Smelling Disorders

Definition

Smelling disorders are disturbances of the olfactory sense, which is known as the sense of smell. These nasal dysfunctions range from the total loss of smell (anosmia ) to dysosmia, a distorted sense of smell.

Description

An awareness of how the olfactory system works is helpful for understanding how smelling disorders affect the sense of smell. People detect odors because sensory receptors located in the nose carry smell sensations to the brain. The receptors, which are nerve cell endings, are found in the mucous membrane in the roof of the nose. This section of the nose called the olfactory area is located just below the brain's frontal lobes.

In the olfactory area are millions of tiny olfactory cells. Each cell contains about 12 cilia, tiny hairs that extend into a mucus layer. The mucus moistens the cilia. Mucus also catches odor molecules, while receptors in the cilia stimulate the molecules and send nerve impulses to the brain.

Olfactory nerve fibers carry the impulse to two olfactory bulbs located in the brain. Information is processed in the bulbs and then sent to the cerebral cortex. Once the transmission is inside the smell center of the brain, a person experiences the sense of smell.

A person with a normal sense of smell (normosmia) is able to distinguish 10,000 odors. The sense of smell stimulates salivary glands. As a result, smelling disorders often affect the sense of taste. The olfactory sense allows people to experience pleasurable odors like the scent of roses. And smell is thought to contribute to sexual attraction.

A smelling disorder that affects the sense of smell is generally not life-threatening. However, it can be dangerous. Without a sense of smell, a person might eat spoiled food. Lack of a sense of smell could pose a health risk if a person has little appetite and fails to eat enough. Furthermore, without a sense of smell, a person might not detect a gas leak or the smell of something burning. Loss of smell and the resulting loss of taste may lead to depression.

Types of smelling disorders

Smelling disorders differ in the way that the sense of smell is affected and how long a person has the disorder. For example, anosmia, the loss of the sense of smell, is often a temporary symptom of a cold or flu. However, a head injury could cause permanent anosmia. In addition, a head injury could produce dysosmia, the distorted sense of smell that could cause a person to hallucinate a foul odor.

Smelling disorders are categorized as:

• Anosmia, the loss of the sense of smell. It is the most common smelling disorder. This condition can be temporary or permanent.
• Dysosmia is a distorted sense of smell. A person senses non-existent unpleasant odors. It can be caused by medical and mental conditions.
• Hyperosmia is an increased sensitivity to smell. It can be a characteristic of someone with a neurotic or histrionic personality.

• Hyposmia is the diminished sense of smell. This is usually a temporary condition that a person may experience after a case of acute influenza. Sometimes this condition is referred to as partial anosmia.
• Presbyosmia refers to the lessening or loss of the olfactory sense that occurs when a person ages.

Smelling disorder demographics

Anosmia occurs in about 10% of head trauma injuries, and head trauma is a leading cause of anosmia in young adults. In older adults, the disorder is generally caused by viral infection. Aging may also bring a loss of the sense of smell. In rare cases, anosmia is inherited. It is a symptom of male hypogonadism (Kallmann's syndrome).

Olfactory hallucinations known as dysosmia are generally associated with psychological conditions. In some cases, people may believe they are the source of foul odors.

Causes and symptoms

Anosmia is the most common type of smelling disorder. Loss of the olfactory sense is generally caused by nasal congestion or obstruction. Temporary partial anosmia often occurs when a person has a cold, the flu, or some types of rhinitis, especially hay fever (allergic rhinitis). During these conditions, nasal mucus membranes become inflamed. Other causes for anosmia are:

• Nasal polyps and other disorders that prevent air from getting to the area in the nose where the smell receptors are found. Hay fever or an allergy may cause one or more polyps to show up.
• Viral upper respiratory infection.
• Atrophic rhinitis. This condition causes mucus membrane to waste away. The person may experience some level of permanent anosmia. One symptom of this condition is that a person expels a foul-smelling discharge.
• Hypertrophic rhinitis. Mucous membrane thickens, covering the olfactory nerve endings. If not treated, hypertrophic rhinitis can lead to permanent anosmia. This discharge could overpower other odors.
• Cigarettes. Smoking aggravates the nose's membrane and intensifys nasal polyp symptoms.
• A crooked nose or a deviated septum.
• When the olfactory bulbs, tracts, or central connections are destroyed. This can occur in situations such as head trauma, infections or nasal or sinus surgery.
• Head injury. If both olfactory nerves are torn during a head injury, permanent anosmia results.
• Medications such as antihistamines and decongestants, especially prolonged use of decongestants.
• Drugs like amphetamines, estrogen, naphazoline, phenothiazines, and resperine.
• The aging process may cause the sense to lessen. In most cases, there is no other obvious cause for the disorder.
• A tumor behind the nose or in the membranes surrounding the brain.
• Lead poisoning.
• Exposure to insecticides or other chemicals.
• Radiation therapy.
• Nervous disorders.
• Idiopathic loss, which means there is no diagnosable cause for the condition.

Anosmia symptoms

Most people with anosmia can distinguish salty, sweet, bitter, and sour tastes since the tongue senses these tastes. However, people with anosmia cannot sense other tastes. Since taste is largely based on the olfactory sense, people complain of losing the sense of taste (ageusia).

Dysosmia

Infected nasal sinuses and damage to the olfactory bulbs can cause dysosmia, the distorted sense of smell. Head trauma can cause this disorder. Poor oral hygiene can lead to dysosmia. In these cases, a person may also find that disagreeable odors are accompanied by the sensing of unpleasant tastes. In addition, brain-stem disease can cause smelling disorders. An epileptic seizure can include olfactory hallucinations.

Mental conditions such as depression and schizophrenia may be accompanied by dysosmia. In addition, when people who are person severely dependent on alcohol quit drinking, they may experience dysosmia.

Diagnosis

If a smelling disorder is a symptom of a mental condition such as schizophrenia, diagnosis should be part of treatment for that condition.

When the condition is caused by a medical condition such as allergies or a viral infection, a person may notice that the olfactory sense is impaired during that condition. If the smelling disorder continues after the person is well, an appointment should be made with a primarily health care provider.

Diagnosis of smelling disorders begins with a health assessment to determine the cause of the olfactory impairment. The patient's primary care doctor will ask if the patient has a cold, allergies, sinusitis, or an upper respiratory infection.

Treatment of a head injury or follow-up medical appointment should address smelling disorders. In all cases, discussion of the symptoms covers issues such as when the smelling disorder started, if this has been an ongoing problem, and whether the disorder is becoming more intense. The assessment will include questions about whether the patient can taste food and if the disorder affects all odors or specific smells. The patient will also be asked about medications taken.

Physical examinations

The physical examination will include a thorough inspection of the nose, nasopharynx, and the examination of the upper respiratory tract. The examination could include sinus transillumination, placement of a light on the face to help determine if sinuses are full. Skull x rays may be required to determine the presence of tumors in the nose or brain.

The patient may be referred to a neurologist;—an ear, nose, and throat specialist;—or to a center that specializes in treatment of smelling disorders.

Other diagnostic tests could be required. These include:

• A CT scan (computed tomography scans ) of the head. Also known as a CAT scan, this process provides a more detailed image than the x ray.
• Olfactory nerve testing.
• Nasal cytology, which involves the study of mucus under a microscope.
• Testing to determine the scope of smelling disorder. A basic smell test involves the patient trying to identify each one of a group of different odors. A variation of this is a scratch-and-sniff test. The patient may be asked to differentiate among concentrations of one odor. The alcohol sniff test that involves use of a material soaked in isopropyl alcohol. Patients close their eyes and the doctor moves around. Patients tell the doctor when they smell the alcohol.
• The patient may also take a taste test.

Medical costs

The costs for diagnosis and treatment vary because of the different types of smelling disorders, the range of causes for olfactory dysfunction, and the different types of treatment.

There are also differences in what health plans require in terms of patient co-pay. A health plan could cover treatments ranging from the initial appointment with a primary care provider to the surgery to remove brain tumors.

In addition, some health plans cover costs of treatment at specialized facilities like the Center for Smell and Taste Disorders at the University of Colorado Health Sciences Center in Denver. A series of tests including a taste-and-smell test cost $250 in May of 2001.

Treatment

Treating a condition that causes a smelling disorder can sometimes restore the olfactory sense. Treatments for smelling disorders are as varied as the olfactory dysfunctions. Treatment for smelling disorders ranges from lifestyle changes to surgery. Treatment of mental conditions could affect the smelling disorder. In some cases, the disorder can't be treated, and the person must adjust to the loss of the sense of smell. Anosmia associated with aging is not treatable.

Basic treatments for anosmia

The sense of smell should return after a condition like a cold or the flu ends. Decongestants such as Sudafed help reduce congestion related to colds, allergies, and sinus conditions. Manufacturer's dosage recommendations should be followed. If anosmia is related to excessive use of nasal decongestants, a person should discontinue use of those medications.

Saline sprays can be used to clean the interior of the nose.

If smoking causes anosmia, a person should quit smoking.

The sense of smell may return after treatment of allergic or bacterial rhinitis and sinusitis. An over-the-counter antihistamine such as Actifed may provide relief.

If allergies cause anosmia, adjustments should be made to avoid allergens. If dust causes allergies, care should be taken to clean areas such as the bedroom.

Antibiotics may be prescribed for infections.

Other medications prescribed for smelling disorders include steroids such as Prednisone. It should only be used for a short time since longterm use could lessen resistance to infection.

Surgical treatment

Removal of nasal polyps and benign tumors may cause the sense of smell to return. Polyp removal is an uncomplicated surgery. Generally, only a local anesthetic is needed.

Septoplasty straightens the nasal passage. It is generally an outpatient surgery, with local or general anesthesia required. Rhinoplasty straightens the structure of the nose. This surgery could be combined with septoplasty.

Endoscopic sinus surgery opens sinus drainage channels. This outpatient surgery is an option after a person sees no improvement after trying treatments such as medications.

Surgical treatment may not be effective in conditions that result in the destruction of the olfactory nerve or its central passages. However, regeneration of those tissues may cause the sense to return.

Enhancing taste

Without a sense of smell, most people can still taste salt and flavors that are sweet, sour, and bitter. People with anosmia could distinguish other tastes by adding spices such as pepper to food. These spices stimulate facial nerves that also sense flavors.

Alternative treatment

Alternative treatments for smelling disorder center around the theory that zinc supplements help improve the sense of smell. The supplement is said to be effective when the olfactory sense is impaired by conditions such as a head injury or an upper respiratory infection. A person should take 50 mg of zinc picolinate each day after eating. This procedure might be effective in the case of head injury. However, it may be several months before results are seen. Acupuncture may also produce results.

If polyps cause a smelling disorder, a change in diet could be helpful. A person should avoid dairy products, take supplements such as garlic, and follow other recommendations from a health care practitioner. A daily dosage of 5,000-10,000 mg of vitamin C could cut back on the amount of polyps. Vitamins should not be taken all at once. A multi-vitamin and mineral complex could also help.

Prognosis

In cases where smelling disorders are treatable, the outcome is positive because the olfactory sense is restored. In those cases where the sense of smell is lost, the person must make adjustments to adapt to life without that sense. Those adjustments include using spices like pepper to stimulate tastebuds.

Since a person with anosmia can no longer smell food to determine whether it is safe to eat, care should be taken. The person who lives with other people can ask them if food smells fresh. People who live alone should discard food if there is a chance that it has spoiled. Other home safety measures include installing smoke alarms and gas detectors. Cooking on an electric stove is preferable to a gas stove.

Furthermore, people with smelling disorders can find support groups. These are often associated with smell and taste clinics. In addition, there are on-line bulletin board where people can share experiences. One site contains descriptions of how things smell. Those words provide a connection to a missing sense in the same way that sign language allows the hearing-impaired to understand the spoken word.

KEY TERMS

Histrionic— A behavior characterized by an excitable nature and the constant desire for stimulation.

Nasopharynx— The passage that connects the nasal cavity to the top of the throat.

Neurotic— Behavior characterized by neurosis, mental functional orders with symptoms such as anxiety, depression, compulsions, and phobias.

Polyp— A benign growth in areas such as the nasal passage.

Rhinitis— The inflammation of the mucous membrane in the nose.

Septum— A sheet of cartilage and bone that separates the nostrils.

Sinusitis— Inflammation of the paranasal sinuses because of allergic reactions or viral, bacterial, or functional infections.

Prevention

Not all causes of smelling disorders can be prevented. However, people with a disorder should not smoke and should ask those around them not to smoke. Those with smelling disorders related to allergies should be taken to avoid allergens. Since head trauma injuries can lead to smelling disorders, people should wear protective helmets when bicycling or participating in sports like football.

Resources

BOOKS

Watson, Lyall. Jacob's Organ and the Remarkable Sense of Smell. New York: W. W. Norton & Company, 2000.

ORGANIZATIONS

American Academy of Otolaryngology-Head and Neck Surgery. One Prince St., Alexandria, VA 23314-3357. (703) 836-4444. 〈http://www.ent.org〉.

Center for Taste and Smell Disorders. University of Colorado Health Sciences Center, 4200 E, Ninth Ave., Denver, CO 80262. (303) 315-5660. 〈http://www.hsc.colorado.edu〉.

U.S. Department of Health and Human Services. 200 Independence Avenue, SW, Washington, DC 20201. (877) 696-6775. 〈http://www.hhs.gov〉.