Olfaction in patients with nasal polyposis: effects of systemic steroids and radical ethmoidectomy with middle turbinate resection (nasalization)

AIM: In this prospective study the effect of medical and surgical treatment on subjective olfaction was studied in patients with nasal polyposis (NPS). The effects on nasal obstruction, anterior and posterior rhinorrhea, sneezing and itching are reported in another article in this issue. PATIENTS AND METHODS: Protocol 1. Twenty-four patients with NPS who complained about anosmia were treated with a 7-days course of systemic steroids. Their subjective overall sense of smell was determined with a visual analog scale (VAS) before treatment, immediately after treatment, and two months later. Subsequently all patients underwent surgery bilaterally according to the nasalization principles. The sense of smell was re-evaluated at 1, 3, 6, 9, and 12 months postoperatively. Protocol 2. Thirty-two patients with NPS not responding to medical therapy who, for different reasons, did not receive oral steroid treatment, received surgery only and were followed up during one year after nasalization. Of these patients, 25 were anosmic and 7 normosmic. RESULTS: Protocol 1. Following the 7-day treatment with systemic steroids the olfactory score increased significantly. During the waiting time for surgery (64 +/- 39 days) this score deteriorated again in a significant way. One month after nasalization which included a depot injection of triamcinolone 80 mg the day after surgery, the olfactory score ameliorated again and remained stable at 3, 6, 9, and 12 months. None of the patients reported any intake of systemic steroids during the one-year of follow-up. Statistically, there was a trend suggesting that the 12 month post-nasalization score was better than the immediate post-oral steroid score. A good correlation between the improvement of the sense of smell after 7 days of systemic steroids and one year after nasalization was found. Protocol 2 One month after the nasalization protocol, olfaction in patients of the hypo-anosmic group had improved considerably. Scores at 3, 6, 9, and 12 remained very stable. The sense of smell in the normosmic group did not change after surgery and remained stable during the year of follow-up. In total, 49 patients with a severe loss of smell showed a significant improvement at 12 months after surgery. CONCLUSION: The present study shows that 1) long-lasting correction of olfactory dysfunction produced by nasal polyposis can be achieved through the combination of nasalization and low dose of nasal steroids, 2) middle turbinate resection does not alter the possibilities to restore the sense of smell.     

Impaired sense of smell in patients with nasal surgery

The aim of the study was to determine the incidence of olfactory disorders before and following nasal and paranasal sinus surgery. It was a prospective observational study. Over a 6-month period, all patients who had been listed for nasal and paranasal sinus surgery underwent preoperative and postoperative evaluation of their sense of smell. A questionnaire and the 'Smell Diskettes Test' were used to assess olfaction. One hundred and eighty-four patients were studied. Preoperatively, 19 patients (10.3%) had an impaired sense of smell (8.1% before septoplasty, 6.1% before rhinoplasty and 17.1% before endoscopic sinus surgery). Only 16 (84%) of these patients were aware of their impaired sense of smell. Following surgery, four patients (2.5%) who were normal preoperatively developed impaired olfaction on questioning, and this was supported by testing it. In the subgroup that had a septoplasty, no patient developed hyposmia compared to one patient (2.6%) after rhinoplasty and one patient (3%) after endoscopic sinus surgery. No patient developed anosmia. Preoperatively, 10.3% of patients had an altered sense of smell, making it desirable that this is documented in order to avoid postoperative claims that this was caused by surgery. It also helps to audit the results of surgery.     

Comparison of the effect of endoscopic sinus surgery versus medical therapy on olfaction in nasal polyposis

Chronic rhinosinusitis is a common inflammatory condition in western countries. Nasal polyposis has different symptoms such as nasal obstruction, anterior or posterior nasal drip, reduced sense of smell, and facial pain. Medical and endoscopic treatments are the two main treatments for nasal polyposis. Our aim was to compare the efficacy of different methods on olfactory function. This is a non-randomized clinical trial study that was done on 60 patients who were divided into two groups (medical and surgical). Patients were matched based on age, history of smoking, and the severity of obstruction. The radiologist score of Lund-Mackay staging system was used to match patients in two arms of the trial based on the severity of nasal obstruction. Patients in surgery groups underwent functional endoscopic sinus surgery under general anesthesia and then received Fluticasone propionate nasal spray for 8 weeks (400 mcg bd). Patients in the medical group were only prescribed with Fluticasone propionate with the same duration and same dose as mentioned. As a result of treatment protocol, both medical and surgical group experienced improvement in olfactory function but statistical analyses revealed that surgery resulted in better resolution of symptoms. Our observation revealed that combined treatment had a better effect than medical treatment in restoring olfaction in patients with nasal polyposis.     

The validity of CCCRC test in patients with nasal polyposis

Both the Connecticut Chemosensory Clinical Research Center (CCCRC) test and Cross Cultural Smell Identification Test (CC-SIT) are used to assess the sense of smell in patients all over the world. Our aim is to know whether the CCCRC test is a valid olfactory test in comparison with CC-SIT. Therefore, we have done a prospective study in 60 adult patients with nasal polyposis to compare the validity of CCCRC with UPSIT. We used the CCCRC olfactory test made up of a threshold and suprathreshold test while CC-SIT relies solely upon suprathreshold measurement. We determined the specificity, sensitivity, positive predictive value and negative predictive value for patients suffering nasal polyposis with the CCCRC test. The validity index was 95% and accuracy rate was 8%. We determined unit cost and the reliability of the CCCRC test. For patients with nasal polyposis: the sensitivity was 86%; the specificity was 94%; the positive predictive value was 93% and the negative predictive value was 88%. The reliability was 92%. The unit cost of the CCCRC was 5.60 euro. The CCCRC test is a valid test in comparison with CC-SIT. CCCRC is cheap and can be used in routine clinical settings.     

Differences between orthonasal and retronasal olfactory functions in patients with loss of the sense of smell

OBJECTIVE: To investigate differences between orthonasal and retronasal olfaction in patients with loss of the sense of smell without taste complaints. DESIGN: Electrophysiological and psychophysical testing of orthonasal and retronasal olfactory functions. SETTING: Outpatient clinics. PATIENTS: A series of 18 patients who had olfactory loss due to various reasons but no "taste" complaints. MAIN OUTCOME MEASURES: Orthonasal and retronasal olfactory functions assessed by olfactory event-related potentials and psychophysical smell tests. RESULTS: Psychophysical testing revealed retronasal olfaction to be normal or slightly altered, whereas orthonasal olfaction was either absent or severely compromised. Findings from nasal endoscopic examinations and computed tomographic scans were within the reference range in all subjects. In response to orthonasal stimulation there were neither detectable olfactory event-related potentials nor any with small amplitudes, whereas olfactory event-related potentials in response to retronasal stimulation were clearly present in some patients. CONCLUSION: These clinical observations, together with the psychophysical and electrophysiological findings, suggest that orthonasal and retronasal olfaction might be processed differently.     

Olfaction in rhinology--methods of assessing the sense of smell

Olfactory disorders frequently occur in rhinological disease. Different subjective and objective test methods are available to assess the sense of olfaction. Among the subjective methods, screening tests and threshold measurements are commonly used to quantify hyposmia or anosmia. Qualitative methods are available using discrimination and identification tests. Objective methods are used in research and in some medicolegal situations. Objective tests include olfactory evoked potentials, functional Magnetic Resonance Imaging and functional Positron Emission Tomography. The measurement of the sense of smell helps to assess the whole spectrum of the effects of nasal disease. This is especially important before rhinological surgery, because a non-detected smell disorder in patients with rhinological disease is common. The assessment of a pre-existing hyposmia or anosmia helps to avoid a postoperative claim that this was caused by surgery. A variety of validated screening tests for olfaction is available and they are a useful tool to document whether a patient is able to smell.     

Olfaction after endoscopic sinus surgery: long-term results

Loss of olfactory function is one of the main symptoms in patients with chronic rhinosinusitis. This prospective, non-randomized interventional study reports five years results of olfaction of patients with chronic rhinosinusitis who underwent endoscopic sinus surgery in conjunction with topical medical treatment. Forty-five patients with chronic rhinosinusitis who underwent endoscopic sinus surgery were evaluated preoperatively, after three months and 34 (76%) of them after five years. Olfactory function was assessed by a subjective visual analogue scale, by a screening test of olfaction with Smell Diskettes and by measuring the N-Butanol threshold. Patient`s subjective sense of olfaction using a visual analogue scale was improved in 79% at 5 years. Objective measurements by Smell Diskettes improved in 53% at 5 years whilst the quantitative measurement by the N-Butanol threshold improved in 85% at 5 years. The high percentage of patients with improvement of olfaction five years after surgery indicates that endoscopic sinus surgery in conjunction with continued topical treatment leads to a long term improvement of the sense of smell. However, it was found that - measured by the sensitive N-Butanol threshold - up to 9% had no improvement and 6% had deterioration in their olfaction at 5 years after endoscopic sinus surgery. This fact has to be considered in the preoperative counselling of patients.     

Olfactory function following nasal surgery

Objective/Hypothesis: This prospective study aimed to investigate predictors of nasal surgery in terms of olfactory function. Study Design: Prospective study. Methods: A total of 775 patients were included in this prospective study (482 men, 293 women; age range 10–81 years, mean age 41 years, standard deviation = 15.3 y). Prior to surgery, patients received a detailed otorhinolaryngologic examination including nasal endoscopy. Olfactory function was assessed with a standardized odor identification test (“Sniffin' Sticks”). In 356 patients, olfactory function was retested 4 months after surgery (63–339 days after surgery; mean 128 days, standard deviation = 29 days); 206 of these patients received sinus surgery, while 150 received surgery involving the septum. Results: Using a conservative definition of change of olfactory function, following sinus surgery, improvement of the sense of smell was found in 23%, no change was seen in 68%, and decreased function was seen in 9% of the patients; in patients with septum surgery, improvement was seen in 13%, no change in 81%, and decreased function in 7%. Patients exhibiting a postoperative decrease of olfactory function had significantly higher preoperative olfactory scores than patients who experienced improvement. In terms of the sense of smell, nasal surgery produced the highest success rates in patients with eosinophilia and a high degree of polyposis. Neither age nor sex had a major impact on the outcome of surgery in terms of olfactory function. Conclusions: These results in a large group of patients confirm previous work. Apart from apparent success in 13 to 23% of patients, there is also a small but significant group of patients (7 to 9%) in whom olfactory function decreases after surgery. Because this decrease was mostly found in patients with relatively good preoperative olfactory function, this group should receive specific attention when counseling patients about the potential risks of nasal surgery.     

Olfactory changes at threshold and suprathreshold levels following septoplasty with partial inferior turbinectomy

Partial inferior turbinectomy with septoplasty is routinely carried out for airway obstruction. However, its effects on the sense of smell have not been systematically evaluated. The aim of this prospective study was to evaluate the influence of septoplasty with partial inferior turbinectomy on threshold and suprathreshold olfactory acuity. The subjects were 30 patients undergoing septoplasty including partial inferior turbinectomy. Olfactory function was determined by the "Sniffin' Sticks," which allow the assessment of odor thresholds, odor discrimination, and odor identification. The patients rated both olfactory function and nasal airflow using visual analog scales. Nasal airflow was measured by anterior rhinomanometry. Multivariate analyses of variance for repeated measures were used to analyze the results before and after surgery (mean interval, 9.1 weeks). After operation, 87% of the patients had increased airflow, 80% had improved olfactory function in terms of odor identification, and in 70% odor discrimination was found to be improved - but only 54% had improved olfactory function in terms of odor thresholds. Surgery increased ratings of nasal airflow in 93%, and those of olfactory function in 77% (p < .001). Similarly, bilateral inspiratory nasal flow increased (p < .001) and olfactory function was improved (p < .001) after surgical treatment. However, this increase was most pronounced for suprathreshold tests, while it was moderate for odor thresholds (interaction "surgery" x "olfactory test," p = .001). The present investigation suggests that septoplasty in combination with inferior turbinectomy has a beneficial effect on olfaction, mainly on suprathreshold olfactory functions. This effect may be partly due to interactions between the increased perception of nasal airflow and cognitive factors involved in olfactory sensitivity. According to the present results and data from the literature, a moderate decrease of olfactory function appears to occur in as many as 20% of patients. However, anosmia seems to be an extremely rare complication of septoplasty and partial turbinectomy.     

Importance of unilateral examination in olfactometry

Hyposmia, the decreased sense of smell, and anosmia, the loss of sense of smell, may be unilateral or bilateral. If the olfactory acuity examined by means of bilateral test is normal, olfactory disorders are not found; unilateral examination is therefore necessary for definite evaluation of olfactory acuity. As evidence, 7 cases out of 94 patients with chronic rhinosinusitis and 6 cases out of 12 patients who received the surgery of anterior cranial fossa showed definite different olfactory threshold between nasal cavities, and there were no patients who recognized the diminished sense of smell in spite of unilateral high olfactory threshold. Additionally, we have experienced that a patient with brain tumor was diagnosed by the help of unilateral olfactory test. We thus strongly recommend the unilateral olfactometry as a method for simple and reliable test in clinical measurement of the sense of smell.     

Evaluation of the efficacy of the ‘nasal airflow‐inducing manoeuvre’ for smell rehabilitation in laryngectomees by means of the Sniffin′ Sticks test

Clin. Otolaryngol. 2011, 36 , 17–23 Objective: To determine the efficacy of the nasal airflow‐inducing manoeuvre (NAIM) as a method for olfactory rehabilitation in laryngectomees by the means of the Sniffin′ Sticks test. Study design: Prospective open interventional trial. Setting: Tertiary academic hospital. Participants: Thirty‐seven patients after laryngectomy have been screened and 25 patients have been included into the study. The participant’s sense of smell was tested with the Sniffin′ Sticks test before and after learning the nasal airflow inducing manoeuvre. The individual level of threshold, discrimination and identification (TDI) was determined and the individual threshold, discrimination and identification score was used to classify the patients as being anosmic, hyposmic or normosmic. Main outcome measures: The primary endpoint was the change of the threshold, discrimination and identification score before and after learning the nasal airflow inducing manoeuvre. The secondary endpoint was a change in the diagnostic group (normosmic, hyposmic and anosmic) after learning of the nasal airflow inducing manoeuvre. Results: There was a statistically significant increase in the total threshold, discrimination and identification score (P < 0.001) and the three sub‐scores (P ≤ 0.02) before and after the learning of the nasal airflow inducing manoeuvre. Patients gained seven points on average in the threshold, discrimination and identification score. Twenty of 25 patients showed an increase of five or more point in the threshold, discrimination and identification score. In the classification of the smell ability, 15 of 25 patients showed a change to a higher class (hyposmic to normosmic or from anosmic to hyposmic or normosmic). Conclusion: The nasal airflow inducing manoeuvre is a method for the successful rehabilitation of the sense of smell in laryngectomees. The evaluation with the Sniffin′ Sticks tests showed a clinically relevant increase of olfaction in 80% of patients. The teaching of the nasal airflow inducing manoeuvre should be included in post‐laryngectomy rehabilitation programmes.     

Effectiveness of olfactory rehabilitation with the nasal airflow-inducing maneuver after total laryngectomy: one-year follow-up study

OBJECTIVE: To assess the long-term results of the nasal airflow-inducing maneuver in olfaction rehabilitation in patients who had undergone laryngectomy. DESIGN: Prospective interventional study. SETTING: University hospital. PATIENTS: Twenty-four patients who had undergone laryngectomy (21 men and 3 women; mean age, 68 years) who received olfactory rehabilitation with the nasal airflow-inducing maneuver were reevaluated 6 and 12 months after primary treatment. MAIN OUTCOME MEASURE: Olfactory function was tested by means of a semistructured interview; the Questionnaire on Olfaction, Taste and Appetite; and the Scandinavian Odor-Identification Test. Quality of life was measured with the European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-H&N35 questionnaires. Patients were categorized as smellers or nonsmellers based on results of the Scandinavian Odor-Identification Test. RESULTS: Before treatment, 10 of 24 patients (42%) were smellers and 14 (58%) were nonsmellers. At 6-month follow-up, 20 of 23 patients (87%) were smellers, whereas after 12 months, 21 of 24 patients (88%) were smellers. Long-term olfaction rehabilitation was achieved in 11 of 14 patients (79%) with anosmia, and 15 of all 24 patients (63%) could be classified as having normal olfactory capacity at the end of the study. CONCLUSION: The nasal airflow-inducing maneuver is a patient-friendly, inexpensive, and effective method for restoring the sense of smell in patients after laryngectomy, and the results persist in the long term.     

Clinical relevance of nasal polyps in individuals recruited from a general population-based study

OBJECTIVE: To compare the clinical presentations of individuals with nasal polyps detected by endoscopy in a general population sample with those of patients with nasal polyp disease seeking medical attention. MATERIAL AND METHODS: A total of 38 individuals with nasal polyps from a population-based sample were compared with 38 matched controls and a third group consisting of 44 patients who presented to an outpatient clinic with symptoms and diagnosed nasal polyps Upper and lower airway symptoms were registered. Polyp size, peak nasal inspiratory flow (PNIF), olfactory function and health-related quality of life were measured. RESULTS: Compared with the individuals with nasal polyps in the population sample, patients actively seeking medical care for nasal polyposis experienced more symptoms of nasal blockage and an impaired sense of smell, and had more extensive polyps and reduced PNIF. There were equal frequencies of asthma symptoms in these two groups. Compared with the controls, the individuals with nasal polyps in the population sample had a greater frequency of asthma symptoms and aspirin intolerance and also experienced an impaired sense of smell. CONCLUSION: Nasal polyps alone, as seen occasionally, are indicative of airway disease involving the upper and lower respiratory tracts.     

Olfactory dysfunction due to nasal sinus disease. Causes, consequences, epidemiology, and therapy

Olfaction not only contributes to our quality of life but, among other functions, it is also necessary for identifying potential dangers, e.g., fire or spoilt food. In general the value of olfaction is only recognized when the sense of smell is impaired or lost. Olfactory dysfunction is diagnosed according to its cause (e.g., sinonasal, post-traumatic, post-upper respiratory tract infection, neurodegenerative, and idiopathic). At present little is known about prognostic factors for predicting resolution of olfactory loss on an individual basis. In cases of impaired olfaction due to sinonasal disease, both conservative and operative treatments have been established. Corticoids are used both topically and systemically. In cases of severe mechanical obstructions or advanced stages of nasal polyposis, FESS (functional endoscopic sinus surgery) seems to be the state of the art.     

Placebo-controlled,randomized, double-blind study evaluating the efficacy of fluticasone propionate nasal spray for the treatment of patients with hyposmia/anosmia

OBJECTIVE: To compare the effect on olfaction of topical glucocorticoid treatment versus placebo given for an extended period in addition to oral short-term glucocorticoids in patients with anosmia/hyposmia. MATERIAL AND METHODS: This was a randomized, double-blind, placebo-controlled study. The criterion for inclusion in the blinded phase was an improvement of at least 2 steps in the butanol odor threshold test following open treatment for 10 days with oral and nasal corticosteroids. Forty patients were included: 20 were randomized to treatment with fluticasone propionate, 10 to placebo and 10 others as controls. The topical treatment was continued for 6 months. RESULTS: The 3 groups showed similar improvements in their sense of smell after the initial 10-day treatment with combined oral and nasal corticosteroids. Patients who continued the local treatment maintained the same level of improvement throughout the study, whether or not they had been given nasal corticosteroids or placebo. We found no significant differences between the treatment groups. CONCLUSIONS: In patients with anosmia/hyposmia partly caused by local inflammation, no further improvement in the olfactory threshold is achieved by continuing with a topical intranasal glucocorticoid after an initial combined topical and systemic glucocorticoid treatment.     

Sinunasal bedingte Riechstörungen

Olfaction not only contributes to our quality of life but, among other functions, it is also necessary for identifying potential dangers, e.g., fire or spoilt food. In general the value of olfaction is only recognized when the sense of smell is impaired or lost. Olfactory dysfunction is diagnosed according to its cause (e.g., sinonasal, post-traumatic, post-upper respiratory tract infection, neurodegenerative, and idiopathic). At present little is known about prognostic factors for predicting resolution of olfactory loss on an individual basis. In cases of impaired olfaction due to sinonasal disease, both conservative and operative treatments have been established. Corticoids are used both topically and systemically. In cases of severe mechanical obstructions or advanced stages of nasal polyposis, FESS (functional endoscopic sinus surgery) seems to be the state of the art.     

Olfactory dysfunction in nasal polyposis: correlation with computed tomography findings

AIMS: This study evaluates if a computed tomography (CT) scan is useful to assess the olfactory loss in sinonasal disease, and if a preoperative CT scan has a predictive value for the long-term outcome regarding olfaction. METHODS: Thirty-one patients with nasal polyposis were included. Olfactory function was assessed with the 'Sniffin' Sticks' test and subjective perception recorded with a visual analogue scale. CT scans were assessed with the Lund-Mackay system and the Damm nasal segmentation. Patients were retested after endoscopic sinus surgery in a follow-up appointment at least 1 year later. RESULTS: Disease in the upper meatus and the posterior portion of the middle meatus strongly affects olfactory function. Lund-Mackay scores were significantly correlated with preoperative olfactory test results. Preoperative subjective ratings had a significant correlation only with present disease in the anterior upper meatus. Postoperative results were significantly decreased. Their relative percentage change was correlated only with the preoperative presence of disease in the anterior upper meatus. No correlation was found between the Lund-Mackay score and the postoperative olfactory results. CONCLUSIONS: Olfactory dysfunction in nasal polyposis is strongly related to specific obstructed nasal areas. A CT scan has no predictive value for the long-term surgical outcome regarding olfaction.     

Effect of surgical treatment of olfactory disturbance caused by localized ethmoiditis

Twenty patients who had disturbance of the sense of smell caused by localized inflammation of the ethmoid sinus were studied to determine the effects of endonasal ethmoidectomy on olfaction. The patients were evaluated pre and post-operatively regarding their subjective olfaction, and with the T&T olfactometry and the Alinamine intravenous administration test, both of which are widely used in Japan. The improvement rate was 70.0% subjectively and 80.0% with T&T olfactometry 6 months after surgery. It is concluded that surgery is worthwhile treatment for olfactory disturbances caused by localized ethmoiditis.     

A prospective study of olfaction following endoscopic sinus surgery with adjuvant medical treatment

Few studies on the outcome of endoscopic sinus surgery have assessed the effect of this treatment on the sense of smell. We have collected data prospectively on 115 patients, before and 6 weeks after surgery. All patients had bilateral chronic rhinosinusitis. Visual analogue and a 4-grade, patient-rated symptom score related to olfaction was collected. Patients were also asked after surgery whether their sense of smell was normal, better, a little better, the same, a little worse or worse. Paired phenylethyl methyl ethyl carbinol olfactory detection thresholds were determined for 102 of the patients. All parameters showed a statistically significant improvement (P < 0.001). Acoustic rhinometry was performed pre- and postoperatively in 96 patients. The improvement in all olfactory symptom scores was found to correlate with the increase in nasal volume (Spearman rank correlation: visual analogue score, P < 0.005; 4-grade scale, P = 0.03; ‘better, same, worse’ scale, P = 0.001).     

The effectiveness of steroid treatment in nasal polyposis

OBJECTIVE: The objectives of the management of nasal polyposis are to eliminate or reduce the size of polyps, reestablish nasal breathing, reduce symptoms of rhinitis, restore the sense of smell, and prevent the recurrence of nasal polyps. Local or systemic steroids have been used in the treatment of nasal polyps, but efficacy of combined (local and systemic) steroids in nasal polyposis has been little investigated. The aim of this study was to evaluate the influence of combined steroid therapy on the symptoms and extent of the disease in patients with nasal polyposis. METHODS: Seventeen patients with nasal polyps were treated with combined steroids. Before and after the therapy, polyp size, nasal symptoms, sense of smell, and headache or facial pain were assessed by an established scoring system. RESULTS: After the therapy, symptom scores of all the patients improved. Of the patients, 12% showed a polyp-free nasal cavity, 76% a clear involution of polyps, and 12% no response to the therapy. There were statistically significant differences (P<0.001) for symptom scores and polyp size. Medical ablation of polyps using steroids was not achieved in 88% patients. CONCLUSION: Steroids can reduce polyp sizes and improve the symptoms, but are inadequate to eradicate the polyps. Surgery still plays a major part in the treatment of the nasal polyposis, but steroids can delay the necessity for surgical intervention.