Evaluation of olfactory loss

olfactory loss immediately follows an upper respiratory infection (URI); other URI symptoms have resolved; patients typically present months to years after onset

nasal examination is normal with no evidence of nasal inflammation or infection; dysosmia is common

olfactory loss has gradual onset; history of frequent sinus infections or known allergies; often nasal congestion and discharge; in approximately 50% patients olfactory loss fluctuates; obstructive rather than sensorineural

nasal exam should show presence of polyps; anterior rhinoscopy may demonstrate nasal polyps; nasal endoscopy will reveal signs of inflammation

olfactory loss has gradual onset; history of frequent sinus infections or known allergies; often nasal congestion and discharge; in approximately 50% of patients olfactory loss fluctuates; obstructive rather than sensorineural

nasal exam should show presence of polyps; anterior rhinoscopy may demonstrate nasal polyps; a deviated nasal septum is rarely associated with olfactory loss; nasal endoscopy will reveal signs of inflammation

olfactory loss immediately follows head trauma, particularly after a frontal or occipital blow, although it may be a week or more before the patient becomes aware of the loss; recovery is rare; majority of patients report anosmia; most are male between the ages of 20 and 50 years, consistent with the group more at risk for head trauma; operative notes from any neurosurgical or maxillofacial procedures should be reviewed

physical signs of head injury may be present; nasal examination is normal unless there are other sequelae from the injury; findings of nasal trauma (such as fracture deviation of the nasal dorsum and a displaced septum) may indicate direct injury to the olfactory cleft, or may still be consistent with a coup-contrecoup injury, or may have led to secondary nasal and sinus pathology causing a conductive olfactory loss

olfactory loss immediately follows head trauma, although it may be a week or more before the patient becomes aware of the loss; majority of patients report anosmia; with concussive injury, patients may experience some recovery of function typically within the first year following the injury; operative notes from any neurosurgical or maxillofacial procedures should be reviewed

physical signs of head injury may be present; nasal examination is normal unless there are other sequelae from the injury; findings of nasal trauma (such as fracture deviation of the nasal dorsum and a displaced septum) may indicate direct injury to the olfactory cleft, or may still be consistent with a coup-contrecoup injury, or may have led to secondary nasal and sinus pathology causing a conductive olfactory loss

olfactory loss has gradual onset

head and neck examination will generally be normal; nasal examination will be normal

sudden excessive exposure to a toxic substance (e.g., phosphorus fire, chlorine gas, metal dusts, solvents, acid fumes, oil vapors, or household cleaners); usually associated with burning and irritation of the nose, eyes, and sometimes mouth and throat; may have history of low-level exposure to toxic substance over many years

nasal examination normal unless patient is evaluated almost immediately after sudden exposure to toxic substance

gradual onset of olfactory loss; possible exposure to chemotherapeutic agents, decongestants, amphetamines, estrogen, naphazoline, phenothiazines, or zinc gluconate, or prolonged use of nasal decongestants; zinc gluconate usually associated with an immediate burning sensation in the nose after using the spray, after which the patient notes a loss of smell

head and neck examination normal; for zinc gluconate, nasal examination normal unless patient is evaluated almost immediately after use of the spray

occurs following radiation therapy

nasal examination normal unless patient is evaluated almost immediately after radiation therapy

olfactory loss of gradual onset; patient may show signs of memory loss or disorientation

head and neck examination will generally be normal

olfactory loss of gradual onset; patient may begin to develop other focal neurologic signs; may report symptoms suggestive of bradykinesia, rigidity, resting tremor, and/or postural instability

head and neck examination will generally be normal unless other neurologic signs of Parkinson have become apparent - for example, resting tremor (less common in the head and neck but may involve the jaw or lips) or bradykinesia (impaired facial expression, eye movements); impaired odor identification associated with more rapid neurologic degeneration, particularly gait disturbance[58]Wilson RS, Arnold SE, Buchman AS, et al. Odor identification and progression of parkinsonian signs in older persons. Exp Aging Res. 2008 Jul-Sep;34(3):173-87. http://www.ncbi.nlm.nih.gov/pubmed/18568978?tool=bestpractice.com

patient will report having had prior surgery for an intracranial lesion (e.g., neoplasm, aneurysm); patient will note loss of smell immediately followed the surgery

nasal examination will be normal; craniotomy scars apparent

history of surgery most often for a neoplastic process involving the anterior skull base; patient will note the loss of smell immediately followed the surgery

nasal examination will vary depending upon the extent of surgery on the nose and paranasal sinuses; patient may or may not have external nasal incisions depending upon whether the facial approach was intranasal (endoscopic) or external

patient will report having smell loss immediately following sinus surgery that has not improved once postoperative intranasal swelling has resolved; if the loss fluctuates, this suggests it may be due to residual inflammatory disease; if it does not, it still may be related to persistent disease, possible scarring in the olfactory cleft, or, less likely, direct injury to the olfactory neuroepithelium

nasal endoscopy will demonstrate inflammatory disease with edema, and possible scarring; the olfactory cleft may not be easily visualized, but the nasal vault will generally demonstrate edema, crusting, or scarring

olfactory loss secondary to chronic sinus disease that may occur in association with granulomatosis with polyangiitis (formerly known as Wegener granulomatosis); patients will usually complain of nasal congestion, crusting, and recurring infections; sinus disease may be the first manifestation, with later development of pulmonary and renal symptoms

nasal examination will demonstrate extensive crusting not only along the nasal septum, but also often along the lateral nasal wall; the mucosa is friable and bleeds easily; patients may present with a nasal septal perforation; saddle nose deformity may be present

olfactory loss may be due to direct involvement of the olfactory neuroepithelium or obstruction of the olfactory cleft secondary to chronic sinus disease that may occur in association with sarcoidosis; patients will usually complain of nasal congestion, crusting, and recurring infections; sinus disease is rarely the first manifestation of sarcoidosis, and patients often have pulmonary, cutaneous, or other manifestations of the disease; may complain of dry mouth (xerostomia) and dry eyes (xerophthalmia)

submucosal nodules appearing slightly yellow in color may be present along the nasal septum or inferior turbinates; friable mucosa with crusting and bleeding may be present; skin lesions, most notably around the nasal alae (lupus pernio), can be seen; parotid gland, lacrimal gland, and cervical lymph node enlargement may be present

olfactory loss may occur in association with complaints of dry eyes (xerophthalmia) and dry mouth (xerostomia); may be associated with symptoms of arthritis including joint pain and stiffness

eyes and mouth may appear dry, usually the nasal examination is normal; parotid glands may be enlarged or slightly tender

patients with sinonasal tumors rarely present primarily for olfactory loss, but will more often present because of nasal obstruction, epistaxis, pain, or mucus drainage; olfactory loss will generally be of gradual onset; unilateral symptoms raise concern about the possibility of neoplastic process

nasal examination, particularly with endoscopy, will reveal a mass lesion within the nasal cavity; associated edema, purulent discharge, polyps, or crusting may be noted; evidence of extension beyond the confines of the nose may be present, such as surrounding induration, orbital displacement, or proptosis

olfactory loss usually associated with bleeding, discharge, obstruction; symptoms may be unilateral; advanced lesions may be associated with proptosis, ophthalmoplegia, or intracranial complications

nasal endoscopy will reveal a reddish-gray friable mass within the nasal vault

these tumors are usually relatively large (>4 cm) when discovered, due to delay in diagnosis; patients present with anosmia and psychiatric symptoms, particularly depression, apathy, and psychomotor retardation; urinary incontinence and gait disturbance are late symptoms; patients may not be aware of the anosmia due to its very gradual onset

nasal examination may be normal; findings of depression, or changes in emotion and cognition, with other potential neurologic findings (e.g., incontinence, papilledema, hemiparesis)

X-chromosome disorder affecting females; if olfactory loss present, patients will present with lifelong inability to smell

phenotype varies but may be associated with short stature, lack of sexual development, webbed neck, broad flat chest, ptosis, low-set ears, multiple pigmented nevi, dry eyes, infertility; heart and kidney defects common

autosomal dominant syndrome characterized by hypogonadotropic hypogonadism and anosmia; complete olfactory loss present since birth; may report fatigue, dyspnea (associated with congenital heart defects)

delayed puberty, lack of secondary sex characteristics; decreased muscle mass and strength, fat distribution over the hips and chest