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aresult,avastnumberofstudieshavedemonstratedage-relateddeclineindetectionsensitivity,intensity
andqualitydiscrimination,identification,andperceivedintensity.
24
DatashowninFig.1.1indicateonly
aslightincreaseinprevalenceofsmelllossfromthe20-to-29-yearstrata(9%acrossgender)tothe50-
to-59-yearstrata (14%), but a rapid increase above that age(80+ year strata,83%).
5
Inanother such
study,theprevalenceincreasedfrom8%at25to34yearsto33%at65to74years.
6
Inyetanotherstudy,
theprevalenceofsmelllossincreasedfrom6%at53to59yearsto62%at80+years.
7
Theimpactofage
onsmellfunctionhasfurtherbeenshownbyalarge-scalepopulation-basedstudyinwhichperformance
onarelativelydifficulttaskofodoridentificationfellfrom~64%correctidentificationsfortheagestrata
45to50yearsto43%forthe85-to-90-yearstrata.
25
Thestronginfluenceofagingonsmellsensitivityhas
alsobeendemonstratedamongpatientsatENTclinics.
26,27
Thereisacleartrendofincreasingheterogeneityofthepopulationinthecourseofaging,asillustrated
inFig.1.2.
28
Thefigureshowsthatsomeelderlypeopleperformjustaswellasthebest-performingyoung
adults.Whydosomeelderlypeopleperformwellwhereasothersdonot?Mackay-Simandassociates
29
studiedhealthy,nonmedicatednonsmokerswithnohistoryofnasalproblems,aswellasparticipantswho
weremedicated,smokers,orhadahistoryofnasalproblems.Basedonacompositescoreofdetection,
discrimination, and identification, they found that the age-related decline in smell function was
considerablylessinthe nonmedicatedandnonsmoking participantswithnohistoryof nasal problems.
Takingthisreasoningastepfurther,arecentstudycomparedodor-detectionsensitivity betweenelderly
people(77to87years),consideredtobe “successfullyaged”intermsofmedicalhealthand cognitive
ability,andyoungadults(20to24years).
30
Thetwoagegroupshadverysimilardetectionthresholdsand
psychometric detection functions (Fig. 1.3), implying that deficits in smell sensitivity in thecourse of
agingmaynotbeinevitable,andthatfactorssecondarytoaging,suchaspoormedicalhealthstatusand
cognitivedecline,maycontributetodeficitsinodordetectabilityinnormalaging.
Fig.1.1Prevalenceofhyposmiaandanosmiainmen(n=668)andwomen(n=719)acrossagestrataassessedwiththeScandinavianOdor
IdentificationTest.(AdaptedfromBrämersonetal.
5
)
Fig.1.2DistributionofnumberofcorrectodoridentificationsontheScandinavianOdorIdentificationTest(max=16)inyoung(n=72)and
elderly(n=147)adults.Meannumbersofcorrectodoridentificationsforthetwoagegroupsareshown.(AdaptedfromMustonenetal.
28
)
TasteLoss
Age-relatedtastelossislessprominentthanage-relatedsmellloss,presumablybecauseoftherobustness
ofthissensorysystemdescribedonpp.168–178.Nevertheless,poordetectionsensitivity,intensity and
qualitydiscrimination,andidentificationoftasteshavebeendocumented,aswellasattenuatedperceived
intensity.Importantly,thereseemtobequality-specificage-relatedchangesintasteperception.Although
theresultsarenotfullyconsistentacrossstudies,bittersensitivityseemstobemostaffectedbyageand
sweetsensitivityleastaffected,whereassaltyandsoursensitivitiesfallinbetween.
24,31
Theprevalence
ofself-reportedtasteproblemshasbeenreportedtoincreasegraduallyacrossagegroupsfrom0.3%at
18 to 24 years to 3.8% at 85+ years.
15
However, these prevalence rates include unspecified taste
problemsotherthantasteloss.
Fig.1.3Frequencydistributionsofindividualodordetectionthresholdsforpyridinefor“successfullyaged”elderly(mean=105ppb;n=16)
andyoungadults(mean=100ppb;n=16).(ReproducedwithkindpermissionofSpringerSciencefromNordins,AlmkvistO,BerglundB.Is
lossinodorsensitivityinevitabletotheagingindividual?Astudyof“successfully-aged”elderly.ChemosensPercept2012;5:188–196.)
Summary
Age-related anatomical andneurological changesinthenasalcavityandolfactorynervous system
resultinthedeclineofvarious smell functions innormal aging.However,smell loss maynotbe
inevitableinagingindividuals.Age-relatedtastelossislessprominentthanage-relatedsmellloss,
probablybecause ofthe general robustness ofthe tastesystem. Theredoes seem tobe a quality-
specificage-relatedlossintasteperception.
ImpactofSmellandTasteLossonQualityofLife
SmellLoss
Olfactionis important as a chemical warning system withemotional impact, inthe regulation of food
intake,andininterpersonalrelations,andstudiesofpatientswithsmelllossshowconsequencesforall
these aspects of life.
32,33
Clinical investigations have demonstrated poor general QoL, depression and
moodchanges,feelingsofvulnerability,anddifficultiesindailylife.Vulnerabilityisrelatedtoworries
andactual experience of safety issues (e.g.,fire andgasleaks), as well as worries of poor personal
hygiene.Anegativeconsequenceofsmelllossfromanutritionalperspectiveisitsimpactonfoodintake:
loss of appetite, changed food preferences, change in body weight, cooking difficulties, and poor
detectionofspoiledfoodarefrequentcomplaintsofthesepatients.Changeinbodyweightmaybeeither
loss or gain, the gain presumablydue to compensation for diminishedflavor by meansoflarger food
intake.Amoredetaileddescriptionoftheinfluenceofsmelllossondietarybehaviorhasbeenprovided
byAschenbrennerandassociates.
34
Smelllosshasalsobeenassociatedwithdecreasedsocialinteraction
withfriendsandcolleagues,anddecreasedintimacywithapartner.Ithasbeensuggestedthatolfactory
lossmaynothaveadirectimpactonsexualappetite,butthatdepressioncausedbyolfactorylosscausesa
decrease in sexual appetite.
35
A limitation in these studies of QoL is that they have investigated
heterogeneousgroupswithrespecttoeitherthetypeofsmelldisorder(sensitivityloss,smelldistortion,
orphantomsmell)ortheprimaryetiologyunderlyingthedisorder,makingitdifficulttoconcludetowhat
extentthe impactonQoLcanbe referredtoa specifictype ofdisorderoretiology.However,arecent
study
36
showsaverysimilarimpactonQoLinapatientgroupwithsmelldisorder(smelllossonly)and
etiology(nasalpolyposis)tothatofanearlierstudiedheterogeneousgroup.
TasteLoss
Tasteisthecoresensorypropertyoffoods,afactunderscoredinWesternculturesbyadivisionoffoods
into“sweet”versus“salty”(or“savory”)categories.Almostallfoodsandbeverageshaveeitherasweet
orasaltytaste,and,dependingonthefood,theseareaccompaniedbysour,bitter,orumamitastes.With
eatingandfoodbeingaprominentsourceofenjoyment,decreasedsensitivitytotastescouldpotentially
changetheperceivedqualityandpleasurederivedfromfood.Clinicallydiagnosedageusiaorhypogeusia
lead to decreased appetite andfoodenjoyment,
37
but they arerareinthegeneral population.Research
addressing the relationship between taste sensitivity (determined by threshold concentrations or
suprathresholdintensityperception oftastecompounds)andpleasantness offoodshasmainlyinvolved
unselected populationswith individual variations in perception, or elderly populations. In general, no
particular relationship between lowerthan-average sensitivity and preference for a taste has been
demonstrated.Thus, for example, optimal perceived saltiness does not vary withindividual detection
thresholdsforsodiumchloride.Itseemsthatculturallylearnedpreferencesoverrideindividualvariations
intasteperception.
Consistentwiththis,elderlypeoplewhoseperceptionoftasteshasbeenimpaireddonotshowaltered
preferences for taste intensities.
38,39
A long history of repeated exposure to culturally typical foods
supportstheadjustmenttoprogressivelyfadingtasteperceptions.Currentknowledgedoesnotsupportthe
notionthatimpairmentoftastewouldbeaprimarycauseoflossofappetiteorbodyweightchangesinthe
elderlypopulation.
Summary
Smell loss may have adverse effects on general QoL and can lead to depression, feelings of
vulnerability, practical issues in daily life, altered food intake, reduced social interaction, and
decreasedintimacywithapartner.Althoughtastelossmaycontributetodecreasedappetiteandfood
enjoyment,itmayonlybeapartialexplanationforlossofappetiteorbodyweightchangesinelderly
people.
ImpactofAmbientOdorantsonBehaviorandHealth
A smell elicits psychological andphysiological responses to guide the individual toward appropriate
behavior.Whethertheresponsewillbe positiveornegativein characterdependspredominantlyonthe
hedonicsofthesmell.Anodorouscompoundwillnothaveadirectimpactonbehaviororhealth.Instead,
the positive or negativehedonic evaluation ofthe compound will moderateemotionsevokedfromthis
evaluation andwillhavepositive or negative consequences onmood,behavior,andhealth (e.g.,calm
state, good cognitive performance and no symptoms versus anxiety, poor cognitive performance and
headache). An example of a powerful negative impact of odors on QoL is industrial wastewater
managementoranimalproductionfacilitiesemittingstrongsmellsinsurroundingresidentialareas(fora
review,seeref.40).
Thenegativeimpactofsmellsonbehaviorandhealthhasvastpublichealthconsequences.Aboutone-
thirdofthegeneralpopulationreportannoyanceandsymptomsfromstrongsmells;inaboutone-fifthof
the population,everyday smells havestrong affectiveandbehavioralconsequences;andabout1 in20
meetcriteriaforaclinicaldiagnosisofhypersensitivitytosmells.
41,42
Symptomsmayvaryconsiderably
among afflictedindividuals, butairway(e.g.,coughandnasal congestion)andgeneral symptoms (e.g.,
headacheandnausea)seemtodominate.
43
Resultsfromacontrolledexperimentalstudysuggestthatmold
smell perse may act as awarning signal and significantlystrengthensymptoms, andthuscontribute to
building-relatedillness.
44
Acknowledgments
ThisworkwassupportedbygrantstoStevenNordinfromtheEuropeanterritorialcooperationprogram
Botnia-Atlantica,RegionVästerbotten(Sweden),andtheRegionalCouncilofOstrobothnia(Finland).
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ISenseofSmell
2FunctionalAnatomyoftheOlfactorySystemI:FromtheNasalCavitytotheOlfactoryBulb
3FunctionalAnatomyoftheOlfactorySystemII:CentralRelays,Pathways,andtheirFunction
4TheHumanVomeronasalSystem
5SmellandTasteDisorders—DiagnosticandClinicalWork-Up
6AssessmentofOlfactionandGustation
7SinonasalOlfactoryDisorders
8PostinfectiousandPost-traumaticOlfactoryDisorders
9MiscellaneousCausesofOlfactoryDysfunction
10ChemosensoryFunctioninInfantsandChildren
11NeurologicalDiseasesandOlfactoryDisorders
12ClinicalDisordersoftheTrigeminalSystem
2FunctionalAnatomyoftheOlfactorySystemI:FromtheNasal
CavitytotheOlfactoryBulb
StructuralConsiderations
DavidE.Hornung
Thenasalairpassagewaysaredelineatedintheanteriorplanebythenasalvalve,inthelateralplaneby
thesuperior,middle,andinferiorconchae(turbinates),andinthemedialplanebythenasalseptum.As
seeninFigs.2.1 and 2.2, these structures define the organizational borders for thenasal air passages,
whichprovidetheconduitthroughwhichairandodorantmoleculesaredeliveredtotheairspaceabove
theolfactoryreceptors.
1
The olfactoryreceptors are located high inthe nose along the septum and on thesuperior concha.
Becauseoftheirlocation,andbecausetheairspacesdefinedbythemiddleandinferiorconchaearemuch
largerthanthoseleadinguptotheolfactoryreceptorregion,duringasniffonly~10%oftheinspiredair
isdirectedtowardtheairspaceincontactwiththeolfactoryreceptors.
2,3
The septumandconchae produce multiple andconvoluted (sometimesturbulent) flow paths for the
inspiredair(Fig. 2.3). By affecting the rateatwhichodorantmolecules are deliveredtothe olfactory
receptorsheet,thestructureofthenoseitselfmaybeoneofthemechanismsinvolvedwithodordetection
anddiscrimination.In addition, some investigators have suggested that therelatively low air volume,
coupled with the convoluted air flow path leading to the receptors, may help protect the olfactory
processingsystemfromparticulatepollutants.
4
Thenasalairpassageways,whichcanhaveadramaticeffectonolfactoryability,aredelineatedby
thesuperior,middle,andinferiorturbinates.Alterationsinthesenasalairpassagewaysoftenhavean
effectonodorantperception.
NasalAirConditioning,ConductionProblemsandtheNasalCycle
The nose serves important functionsbeyond odorant identification. These nonolfactorynasal functions
together will be referred to as “nasal air conditioning.” During the process of air conditioning, the
inspiredairisbroughttothetemperatureandhumidityofthelungs.Inaddition,afiltrationprocessoccurs
inwhichparticlesintheinspiredair,rangingfromcombustionproductstoairbornebacteria,aretrapped
inthemucusandremoved.Someaspectsofnasalairconditioningarebrieflydiscussedbelowbecause
thesenonolfactoryphysiologicalprocessescanhaveaprofoundeffectontheabilitytodetectodorants.
5
Themajorfunctionofthenoseistoprovidethelowerairwayswithclean,humidified,andwarmair.
The epithelial cells lining the structures of the internal nose have a very rich blood supply and are
coveredbywaterymucusthatiscontinuallyflowingintothebackofthethroat.Byregulatingtheamount
ofbloodinthedensecapillarybedsservicingthestructuresoftheinternalnose,thesizeoftheairspace
definedbytheseorganizationalstructurescanbechangedquicklyanddramatically.Becauseofthespeed
andthe amountofchangethatcanoccur around the inferior concha, these areas ofthe noseare called
“swellspaces.”
1
Ifolfactorycomplaintsareduetotheproblemofodorantmoleculesnotgettingtotheheadspaceabove
the olfactory receptors (a conduction problem), breathing warm, humidified air can sometimes
temporarilyrestoresomelostolfactoryabilitybyincreasingthesizeofthenasalairpassageways.Given
theimpacttheswellspacescanhaveonnasalpatency,questionsabouthowolfactoryabilitychangesas
the ambienttemperatureor humidity changeshouldbeincludedas partofa routinehistoryforpatients
witholfactorycomplaints.
Fig.2.1Across-sectionalviewofthehumanhead.Theinferior(I),middle(M),andsuperior(S)conchaearelocatedabovethehardpalate.
Thelocationoftheolfactoryreceptorcellareaisaroundthesuperiorturbinate.(ModifiedfromHornung2006.
1
)
Fig.2.2 Across-sectionalview oftheairspacesonthehumannose.Theairspace forthe leftnostril(therighthandsideofthedrawing)is
filledin.Thebluecolorindicatestheairspaceadjacenttotheolfactoryreceptorregionandtherestoftheairspaceisdelineatedbythegreen.
S,superiorconcha;M,middleconcha;I,inferiorconcha.(ModifiedfromHornung2006.
1
)
Fig. 2.3 Cartoon showing the generaldirectionof nasalairflowin theairspaces definedby the inferior (I),middle (M), andsuperior (S)
turbinates.Thethickertheline, thelargerthepercentageofairflowthatmovesalongthatparticularflowpath.Theolfactoryreceptoristhe
shadedarealocatedaroundtheanteriorportionofthesuperiorturbinate.
Conductionproblemscanhappenasaresultofstructuralblockagesorasaresultoftemporarychanges
inthenasalairpassagewaysduetoconditionssuchasallergicrhinitis.
6
Structuralblockagescanoccuras
aresultofconditionssuchaspolyposisorasaresultofanalterationinthenasalpassageways,suchasa
severelydeviatednasalsystemorfacialtrauma.Withconductionproblems,restoringthepatencyofthe
nasalpassagewaysoftenrestoresolfactoryfunction.
1
Inflammatory processesmayproduceconductionproblems. However,inflammatoryprocessesmay
alsoproduceolfactorylossinthepresenceofopennasalpassages.
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