8/17/2012. Demonstrate knowledge of basic anatomy of the nose and mouth as it pertains to smell and taste

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1 Demonstrate knowledge of basic anatomy of the nose and mouth as it pertains to smell and taste Identify causes and treatments of taste and smell disorders Troy Woodard, MD Kathleen Yappel Sinkko, CNP Rhinology, Sinus, and Skull Base Surgery Provide cases and identify educational needs of a patient with a smell and taste disorder Estimated that 2.7 million Americans have olfactory problems 2/3 rd of which report gustatory problems 1.1 million Americans have gustatory problems Approximately 80% of taste disorders are a result of a smell disorder Very difficult to diagnose and treat Lack of knowledge of these diseases Secondary problem from another disease state Effects of these disorders vary Minimal Anxiety provoking Depression Life Threatening Poor quality of life Smell is a form of chemoreception Chemicals (odorants) absorbed into mucus Stimulate olfactory receptors Neuroepithelium Located in the superomedial and lateral nasal cavity Purpose Identify food, mates, predators Warns of danger Fire Spoiled food Gas Leaks 1

2 Olfactory receptors Bipolar neurons that extend into the CNS Up to 100 million olfactory neurons on each side Generated every days G-protein mediated different types 1 neuron to only 1 receptor type Only body site with exposed neurons to the external environment More venerable to damage from pathogens, toxins, physical trauma Covered by mucus from the Bowman s Glands Protects against microbial invasion IGA and IGM Lactoferrin Lysozyme Surrounded by supporting cells Sustenacular cells Basal Cells Bowman s glands Odorant-binding proteins Transport molecules to olfactory receptors Taste is a form of chemoreception Performed by specialized modified epithelial cells Ions and molecules dissolved in saliva Enter taste pore and stimulates taste cells Taste buds- collection of taste cells Continuously form by the basal layer Role of saliva Transport medium for tastants Digestion Immunity 4 primary tastes Sweet, Sour, Bitter, and Salty Is there a 5 th taste? Umami(Savory- glutamate) NEW! Salty and Sour- Ion (NaCland H+ dependent) Sweet, Bitter -G-protein dependent What is Flavor? Sensation caused by combination of Smell, taste, touch (trigeminal), sight, temperature, audition 4 types of lingual papillae Fungiform CN VII Circumvallate CN IX Foliate CN IX Filiform No taste buds 4,600 taste buds on tongue 2

3 Other locations for taste buds Palate CN IX Epiglottis and Larynx Superior laryngeal branch of CN X Pharynx CN IX and CN X Is taste regionalized? Free nerve endings from CN V Irritants, burning, tickling, stinging Sensitive to just about all chemicals if concentrated enough Sweetness-tip of the tongue Salty- anterolateral tongue Sour- lateral Bitter- posterior tongue All taste qualities can be detected in all regions of the tongue Chemical Stimulation G-protein Direct neural stimulation Millions of neurons 1 neuron to 1 receptor type receptor types Develop every days Chemical Stimulation Ions and G-protein Indirect neural stimulation Thousands of taste buds 1 neuron to >1 taste buds 4 primary taste types Develop every 10 days K (Congenital) Inflammatory Trauma Endocrine Neoplasia, Neuro S(Psychiatric) 3

4 K congenital Conductive - Choanal atresia, Vestibular stenosis, Adenoid hypertrophy, Cysts Sensorineural - Agenesis of neuroepithelium, I.U. Or Post natal viral infections Inflammatory Conductive Rhinitis, Sinusitis (bacterial, viral, allergic, fungal Immune Disorder (Wegners, Sjogren s, Sarcoidosis, AIDS) Sensorineural URI injury of neuroepithelium, CNS infection and Degenerative Conductive -- Atrophic Rhinitis Sensorineural Age, CVA, Alzeheimer s, Parkinson s, Drugs, ETOH, ZINC Trauma Conductive - Mucosal edema, Foreign body, Nasal deformity, Laryngectomy Sensorineural post surgical (Endoscopic or Open Craniofacial) Endocrine and malnutrition Conductive- Rhinitis of pregnancy, hypothyroidsm Sensorineural Diabetes, Vit. A, B, Zn or Cu deficiency, renal failure, cirrhosis Neoplasia Neurologic Conductive -Benign (papilloma, angiofibroma, osteoma, schwannoma) Malignant ( SCCA, adenocarcinoma) Sensorineural Benign (meningioma, pit adenoma, craniopharyngioma, glioma) Malignant (esthesioneurolastoma, lukemia, metastastic ), seizures S(Psychiatric) Conductive Foreign body Sensorineural Depression, psychosis, K (Conductive) Inflammatory Trauma Endocrine Nasal Neoplasia S(Psychiatric) K(Conductive ) Xerostomia Inflammatory and Infections Autoimmune- Pemphigus, Sjrogren Syndrome Infections- Bells palsy, Herpes Zoster, Candida, Gingivitis, Herpes Simplex, Periodontis, Sialadentis Drugs (abx, physchotropics, chemotherapeutic, anesthetics) Trauma Head Trauma Surgery (Cutting the chorda tympani) Endocrine and malnutrition Adrenal cortical insufficiency, Cushing s, Diabetes, Hypothyroidsm, panhypopituitarism, Turner s Syndrome Vit. B3 and Zn deficiency, renal failure, cirrhosis Nasal Usually decreased flavor Neoplasia Oral Cavity Cancers Skull Base neoplasm S(Psychiatric) Depression Schizophrenia History Timeframe Onset, Fluctuating? Recent URI, trauma, sinus problems? Neurologic complaints? Pain? Nasal congestion? Medications? Occupational Exposure? Smoker? Drinker? 4

5 Physical Exam CN exam Nasal endoscopy Mirror or flexible endoscopy Oral cavity Ear exam Imaging CT scan of sinuses Best for bony detail Look for any sinus pathology Evaluate the anterior skull base/cribriform MRI --Consider if there are neurological deficits Evaluate olfactory bulbs Evaluate brain Laboratory tests- usually low yield Allergy testing Electrolytes, Glucose, Vitamin deficiencies Renal and LFT s Thyroid and other endocrine function test Epithelial Biopsy Generally only reserved for research purposes Can be risky Several tests to measure olfaction University of Pennsylvania Smell Identification Test (UPSIT) 40 Scratch and Sniff questions Scores are compared against age and sex related norms Not based on threshold Based on number correct Normosmia Microsmia Anosmia is 6-18 Malingering <= 5 Cross Cultural Smell Identification Test Shorter Version Sniffin Sticks Reusable pen like instruments Test odor identification, discrimination, and threshold 3-16 odorants are used Butanol Threshold Test Records concentration at which patient detects butyl alcohol Not as common and as developed as smell tests All patients should also have a smell test Only 4 tastes are generally tested Quality and Intensity Spatial Testing Tasting functional based on anatomic location Able to identify which nerve (CN7, CN IX or CN X) is damage Samples of the basic tastes are randomly placed on 4 quadrants of the tongue and identified and the intensity is rated compared to a whole mouth assessment. 5

6 Pro s Assess the degree of chemosensory dysfunction Cons Time consuming Can slow clinic May need to have multiple exam rooms to continue while testing is performed Difficult to perform Must first the identify etiology of abnormality Can be VERYdifficult Important to do a complete H&P Remember KITTENS in diagnosing 3 most common causes URI Nasal/Sinus disease Head Trauma Conductive causes are the most amenable to correct Remove obstruction ( medicine or surgery) Sensorineural causes are very hard to correct Generally treated with a steroid trial Can take weeks to months to return to normal Rhinitis/sinusitis Abx, Saline, Decongestants, Steroids Surgical management polyps, deviation. Viral Steroids Alpha Lipoic Acid Hummel et al. Anti-oxidant 600 mg/day for 4.5 months 61% patients demonstrated improvement in smell after URI Eliminate exposure to toxins Endocrine and Malnutrition Replace hormones Replace vitamin deficiency Zinc (Systemic. NOT topical zinc sprays!!!) Many cases are UNTREATABLE Reassurance Education Life threatening situations Smoke detectors, natural gas detectors Check expiration dates on food Try to identify etiology Remember KITTENS Treat nasal pathology first Abx, Saline, Decongestants, Steroids, Surgery Treat any mucosal disorders Infectious Inflammatory Eliminate exposure to toxins Consider stopping medication 6

7 Endocrine and Malnutrition Replace hormones Replace vitamin deficiency Neoplasia Artificial saliva Reduce oral irritants Tobacco, mouthwash, ill fitting dentures Modify chewing food Chew food well Switch food regularly to avoid adaptation Exhale after swallow to aid in retronasal olfaction Difficult to treat Very important to our patients Poor quality of life Often overlooked Multi-factorial Cause Complicated Assessment Measurement is imprecise Case Presentations Take steps to discover etiology Treat appropriately Potentially Reversible Reassure and educate our patients ID: 65 year old male CC: loss of smell and taste for one year HPI: loss of smell/taste and nasal obstruction onset did not appear related to acute illness. Accompanied by nasal congestion and nasal drainage. HPI (cont). Pt had recurrent sinus infections. Symptoms: - discolored drainage - facial pressure -pain in upper teeth - increased nasal congestion. These symptoms were alleviated by antibiotics. (pt had completed multiple 10 day courses of antibiotics.) 7

8 Past Medical history: -Environmental allergies -Asthma (controlled with meds) -No history of facial or head trauma -Nonsmoker Current nasal medications: -Veramyst 2 sprays each nostril QD -Astelin nasal spray 2 sprays each nostril BID Past surgical history: -No history of sinus or nasal surgery Physical Exam What s Next? Physical exam findings: -Anterior rhinoscopy: left septal deviation and right sided nasal polyps -Nasal endoscopy: bilateral polyps filling the nasal cavity 8

9 What is the mechanism of this smell disorder? K (Congenital) Inflammatory Trauma Endocrine Neoplasia, Neurologic S(Psychiatric) Diagnosis: -Chronic rhinosinusitis -Sinonasal polyposis Antibiotics Oral steroids Topical nasal steroid sprays Consider Functional Endoscopic sinus surgery if medical therapy fails Outcome: -Pt failed medical therapy -Had bilateral FESS (endoscopic sinus surgery) -Pt had resolution of his sense of smell as well as resolution of nasal obstruction Post op 9

10 ID: 49 yo female CC: Phantom smell So what s next? Get a thorough history Ask what, when, where? Timeframe Onset, Fluctuating? Recent URI, trauma, sinus problems? Neurologic complaints? Pain? Nasal congestion? Medications? Occupational Exposure? Smoker? Drinker? HPI: Past 6 months Intermittently smell an odor that is not present to others Odor smells of smoke She states she does not smoke and no one in her family smokes The odor can be present at different locations During the initial onset of this symptom, pt did have a virus from which she recovered She has not tried any topical nasal sprays or other medications Other symptoms: -Mild nasal stuffiness -No nasal drainage -No nasal facial pain or pressure Past Medical history: -Breast Cancer 2008 treated with surgery/chemo -No known history of facial or head trauma -History of depressive disorder -History of seizure disorder, seizure free on medication -Nonsmoker Past Surgical history: -L lumpectomy 10

11 Social history: -Nonsmoker -No alcohol or drug use Medications: -Zonisamide 100mg 1 po bid Physical Exam: -HEENT normal -Flexible laryngoscopy/nasal endoscopy revealed that the overall appearance of the nasal lining was healthy -Olfactory clefts were visualized and patent -Nasopharynx and larynx were unremarkable What are the possible mechanisms of this patients smell disorder? K (Congenital) Inflammatory Trauma Endocrine Neoplasia, Neurologic Inflammatory(onset occurred after virus, pt c/o nasal stuffiness) - conductive vs. sensorineural Neoplasm (history of breast cancer) Psychiatric-(history of depressive disorder) Toxin-(history of chemotherapy) Neurologic-(history of seizure disorder) S(Psychiatric) Assessment: - Dysosmia (phantosmia) - H/o breast cancer - H/o depressive disorder - H/o seizure disorder Initial Treatment Plan: -Initiate topical nasal steroid spray -Initiate oral steroid burst and taper -MRI at return visit 11

12 Follow up visit: CC: dysosmia had improved HPI: smell of smoke went away after treatment with oral steroids and topical nasal steroids. However stopped TNS due to headaches and just noticed a gas odor the day before this visit. Still stuffy but this also improved while on topical nasal steroids. Physical Exam normal MRIis normal without evidence of tumor, metastasis, or sinus disease Plan: pt to switch to another topical nasal steroid spray, if no improvement, can consider other causes (seizure, psyche) Not all patients who present with smell/taste disorders have happy endings Sense of smell and taste: -is protective. Sense of smell and taste can warn you of chemical dangers, fires, spoiled food. -is linked to memories. (Holidays, people, events, etc.) -enjoyment of food (social and nutritional implications.) 12

13 -Can effect patient s careers Education: - Label foods, check expiration dates - Have working smoke detectors Consider counseling referral: -Depression -Pt seems to be having difficulty coping with loss Thank you 13