Abstract
Purpose
Upper respiratory tract infections (URTIs) are among the most frequent causes of dysosmias. It has been reported that acute anosmic patients often experience a feeling of personal isolation, display less interest in eating, and feel emotionally impaired. Our goal is to describe the quality of life (QOL) in patients with URTI olfactory loss.
Material and Methods
A retrospective and descriptive patient-based study was performed. From 2002 to 2007, 51 patients with URTI olfactory loss (40 women [78.4%] and 11 men [21.6%]) were studied. The mean age was 53.3 ± 1.8 years. Olfactory function was assessed using the Connecticut Chemosensorial Clinical Research Center test. All patients completed the QOL questionnaire Rhinosinusitis Disability Index. The following were determined: total score; visual analogue scale from 1 to 10; and functional, emotional, and physical domains. Descriptive analysis and Mann-Whitney U nonparametric test were used.
Results
Rhinosinusitis Disability Index data showed that questions f2, f4, p8, and p20 reached the highest score. The patients’ mean overall rating of the severity of olfactory impairment was 3.9 ± 2.8, which fell into the moderate category.
Conclusions
The patients’ mean overall rating of the severity of olfactory impairment fell into the moderate category. The follow-up time span is important to assess the QOL of patients.
1
Introduction
Olfactory disorders occur at a much higher rate than previously thought, as demonstrated in recent population-based studies . The frequency of a decreased olfactory function was as high as 16% in one studied population, with at least 5% of the general population being functionally anosmic. It is estimated that the prevalence of impaired olfaction was 25% in adults 50 years and older . These surveys report that upper respiratory tract infections (URTIs) are among the most frequent causes of dysosmias. In contrast to a slowly progressive decrease of olfactory function, patients with post-URTI and posttraumatic dysosmia experience sudden olfactory loss .
From a total of 750 patients with chemosensory dysfunction, 68% viewed their chemosensory dysfunction as affecting their quality of life (QOL), 46% reported that the disorder had changed either their appetite or body weight, and 56% reported that their daily living and/or psychological well-being was altered . In addition, it has been reported that anosmic patients often experience a feeling of personal isolation, display less interest in eating, and feel emotionally impaired . However, there seem to be numerous people who do not notice their olfactory dysfunction and hence do not experience impairment. This seems to relate specifically to cases where olfactory loss occurs gradually in Parkinson disease or aging . Thus, there appears to be a high degree of interindividual variability with regard to the subjective perception of olfactory dysfunction.
The Rhinosinusitis Disability Index (RSDI) questionnaire is an instrument that has been rigorously validated with excellent internal consistency and little random error on test-retest (Cronbach α , Spearman correlation) while exhibiting good construct and content validity . The survey measures rhinologic-related health via 30 questions in 3 domains: physical, functional, and emotional. Some authors have used the RSDI to investigate the disability of individuals with rhinologic disease—not just rhinosinusitis, but other rhinologic disorders as well—to understand the overall and relative levels of disability .
The purpose of this article is to describe how QOL is compromised in patients with URTI olfactory loss.
2
Material and methods
Although there is no definitive test that identifies clearly an olfactory loss as being postviral, we included patients with sudden smell loss secondary to URTI (cold or flu). This loss will persist even several months after the infection. If the patient does not describe a cold or flu episode, we think that it is inappropriate to diagnose the loss as being postviral . We ruled out other causes of smell loss such as head trauma, chemical exposure, drugs intake (especially topical zinc-containing preparations that are not available in Spain), any kind of chronic rhinosinusitis, systemic diseases (hypertension, diabetes, and immunological disease), smoking, or alcoholic habits. All of them were thoroughly examined by experienced otorhinolaryngologists compiling complete clinical history, endoscopic views, and computed tomographic (CT) scan pictures. In all patients, endoscopic exploration and CT scan pictures were normal.
A total of 51 patients suffering from changes in olfactory function by URTI were investigated (40 women and 11 men; mean age, 53.3 ± 1.8 years; confidence interval [CI], 49.6–57.1). The patients were thoroughly examined by experienced otorhinolaryngologists, including an endoscopic and CT scan in coronal projection of the nasal cavity. Based on the clinical examination (no findings in endoscopic and CT scan) and the detailed, structured history, olfactory dysfunction was classified as viral postinfection. In all the patients, the loss of smell lasted more than 3 months. The patients did not have any other concomitant systemic disease or drugs intake that could produce olfactory impairment. Because the presentation of the patients to our clinic is dependent on their subjective degree of complaint and on the often-ignoring attitude of clinicians and the social environment toward olfaction and its problems, the time span between appearance of olfactory disturbance and first visit varied from 1 to 14 months. All of them were thoroughly examined by experienced otorhinolaryngologists. The study protocol was approved by the ethical committee of our hospital according the Helsinki recommendations. All the patients signed one specifically designed informed consent for the study.
Olfactory testing was performed using the Connecticut Chemosensorial Clinical Research Center test kit. This test was manufactured in our institution with the collaboration of the Pharmacy Department following the guidelines of the original article of Cain et al , who were the first to describe this olfactory test. This test was made up of 2 parts: the butanol threshold test and the identification test. The threshold test used aqueous dilutions of 1-butanol, where successive dilutions differed by a factor of 3. The highest aqueous concentration equaled 4%. The number of dilution steps ranged from 0 to 8 depending on testing circumstances. The test solutions were presented for smelling in 250-mL capacity polyethylene bottles containing 60 mL of solution. The bottle closure had a pop-up spout that fitted to both nostrils. To sample a bottle, the person placed the spout into both nostrils and then sniffed simultaneously. Testing began with the lowest concentration. The test participant received the bottle with this concentration along with a blank and had to decide which smelled stronger. If incorrect, the participant received another blank paired with the next higher concentration. Errors triggered increments in concentration, whereas correct choices led to another presentation of the same concentration (in another bottle) and a blank. Four correct choices in a row led to an end of the testing. The concentration at which this occurred marked the threshold.
The participant received the identification test after the threshold test. A kit was composed of ten 180-mL opaque plastic jars containing 5 g of the substance in sachet-like packets of stimuli. Based on the performance of anosmic patients, we can say that 7 stimuli appealed exclusively, or almost so, to the sense of smell (baby powder, chocolate, cinnamon, coffee, mothballs, peanut butter, and bar of soap) and one appealed to the common chemical sense as well (Vicks). The 8 items were presented in the same order for both nostrils. When presented with an item, the participant chose from a 20-item list. The list contained the names of the 8 test items and of 13 distractors. In addition to the names on the list, responses of “no sensation” and “do not know” were permitted. The examiner gave corrective feedback whenever the participant made an error. If the participant exhibited some evidence of function, but nevertheless made mistakes, the examiner presented missed items for a second time. A correct answer upon second presentation cancelled a previous error. This allowed a participant to rectify mistakes and thereby decreased the possibility of cognitive errors. In such cases, the first trial with an item served as training. The score for the test comprised the number of olfactory items out of 7 correctly identified and a notation regarding ability to perceive trigeminal stimulation.
The outcome of the threshold and identification test was combined into a composite score, an average of the 2 tests.
As defined in Toledano et al , a score of 5 points or more indicates normosmia, a score between 2 and 4.5 points indicates reduced olfactory function in terms of hyposmia, and a score of less than 2 points indicates functional anosmia.
All patients completed the RSDI questionnaire ( Table 1 ). Thirty questions were asked, and each was scored on a 0 to 4 scale (0 = never, 1 = almost never, 2 = sometimes, 3 = almost always, and 4 = always). We added each question results of the questionnaire and got a final result. Later, we obtained the average of the final results of the 51 questionnaires, as well as the average of the final results of each of the domains: functional (questions f1–5, f13, f23, f28, and f29), emotional (questions e12, e14–19, e21, e26, and e27), and physical (questions p6–11, p20, p22, p24, p25, and p30). At the end of the questionnaire, the subjects had to rate how severe they felt their olfactory impairment was on a visual analogue scale (VAS) from 1 to 10.
| The purpose of this scale is to identify difficulties that you may be experiencing because of your nose or sinus problems. Please answer never , almost never , sometimes , almost always , or always to each item. Answer each item as it pertains to your nose and sinus problem only. | |||||
|---|---|---|---|---|---|
| Never (0) | Almost never (1) | Sometimes (2) | Almost always (3) | Always (4) | |
| f1. Because of my problem, I feel handicapped. | 0 | 1 | 2 | 3 | 4 |
| f2. Because of my problem, I feel restricted in performance of my routine daily activities. | 0 | 1 | 2 | 3 | 4 |
| f3. Because of my problem, I restrict my recreational activities. | 0 | 1 | 2 | 3 | 4 |
| f4. Because of my problem, I feel frustrated. | 0 | 1 | 2 | 3 | 4 |
| f5. Because of my problem, I feel fatigued. | 0 | 1 | 2 | 3 | 4 |
| p6. Because of my problem, I do not sleep well. | 0 | 1 | 2 | 3 | 4 |
| p7. I have difficulty with exertion due to my nasal obstruction. | 0 | 1 | 2 | 3 | 4 |
| p8. I am inconvenienced by my chronic runny nose. | 0 | 1 | 2 | 3 | 4 |
| p9. The pain of pressure in my face makes it difficult for me to concentrate. | 0 | 1 | 2 | 3 | 4 |
| p10. The pain in my eyes makes it difficult for me to read. | 0 | 1 | 2 | 3 | 4 |
| p11. I have difficulty stooping over to lift objects due to face pressure. | 0 | 1 | 2 | 3 | 4 |
| e12. Because of my problem, I feel stressed in relationships with friends and family. | 0 | 1 | 2 | 3 | 4 |
| f13. Because of my problem, I avoid traveling. | 0 | 1 | 2 | 3 | 4 |
| e14. Because of my problem, I feel confused. | 0 | 1 | 2 | 3 | 4 |
| e15. Because of my problem, I have difficulty paying attention. | 0 | 1 | 2 | 3 | 4 |
| e16. Because of my problem, I avoid being around people. | 0 | 1 | 2 | 3 | 4 |
| e17. Because of my problem, I am frequently angry. | 0 | 1 | 2 | 3 | 4 |
| e18. Because of my problem, I do not like to socialize. | 0 | 1 | 2 | 3 | 4 |
| e19. Because of my problem, I frequently feel tense. | 0 | 1 | 2 | 3 | 4 |
| p20. Food does not taste good because of my change in smell. | 0 | 1 | 2 | 3 | 4 |
| e21. Because of my problem, I frequently feel irritable. | 0 | 1 | 2 | 3 | 4 |
| p22. Because of my problem, I have difficulty with strenuous yard work and housework. | 0 | 1 | 2 | 3 | 4 |
| f23. Because of my problem, I miss work or social activities. | 0 | 1 | 2 | 3 | 4 |
| p24. My frequent sniffing is irritating to my friends and family. | 0 | 1 | 2 | 3 | 4 |
| p25. Straining increases or worsens my problem. | 0 | 1 | 2 | 3 | 4 |
| e26. Because of my problem, I am depressed. | 0 | 1 | 2 | 3 | 4 |
| e27. My problem places stress on my relationships with members of my family of friends. | 0 | 1 | 2 | 3 | 4 |
| f28. My outlook on the world is affected by my problem. | 0 | 1 | 2 | 3 | 4 |
| f29. Because of my problem, I find it difficult to focus my attention away from my problems and on other things. | 0 | 1 | 2 | 3 | 4 |
| p30. My sexual activity is affected by my problem. | 0 | 1 | 2 | 3 | 4 |
| Please evaluate the overall severity of your nasal-sinus problem: | |||||
| Mild | Moderate | Severe | Total | ||
| 1 2 3 | 4 5 6 | 7 8 9 | 10 | ||
Statistical analyses were performed using SPSS 15.0 (SPSS Inc, Chicago, IL). The α level was .05. After testing for normal distribution of the data for analysis of group differences, Mann-Whitney U test was applied. The P level was set at .05.
2
Material and methods
Although there is no definitive test that identifies clearly an olfactory loss as being postviral, we included patients with sudden smell loss secondary to URTI (cold or flu). This loss will persist even several months after the infection. If the patient does not describe a cold or flu episode, we think that it is inappropriate to diagnose the loss as being postviral . We ruled out other causes of smell loss such as head trauma, chemical exposure, drugs intake (especially topical zinc-containing preparations that are not available in Spain), any kind of chronic rhinosinusitis, systemic diseases (hypertension, diabetes, and immunological disease), smoking, or alcoholic habits. All of them were thoroughly examined by experienced otorhinolaryngologists compiling complete clinical history, endoscopic views, and computed tomographic (CT) scan pictures. In all patients, endoscopic exploration and CT scan pictures were normal.
A total of 51 patients suffering from changes in olfactory function by URTI were investigated (40 women and 11 men; mean age, 53.3 ± 1.8 years; confidence interval [CI], 49.6–57.1). The patients were thoroughly examined by experienced otorhinolaryngologists, including an endoscopic and CT scan in coronal projection of the nasal cavity. Based on the clinical examination (no findings in endoscopic and CT scan) and the detailed, structured history, olfactory dysfunction was classified as viral postinfection. In all the patients, the loss of smell lasted more than 3 months. The patients did not have any other concomitant systemic disease or drugs intake that could produce olfactory impairment. Because the presentation of the patients to our clinic is dependent on their subjective degree of complaint and on the often-ignoring attitude of clinicians and the social environment toward olfaction and its problems, the time span between appearance of olfactory disturbance and first visit varied from 1 to 14 months. All of them were thoroughly examined by experienced otorhinolaryngologists. The study protocol was approved by the ethical committee of our hospital according the Helsinki recommendations. All the patients signed one specifically designed informed consent for the study.
Olfactory testing was performed using the Connecticut Chemosensorial Clinical Research Center test kit. This test was manufactured in our institution with the collaboration of the Pharmacy Department following the guidelines of the original article of Cain et al , who were the first to describe this olfactory test. This test was made up of 2 parts: the butanol threshold test and the identification test. The threshold test used aqueous dilutions of 1-butanol, where successive dilutions differed by a factor of 3. The highest aqueous concentration equaled 4%. The number of dilution steps ranged from 0 to 8 depending on testing circumstances. The test solutions were presented for smelling in 250-mL capacity polyethylene bottles containing 60 mL of solution. The bottle closure had a pop-up spout that fitted to both nostrils. To sample a bottle, the person placed the spout into both nostrils and then sniffed simultaneously. Testing began with the lowest concentration. The test participant received the bottle with this concentration along with a blank and had to decide which smelled stronger. If incorrect, the participant received another blank paired with the next higher concentration. Errors triggered increments in concentration, whereas correct choices led to another presentation of the same concentration (in another bottle) and a blank. Four correct choices in a row led to an end of the testing. The concentration at which this occurred marked the threshold.
The participant received the identification test after the threshold test. A kit was composed of ten 180-mL opaque plastic jars containing 5 g of the substance in sachet-like packets of stimuli. Based on the performance of anosmic patients, we can say that 7 stimuli appealed exclusively, or almost so, to the sense of smell (baby powder, chocolate, cinnamon, coffee, mothballs, peanut butter, and bar of soap) and one appealed to the common chemical sense as well (Vicks). The 8 items were presented in the same order for both nostrils. When presented with an item, the participant chose from a 20-item list. The list contained the names of the 8 test items and of 13 distractors. In addition to the names on the list, responses of “no sensation” and “do not know” were permitted. The examiner gave corrective feedback whenever the participant made an error. If the participant exhibited some evidence of function, but nevertheless made mistakes, the examiner presented missed items for a second time. A correct answer upon second presentation cancelled a previous error. This allowed a participant to rectify mistakes and thereby decreased the possibility of cognitive errors. In such cases, the first trial with an item served as training. The score for the test comprised the number of olfactory items out of 7 correctly identified and a notation regarding ability to perceive trigeminal stimulation.
The outcome of the threshold and identification test was combined into a composite score, an average of the 2 tests.
As defined in Toledano et al , a score of 5 points or more indicates normosmia, a score between 2 and 4.5 points indicates reduced olfactory function in terms of hyposmia, and a score of less than 2 points indicates functional anosmia.
All patients completed the RSDI questionnaire ( Table 1 ). Thirty questions were asked, and each was scored on a 0 to 4 scale (0 = never, 1 = almost never, 2 = sometimes, 3 = almost always, and 4 = always). We added each question results of the questionnaire and got a final result. Later, we obtained the average of the final results of the 51 questionnaires, as well as the average of the final results of each of the domains: functional (questions f1–5, f13, f23, f28, and f29), emotional (questions e12, e14–19, e21, e26, and e27), and physical (questions p6–11, p20, p22, p24, p25, and p30). At the end of the questionnaire, the subjects had to rate how severe they felt their olfactory impairment was on a visual analogue scale (VAS) from 1 to 10.
