Clinical History

A patient's description of the nature and onset of the chemosensory problem is an essential element of the clinical history, as is an historical assessment of the patient's general health, including endocrinological state, hospital admissions, surgical interventions, radiological treatments, and medications received for other conditions. The use of thyroid agents and drugs that affect cell turnover (e.g., chemotherapeutic drugs) may be of etiological significance. Retarded or delayed puberty in association with anosmia (with or without midline craniofacial abnormalities, deafness, and renal anomalies) suggests the possibility of Kallmann's syndrome. Importantly, associated events such as viral or bacterial respiratory infections, head trauma, exposure to toxic fumes, systemic diseases, and signs of early parkinsonism or central tumors are critical for arriving at an etiological diagnosis, which is possible in the majority of cases. Information related to exposure to environmental chemicals and signs of seizure activity (e.g., automatisms, occurrence of blackouts, deja vu, etc.) should be sought, particularly in patients in whom heightened sensitivity is a symptom. Attention to the possibility of renal disease as well as liver disease is crucial, given reports of alterations of olfactory function in patients with cirrhosis of the liver, acute viral hepatitis, or renal dysfunction. Decreased olfactory function has been observed in some persons with human immunodeficiency virus (HIV) infection.

In patients complaining of anosmia or hyposmia, it is useful to ask whether smell function is diminished or completely lost, localized to the right or left nostril, or both, and whether the dysfunction is for all odorants or only a few. Patients with loss due to nasal sinus disease are more likely to experience a gradual loss of function than those who have loss due to a prior upper respiratory infection or to head trauma. [1] Some patients report temporary recovery of function in circumstances in which nasal patency is increased, such as on warm days or during exercise, showering, or treatment with corticosteroids; this implies a problem with intranasal airway blockage (as in allergic rhinitis) rather than a sensorineural problem.

The smoking history should be explored in light of evidence that the ability to smell decreases as a function of cumulative smoking dose and that cessation of smoking can result in improvement in olfactory function over time. [2] A history of allergy should be sought, as should a history of current or past nasal or paranasal sinus infections. Inquiry should be made about nasal or paranasal sinus operations or other treatments such as the use of topical intranasal medications. Importantly, the association of nasal obstruction, headache, facial pain, postnasal discharge, purulent or clear rhinorrhea, ear symptoms, and throat symptoms should be sought with specific questioning. The order in which the symptoms appeared and regressed is at times helpful. The duration of the problem is important in relation to the possibility of spontaneous recovery, which is generally assumed to be unlikely after 6 months if damage to the olfactory epithelium has occurred.

The patient should be asked about olfactory distortions and whether they seem to be bilateral or are confined to one or the other nasal chamber. In various stages of olfactory epithelial degeneration or regeneration, a dysosmia--usually foul--is often present that may or may not require an inhaled stimulus for elicitation. Dysosmias are sometimes associated with certain mental disorders, including epilepsy, psychosis, schizophrenia, and depression-related syndromes such as the olfactory reference syndrome.^ In some cases, aura-like dysosmic phenomena may occur without any evidence of seizure activity. Fortunately, most olfactory perversions are temporary, although long-standing cases have been reported.

Exploring a patient's complaint of taste loss is essential because it usually reflects an olfactory disorder. It is useful to have the patient differentiate between the loss of perception of flavors of food or beverages and the loss of perception of sweet, sour, bitter, and salty stimuli. The physician can ask whether the patient is able to perceive saltiness in potato chips, sourness in lemonade, or sweetness in sugar on cereal to arrive at this differentiation. A patient with anosmia may be able to taste the sweetness of an apple or a pear but is unable to distinguish between their flavors.


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