Anosmia: A Merck Manual of Patient Symptoms podcast

Anosmia is complete loss of smell. Hyposmia is partial loss of smell. Most patients with anosmia have normal perception of salty, sweet, sour, and bitter substances but lack flavor discrimination, which largely depends on olfaction. Therefore, they often complain of losing the sense of taste (ageusia) and of not enjoying food. If unilateral, anosmia is often unrecognized.

Etiology

Anosmia occurs when intranasal swelling or other obstruction prevents odors from gaining access to the olfactory area; when the olfactory neuroepithelium is destroyed; or when the olfactory nerve fila, bulbs, tracts, or central connections are destroyed (see Table 4: Approach to the Patient With Nasal and Pharyngeal Symptoms: Some Causes of Anosmia).

Table 4
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Some Causes of Anosmia Cause Suggestive Findings Diagnostic Approach Intranasal obstruction Allergic rhinitis History of chronic allergic symptoms (eg, congestion, clear rhinorrhea), no pain Clinical evaluation Nasal polyps Polyps usually visible on examination Clinical evaluation Destruction of olfactory neuroepithelium Atrophic rhinitis Chronic rhinitis with atrophic and sclerotic mucous membranes, patency of nasal passages, crust formation, foul odor Clinical evaluation Sometimes biopsy, which shows the normal ciliated columnar epithelium converted to stratified squamous and the lamina propria reduced in amount and vascularity Chronic sinusitis Chronic mucopurulent drainage, documented infections Clinical evaluation CT Panograph, which shows apices of maxillary teeth to rule out tooth abscess Some viral URIs Onset after clinical infection Clinical evaluation Tumors (rare cause) Possibly visual difficulty or only anosmia CT MRI Drugs (eg, amphetamines, enalaprilSome Trade Names VASOTEC Click for Drug Monograph , estrogen, naphazoline, phenothiazines, reserpineSome Trade Names SERPASIL Click for Drug Monograph ; prolonged use of decongestants) Usually, an apparent history of exposure Clinical evaluation Toxins (eg, cadmium, manganese) Usually, an apparent history of exposure Clinical evaluation Destruction of central pathways Alzheimer's disease Progressive confusion and loss of recent memory MRI Sequential memory tests Degenerative neurologic disorders (eg, multiple sclerosis) Intermittent episodes of other neurologic symptoms (eg, weakness;, numbness; difficulty speaking, seeing, or swallowing MRI Sometimes lumbar puncture Head trauma Apparent by history CT Intracranial surgery, infection, or tumor Surgery and CNS infection apparent by history Tumors with or without other neurologic symptoms CT or MRI Some Causes of Anosmia Cause Suggestive Findings Diagnostic Approach Intranasal obstruction Allergic rhinitis History of chronic allergic symptoms (eg, congestion, clear rhinorrhea), no pain Clinical evaluation Nasal polyps Polyps usually visible on examination Clinical evaluation Destruction of olfactory neuroepithelium Atrophic rhinitis Chronic rhinitis with atrophic and sclerotic mucous membranes, patency of nasal passages, crust formation, foul odor Clinical evaluation Sometimes biopsy, which shows the normal ciliated columnar epithelium converted to stratified squamous and the lamina propria reduced in amount and vascularity Chronic sinusitis Chronic mucopurulent drainage, documented infections Clinical evaluation CT Panograph, which shows apices of maxillary teeth to rule out tooth abscess Some viral URIs Onset after clinical infection Clinical evaluation Tumors (rare cause) Possibly visual difficulty or only anosmia CT MRI Drugs (eg, amphetamines, enalaprilSome Trade Names VASOTEC Click for Drug Monograph , estrogen, naphazoline, phenothiazines, reserpineSome Trade Names SERPASIL Click for Drug Monograph ; prolonged use of decongestants) Usually, an apparent history of exposure Clinical evaluation Toxins (eg, cadmium, manganese) Usually, an apparent history of exposure Clinical evaluation Destruction of central pathways Alzheimer's disease Progressive confusion and loss of recent memory MRI Sequential memory tests Degenerative neurologic disorders (eg, multiple sclerosis) Intermittent episodes of other neurologic symptoms (eg, weakness;, numbness; difficulty speaking, seeing, or swallowing MRI Sometimes lumbar puncture Head trauma Apparent by history CT Intracranial surgery, infection, or tumor Surgery and CNS infection apparent by history Tumors with or without other neurologic symptoms CT or MRI

Major causes include

• Head trauma (young adults)
• Viral infections and Alzheimer's disease (older adults)

Prior URI, especially influenza infection, is implicated in 14 to 26% of all presenting cases of hyposmia or anosmia.

Drugs can contribute to anosmia in susceptible patients. Other causes include prior head and neck radiation, recent nasal or sinus surgery, nasal and brain tumors, and toxins. The role of tobacco is uncertain.

Evaluation

History: History of present illness should assess the time course of symptoms and their relation to any URI or head injury. Important associated symptoms are nasal congestion, rhinorrhea, or both. The nature of rhinorrhea should be assessed (eg, watery, mucoid, purulent, bloody).

Review of systems should assess neurologic symptoms, particularly those involving mental status (eg, difficulty with recent memory) and cranial nerves (eg, diplopia, difficulty speaking or swallowing, tinnitus, vertigo).

Past medical history should include history of sinus disorders, cranial trauma or surgery, allergies, drugs used, and exposure to chemicals or fumes.

Physical examination: The nasal passages should be inspected for swelling, inflammation, discharge, and polyps. Having the patient breathe through each nostril sequentially (while the other is manually occluded) may help identify obstruction.

A complete neurologic examination, particularly of mental status and cranial nerves, is done.

Red flags: The following findings are of particular concern:

• Previous head injury
• Neurologic symptoms or signs
• Sudden onset

Interpretation of findings: Sudden onset after significant head trauma or toxin exposure strongly implicates that event as the cause.

A history of chronic rhinosinusitis is suggestive, particularly when significant congestion, polyps, or both are visible on examination. However, because these findings are common in the population, the physician should be wary of missing another disorder. Progressive confusion and recent memory loss in an elderly patient suggest Alzheimer's disease as a cause. Waxing and waning neurologic symptoms affecting multiple areas suggest a neurodegenerative disease such as multiple sclerosis. Slowly progressive anosmia in an elderly patient with no other symptoms or findings suggests normal aging as the cause.

Testing: An in-office test of olfaction can help confirm olfactory dysfunction. Commonly, one nostril is pressed shut, and a pungent odor such as from a vial containing coffee, cinnamon, or tobacco is placed under the open nostril; if the patient can identify the substance, olfaction is presumed intact. The test is repeated on the other nostril to determine whether the response is bilateral. Unfortunately, the test is crude and unreliable.

If anosmia is present and no cause is readily apparent on clinical evaluation (see Table 4: Approach to the Patient With Nasal and Pharyngeal Symptoms: Some Causes of Anosmia), patients should have CT of the head (including sinuses) with contrast to rule out a tumor or unsuspected fracture of the floor of the anterior cranial fossa. MRI is also used to evaluate intracranial disease and may be needed as well, particularly in those patients with no nasal or sinus pathology on CT.

A psychophysical assessment of odor and taste identification and threshold detection is done as well. This assessment commonly involves use of one or several commercially available testing kits. One kit uses a scratch-and-sniff battery of odors, whereas another kit involves sequential dilutions of an odorous chemical.

Treatment

Specific causes are treated; however, smell does not always recover even after successful treatment of sinusitis.

There are no treatments for anosmia. Patients who retain some sense of smell may find adding concentrated flavoring agents to food improves their enjoyment of eating. Smoke alarms, important in all homes, are even more essential for patients with anosmia. Patients should be cautioned about consumption of stored food and use of natural gas for cooking or heating, because they have difficulty detecting food spoilage or gas leaks.

Geriatrics Essentials

There is a significant loss of olfactory receptor neurons with normal aging, leading to a marked diminution of the sense of smell. Changes are usually noticeable by age 60 and can be marked after age 70.

Key Points

• Anosmia may be part of normal aging.
• Common causes include URI, sinusitis, and head trauma.
• Cranial imaging is typically required unless the cause is obvious.

Last full review/revision July 2012 by Marvin P. Fried, MD

Content last modified July 2012