8/17/2012

1

Troy Woodard, MDKathleen Yappel Sinkko, CNP

Rhinology, Sinus, and Skull Base Surgery

� 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

� Provide cases and identify educational needs of a patient with a smell and taste disorder

� Estimated that 2.7 million Americans have olfactory problems� 2/3rd 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

� Purpose

▪ Identify food, mates, predators

▪ Warns of danger

▪ Fire

▪ Spoiled food

▪ Gas Leaks

� Neuroepithelium

� Located in the superomedial and lateral nasal cavity

8/17/2012

2

� Olfactory receptors

� Bipolar neurons that extend

into the CNS

� Up to 100 million olfactory

neurons on each side

� Generated every 30-60 days

� G-protein mediated

� 300-400 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 5th taste?

� Umami (Savory- glutamate) NEW!

� Salty and Sour- Ion (NaCl and 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

8/17/2012

3

� Other locations for taste buds

� Palate

▪ CN IX

� Epiglottis and Larynx

▪ Superior laryngeal branch of CN X

� Pharynx

▪ CN IX and CN X

� Free nerve endings from CN V� Irritants, burning, tickling, stinging

� Sensitive to just about all chemicals if concentrated enough

Is taste regionalized?

� 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

� 300-400 receptor types

� Develop every 30-60 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

� Toxins

� Trauma

� Endocrine

� Neoplasia, Neuro

� S (Psychiatric)

8/17/2012

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

� Toxins 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

� Toxins

� 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

� Toxins� 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?

8/17/2012

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 34-40

▪ Microsmia 19-33

▪ 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.

8/17/2012

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 VERY difficult

� 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

� Toxins� 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

� Toxins▪ Eliminate exposure to toxins

▪ Consider stopping medication

8/17/2012

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

� Take steps to discover

etiology

� Treat appropriately

� Potentially Reversible

� Reassure and educate

our patients

Case Presentations

� 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.)

8/17/2012

8

� Past Medical history:

-Environmental allergies

-Asthma (controlled with meds)

-No history of facial or head trauma

-Nonsmoker

� Past surgical history:-No history of sinus or nasal surgery

� Current nasal medications:

-Veramyst 2 sprays each nostril QD

-Astelin nasal spray 2 sprays each nostril BID

What’s Next?

� Physical Exam

� Physical exam findings:

-Anterior rhinoscopy: left septal deviation and

right sided nasal polyps

-Nasal endoscopy: bilateral polyps filling the nasal cavity

8/17/2012

9

� K (Congenital)

� Inflammatory

� Toxins

� Trauma

� Endocrine

� Neoplasia, Neurologic

� S (Psychiatric)

� What is the mechanism of this smell

disorder?

� 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

8/17/2012

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

8/17/2012

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

� K (Congenital)

� Inflammatory

� Toxins

� Trauma

� Endocrine

� Neoplasia, Neurologic

� S (Psychiatric)

� What are the possible mechanisms of this

patients smell disorder?� 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)

� 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

8/17/2012

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

� MRI is 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.)

8/17/2012

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