DISORDERS OF SMELL

DR.RAJA NAGA MAHESH.M

MODERATOR:
DR.SHIVASHANKAR

TOPICS OF DISCUSSION

ANATOMY OF OLFACTION
PHYSIOLOGY OF OLFACTION
PATHOLOGY
SYMPTOMATOLOGY
EXAMINATION
DIFERENTIALS INVOLVED
ETIOLOGY
MANAGEMENT

ANATOMY
YELLOW PIGMENTED PSUEDOSTRATIFIED
CILIATED COLUMNAR EPITHELIUM
AREA 0F 2.5 SQ CM
TYPES OF CELLS
(a) Olfactory or receptor cells
(b) Sustentacular or supporting cells :
maintain
electrolyte levels in ECF
(c)Basal cells or stem cells: regenerate
olfactory and sustentacular cells during
regeneration

 Olfactory neurons:
bipolar neurons
numbering between 6 to 10 millions
carrying 10,000 different odours
Olfactory sensory neuron gives dendrite that
terminates in a knob having 6-12 cilia.
Cilia are unmyelinated 5-10microns in length and
0.1-2 microns in diameter having odorant receptors
Free endings of trigeminal pain fibres stimulated by
irritating substances such as pippermint ,menthol
and chlorine

 Olfactory bulb
Olfacotry glomerulus site of
convergence
Mitral and tufted cells
Periglomerular inhibitory cells
connecting one glomerulus to another
Granule cell- excited through gluatmate
bby mitral/ tufted cell which inturn
inhibits them by GABA

Olfactory cortex
Anterior olfactory nucleus
Olfactory tubercle
Piriform cortex
Amygdala
Entorhinal cortex
Receive inputs from lateral olfactory stria
Orbitofrontal activation is greater on greater on
right side than left
Anterior olfactory tract to vomeronasal organ
concerned with pheromones

Olfactory
receptor

Olfactory
bulb

Olfactory
cortex

G Protien coupled
Graded receptor potential threshold action
potential

Sharpens and focuses olfactory signals

Emotional responses and olfactory memories

Adaptation or
desensitization
Short term- calcium calmodulin
dependent protien kinase 2 acting on
adenylyl cyclase
Long term- activation of guanylate
cyclase and cyclic gmp production

Clinical features

Clinical manifestations

Higher order loss of

olfactory
descrimination(olfactory
agnosia)

Quantitative
abnormalities(anosmia ,
hyposmia and
hyperosmia
Qualitative(dysoamia
and parosmia)

Olfactory hallucinations
and delusions

Symptomatology
Anosmia : inability to smell
Hyposmia or hypesthesia : diminished
olfactory sensitivity
Hyperosmia : enhanced olfactory sensitivity
Dysosmia : distorted sense of smell
Presbyosmia : olfaction diminished with
aging
Specific anosmia: normal olfactory acuity
encounters acompuond that is odourless to
him.

Clinical bedside assessment

Establish patency first
Nonirritating substances should be used
Abnormal side should be tested first
followed by normal side
Substances used coffee, winter green,cloves
Appreciation of smell(requires intact
neuronal pathway) even with out
recognition excludes anosmia
Lesion of cortex never produces anosmia

Objective assessment
Scratch and sniff test( university of
pennsylvania smell identification test): forced
choice design helps to identify malingering
Connecticut chemosensory test
Air dilution olfactory detection: dtermining
threhold of sensation and of demonstrating
normal olfactory perceptionin absence of
odour identification
Olfactory evoked potentials : reliability
uncertain.

Loss of
smell

Anosmia or loss of sense of

smell
nasal
Olfactory
neuro
epithelial
central

CAUSES OF ANOSMIA
NASAL

OLFACTORY
EPITHELIUM

CENTRAL

FUNCTIONAL

TRAUMA

EPILEPSY
DISORDERS

MALINGERING

CHRONIC
RHINITIS

METABOLIC

DEGENRATIVE
DISEASES

CHRONIC USE
OF NASAL
VASOCONSTRIC
TOR

COMPRESSIVE
LESIONS

EPILEPSY
SURGERIES

SMOKING

TOXIC

Contd..
Nasal :
Heavy smoking
Chronic rhinitis,
Over use of nasal vasoconstrictors

Contd..
Olfactory epithelium:
head injury,cranial surgery,subarachanoid
haemorrhage ,chronic meningitis
Toxic:
Steroids
Aminiglycosides
Methotrexate
Opiates
L-dopa
Wegeners granulomatosis
Compressive and infiltrative
lesions(craniopharygioma,meningioma and aneurysm)

Contd
Metabolic:
Thiamine
Vitamin B12 deffeciency
Chronic renal failure
Cirrhosis,
Thyroid deffeiciency
Menstruation

Contd..
Central :
Degenerative diseases :
Parkinsons
Alzheimer disease
Huntingtons disease
Temporal lobe epilepsy(ant temporal
lobectomy)

Contd
Malingering ( bilateral anosmia
usually not ass with loss of taste) and
hysteria

Contd..
Foster kennedy syndrome: anosmia with
unilateral optic atrophy and contralateral
papilledema classically due to large tumour
involving orbito frontal region
Kallmanns syndrome :x linked which causes
hypogonadotrophic hypogonadism and
anosmia due to aplasia of olfactory bulbs and
tracts
Rem sleep behaviour disorder(RBD) suspected
prequal of neurodegenerative disorders also
has anosmia/hyposmmia

Dysosmia or parosmia
Nasopharyngeal conditions like
sinusitis and urti.
Olfactory bulbs effected depression
and psychotics
Management : many cases subside
spontaneously. zinc,
vitamins,repeated anesthetisation of
mucosa.

Olfactory hallucinations
Phantosmia accompained or followed by alteration
of conciuosness and other manifestations of
epilepsy- temporal lobe epilepsy
Convinced of hallucination and gives it personal
origin it assumes status of a delusion. Along with
halucination delusions signifies psychiatric illness.
External source ( extrinsic hallucinations) usually
seen in schizophrenia where as intrinsic
hallucinations are usually seen in depression
May occur in alzheimers dementia but more likely
probability is late life depression

Olfactory agnosia(lack of
discrimination)
Identification requires special tests
Medial temporal lobes and medial
dorsal nucleus of thalamus are
required for this function
Usually seen in alcoholic korsakoff
psychosis due to defect in medial
dorsal nucleus of thalamus and its
connections to orbitofrontal cortex

Management
Identify treatable causes like hypothyroidism,
diabetes and infections and treat them.
Obstructive causes should be delt through
medical or surgical interventions
Steroids systemic better than topical intranasal
are used in management of traumatic anosmia
and some inflammatory conditions. Dysfunction
at time of presentation is better predictor of
prognosis
Smelling strong odours before bed: increases
neuronal activity with in olfactory bulb.

contd
Supplementation of Zinc and vitamin A not yet proved
Supplementing vitamins like B12, B2(riboflavin) and
Zinc in deffeiciency states may be useful
Vitamin D is a co factor in chemotherapy induced
muco cutaneous toxicity so it may be useful
Other drugs like theophylline are under study
Anti epileptics and antidepressants used to treat
dysosmia and smell distortions following head trauma
Centrally acting anti cholinesterase inhibitors like
DONEPIZIL showed improvement in smell identification
in alzeihmers disease