OLFACTION

Literature Reading
Rhinology

Achmad Prihadianto
Supervisor :
dr. Melati Sudiro, M.Kes, Sp.THT-KL(K)

Dept of Otorhinolaryngology - Head and Neck Surgery

Faculty of Medicine Universitas Padjadjaran / Hasan
Sadikin General Hospital
Bandung
2015
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INTRODUCTION
The sense of smell is absolutely crucial
for Safety and quality of life .
The sense of smell have variety
function
Determine the flavor of foods and
beverages
Detecting dangerous environmental
situations exp. The presence of fire,
spoiled food, and leaking natural gas

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014
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OLFACTORY DISORDERS

Anosmia
Hyposmia
Dysosmia
s
Phantosmi
a
parosmia

Complete absense of sense of smell

refers to decreased ability to smell

alteration (decrease or distortion ) in smell

A smell perceived in the absence of true odor

in the environment
An alterated perception of an odor in the
environment different from what is usually
experienced for that odor

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014
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EPIDEMIOLOGY
19 % of the population over the age of 20 yo

25 % of the population over the age of 53 yo

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014
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ANATOMY

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014

ANATOMY

The front and top of the nasal cavity gets sensory

innervation of anterior Etmoidalis nerve
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ANATOMY

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014

HISTOLOGY
Neuroepithelium dan Reseptor Olfaktorius

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology, 6th

Ed, Lippincott Williams & Wilkins, 2014

ANATOMY

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014

ANATOMY

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014

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PHYSIOLOGY

11Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014

ANATOMY

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery Otolaryngology, 6th Ed, Lippincott Williams & Wilkins, 2014

ANATOMY

The
bipolar
recept
or cells

as the receptor cell and the

first-order neuron,
project directly from the
nasal cavity into the brain
regenerate from basal cells

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology, 6th Ed,
Lippincott Williams & Wilkins, 2014
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PHYSIOLOGY OF OLFACTION

transported through
the mucus by small
water-soluble
proteins (termed
odorant binding
proteins)

odorants, most of
which are
hydrophobic, move
from the air phase
of the nasal cavity
into the aqueous
phase of the
olfactory mucus

bind to the
proteinaceous
olfactory receptors
located mainly on
the cilia action
potentials

Olfactory
Transduct
ion

500 to 1,000 genes

are expressed in
olfactory receptors
Each receptor cell
seems to express
only one or, at
most, a few
receptor genes

Neurons expressing
the same gene to
olfactory bulb

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology,

6th Ed, Lippincott Williams & Wilkins, 2014

ETIOLOGI OF OLFACTORY
LOSS

sensorineural factors
Conductive factors
Numerous causes for a decrease in ability to smell
and multipel reports from various smell and taste
centers have consistenly recognized similar
etiologi.
The three most common are :
a)
b)
c)

Head trauma
Upper respiratory infection (URI)
Cronic Rhinosinusitis

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology, 6th Ed, Lippincott
Williams & Wilkins, 2014
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ETIOLOGI OF OLFACTORY LOSS

1. Head
Trauma
occurs in 15%
of patients
with significant
head trauma
Occipital blows
> frontal
blows.
Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology,
6th Ed, Lippincott Williams & Wilkins, 2014
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ETIOLOGI OF OLFACTORY LOSS

2. Upper Respiratory Infections

the most common cause of permanent smell
loss in adulthood
Factors that predispose individuals to virus
induced
smell
dysfunction
and
the
mechanisms underlying it remain unclear

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology,

6th Ed, Lippincott Williams & Wilkins, 2014

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ETIOLOGI OF OLFACTORY LOSS

Cronic
Rhinosinusitis

3.

Not solely caused by

decreased conduction of
airflow to the olfactory
receptors
Chronic inflammation is, in

fact, likely toxic to olfactory

Bailey,Byron,Johnson,Jonas T, Newlands, Shawn D, Head & Neck Surgery - Otolaryngology,
neurons
6th Ed, Lippincott Williams & Wilkins, 2014

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ETIOLOGI OF OLFACTORY LOSS

4. Other causes:
a) Congenital anosmia ( associated with
Kallmann syndrome
(hypogonadotrophic hypogonadism)
b) Neurodegenerative diseases such as
Alzheimer and Parkinson disease.
c) Schizophrenia has also been
associated with smell disorders
resulting in difficulty with identification
of odors
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EVALUATION
etiology of smell loss is obtaining a
detailed
history.
Clues
as
to
surrounding circumstances can point to
a source of the disorder, and timing can
also provide prognostic information
The physical exam in evaluation of
smell disorders includes a thorough
head and neck examination with
assessment of cranial nerve function
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PHISICAL EXAMINATION

otolaryngologic examination :
ant. rhinoscopy and nasal endoscopy the
olfactory cleft, nasal mucus membranes,
polyp, masses,adhesions of the turbinates,
deviations of the septum, and mucopus of the
eustachian tube orifice

neurologic evaluation :
cranial nerve function and intracranial lesions

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OLFACTORY TESTING
Examination of olfactory sensory functions
required to :
1. Ensure the patient's complaints
2. Establish the validity of a patients
complaint
3. Evaluate the efficacy of therapy, and
4. Determine the degree of permanent
disturbance.
5. Indentify malingering
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OLFACTORY TESTING
Psychophysical Tests
TWO TYPES OF
OLFACTORY
TESTING

UPSIT (University of
Pennsylvania Smell
Identification Test)
Sniffin Sticks test
CCRS (Connecticut
Chemosensory Clinical
Research Center test)

Electrophysiological
Tests
OERP (Odor Event-Related
Potentials)
The Electro-Olfactogram

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OLFACTORY TESTING
Psychophysical tests are more
common in clinical practice, many of
which are easy to use and the results
can be compared to known
population standards
Threshold tests measure the ability to
detect an odor (such as butyl alcohol)
at the lowest concentration compared
with a blank
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OLFACTORY TESTING
scratch and snif

UPSIT (University of Pennsylvanias smell identification test )

e 40-item SIT (Sensonics, Inc., Haddon Heights, NJ) consists of 40
scratch-and-sniff samples matchad with the names of four possible
odors the patient can choose from. 'The number of correct responses
correlates with the degree of oH'actory ability.
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OLFACTORY TEST
Sniffin
sticks

simple measuring devices,

sensitivity 95% and specificity of 88% easily portable and can

be applied in the clinic,

can assess and measure the discrimination threshold of smell.
The aroma contained aroma of citrus fruits, coffee, onions,
and other
How to: open the hood of a pencil tip for 3 seconds and then
positioned as far as 2 cm from the nostril, the patient was
asked to recognize the scent there and then the examiner
noted the results of the examination.
The format is designed for three examinations, measurement
threshold, discrimination and identification

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OLFACTORY TESTING

The butanol threshold test consists of 8 series of progressively stronger

butanol dilutions {outer 10 bottles) and blank controls (center four
bottles).Patients asked to Identify the bottle containing butonal after
smelling a puff of air squeezed from the dilution and a blank.

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IMAGING
Because a detailed history provides
the underlying etiology of olfactoty
disorders in the majority of cases,
imaging studies are usually not
needed.
A sinus computed tomography (CT) is
helpful for the assessment of CRS
and obstruction of the olfactory cleft.
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IMAGING STUDIES
MRI when the olfactory disorder occurs :
a) in the absence of a clear etiology,
b) with an unusual presentation,
c) under suspicion of intracranial lesion
based on history and exam,
d) with suspicion of a neurodegenerative
process
e) In congenital anosmia for assessment of
the olfactory bulbs and gyrus rectus.
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PANTOSMIA/DYSOSMIA
CONSIDERATION
Qualitative olfactory changes related to
perceived distortions of inhaled odorants are
called parosmia while the perception of smell
when there is no odorant in the environment is
known
as
phantosmia
or
olfactory
hallucination.
survey of 193 patients with olfactory
complaints, Landis et al. noted that patients
with parosmia frequently have a close temporal
history of head trauma or URI.
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PANTOSMIA "olfactory
hallucination".
Phenomenon of smelling odors that
aren't really present

Olfactory
hallucinations
without
subsequent myoclonic activity have not
been well characterized or understood
Mechanisms responsible for phantosmia
in each group were related to decreased
gamma-aminobutyric
acid
(GABA)
activity in specific brain regions.
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PANTOSMIA "olfactory
hallucination".
There are a wide range of possible causes of
phantosmia, include:
nasal infection
nasal polyps, which are abnormal tissue growths that
form inside the nasal passages and sinuses
migraine with aura some people smell phantom
odours just before or during a migraine
dental problems
smoking
exposure to certain chemicals such as insecticides
radiation for treatment of head and neck cancer
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PANTOSMIA Olfactory
hallucination
Neurological(nervous system) conditions
Less commonly, the cause of phantosmia is either nerve
cells sending abnormal smell signals to the brain, or a
problem with the brain itself.
This may be the result of:
a disease afecting the nervous system, such as
epilepsy, Parkinsons disease or Alzheimers disease
a stroke
a head injury
cancer usually a brain tumour or neuroblastoma (a
rare cancer that may start in the olfactory nerve)
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PANTOSMIA Olfactory
hallucination
Some people with phantosmia will find that the smell
gradually fades over a few months, and no treatment
is needed.
treatments may be tried:
A. Rinsing out the nasal passages with saline solution
B. Nasal drops or spray
C. Sedatives, antidepressants or anti-epileptic drugs

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TREATMENTS
effective treatment
for quantitative
olfactory losses is only available for the
conductive type where odorant molecules
cannot physically access the olfactory
receptors.
For neural quantitative losses, there are
generally no effective therapies. There is
no documented return of smell in patients
with complete congenital olfactory loss
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TREATMENT
For the two most common types of neural
losses, post head trauma and URI-related loss,
there is no predictably effective therapy
Olfactory training has been recently touted as
an effectivetherapy for those who have some
remaining olfactory ability (hyposmia, not
anosmia)
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HIGHLIGHTS
Disorders of smell are not infrequent and have a significant impact on
quality of life for those who are afflicted.

Olfactory receptor neurons are unique in their direct connection to the

brain and the regenerative capacity of the olfactory epithelium to replace
them throughout the life of the organism.
URis, head trauma, CRS, and aging are the mostcommon identifiable
etiologies for smell loss. In many cases, a cause for smell loss is never
identified.

Anamnesis and nasal endoscopy are crucial in the evaluation of patients

complaining of smell disorders.
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HIGHLIGHTS
Validated tests of smell are
available for use by all physicians
and allow for a subjective
assessment of the degree of
impairment.
Phantosmia and parosmia
commonly occur with olfactory loss,
but usually resolve spontaneously.

Physicians evaluating patients with

smell disorders need to discuss
hazards associated with smell loss
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Thank You

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