[Olfactory dysfunction. Epidemiology, pathophsiological classification, diagnosis and therapy]. / Riechstörungen. Epidemiologie, pathophysiologische Klassifikation, Diagnose und Therapie.

The present manuscript is the result of a collaborative effort within the framework of the Working Group of Olfactology and Gustology of the German Society for ENT, Head and Neck Surgery. It provides a comprehensive overview about the current views on the epidemiology, terminology, diagnostics, and therapy of olfactory dysfunction, and aims to offer a framework for the standardized procedures for the diagnosis and therapy of olfactory disorders.

[Drug therapy for disturbances of smelling]. / Medikamentöse Therapie der Riechstörungen.

Disorders of the sense of smell are frequent. This severely can affect the quality of live. Appropriate testing is needed to determine the nature of the patient's complaints. Following the pathogenesis, two main groups of smell disorders are discernable: The conductive-respiratory smell disorders, where the odour can not reach the receptor and the senso-neuronal disorders where perception or transduction is affected. Therefore two different therapeutical approaches are described.

[Olfactory dysfunctions. Epidemiology and therapy in Germany, Austria and Switzerland]. / Riechstörungen. Epidemiologie und Therapie in Deutschland, Osterreich und der Schweiz.

INTRODUCTION: Olfactory dysfunction has been reported to affect more than 200,000 patients a year in the USA. The aim of this survey was to obtain comparable epidemiological data and treatment information on olfactory dysfunction in German speaking countries. METHODS: Questionnaires were sent to all otorhinolaryngology departments in Germany, Austria and Switzerland; 52% of hospitals completed the survey. RESULTS: An average of 46 patients with olfactory dysfunction were treated per hospital every month. Hyp- and anosmia were most commonly caused by inflammatory diseases of the nose/paranasal sinuses (53%), respiratory dysfunction (19%), or postviral conditions (11%). Steroids were used most frequently for pharmacological treatment (topically 82%; orally 65%). Approximately one third of the clinics used B vitamins, or zinc; 80% of the hospitals performed surgery to treat underlying diseases. Acupuncture and smell training was used by approximately 20%. CONCLUSION: A total of 79,000 patients per year are treated for olfactory dysfunction in German hospitals. The vast majority of these disorders (72%) is caused by sinunasal diseases. The quality control of therapeutic strategies is urgently needed.

Quantitative assessment of gustatory function in a clinical context using impregnated "taste strips".

Assessment of gustatory sensitivity in a clinical setting is the prerequisite for correct diagnosis and adequate treatment of taste dysfunction. Despite of this, no taste test has been established for the routine clinical testing. The aim of the present study was to create a protocol which is easy to administer. The presently used technique is based on strips made from filter paper which were impregnated with different taste solutions (four concentrations each for sweet, sour, salty and bitter). These strips are placed on the tongue and subjects are asked to identify the taste quality. After establishing the concentration range of the taste solutions, the test was tried in 69 subjects. Each subject received eighteen taste strips (four concentrations of each taste quality plus two blanks) in a pseudo-randomized sequence. Results from this new procedure correlated significantly with the results of the well established extensive three-drop-technique (r69 = 0.67). Repeated measures indicated good reproducibility of the results for the taste strips (r69 = 0.68). These data suggest the usefulness of this new technique in routine clinical practice. Major advantages are long shelf-life, convenience of administration, short time needed for testing (approximately 8 min), and the possibility to test each side of the tongue separately.

Olfactory function in HIV-positive subjects.

The aim of this study was to reinvestigate previous reports of chemosensory dysfunction in HIV-positive subjects. Odor thresholds, odor discrimination and odor identification were assessed using the Sniffin' Sticks test battery. Seventy-four HIV-positive patients were tested. According to CDC criteria, 38 subjects were classified as stage A, 10 as stage B and 26 as stage C. None of the subjects exhibited severe cognitive impairment. Compared to normative data all subjects had normal odor identification and discrimination. However, odor thresholds were well below the median of a normal population. There were no significant differences between stage A, B or C subjects. This may be interpreted as indicating that olfactory dysfunction is among the primary deficits of HIV infection and occurs independently of disease stage. These results confirm previous work suggesting that odor thresholds are elevated early in HIV infection whereas a decline in identification and discrimination abilities is correlated with reduced cognitive abilities.

Different patterns of angioedema in patients with and without angiotensin-converting enzyme inhibitor therapy.

BACKGROUND: There is convincing evidence for a causal relationship between angiotensin converting enzyme inhibitor (ACEI) therapy and angioedema, but the clinical features of the patients remain unclear. The aim of the study was to compare patterns of angioedema in patients under ACEI therapy and those without ACEI therapy. METHODS: One hundred and seventeen consecutive patients with angioedema treated in the emergency department of a 2000-bed tertiary care university hospital were included. A retrospective cohort study was performed, the exposure being ACEI therapy. The pattern of location of angioedema was the primary outcome measure. RESULTS: Of 117 patients with angioedema, 25 (21%) received ACEI therapy. In a multivariate logistic regression model, angioedema of the cheeks, eyelids or nose was independently negatively associated with ACEI therapy [adjusted odds ratio 0.13 (95% confidence interval 0.03 to 0.49), p = 0.003]. Higher age was also significantly associated with ACEI therapy [adjusted odds ratio 1.85 (95% confidence interval 1.23 to 2.80), p = 0.003]. Furthermore, a trend towards an independent negative association between a history of allergies and angioedema under ACEI therapy was seen. CONCLUSION: Patients with angioedema under ACE inhibitor therapy differ significantly from those receiving no ACEI therapy in terms of patterns of angioedema and age. The applicability of this observation as a tool for deciding whether to continue or terminate ACEI therapy requires prospective evaluation.

Patterns of non-conductive olfactory disorders in eastern Austria: a study of 120 patients from the Department of Otorhinolaryngology at the University of Vienna.

BACKGROUND: About 1% of the population suffer from disorders of the chemosensory system. In the United States at least two million people have problems related to smell and taste. The sense of smell enables the individual to determine the flavour of food and beverages and is most important as a sophisticated warning system. For the present investigation, we collected data on the age pattern and causes of olfactory disorders in eastern Austria. METHODS: 120 patients with non-conductive olfactory disorders were examined over a 9-month period starting from July 1998 at the outpatient clinic of the Ear Nose and Throat Department of the University of Vienna. Data concerning the underlying population taken from the 1998 population census in Vienna were used for comparison, in order to gain a more representative estimation of the distribution of these disorders. The diagnosis was based on thorough history taking, physical examination, CT scan, and olfactory testing for sensitivity by means of so-called "sniffin' sticks". RESULTS: The patients' ages ranged from 16 to 86 years (mean, 54.5 years; 74 females, 46 males). Those older than 50 years seem to have a higher risk of developing olfactory disorders. Only 15 of the female patients were pre-menopausal. Olfactory disorders were most frequently caused by viral infections in the upper respiratory tract (n = 51). Fifteen patients reported head trauma as a cause of olfactory loss, and 45 causes were idiopathic. Most of those in whom the olfactory disorder had been in existence for less than 3 months were anosmic (84%), very few were hyposmic (16% of a total of 19 patients). In contrast, 38% (of a total of 29 patients) in whom the disease had been in existence for 3 and 6 months were hyposmic. Parosmia was reported in 16 cases. Most parosmias appeared after viral infection (56%). Eight of the 120 patients reported dysgeusia. CONCLUSIONS: The present study is a first step towards an assessment of olfactory disorders in Austria. We found similar causes of non-conductive olfactory disorders as have been reported in the literature for other countries, namely upper respiratory infection leading to postviral olfactory disorders, and head trauma. With increasing age women seem to suffer more often from chemosensory dysfunction than men, which may be related to hormonal factors.

Olfactory function in patients with olfactory groove meningioma.

OBJECTIVES: Olfactory meningiomas are rare benign tumours and represent about 12% of all basal meningiomas. Anosmia is thought to be among the first symptoms, even though patients often present with headaches or visual problems. However, so far no detailed psychophysical tests of olfactory function have been performed in a large number of those patients. METHODS: Twelve patients (five men, seven women; mean age 52 years) with olfactory meningiomas were examined. In all patients extensive preoperative and postoperative lateralised olfactory testing was performed using the "Sniffin' Sticks" test battery, a psychometric testing tool. In eight cases the meningioma was lateralised (five left, three right), in four patients a bilateral meningioma was found. In addition to a detailed ear, nose, and throat examination MRI was performed in all patients. RESULTS: In preoperative testing six patients were found to be anosmic on the side of the tumour, two were hyposmic. Four patients were normosmic. Postoperative investigations showed lateralised anosmia in four patients on the operated side, three were normosmic on the contralateral side and one hyposmic. The remaining eight patients were completely anosmic postoperatively. CONCLUSIONS: (1) Contrary to expectations, olfactory testing seems to be of little help in detecting olfactory meningiomas. (2) The likelihood of normal postoperative olfactory function contralateral to the tumour was high when the tumour was less than 3 cm in diameter and preoperative normosmia had been established. (3) Preservation of olfactory function ipsilateral to the tumour seems to be extremely difficult, irrespective of tumour size or surgical approach.

Upper airway findings in patients with nocturnal breathing disorders.

This prospective open study was performed to examine the relation between pathologic findings of the upper respiratory tract and the types of noncentral sleep disorders (rhonchopathy, obstructive sleep apnea). 312 men and 274 women aged between 35-75 years attended our outpatient department for relief of their nocturnal breathing disorder. About 1/3 of the patients suffered only of habitual rhonchopathy and 2/3 were obstructive. No findings of the head and neck examination could predict the degree of oxygen desaturation, although pathologies of the nose (73.68%), the soft palate (94.1%) and narrowing of the oro- and hypopharynx (74.19%) were very common in patients with sleep disorder. At least one pathology could be found in every patients. The more pathologies were found the higher was the risk of obstructive sleep apnoea with desaturation below 70%. Unrelated tonsillectomy (51.36%) did not prevent nocturnal breathing disorders.

Multicenter investigation of 1,036 subjects using a standardized method for the assessment of olfactory function combining tests of odor identification, odor discrimination, and olfactory thresholds.

"Sniffin' Sticks" is a test of nasal chemosensory performance that is based on penlike odor-dispensing devices. It is comprised of three tests of olfactory function: tests for odor threshold, discrimination and identification. Previous work has already established its test-retest reliability and validity in comparison to established measures of olfactory sensitivity. The results of this test are presented as a composite TDI score--i.e., the sum of results obtained for threshold, discrimination and identification measures. The present multicenter investigation aimed at providing normative values in relation to different age groups. To this end, 966 patients were investigated in 11 centers. An additional study tried to establish values for the identification of anosmic patients, with 70 anosmics investigated in five specialized centers where the presence of anosmia was confirmed by means of olfactory evoked potentials. For healthy subjects, the TDI score at the 10th percentile was 24.5 in subjects younger than 15 years, 30.3 for ages from 16 to 35 years, 28.8 for ages from 36 to 55 years and 27.5 for subjects older than 55 years. While these data can be used to estimate individual olfactory abilities in relation to a subject's age, hyposmia was defined as the 10th percentile score of 16- to 35-year-old subjects. Our latter study revealed that none of 70 anosmics reached a TDI score higher than 15. This score of 15 is regarded as the cut-off value for functional anosmia. These results provide the basis for the routine clinical evaluation of patients with olfactory disorders using "Sniffin' Sticks."

[Glomus caroticum chemodectoma. Review on current diagnosis and therapy]. / Glomus caroticum--Chemodectom. Ubersicht über die aktuelle Diagnostik und Therapie.

Carotid body tumors are rare neoplasms arising from the small chemoreceptor organ in the adventitia of the common carotid bifurcation. Patients with carotid body tumours usually present with a gradually enlarging non-tender anterolateral neck mass. Differential diagnosis includes metastatic lymph nodes, carotid artery aneurysm, salivary gland tumour, branchial cleft cyst, and neurogenic or thyroid tumours. When such a lesion is suspected, a non-invasive Doppler colour flow ultrasonography enables the clinician to arrive at a definite diagnosis. Subsequent arteriography is mandatory, because the finding of an intensely blushing hypervascular mass spreading into the carotid bifurcation further supports the diagnosis and provides accurate preoperative information concerning arterial blood supply. Computed tomography scanning is appropriate to delineate the relation of the tumour to adherent structures, while magnetic resonance tomography demonstrates the relation of the tumour to the adjacent internal jugular vein and the carotid artery. Selective embolization should be performed for safe surgical removal with less bleeding. Early surgery is the treatment of choice and is recommended in order to minimize major risks. Subadventitial resection is the most established technique. Radical resection prevents local recurrence and has the best long-term results. Removal of the internal or common carotid arteries can become mandatory in selected cases of extensive disease. Surgical treatment by an experienced team is associated with considerably low mortality and morbidity.

Hearing loss and tinnitus in acute acoustic trauma.

Despite extensive educational and protective measures, acute acoustic trauma continues to be a major problem in young military recruits. This retrospective study concern conscripts from eastern Austria who were referred to the Central Military Hospital for acute acoustic trauma (AAT) during the last 18 months. The study was designed to provide information on the profile of hearing loss and the presence of tinnitus after AAT. At the time when AAT occurred, hearing protection was not used in the majority of cases. In more than 75% of the ears hearing loss was registered in the high-frequency region (above 2 kHz). In the remaining 25% the speech frequency range under 2 kHz was also affected. Interestingly, the degree of hearing loss was independent of the type of firearm used, the number of shots and the use of hearing protection (ear plugs). Hearing loss occurred asymmetrically due to one-sided noise, whereas the distribution of tinnitus was symmetrical. The majority of patients experienced both, tinnitus and hearing loss as a consequence of AAT. Yet, in 6.2% of the subjects tinnitus was the only symptom. These results strongly suggest that tinnitus is as important a symptom of AAT as is hearing loss. Therefore, we believe that a tinnitus match should be performed in every patient with suspected AAT.

Reversible sensorineural hearing impairment induced by a carotid body tumor.

A case of a 62-year-old Austrian man having a 25-year history of a right-sided carotid body tumor (CBT) is presented. Three months before being transferred to the University of Vienna for tumor resection the patient developed symptoms of tinnitus, progressive ipsilateral hearing loss and dysphagia. Pure-tone audiometry demonstrated a 50 dB right sensorineural hearing loss. A 6 x 6 x 4 cm firm, pulsatile mass was found in the right carotid triangle and extending towards the base of the skull. One week after radical tumor resection all preoperative symptoms disappeared and hearing of the right ear recovered. Review of the available literature showed that hearing loss and tinnitus are unusual symptoms of a CBT. Our findings suggest that routine audiometric evaluations in such cases of CBT patients should be obtained in order to determine the real incidence of audiological disorders.

Topical ephedrine administration and nasal chemosensory function in healthy human subjects.

OBJECTIVE: To investigate dose-related effects of ephedrine on olfactory function in healthy subjects. DESIGN: Placebo-controlled, randomized, double-blind study. METHODS: Drug effects were assessed using olfactory and trigeminal psychophysical measures (intensity ratings, odor discrimination, butanol and formic acid thresholds); nasal patency was assessed by means of anterior rhinoresistometry. The investigation was performed in 24 healthy volunteers; subjects were assigned to treatments A, B, or C (3 groups with 8 subjects each; 4 women and 4 men per group). All subjects received either placebo or ephedrine in both nostrils; group A subjects received placebo, and group B and C subjects received ephedrine in dosages of 0.12 and 0.24 mg, respectively. RESULTS: Treatment with ephedrine produced a tendency toward an increase of nasal airflow. However, during the time of observation there was no significant difference between effects produced by the 2 dosages. Ephedrine had no systematic effect on measures of olfactory function. The only significant correlation to the nasal airflow was found for perceived intensity of the trigeminal stimuli, which increased with increasing flow. CONCLUSIONS: Ephedrine appeared to have neither negative nor major positive effects on intranasal chemosensory function in healthy subjects. This indicates that ephedrine may be used as a decongestant in studies on olfaction.

The role of fibroblasts from oropharyngeal mucosa in producing proinflammatory and mitogenic cytokines without prior stimulation.

Cytokine production by fibroblasts is not only important for immunological and inflammatory reactions in the epidermis and mucosa, but also for growth and differentiation of epithelial cells. To characterize the role of fibroblasts in the oropharyngeal mucosa, the expression of a panel of cytokines and cytokine receptors by fibroblasts isolated from normal human oropharyngeal mucosa was investigated by enzyme-linked immunosorbent assay (ELISA), reverse transcribed polymerase chain reaction (RT-PCR) and flow cytometry (FACS). Oropharyngeal fibroblasts produced the proinflammatory cytokines interleukin 1 alpha (IL-1 alpha), IL-6 and IL-8 without addition of phorbol-12-myristate-13-acetate (PMA) or biological response modifiers, suggesting an active involvement of these cells in host defence mechanisms. Keratinocyte growth factor (KGF), a growth factor for epithelial cells, and the angiogenetic fibroblast growth factors acidic and basic FGF (aFGF, bFGF) were also synthesized. Expression of receptors for IL-1, IL-4, IL-6, platelet-derived growth factor (PDGF) and epidermal growth factor (EGF) was found. These results indicate that oral fibroblasts are capable of producing a number of cytokines without the need for additional stimuli and emphasize their active regulatory role in the maintenance of the oral mucosa.

Effects of ethanol treatment of proliferation and differentiation in a head and neck squamous cell carcinoma cell line.

INTRODUCTION: Epidemiologic studies have provided evidence that chronic ethanol consumption is an independent risk factor in upper aerodigestive tract cancer, but the underlying mechanisms are largely unknown. METHODS: To examine ethanol effects on mucosal keratinocytes in vitro, we used a squamous cell carcinoma of the head and neck (SCCHN) cell line as a model and, to exclude line specific effects, two other cell lines. The influence of ethanol on proliferation (using [3H]thymidine uptake/cell number), cell cycle distribution, cytokeratin pattern, and growth factor receptor expression (using FACS analyses) was investigated. RESULTS: Ethanol increased in a dose dependent manner (tested range 10(-3) M to 10(-10) M) the [3H]thymidine uptake and cell number, with unaltered viability (>95%) in all concentrations. In all tested cell lines, addition of 10(-3) M ethanol caused: (a) a significant increase of cells in the S-phase of the cell cycle; (b) a shift of cytokeratin pattern that suggested inhibition of differentiation; and (c) significant upregulation of EGF, IL-4, and PDGF receptors. CONCLUSIONS: Our results demonstrated an increased proliferation and reduced differentiation induced by ethanol in mucosa derived neoplastic cells, which may enhance further growth of neoplastic cells. These effects may also be involved in the carcinogenesis of upper aerodigestive tract malignancies.

Rhinoresistometry versus rhinomanometry--an evaluation.

Allergic nasal hyperreactivity is a common problem and many patients suffer from daily symptoms. Rhinomanometry is so far the only well established clinical method for objective assessment of nasal patency, although several expressions of nasal patency have been reported. Universal standardisation was achieved in 1983 in Brussels by Clement et al. [1], but many specialists are looking for a system giving more information on the functional aspects of the nose. A new development arising from active anterior rhinomanometry is rhinoresistometry. We tested this equipment, which has been introduced with new software for calculation and graphic presentation. 24 adult volunteers with proven allergy to grass pollen were examined immediately after long-term challenge in the Vienna Challenge Chamber [3] and 15 minutes after decongestion by application of 5% ephedrine solution. The similarity and differences between rhinomanometry and rhinoresistometry, as well as the value of the additional parameters are pointed out. Our data indicate that rhinoresistometry is a rapid, reproducible and non-invasive technique, which gives extended information in comparison to classic rhinomanometry. The results correlate very well with the findings obtained by the standard method. This pilot study demonstrates the benefit of the new parameters.