisorders,
19
althoughtheserecommendationsareinpartveryspecificforGermany.Amore
generalmodificationoftheserecommendationsisgiveninthefollowingtextbox.
InformationoftheOlfactologyandGustologyTaskForceforProvidingExpertOpinionfor
OlfactoryandGustatoryDisorderswithintheStatutoryAccidentInsurance(modifiedversion
forthisbook)
According tothecriteriafor providing medical expertopinioninsocial compensation legislation
andaccordingtotheGermanSeverelyHandicappedPersonsActof2004anditsamendments,a15%
reduction in earning capacity for the complete loss of olfactory capabilities and the associated
impairmentoftaste,anda10%reductionforthecompletelossoftaste,isusuallyrecommended.
18
Withpartialdamage,thereductioninearningcapacityislower.Hyposmia,forexample,withaTDI
score between15 and 20 can absolutelyjustify a reduction inearning capacity of 10%. That the
gustatory perception of food or drink is always affected in anosmia is explained by the
discontinuation of the olfactory input. The taste of food is a complex experience of olfactory,
gustatory,trigeminal,visual,andalsosonicperceptionandtheircentralprocessing.Acompleteloss
ofolfactoryorgustatoryperceptionmeansthecompletelossoftheperceptionofsweet,sour,salty,
orbittertastes.
An important point inassessing the level of reduction inearning capacity—when the function of
chemical senses in workinglife is lost—is a moreprecise assessmentthattakesintoaccount the
increasedimportanceofchemicalsenses(e.g.,theabilitytodetecthazardoussituations).Thisalso
reflectstheincreasedesteemoftheolfactoryandgustatorysensesinthehealthconsciousnessofthe
generalpopulation.Thereductioninearningcapacitymustbeseenhereasanabstractparameterof
lossofhealth.
In general, a loss of olfactorycapacity is associated with a decline—but not complete loss—in
gustatorycapabilityandthetrigeminalsensitivityofthenasalmucosa.Inprovidingexpertopinion,
this combined effect of damage must always be verified individually and acknowledged where
appropriate.Obviously,inprovidingexpertopinion,thetotalolfactoryandgustatoryabilitiesareat
issue,andnottheverificationofaregionallossoffunction.
Therare(0.5%ofallcraniocerebraltraumas)post-traumaticanosmia/ageusiasyndromerepresents
the most severe form of this combined effect of damage. In this syndrome, the Task Force
recommendsan integratedreduction inearningcapacity of20%. Thecombinedeffectofdamages
shouldberatedhigherthanthesoleanosmia.
AccordingtotheTaskForce,aparosmiaorparageusiaassociatedwithanimpairmentofolfactory
orgustatory capabilitieswith a simultaneouspsychovegetativeaftereffectsuch as loss ofappetite,
dysphagia, or malnutrition should be rated withan integrated level of 0 to 10% of reduction in
earning capacity.If theparosmiaorparageusiais notcausedbydamagetothechemicalsenses,a
neuropsychiatricexpertopinionshouldbeobtained.Ifthesymptomsofparosmiaorparageusiaare
notprimarilyandspontaneouslyreportedbythepatient,theyarenotratedasrelevant.
Ifanolfactorydisordercausedbyoccupationalpollutantsissuspected,thisshouldbereportedtothe
properEmployers’LiabilitiesInsuranceAssociation.Work-relatedolfactorydisordersarenotcited
in the list of occupational diseases. Patients with anosmia with a particular occupational impact
(e.g.,thoseemployedinthefoodindustry)areawardedalevelof20%reductioninearningcapacity
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accordingtocurrentruling. In thecaseofhighlyspecializedoccupations(i.e.,perfumers,or food
supervision and control), the courts or administrative authorities can declare the individual
incapabletopractisehisprofession.
ExpertOpinioninGustatoryDisorders
Disordersofperceptionofthebasictastessweet,sour,salty,bitter,andumami—astheyarerelayedby
the gustatory system—require expert opinionsubstantiallyless frequently than olfactorydisorders, not
leastbecauseofthesensoryinnervationofthetongue.Gustatorydisorders,however,arealmostalways
reported by patients being assessed for olfactory and gustatory disorders. Primarily, patients report
gustatory impairment due to olfactory disorders (see assessment of olfactory disorders, p. 63).
Examinationofolfactorycapabilityis,therefore,essentialinpatientswithgustatorydisorders,andvice
versa.
MedicalHistory
Inthe assessment ofgustatory disorders,the medical historyis vitaltodistinguish betweenagustatory
disorderitselfandaprimarilyolfactorydisorder.Furthermore,gustatoryfunctionbeforetheonsetofthe
disordershouldbeascertained,aswellasthecourseofitsdevelopment.Themedicalhistoryshouldalso
reveal if a quantitative dysfunction (hypogeusia or ageusia) or a qualitative dysfunction (parageusia,
where tastesensationsare altered, e.g.,perceived as bitter ormetallic)ofthe gustatory systemexists.
Also,cleargustatorydisorders,inparticulardysgeusia,areoftenaccompaniedbylossofappetite.Inall
cases,ahistoryoffoodintakeandanyresultingweightlossmustbetaken.
Another aspect of the medical history is a systematic interrogation into well-known triggers for
gustatory disorders. This particularly applies to medical conditions that can often cause gustatory
disorders (e.g., diseases of the liver and kidneys, vitamin B12 deficiency with consecutive glossitis,
diabetes,Sjögrensyndrome,hypothyroidism,orCushingsyndrome)aswellastheintakeofmedications
thathavebeendocumentedtocausegustatorydisorders(e.g.,chlorhexidine,penicillamine,cytostatics,or
ametallictastecausedbycarboanhydraseinhibitors).
20
Work-related disorders of gustatory function are rare. A report by the German Statutory Accident
Insuranceshowedthat a totaloffivegustatorydisorders (“reducedgustatorysense”)wererecordedas
occupationaldiseasebetween1999and2006.“Aromatichalogenatedcarbonhydride,”trichloroethylene,
“chromeanditscompounds,”“phosphorus,inorganic,”andhydrogensulfidewerecitedonceeachasthe
cause; more specific dataare not available. According tocurrentscientificknowledge,relativelyfew
working materials cause hypogeusia or ageusia. Reduced gustatory function was also reported after
occupational exposure to antimony, cadmium, chromates, cyanides, hydrogen sulfide, selenium, and
vanadium
21–24
;afew moresubstancesare under suspicion.
25,26
Ametallic tastewas experienced after
intoxicationwith,forexample,arsenic,lead(sweetishmetallictaste),inorganicmercury,andtellurium.It
wasalsofoundwithmetalfumefeverandindeep-seawelders.
23,27–29
Adetailedmedicalhistoryofthe
occupationalenvironmentcanbehelpfulfortheevaluationofgustatorydisordersaswellasimpairment
ofolfactorysenses.Work-relatedgustatorydisorderscanonlybeexpectediftherehasbeenasignificant
breachofindustrialsafetyregulations,orinoccupationalaccidents.
Disordersofsalivationasanundesirablesideeffectofmedicationorasaresultofradiotherapymust
also be mentioned here. Traumatic or surgical damage to relevant neural structures (e.g., due to
interventionsintheupperaerodigestivetract,theneck,ortheskullbase)shouldbeaskedabout,ifnot
alreadystatedaspossibletriggersforgustatorydisorders.Centralnervouscausesofgustatorydisorders
are rare (e.g., brain tumors, neuro-degenerative diseases, lesions of the brainstem, or epileptoid
disorders)butshouldneverthelessbeincludedinthemedicalhistory.Itisessentialtoaskaboutprevious
tonsillectomyorsurgeryofthemiddleear.Transient changesingustatoryfunctionareoftenreportedin
the immediatepostoperative period, but longer lasting impairmentaftertonsillectomy is not infrequent
(especiallydysgeusia).
30
This is important in terms of expert opinion in a compensation trial. Direct
damagetothe glossopharyngeal nerve inthe spatiumparapharyngeum, as wellas damagetoneural or
receptive structures due to thepressure from the surgical spatula, are discussedas possible causative
factors.
31–33
Gustatorydisordersfollowingsurgeryofthemiddleearcanbeaconsequenceofalesionof
the chordatympani, althoughsuchlesionsmay havepre-existedwith relevantconditionsofthemiddle
ear.Itcannotalwaysbeavoided,andone-sidedimpairmentoftenisnotevennoticedbythepatientand
generallylessens with time. In addition,damagetothe lingual nerve can occurduring oral surgery or
dental procedures, resulting in unilateral ageusia. Potential taste disorders as a complication of such
interventionsshouldbeincludedintheinformedconsent,especiallybeforetonsillectomyandmiddleear
surgery.
If a gustatory disorder is reported after an intracranial injury (generally associated with olfactory
dysfunction),thencomprehensiveinformationshouldbeobtainedregardingtheextentofthedamage(e.g.,
CTorMRIofthecranium,orreportsondiagnosticfindingsandprogression),asalreadyoutlinedabove.
Combinedfailureofbothsensorysystemsisrareandis,ingeneral,associatedwithseveretrauma(e.g.,
contusion,prolongedunconsciousness).Isolatedbilateralageusia,asadirectresultofanaccident,occurs
evenlessfrequently,ifatall.
Examination
ClinicalandTechnicalExamination
The clinical examinationcan help detectinsufficient oral hygiene,faulty prosthetic materials (fillings,
inlays,etc.),ormorphologicalchangesonthesurfaceofthetonguethatmustbetakenintoconsiderationin
adifferentialdiagnosis.Eventhoughcongenitaloracquiredmorphologicalmutationsofthesurfaceofthe
tongue (e.g.,linguageographica,or hairytongue) are notassociated with agustatory dysfunction,such
aberrations should be documented. Particularlyinthe case ofunclear or suspiciouschanges, a biopsy
might be beneficial, not least to exclude neoplastic changes. Furthermore, clinical examination might
revealpossibleeffectsofsurgicalinterventionortrauma,orthepresenceofacuteinflammationortumors
ofthe oral cavity ororopharynx. Aclinical examination oftheupperrespiratorytract,thenoseandits
mucous membranes should be conducted, as described on pp. 49–57. Examination of the middle ear
shouldalsobeincludedsoinflammatorychangesandprevioussurgeryarenotoverlooked.
Ifthereisanysuggestionofunilateraldysfunctionorlocaltraumaofthechordatympani,thesensitivity
ofthebuccalmucosashouldbeexaminedtodetectinvolvementofthelingualnerve,whichrunsadjacent
tothechordatympaniintheoralcavity.
GustatoryTesting
Apartfromextensiveolfactorytesting,asdescribedonp.58–75,gustatoryfunctionshouldbetestedas
follows. This can be done in the form of a full mouth test, but, in patients complaining of unilateral
symptoms, a separate test should be performed on each side of the tongue. Initially, an orienting
identificationtestwith supraliminal testing substances canbe conductedforeachside separately. This
testsidentificationofsweet,sour,salty,andbittertastes.Inadvisoryissues,aquantitativetestshouldalso
beused,forexample, usingthe “threedropmethod”or“tastestrips”(seeChapter14).Itisimportant,
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however, that standard parameters are available for the chosen methods that allow classification of
normogeusia,hypogeusia,orageusia.Iftestsofthegustatoryabilityofparticularareasofthetongueare
required (e.g., if a damage of distinct neural structures is suspected), “taste strip” testing or
electrogustometrycanbe performed(see Chapter14).Notleastbecauseofthe limitedavailabilityand
poor compliance of this method, the authors feel that neither electrogustometry nor gustatory-evoked
potentials or functional MRI should be routine clinical investigations for advisoryissues. In advisory
issues inwesternEurope andthe USA, thequality umami is nottested, as patientsand examiners are
usuallyunfamiliarwithit.
SpecialAspectsofAssessment
Acommonproblemintheassessmentofgustatorydisordersisthelackofavailabilityofquantitative—or
evenqualitative—gustatorytestingbeforetheonsetofthedisorder.Therefore,asarule,theadvisorhas
to rely on the patient’s subjective report. An objective test of gustatory function has recently been
developedbasedongustatoryERPs;nevertheless,thistechniqueissofaronlyavailableinaverylimited
numberofcenters.
34
Asaconsequence,directedsimulationsarehardtodetect.Usually,theadvisorwill
have to rely on theplausibilityof thesymptoms in the contextof an adequate comprehensible cause.
Overall,isolatedgustatorydisordersareextremelyrareinadvisoryissues.Fromtheirownexperience,
theauthorshavebeeninvolvedintheassessmentofgustatorydisorders(ageusia)aftertonsillectomyor
decimationofgustatoryfunction(hypogeusia)aftermiddleearsurgery.Additionally,theauthorsknowof
acase ofhemiageusia with ipsilateraldysfunction ofsensitivity,combinedwith a lesionofthechorda
tympaniandthelingualnerve,afterdentalsurgery.
In terms of assessment of a possible impairment of earning capacity within the regulations of the
Statutory AccidentInsurance,a reduction of10%is suggestedinGermanyforanisolatedageusia.
14
A
particular occupational impact canoccur in thecase of cooksandcomparable worksituations where
gustatory function plays a major role in the occupation analogous to olfactory dysfunction. Here, the
specific requirements for gustatory function must be evaluated in the particular work situation.
Additionally, a gustatory disorder associated with a documented olfactory disorder (anosmia) can
necessitateanincreaseoftheanosmia-inducedimpairmentofearningcapacityupto20%.
CaseStudies
CaseStudy1:Post-traumaticAnosmia
A45-year-oldschoolteacherwashitbyacarthathadtakenherrightofwaywhileshewasridingher
bicycletothemarket.Shewasflungontothestreetandstruckherheadonthesurface.Owingtolossof
consciousnessandsubsequentamnesia,shewasnotabletomakea statement concerningthe immediate
period after the accident. Shewas taken to a nearbyhospital by theemergencymedical service. Her
medical filesstatethata closedcraniocerebral traumawasdiagnosed, which hadled toseveralminor
frontoparietal hemorrhages due to contusion. An initial rhinoliquorrhea resolved after a few days.
Neurosurgical intervention was not required. A series of small, superficial injuries of the facial soft
tissues was initially treated surgically, and a distal radius fracture was treated conservatively witha
forearmplastersplint.
Thepatientreportednoticingacompletelossofolfactoryfunctionandaclearimpairmentofgustatory
functionafterafewdaysinthehospital.Shewasnolongerabletosmelltheflowersinherroom,orher
breakfastcoffee.Hermealshadtastedbland,soshehadnotbeenabletoregainherappetiteandhadlost
severalkilogramsinthecourseofafewweeks.Herolfactoryandgustatoryfunctionhavenotimproved
since.Shedidnotreportany othercomplaintsofthenoseor paranasalsinuses.Apartfrom occasional
analgesicsthatshetakesforintermittentpainin thelumbarspine,nodrugsaretaken. Thepatienthada
tonsillectomyasachild;anappendectomywasperformed4yearsago.Additionalinterventionsintheear,
nose,andthroatregionwerenotspecified.Therearenootherrelevantpre-existingconditions.
Expertopinionwasrequested8monthsaftertheaccident.Thewomanhadsuedthepartyresponsible
fortheaccidentfordamagesandcompensation;theadversary’sliabilityinsurancedoubtedtheolfactory
disorderwascausedbytheaccidentandrequestedanexpertopinion.
Clinical examinationdid not reveal any visibleinjuries of theneurocraniumorviscerocraniumthat
couldhavebeencausedbytheaccident.Rhinoscopywasnormal,withoutrelevant impairmentofnasal
airflow. Endoscopy of the main nasal cavity showed normal nasal mucosa; the fossa olfactoria was
unobstructedandclearlyvisible.Intra-oralexaminationwasunremarkableandbilateralearmicroscopy
normal.
Rhinomanometry confirmed sufficient nasal airflow. Subjectiveolfactorytestingwith Sniffin’ Sticks
revealedaTDIscoreof12(threshold,1;discrimination,5;identification,6),accordantwithafunctional
anosmia.Resultsofthetastestripstestwerenormalforthequalitiessweet,sour,andbitter,butsaltytaste
wasnotrecognizeduntiltheconcentrationhadbeenincreased.Subsequentobjectiveolfactometryshowed
residualpotentialsof40and60% v/vCO
2
ontrigeminalstimulation;accordantpotentialsonolfactory
stimulation withH
2
S(2 and 4ppm)couldnotbe evoked.Previousfindingsofolfactory andgustatory
functionwerenotavailable.MRIcarriedoutdaysaftertheaccidentshowedthedescribedcontusions.An
initial CT did notshow any discernible fractures. The paranasal sinuses were inconspicuous in both
examinations.
The patientwasdiagnosed withanosmia.Itwasstatedthattheanosmia wascausedby theaccident
“withtheutmostprobability”(post-traumaticanosmia)andare-evaluationin12monthswassuggested.
CaseStudy2:AnosmiaasanOccupationalDisorder
In2004,a44-year-oldGermanplumberwasexaminedforanexpertopiniontodetermineifhisanosmia
wasworkrelated.Hehadbeenweldingonandofffrom1975to1993,mainlywithoutvacuumdevicesor
respiratoryprotection.Duringamajorcontractfromlate1993toearly1996,helaidpolyvinylchloride
pipesfortapsinpoorlyventilatedrooms.First,hecleanedthepipeswithpapertowelssoakedinsolvent
mixtures. Then,heapplied theadhesive witha brush, andfitted thepipes together.Thebasicsolvents
weretetrahydrofuran,cycloheranone,acetone,andfurtherketones.Theseoperationsoftenlastedseveral
hoursperday.Respiratoryprotectionwasnotavailable.Whencleaningandbonding,theplumberalways
feltastingingsensationinhiseyesandnose.Inthecourseof1or2hours,nasalsecretionsturnedfrom
waterytobloody.Lessfrequently,healsohadheadachesandafeelingofslighttipsinesswithouthaving
consumed alcohol earlier.All thesesymptoms appeared strictlyworkrelated.From 1996totoday the
patienthasrarelyconductedbonding.Inlate1995,hefirstnoticedanimpairmentofhisolfactoryfunction.
However,hecontinuedtoinstallgaslines.InMarch1996,hewasexaminedasanoutpatientbyanear,
nose, and throat specialist, and a deviated septum and reddened nasal mucosa were found.
Rhinomanometryshowedslightlyimpairednasalairflowonbothsides.Gustatorytestingandradiography
results of the paranasal sinuses were normal. The company physician reported these results as an
occupationaldiseaseaslateas2001.Thepatientsmokedonepacketofcigarettesperday.Themedical
historygavenoindicationofothercausesofolfactorydysfunction.Ontheoccasionoftheexpertopinion
examinationinMarch2004,thenasalmucosawasdrywithsomecrusts.Thelowernasalconchaewere
slightly enlarged; the fossa olfactoria was not visualized. Anterior rhinomanometry and acoustic
rhinometrywerenormal.OlfactoryexaminationwithSniffin’SticksshowedaTDIscoreof10(threshold,
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1;discrimination,5;identification,4),whichsuggestsfunctionalanosmia.Thediagnosiswassecuredby
meansofobjectiveolfactometry.
Onsubjectivegustatorytesting(fullmouthtest),thequalitiessweet,bitter,andsaltywereidentifiedin
contrasttosour. Theresultwasassessed as non-impairedgustatory function. Themedical history,skin
pricktest,andintracutaneoustestwiththemostfrequentseasonalandperennialallergensdidnotsuggest
allergicrhinitis.CToftheparanasalsinusesshowedaminimalshadowintheareaoftheethmoidcells.
The basic cause of the disorder was the very high exposure to solvents. The Employers’ Liabilities
Insurance Associationfollowed the expertadvisor’srecommendation toacknowledge a toxic anosmia
andrhinitis,withareductioninearningcapacityof20%.Partoftheplumber’sjobincludedlayinggas
linesandconnectingappliancesoperatingongas.HencetheEmployers’LiabilitiesInsuranceAssociation
initiatedthepurchaseofagasdetector,sothatthepatientwasabletostayinhisworkplace.Withoutthis
technicalsolution,anincreasedlevelofreductioninearningcapacitywouldhavebeenpossiblebecause
oftheparticularwork-relatedimpact.
35
References
1. Smith WM, Davidson TM, Murphy C. Toxin-induced chemosensory dysfunction: a case series and review. Am J Rhinol Allergy
2009;23(6):578–581
2.AlexanderTH,DavidsonTM.Intranasalzincandanosmia:thezinc-inducedanosmiasyndrome.Laryngoscope2006;116(2):217–220
3.DavidsonTM,SmithWM.TheBradford Hillcriteria andzinc-inducedanosmia:acausalityanalysis.ArchOtolaryngolHeadNeckSurg
2010;136(7):673–676
4. Gudziol H, Rahneberg K, Burkert S. Anosmics are more poorly able to taste than normal persons. [Article in German]
Laryngorhinootologie2007;86(9):640–643
5.FrasnelliJ,Hummel T.Interactionsbetweenthechemical senses:trigeminalfunctioninpatients witholfactory loss. IntJPsychophysiol
2007;65(3):177–181
6. Frasnelli J, Schuster B, Zahnert T, Hummel T. Chemosensory specific reduction of trigeminal sensitivity in subjects with olfactory
dysfunction.Neuroscience2006;142(2):541–546
7. Hummel C, Frasnelli J, Gerber J, Hummel T. Cerebral processing of gustatory stimuli in patients with taste loss. Behav Brain Res
2007;185(1):59–64
8.WuAP,DavidsonT.Posttraumaticanosmiasecondarytocentralnervoussysteminjury.AmJRhinol2008;22(6):606–607
9.SametJM.Adverseeffectsofsmokeexposureontheupperairway.TobControl2004;13(Suppl1):i57–i60
10.ShustermanD.Toxicologyofnasalirritants.CurrAllergyAsthmaRep2003;3(3):258–265
11.DelankKW,StollW.Olfactoryfunctionafterfunctionalendoscopicsinussurgeryforchronicsinusitis.Rhinology1998;36(1):15–19
12.KobalG,KlimekL,WolfensbergerM,etal.Multi-centerinvestigationof1,036subjectsusingastandardizedmethodfortheassessmentof
olfactory function combining tests of odor identification, odor discrimination, and olfactory thresholds. Eur Arch Otorhinolaryngol
2000;257(4):205–211
13.StuckBA,FreyS,FreiburgC,HörmannK,ZahnertT,HummelT.Chemosensoryevent-relatedpotentialsinrelationtosideofstimulation,
age,sex,andstimulusconcentration.ClinNeurophysiol2006;117(6):1367–1375
14.LötschJ,HummelT.Theclinicalsignificanceofelectrophysiologicalmeasuresofolfactoryfunction.BehavBrainRes2006;170(1):78–83
15.MuttrayA,KlimekL,JungD,RoseDM,MannW,KonietzkoJ.DietoxischeHyp-undAnosmie—eine“vergessene”Berufskrankheit?
ZblArbeitsmed1998;48:66–71
16.MuttrayA,MollB,Letzel S. DiesozialmedizinischeBedeutungvon RiechstörungenamBeispiel einerKasuistik.ArbeitsmedSozialmed
Umweltmed2003;38:428–434
17. Schönberger A, Mehrtens G, Valentin H. Arbeitsun-fall und Berufskrankheit. Rechtliche und medizinische Grundlagen für Gutachter,
Sozialverwaltung,BeraterundGerichte.ErichSchmidtVerlag;2009:261–264
18.FeldmannH.DasGutachtendesHals-Nasen-Ohren-Arztes.6thed.Stuttgart,NewYork:Thieme;2006
19.Gudziol H.Mitteilungder ArbeitsgemeinschaftOlfaktologie und GustologiezurBegutachtungvon Riech-und Schmeckstörungeninder
gesetzlichen Unfallversicherung. 2007. http://www.uniklinikum-dresden.de/das-klinikum/kliniken-polikliniken-
institute/hno/forschung/interdisziplinares-zentrum-fur-riechenund-schmecken/downloads/kongresse/prot_muenchen_06.pdf
20.ReiterER,DiNardoLJ,CostanzoRM.Toxiceffectsongustatoryfunction.AdvOtorhinolaryngol2006;63:265–277
21.HirschAR,ZavalaG.Long-termeffectsontheolfactorysystemofexposuretohydrogensulphide.OccupEnvironMed1999;56(4):284–
287
22. Seeber H,Fikentscher R, RoseburgB. Smell andtaste disturbances in chromium dye workers. [Articlein German] Z GesamteHyg
1976;22(11):820–822
23.ShustermanDJ,SheedyJE.Occupationalandenvironmentaldisordersofthespecialsenses.OccupMed1992;7(3):515–542
24.SeeberH,FikentscherR.Tastedisordersinchromiumexposedworkers.[ArticleinGerman]ZGesamteHyg1990;36(1):33–34
25. Rossberg G, Schaupp H, Schmidt W. Geruchsund Geschmacksvermögen bei Arbeitern der Chemischen und Metallverarbeitenden
Industrie(OlfaktometrischeundElgustometrischeSchwellenuntersuchungen).ZLaryngolRhinolOtol1966;45:571–590
26.SeeberH,HansonJ,HapprichF.ÄnderungderchemischenSinneuntertäglicherKarbidstaubexposition.ZblHNO1993;143:775–776
27.HallAH.Chronicarsenicpoisoning.ToxicolLett2002;128(1–3):69–72
28. Kachru DN, Tandon SK, Misra UK, Nag D. Occupational lead poisoning among silver jewellery workers. Indian J Med Sci
1989;43(4):89–91
29.MüllerR,ZschiescheW,SteffenHM,SchallerKH.Tellurium-intoxication.KlinWochenschr1989;67(22):1152–1155
30.HeiserC,Landis BN,Giger R,etal.Tastedisturbancefollowing tonsillectomy—aprospectivestudy.Laryngoscope2010;120(10):2119–
2124
31.TomitaH,OhtukaK.Tastedisturbanceaftertonsillectomy.ActaOtolaryngolSuppl2002;(546):164–172
32.ColletS,EloyP,RombauxP,BertrandB.Tastedisordersaftertonsillectomy:casereportandliteraturereview.AnnOtolRhinolLaryngol
2005;114(3):233–236
33. Tomofuji S, Sakagami M,KushidaK, Terada T,Mori H,Kakibuchi M. Taste disturbance aftertonsillectomy and laryngomicrosurgery.
AurisNasusLarynx2005;32(4):381–386
34.HummelT, GenowA,LandisBN. Clinical assessmentofhumangustatoryfunctionusingeventrelatedpotentials.J Neurol Neurosurg
Psychiatry2010;81(4):459–464
35. Muttray A,Haxel B, MannW, LetzelS. Toxic anosmia and rhinitisdue tooccupational solvent exposure. [Article inGerman]HNO
2006;54(11):883–887
36. Stuck BA, Muttray A. Begutachtung von Riech- und Schmeckstörungen. In: Hummel T, Welge-Lüssen A, eds. Riech- und
Schmeckstörungen.Stuttgart:GeorgThiemeVerlag;2008:123–136,157–158
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19Flavor:InteractionBetweentheChemicalSenses
AntjeWelge-Luessen,DanaM.Small,ThomasHummel
Summary
Bothchemical senses,smellandtaste,contributeenormouslytoflavor perception,but ithasbeen
shownthatvisualandtrigeminalinputsalsoinfluenceolfactoryandgustatoryperception.Intermsof
olfaction, orthonasal and retronasal perception differ: Retronasal thresholds are higher and
perceivedintensityofidenticalstimuliisreduced,suggestingdifferentcentralprocessing,whichhas
been confirmed on functional magnetic resonance imaging studies. Application of congruent
olfactoryandgustatorystimulihasbeenshowntoproducesuperadditivecentralresponsescompared
with unimodal stimulation alone. Moreover, simultaneous application of congruent odorants can
increase the perceived intensity of tastants. Trigeminal and olfactory stimuli, both perceived
intranasally, interact; and the trigeminal threshold is increased in patients with anosmia. Visual
stimuli, if present as congruent visual cues while presenting odorants, can also enhance odorant
processing.Theseinteractionsexplainthecomplaintsofpatientssufferingfromanisolatedolfactory
losswhoneverthelesscomplainaboutchangesintheperceptionoftrigeminalandgustatorystimuli
aswell.
Introduction
The chemicalsenses of tasteandsmell interactwith eachotherduring eating and drinking to produce
flavor perceptions. In everyday life, it is very rare to sense taste without also sensing smell. This
contrastswithhowtasteandsmellaregenerallystudiedinthelaboratoryasindependentmodalities.Itis
alsorecognizedthatotherfactorsinfluenceflavorperception.
1
Thisisillustratedbyimaginingadinnerin
anicerestaurant with musicandcandlelight: Notonlyis theflavorofthefoodperceived, butalsothe
visualandacousticsensoryinputs.Theseadditionalsensationscontributenotonlytotheatmosphere,but
also to the perception of flavor. However, although there is general agreement that many modalities
contribute to flavor perception,there continuestobe significantdebateover just how manymodalities
shouldbeincluded.Here,thecoreflavormodalitiesaredefinedasthosesensationsthatarise,orappear
toarise,from themouth.
2
Thesesensations includeolfaction,gustation,andoral somatosensation.The
goalofthischapteristoprovideanoverviewofchemosensoryintegrationinhealthysubjects,andthenin
subjectswithknownchemosensorydeficits.
FlavorPerception
Olfactoryandgustatoryinputsarethemaincontributorstoflavorperception,alongsidetrigeminalinputs
suchastemperatureandtextureofthegivenfood.
3
Beforelookingatfurtherdetails,onehastokeepin
mindthatodorantsareperceivedintwoways:Orthonasally,beforetheyenterthemouth;andretronasally,
whenodorantstraversethenasopharynx.Tounderstandinteractionsinflavorperceptionandtheimportant
role ofretronasalodorantperceptioninflavor perception, themaindifferencesbetweenorthonasaland
retronasalperceptionwillbebrieflydiscussed.
OrthonasalversusRetronasalOlfactoryPerception
The olfactory components of food are first sensed orthonasally, before the food is placed inside the
mouth,andthenretronasally,whenthefoodentersthemouth(Fig.19.1).Inbothcasestheodormolecules
bindtoreceptorsintheolfactoryepithelium.
4
In 1982,Rozinnotedthatolfactionistheonlydualsense
modality,inthatitprovidesinformationaboutobjectsdistalandproximaltotheobserver.
5
Hetherefore
suggestedthatolfactionshouldbeconsideredastwodistinctsenses.Itisnowadaysknownthatodorants
ofthesameconcentrationareperceivedlessintenselywhenappliedretroansally.
6
Moreover,retronasal
thresholdsarehigherthanorthonasalthresholdseveninodorantsidenticalinhedonicsandconcentration,
thus supporting the idea that orthonasal and retronasal odorants are processed differently.
7,8
Using
functional magnetic resonance imaging (fMRI), Small and colleagues showed that the brain responds
differently to the same food odor sensed orthonasally than retronasally.
9
In a subsequent study using
olfactoryevent-relatedpotentials(OERPs),HummelandHeilmann
10
wereabletodemonstratethatOERP
responseswerelargerwhenanodorunrelatedtofoodwaspresentedinanunusualsite(i.e.,retronasally)
thanwhenthesameodorwaspresentedatanorthonasalsite.Theresultwastheotherwayaroundfora
food-related odor. Odorants were presented using anolfactometer and a tube close to the epipharynx,
mimicking molecules coming from the epipharynx (see Fig. 19.2). In patients with endonasal polyps,
retronasalfunctionwasfoundtobesignificantlybetterthanorthonasalolfactoryfunctioncomparedwith
controls.
11
Retronasalolfactoryfunctionwasalsofoundtobebetterthanorthonasalfunctioninpatients
with olfactory disorders because of other reasons, further supporting the different processing of
orthonasalandretronasalstimuli.
12
Performinganinterestingexperimentinvolvingmechanicalblocking
of the anterior part of the olfactory cleft, Pfaar et al were able to demonstrate that orthonasal and
retronasal perception differ.
13
Further findings regarding orthonasal and retronasal olfaction will be
discussedbelowwithintheflavorperceptionsection.
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