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Home , Laryngectomy, Rhinoplasty

B-ENT , 2009, 5, Suppl. 13, 77-87 Surgical therapy and olfactory function

P. Bonfils, D. Malinvaud, Y. Soudry, M. Devars du Maine and O. Laccourreye ENT Department, European Hospital Georges Pompidou, Faculty of Paris-Descartes, University Paris V, Paris, France

Key-words. ; olfaction; rhinosinusitis; nasal polyposis; ; ; ; neurosurgery; FESS;

Abstract. Surgical therapy and olfactory function. This report provides an overview of the relationship between olfaction and surgery. Surgery can be considered as treatment for some olfactory dysfunctions. Moreover, olfactory dysfunction can be analysed as a of some surgical procedures. An impaired sense of smell is a common problem affecting approximately 65% of patients with chronic sinusitis. Much of the literature about the effect of surgery on the olfactory system is based on subjective reports of olfactory function, which do not accurately assess objective smell dysfunction. A small number of prospective studies have been published. All studies looking at the sense of smell have found overall post-operative improvement compared with pre-operative symptoms. The range of improve - ment compared with pre-operative scores ranged from 13 to 91%, with a median of 31%. Olfaction dysfunction can be a complication of various surgical procedures such as laryngectomy, septoplasty, rhinoplasty, ethmoidectomy, and some neurosurgical procedures.

Introduction On the other hand, all naso- have studied the relationship sinusal surgery may involve a risk between olfactory function (odour All pathology of the upper respira - for olfaction. Only a few studies identification test, odorant confu - tory tract may be associated with have investigated correlations sion matrix) and nasal anatomy impaired sense of smell. Nasal between olfaction and surgical (evaluated using computed obstruction induced by septal procedures: laryngectomy, anteri - tomography) in hyposmic deviation or turbinate hypertrophy or base surgery, rhinoplasty, patients. They identified three fac - is frequently associated with septoplasty, turbinectomy and tors that influence olfaction: olfactory dysfunction. Only a few turbinoplasty. (i) the space anterior to, and no studies have discussed the rela - The aim of this paper is to more than 5 mm below, the cribri - tionship between olfactory ability review all these relationships form plate, ( ii ) the space between and septoplasty, turbinoplasty, tur - between surgery and olfaction. 10 and 15 mm below the cribri - binectomy, and surgery of choanal form plate, and ( iii ) the space pos - atresia. Chronic rhinosinusitis is Surgery as treatment for olfac - terior to, and between 10 and the most common chronic inflam - tory dysfunction 15 mm below, the cribriform matory disease, and is frequently plate. Recently, Damm et al .4 have Anatomical surgery (septoplasty, associated with olfactory distur - measured olfactory function rhinoplasty, turbinectomy) and bance. The main symptom of nasal (phenyl ethyl alcohol threshold, olfactory function polyposis is . Functional odour discrimination and identifi - endoscopic sinus surgery is widely The volume and shape of the cation) in 50 healthy subjects, and accepted as treatment for chronic influence olfactory compared these olfactory results rhinosinusitis and/or nasal poly - physiology. The number of olfac - with intranasal volume measured posis in the setting of failure of tory molecules transported to the by magnetic resonance imaging. medical management. All studies olfactory neuro- varies Significant correlations were looking at the sense of smell as a function of the intranasal air - found between odour thresholds have stated overall post-operative flow. 1 The relationship between and the volumes of the anterior improvement compared with pre- olfactory ability and nasal struc - part of the right lower and upper operative symptoms. ture is complex. Leopold et al .2,3 meatus. These results suggest the 78 P. Bonfils et al. interest for nasal surgery, mainly 4 weeks after septoplasty. More rhinoplasty. Champion has reported for inferior turbinate resection and recently, Pfaar et al .11 evaluated temporary anosmia in about 10% septoplasty, of two anatomical septoplasty-related changes of of patients, lasting 6 to 18 months segments: ( i) the segment in the lateralised olfactory function after rhinoplasty. Kimmelman 10 upper meatus below the cribriform (Sniffin’Sticks test battery) evaluated olfactory function plate, and ( ii ) the anterior segment before, 4 and 9 months after a (UPSIT test) before and after of the inferior meatus. septoplasty in 30 patients. Before rhinoplasty in 15 patients (follow- Nasal obstruction induced by septoplasty, patients had signifi - up: 2 and 4 weeks). A small but septal deviation or turbinate cantly higher odour thresholds for significant increase in UPSIT hypertrophy is frequently associ - the obstructed nostril compared scores was observed following ated with olfactory dysfunction. 5-8 to contralateral thresholds. The surgery. However, this conclusion Septoplasty and turbinectomy difference in odour thresholds is weakened by methodological constitute a common procedure between obstructed and non- considerations. 9 Furthermore, an for the treatment of nasal obstruc - obstructed sides disappeared after analysis of the literature seems to tion related to an anatomical surgery. No such results were indicate that a relevant increase in abnormality. The effects of nasal observed for suprathreshold olfactory function may not be surgery on olfaction have not been measures . Following septal sur - expected after rhinoplasty. well documented in the literature. gery, a significant decrease in The effects of turbinectomy on The available data on olfactory odour discrimination was found olfaction have been documented in outcome after such nasal surgery by comparison with the pre-opera - a few publications. Ophir et al .14 is limited. tive results. There was no signifi - reported on a series of 150 patients Septoplasty is frequently per - cant change in odour thresholds who underwent total inferior tur - formed in patients with nasal and odour identification after sur - binectomy with a mean follow-up obstruction due to septal anatomi - gery. In conclusion, no significant of 2.5 years. Olfactory testing con - cal abnormalities. Olfactory change in overall olfactory ability sisted of a forced-choice format function may only be influenced was found following septoplasty. for standardised odorants. None of indirectly, through changes asso - An analysis of the literature seems the patients were found to have ciated with airflow. Only a few to indicate that a relevant increase anosmia, but 27% of the patients studies have discussed the in olfactory function may not be noted an improvement in olfac - relation ship between septoplasty expected after septoplasty. 11 Never - tion. Odetoyinbo 15 addressed this and olfactory ability. 9 Stevens et theless, some authors reported issue by following 58 patients who al .6 compared olfactory thresholds hyposmia and anosmia following underwent bilateral inferior tur - of 100 patients before and after septal surgery. binectomy. Olfactory assessment nasal surgery, including septo - The effects of rhinoplasty on of the patients was by question - plasty (n = 63), rhinoseptoplasty olfaction have not been well docu - naire: 61% noted an improve - (n = 24), inferior turbinate resec - mented. 9 Goldwyn and Shore 5 ment in olfaction. Elwany and tion (n = 3), and polypectomy (n = compared olfaction in 97 consecu - Harrisson 16 compared four inferior 10). Data for each type of opera - tive patients undergoing rhino - turbinectomy techniques (partial tion was not provided separately. plasty and/or submucous resection turbinectomy, laser turbinectomy, The authors concluded that nasal with 57 normal control subjects. cryoturbinectomy, turbinoplasty) surgery, including septoplasty and Olfaction was evaluated on the in terms of their effects on nasal inferior turbinate resection, basis of the subjects’ response to obstruction and olfaction (n = 80 improved olfactory function. But, smelling oil of clove, oil of pep - patients). Olfactory thresholds this conclusion is weakened by permint, and ground coffee. Two, were determined for citral and methodological considerations. 9 six and twelve months after sur - eugenol. Post-operative improve - Kimmelman 10 evaluated olfactory gery, none of the patients had any ments in olfaction correlated posi - function (UPSIT test) before and change in their olfaction by com - tively with the patency of the nasal after septoplasty in 34 patients. parison with the pre-operative airway. Damm et al .8 evaluated the UPSIT scores were equivalent results. Others authors 11-13 also influence of septoplasty associated before and after surgery. But 1% reported that subjective olfactory with partial inferior turbinectomy of the patients showed anosmia 2- function was not improved after (n = 30 patients) on threshold and Surgical therapy and olfactory function 79 suprathreshold olfactory acuity. Identification Test (IPSUT). of patients with a fungus ball. 22 Olfactory function was deter - Patients with choanal atresia had a The prevalence of cacosmia in mined with Sniffin’Sticks (odour significant loss of olfaction (p = localised anterior sinusitis is threshold , discrimination and 0.03). Patients with choanal atre - 26%. 19 The treatment of such identification). After surgery, 80%, sia had moderate hyposmia (score: odontogenic sinusitis usually 70% and 54% of patients had 27/40) while control subjects had requires a combination of medical improved olfaction in terms of normal olfaction (score: 37/40). and surgical management. 23 odour identification, odour dis - Elimination of the cause, either by crimination or odour thresholds Surgery of rhinosinusitis and treating an infected tooth with root respectively. This study suggests olfactory function canal therapy or extraction, or that septoplasty associated with removal of a fungus ball from the Chronic rhinosinusitis is a group partial inferior turbinectomy has a sinus, is required to prevent recur - of pathologies characterised by positive effect on olfaction, mainly rence of the disease. After dental the inflammation of the mucosa of on suprathreshold parameters. An treatment and medical manage - the nose and for analysis of the literature therefore ment including a 7- to 10-day at least twelve consecutive weeks. seems to indicate that a relevant course of oral with ade - In most cases, patients complain increase in olfactory function may quate sinus coverage, persistent of nasal discharge, nasal obstruc - be expected after turbinec tomy. symptoms require functional tion and olfactory dysfunction. On Only two publications of endoscopic sinus surgery. the basis of an anatomical distinc - patients with choanal atresia Unfortunately, the results of sur - tion, 19 it is possible to define three report on the effects of surgery gery for odontogenic sinusitis or main clinical entities for chronic repair on olfaction. Gross-Isseroff fungus balls never include cacos - rhinosinusitis: chronic rhinitis, et al .17 were the first to report, in mia. For example, Dufour et al .24 localised sinusitis, and diffuse rhi - 1989, on olfactory function fol - reported on a retrospective series nosinusitis. Diffuse rhinosinusitis lowing the repair of choanal atre - of 175 patients suffering from is mainly represented by nasal sia. Threshold determination and paranasal sinus fungus balls con - polyposis. 20,21 The symptom pat - odour identification were evalu - firmed by histopathology or terns of these three main clinical ated in three cases of bilateral and mycological culture. The study entities vary considerably, particu - one case of unilateral choanal was based on analysis of medical larly the olfactory symptoms. atresia. These four patients under - files, operative charts, and follow- Olfactory dysfunction can consist went the successful choanal atre - up evaluation reports. Only one of either hyposmia, anosmia, or sia repair procedures at ages vary - case of local failure was observed cacosmia. Hyposmia is mainly ing between 8 and 31 years old. in the , as well as present in patients with rhinitis or Patients with bilateral atresia had 6 cases of persisting fungus ball, moderate diffuse rhinosinusitis. permanent olfactory deficits while in a mean follow-up of 5 years. Anosmia is found to be rather the patient with unilateral atresia However, the report on this large common in patients with diffuse had normal olfactory function. series did not include any data rhinosinusitis, particularly in nasal This paper suggested that early about cacosmia. Nevertheless, the polyposis; it represents an impor - olfactory exposure might be disappearance of the tant patient complaint. In contrast, needed for the normal develop - could be associated with the dis - cacosmia is mainly associated ment of the olfaction system. appearance of the cacosmia. with localised anterior sinusitis, Leclerc et al .18 reported, ten years particularly in cases of odonto - after, on a series of 7 patients born genic sinusitis or fungus balls. 19 Surgery for diffuse rhinosinusitis with choanal atresia (5 bilateral and anosmia and 2 unilateral). This case-con - Surgery for localised sinusitis and trol study was conducted to com - The most common surgical proce - cacosmia pare olfaction in this group of dures impacting olfaction are per - patients to a similar group of The surgical treatment for cacos - formed in patients with diffuse normal subjects. Olfactory investi - mia is the surgical treatment of rhinosinusitis and/or nasal poly - gations were conducted with the odontogenic sinusitis or fungus posis 9 after medical treatments University of Pennsylvania Smell balls. Cacosmia is present in 21% have failed. 25 The management of 80 P. Bonfils et al. nasal polyposis has been a topic of major variations in the way observed two weeks after treat - frequent heated debate for many patients are selected for surgery. ment began in both groups, and decades. Most authors agree that A range of factors have been this was maintained throughout nasal polyposis management reported as a basis for patient the following year. El Nagger et should be based primarily on a selection. They include symptom al .30 studied olfaction in 29 patients medical approach to be completed scores, extent of disease ( i.e. with nasal polyposis before and by surgical procedures only in the endoscopic and/or CT scores) and after a polypectomy, followed by a case of drug failure. 20,26 Abundant failed medical treatment. A num - 6-week course of beclomethasone literature has been dedicated to ber of publications had poor exter - nasal spray to one nostril, with the this treatment modality, but most nal validity with poorly defined other acting as a control. The of the publications deal with a sin - patient groups, a lack of clear study used the University of gle administered either inclusion and exclusion criteria, Pennsylvania Smell Identification orally or in a spray. Intranasal and little or no description of the Test (UPSIT). Smell function did are the best documented surgical procedure. 29 Moreover, not change after this procedure, type of treatment for rhinosinusi - the majority of studies of out - either with or without beclometha - tis and/or nasal polyposis. 27 A comes after FESS group patients sone nasal spray. number of placebo-controlled with a variety of polypoid and A systematic review of the studies have shown a significant non-polypoid diseases. The analy - clinical effectiveness of endo - clinical effect. Some studies were sis of the outcomes of surgery in scopic sinus surgery for the dedicated to systemic steroid terms of olfaction in chronic rhi - removal of nasal polyposis has therapy , showing genuine efficacy nosinusitis must therefore take been published by Dalziel et al .31 for all symptoms, especially anos - several criteria into account: ( i) Pre-operative smell disturbance mia. Topical steroids can also be the group of patients studied (i.e. percentages varied from 16% to used as long-term therapy, either mean doses of medical treatment 100% in the publications covered. alone in mild cases, or in combi - administered before surgery), ( ii ) This major variation suggests that nation with systemic steroids in the surgical procedure used (i.e. the inclusion criteria were differ - more severe cases. A limited num - polypectomy, partial or radical ent in these reports. Mean doses of ber of publications have reported ethmoidectomy), ( iii ) the method medical treatment administered on the efficacy of a standardised for the evaluation of olfaction ( i.e. before and after surgery were not drug administration protocol self-perceived olfactory function systematically reported. Never- based on a short-term oral steroid or quantitative measures). theless, all the studies that covered prescription combined with the The surgical options described in sense of smell stated overall post- daily and long-term administra - the treatment of chronic rhino si - operative improvement compared tion of topical steroids. 19,28 Short nusitis and/or nasal polyposis can with pre-operative symptoms. The courses of systemic steroids com - be broadly divided into simple range of improvement compared bined with long-term steroid snare polypectomy or endoscopic with pre-operative scores ranged intranasal spray treatment led to sinus surgery. The only attempt from 13 to 91% with a median of satisfactory results in 85% of the at a randomised comparison of 31%. 31 patients. In about 15% of cases, steroid therapy and polypectomy Jafek et al .32 were the first to medical treatment alone fell short was performed by Lildholdt in report on the concept of steroid- of the expected effects, in particu - 1989. 21 In a prospective study, dependent anosmia and the influ - lar on nasal obstruction and olfac - patients (n = 53) received continu - ence of nasal surgery on smell tion, and surgery had to be con - ous topical treatment with either a function. Some publications sidered. 19 polypectomy or an intramuscular examined a limited series of Functional endoscopic sinus injection of betamethasone dipro - patients ( i.e. fewer than surgery (FESS) is widely accepted pionate and betamethasone sodi - 30 patients). 10,30,33-35 Park et al .36 as a treatment for chronic rhinosi - um phosphate. Patients were fol - reported on a retrospective series nusitis and/or nasal polyposis sub - lowed up for one year. The smell of 79 patients with chronic rhinos - sequent to the failure of medical evaluation methodology was not inusitis or recurrent acute sinusi - management. Nevertheless, the described. Significant subjective tis, including 73% with nasal literature shows that there are and objective improvement was polyposis. Surgery consisted of Surgical therapy and olfactory function 81

FESS, with the removal of the anosmia, 52% hyposmia, and 17% tion was evaluated by question - bulla ethmoidalis, uncinate normosmia. Following FESS, naires. The length of follow-up process and anterior ethmoid 11% of patients had anosmia, 57% was one year. Anosmia was cells. Olfactory disturbance was hyposmia, and 31% normosmia. reported by 48% of patients with reported in 72% of patients pre- Improvement occurred in 70% nasal polyposis before surgery operatively compared with 38% of patients with anosmia or compared with 21% one year after (p< 10 -4 ) following FESS. Lund hyposmia . Olfaction worsened FESS (Stammberger technique). and Scadding 37 evaluated olfaction following 8% of FESS proce - Litvack et al .46 confirmed that in 50 patients with chronic dures. There was a correlation olfactory impairment was com - rhinosinusitis , using UPSIT and between olfactory loss and the mon in 111 patients with chronic a one-year follow-up period. extent of sinus disease. Klimek et rhinosinusitis. All patients had a Endoscopic sinus surgery included al .41 determined the odour identifi - diagnosis of chronic rhinosinusitis different procedures: anterior cation and discrimination of 31 based on the rhinosinusitis task ethmoidectomy and/or anterior + patients with nasal polyposis force criteria. An objective posterior ethmoidectomy. Surgery before and after surgery. Endo - measure of olfactory function, the was followed by a 3-month period nasal sinus surgery resulted in SIT from Sensonics, Inc, was of topical steroids. Significant improved olfaction, with the best administered before and after post-operative improvements in results within three months after endoscopic sinus surgery. Olfac - UPSIT scores were observed. surgery. Min et al .42 tested butanol tory function improved in patients Lund and MacKay 38 also reported thresholds before and after FESS with pre-operative anosmia, and on a retrospective series of 650 in 80 patients with chronic rhinos - was sustained at one-year follow- patients with chronic rhinosinusi - inusitis. Before surgery, 33% of up. Nevertheless, patients with tis (51%), recurrent acute sinusitis patients had anosmia; 45% of pre-operative hyposmia did not (2%) and nasal polyposis (47%). patients had hyposmia. After sur - improve after sinus surgery. Only 23% of the patients had a gery, these percentages were 16% Recently, Bonfils 29 reported on a smell dysfunction pre-operatively. and 46%. Klossek et al .43 reported prospective series of 194 consecu - Six months after an endoscopic on a retrospective series of 50 tive patients with nasal polyposis sinus surgery, 21% of patients patients with extensive nasal poly - who were examined, operated on, reported being the same, 79% posis. Pre-operatively, 100% of and followed by the same . reported improved olfaction, and the patients had anosmia for at Before surgery (total ethmoidec - 12% reported being cured. least six months per year. At three- tomy), all patients received sys - Downey et al .39 assessed olfactory year follow-up, 78% of the tematic and standardised medical function in 50 patients with chronic patients retained their sense of treatment, including washing of rhinosinusitis, before and after smell. This percentage was lower the nasal cavities, long-term topi - endoscopic sinus surgery, using one year later (60%) and three cal steroids, and short courses of UPSIT. After surgery, 52% of years later (58%). Levine 44 report - systemic steroids. The minimum patients had higher UPSIT scores, ed on a retro spective study of 250 duration of medical treatment and self-reported significant patients with nasal polyposis (n = before surgery was six months. improvement in olfaction. UPSIT 131) or chronic sinusitis (n = Patients were selected for surgical scores were correlated with the 119). Surgery consisted of FESS, treatment when more than three severity of the disease, as defined using a modified Messerklinger systemic courses of prednisone by the Kennedy staging system. technique. Only 16% of the per year proved to be necessary to Delank and Stoll 40 reported on a patients had a smell disturbance control nasal polyposis symptoms. prospective series of 115 patients before surgery. After a mean fol - The mean follow-up duration after with chronic rhinosinusitis, low-up of one year after surgery, surgery was 6 years. 84% of including 77% with nasal polypo - 3% of patients reported anosmia. patients had anosmia before sur - sis. FESS was conducted with a Jakobsen and Svendstrup 45 gery. The 5-year actuarial anosmia Wigand approach. Olfaction was reported on a retrospective study control rate was 66%. However, evaluated by olfactory tests and of 237 patients with either chronic only 18% of the patients con- self-rating questionnaires. Pre- infectious sinusitis (n = 91), or sidered their olfaction to be operatively, 31% of patients had nasal polyposis (n = 146). Olfac - normal 5 years after surgery. 82 P. Bonfils et al.

Three years after surgery, the and 200 mg propophol promised transport of odorant smell loss severity index was administered intravenously for molecules to the olfactory mucosa reduced by 45%. These surgical induction, 80 mg succinylcholine because of the loss of the ability to results were not modified either to facilitate , sniff air through the nose. 62 Other by the presence of allergy, 47 and 1-2% isoflurane in 60% N2O authors have suggested that surgi - bronchial hyperresponsiveness, 48 with oxygen for maintenance. The cal interference with sensory or by the eosinophilic infiltration anaesthetic was uneventful; the from the might alter index of polyps. 49 patient was discharged the same olfactory function through a Some publications compare the day. The anaesthetist did believe complex feedback mechanism. 63,64 impact of different surgical there was a causal relationship. Welge-Luessen et al .65 insufflate approaches on the sense of smell. Unfortunately, the patient the odorant directly into the nose Jankowski et al .50 compared two remained unconvinced and in order to determine whether series of patients with diffuse brought the matter to litigation. olfactory event-potentials can be nasal polyposis: 37 patients under - An expert related the patient’s induced in post-laryngectomy going functional ethmoidectomy symptoms to the anaesthetic she patients when the airstream is and 39 patients undergoing radical had received. Specifically, he forced into the nose. Olfactory ethmoidectomy. Olfaction was stated that halogenated hydrocar - evoked-potentials were recorded evaluated with a 10-point visual bons could induce taste and smell in 64% of the patients tested. analogue scale. Both groups had distortions. The lawsuit was dis - Anosmia therefore appears to be similar scores pre-operatively. missed. 53 A variety of drugs have mainly due to the impaired trans - Improvement in olfaction was been described as altering taste port of molecules to the olfactory similar in both groups six months and smell after oral administra - neuro-epithelium. On the other after surgery. Nevertheless, impro - tion, systemic injection or topical hand, histological evidence that vement was stable in the radical application. 54 Some of these drugs some damage may be present in ethmoidectomy group but olfac - are used in local and general the olfactory neuro-epithelium in tion decreased after six months in anaesthesia. Benzocaine, 55 hydro- post-laryngectomy patients. 66 the functional ethmoidectomy chloride, 55 and lidocaine 56 interfere This clinical evaluation was group. with the taste system; and confirmed by olfactometry and lodicaine 57 interfere with the smell chemosensory evoked potentials. system. 58 An unpleasant smell of The psychophysical data revealed Olfactory dysfunction as a halogenated volatile agents can be that laryngectomees are either complication of surgery perceived during inhalational functionally anosmic or hypos - induction but without any defini - mic. Olfactory evoked potential Olfactory dysfunction and anaes - tive smell loss. 59,60 studies suggested that, in two- thesia thirds of the patients, the olfactory Is there a relationship between system retained some function, Olfactory dysfunction after total olfactory dysfunction and general even up to 22 years after laryngec - laryngectomy anaesthesia? A very limited num - tomy. 65 Van Dam et al .67 analysed ber of publications have reported Olfaction is frequently altered 63 post-laryngectomy patients on the effects of anaesthesia on after total laryngectomy. Severe with two different olfactory tests: olfaction. For some authors, anos - hyposmia has been reported in an odour-detection test and an mia may occur after general two-thirds of patients who under - odour-differentiation test. Patients’ anaesthesia during the course of go laryngectomy, and moderate assessments of their own olfaction surgical interventions not neces - hyposmia was found in the were assessed with a question - sarily associated with naso-sinusal remainder. 61 The reason for olfac - naire, and by means of self- surgery. 51,52 Adelman 53 related tory loss is still a matter for reports. One-third of the patients changes in taste and smell experi - debate. Some authors propose were able to smell the odorous enced approximately 6 weeks an anatomical explication: after substances used in the olfactory after having received a general total laryngectomy the absence tests. The smellers used a variety anaesthetic for cystoscopy. The of olfaction and perception of of methods to smell; in most anaesthetic consisted of 50 mg flavours could be due to the com - patients the method consisted of Surgical therapy and olfactory function 83 the active use of facial muscles. 30 minutes a day for 3 months. Sixty-one patients (66%) had The non-smellers reported a more They were also asked to use a either improved or unchanged severe decrease in gustation after diary to record subjective ratings UPSIT scores after surgery; the the operation. Patients who report - of their sense of smell and the remaining 32 patients (34%) had ed the deterioration of olfaction practicability of using the device lower scores. One patient (1%) and gustation tended to experience every day. Three months later, became anosmic. Stevens et al .6 negative consequences such as the patients experienced a significant reported on a prospective study of inability to smell smoke, leaking olfaction improvement as assessed 100 patients undergoing nasal gas, or agreeable odours. Leon et with the Sniffin’ Sticks test. One surgery. Olfaction was evaluated al .61 studied the retronasal and year later, the same authors 69 com - pre- and post-operatively. Eight orthonasal olfactory function pared the larynx bypass with a patients experienced impaired after laryngectomy: 36 volunteer new instrument: the scent-dif - olfaction after surgery. Two of patients who underwent laryngec - fusing ventilator. Olfac tory func - these cases were related to allergic tomy were compared with 36 con - tion significantly improved with rhinitis. One patient had a total trol subjects without laryngecto - the two systems but the scent-dif - loss of olfaction following septo - my. Scores were established using fusing ventilator was much easier rhinoplasty. The authors conclude psychophysical tests (Connecticut to use than the larynx bypass. that most patients undergoing Chemosensory Clinical Research They concluded that technical nasal surgery will experience Center) for orthonasal and improvements are necessary to either an improvement or no retronasal olfaction and self-rating make the scent-diffusing ventila - change in olfaction after surgery. scores for smell using a visual tor an established part of the reha - In conclusion, the occurrence of analogue scale. The assessment bilitation of the olfactory function olfactory disease after endonasal of orthonasal olfactory ability in patients with laryngectomy. surgery has been reported to be as yielded a mean composite score of high as 1%. 52 4.3 for the laryngectomy group Olfactory dysfunction after nasal and 5.3 for the control group. The surgery Olfactory dysfunction after neuro - evaluation of retronasal olfactory surgery ability resulted in mean scores of Implicit in all types of nasal 11.0 for the laryngectomy group surgery is the potential for a Olfactory function is often sacri - and 14.3 for the control group. worsening of olfactory function. ficed to gain access to the anterior The mean self-rating scores for Hyposmia or anosmia may be and central cranial base 70 . smell were 2.9 and 6.6 for the attributable to several mecha - Olfactory structures, mainly the laryngectomy group and control nisms: tissue, granulation olfactory bulb, constitute a natural groups respectively. The dif - tissue, persistent mucosal oedema obstacle to the approach of the ferences were significant. Self- or inflammation, or olfactory anterior cranial fossa. Anosmia is assessment with a simple visual neuro-epithelium lesions. 52 Such therefore a major sensory compli - analogue scale successfully iden - olfactory dysfunction can be cation associated with this sur - tifies many laryngectomy patients observed after rhinoplasty, gery. Passagia et al .70 suggested who have objective evidence of septoplasty, turbinectomy and that the most important considera - olfactory dysfunction. functional endoscopic sinus tion is to respect the supply Furthermore, the use of larynx surgery. Kimmelman 10 examined to the olfactory bulb. New tech - bypasses demonstrates that sub - 93 patients undergoing various niques, modified approaches, and normal olfactory function is pres - types of nasal surgery, including microneurosurgery have been ent in patients after laryngecto - ethmoidectomy, polypectomy, described as potential ways to pre - my. 68,69 Larynx bypasses have been Caldwell-Luc procedure, open serve olfactory function. 71 In 1993, used to rehabilitate olfactory func - reduction of nasal fracture, closed Spetzler et al .71 preserved olfaction tion in patients after laryngecto - reduction of nasal fracture, rhino - in four consecutive patients with my. Göktas et al .68 have evaluated plasty, and septoplasty. Olfactory extradural anterior cranial base olfaction in 16 post-laryngectomy function was evaluated using the tumours by circumferentially patients. Patients were asked to University of Pennsylvania Smell cutting the , and use the device at home for at least Identification Test (UPSIT). leaving the neuro-olfactory 84 P. Bonfils et al. epithelium attached to it. Feiz- normal olfaction had normal unilateral frontal approach (n = 4), Erfan et al .72 reported on the long- olfaction, whereas 91% of those and in a supra-orbital approach term impact on olfactory function reporting anosmia were anosmic. (n = 3). The extent of tumour in 24 patients who underwent On the other hand, Martin et al .74 resection according to Simpson’s anterior craniofacial surgery and a compared two groups of patients classification system was grade I cribriform plate osteotomy to pre - (n = 39 patients) with anterior in 42.9%, and grade II in 57.1% of serve olfaction. Olfactory evalua - communicating artery aneurysms. the cases. Olfaction was preserved tion was defined by the subjective Olfactory function was assessed in 24% of patients. Welge- ability to detect smells such as using the University of Luessen et al .76 examined twelve coffee, chocolate, roses, and Pennsylvania Smell Identification patients with olfactory menin - orange juice regardless of the Test (UPSIT). A significant and giomas. In 8 cases, the menin - intensity of the sensation, and the severe olfactory impairment was gioma was lateralised (five left, follow-up was based on phone observed in patients with ruptured three right), and in four patients, calls to patients without any olfac - anterior communicating artery the meningioma was bilateral. tory tests (except in 5 patients). aneurysms compared with the Olfactory testing was performed Olfaction was spared in control group. Only one control using the “Sniffin’ Sticks” test. 22 patients, and was confirmed by subject had a smell identification Before surgery, six patients were olfactory testing in 5 patients. deficit versus 17 patients with found to be anosmic on the side of Only two patients were therefore ruptured aneurysms (44%). In this the tumour; two were hyposmic. anosmic. The authors concluded series, 17 patients underwent Four patients were normosmic. that olfaction can be preserved in aneurysmal clip placement, and After surgery, four patients had selected patients undergoing ante - 22 underwent coil embolisation. lateralised anosmia on the operated rior craniofacial surgery. At least 59% of the patients who under - side, three were normosmic on the 1 cm of nasal mucosa should went aneurysmal clip placement contralateral side and one was remain attached to the cribriform and 28.5% of patients who under - hyposmic. The remaining eight plate. This can be achieved by went coil embolisation scored patients were completely anosmic including the nasal in the below the 25th percentile on the post-operatively. The preservation osteotomy of the orbital bar. UPSIT. The olfactory test per - of olfaction ipsilateral to the Olfaction can therefore be pre - formed worse in patients subjected tumour therefore seems to be served in selected patients under - to endovascular coil embolisation extremely difficult, irrespective of going anterior craniofacial sur - when cerebral vasospasm or tumour size or surgical approach. gery. This procedure is particular - frontal cerebral lesions were However, the likelihood of normal ly suitable for benign or low-grade present . This difference was not post-operative olfactory function malignant tumours, primarily observed in patients who under - contralateral to the tumour was extradural tumours, or for went surgery. The authors con - high when the tumour was less intradural tumours with an cluded that olfactory deficits were than 3 cm in diameter and pre- extradural extension if the cribri - present in both groups of patients operative normosmia had been form plate is not involved by the treated with the two techniques. established. tumour. 72 Only a few publications report Cerebrospinal fluid rhinorrhoea Bifintal craniotomy can be used on the olfactory function after sur - can be managed either by neuro - to treat anterior communicating gical resection of olfactory groove or otorhinolaryngolo - artery aneurysms. Suzuki et al .73 meningiomas. Bassiouni et al .75 gists. Neurosurgeons often use an described a series of 110 cases. reported on a series of 56 con - intracranial approach and otorhi - The olfactory tracts were pre - secutive patients suffering from nolaryngologists an extracranial served bilaterally or unilaterally in olfactory groove meningiomas approach. Recently, transnasal 65% of the cases. 33% of the treated microsurgically. Pre- endoscopic techniques have been patients with bilateral olfactory operative neurological examination introduced that significantly tract damage reported subjectively revealed deficits in olfaction in reduce the morbidity of surgical normal olfactory. The objective 71.7%. The tumours were resected repair by comparison with intra - examination of olfaction showed via a bifrontal craniotomy (n = cranial approaches. Olfaction was that 84% of the patients reporting 36), a pterional route (n = 13), a preserved in all patients who Surgical therapy and olfactory function 85 underwent the endoscopic repair 2. Leopold DA. The relationship between 17. Gross-Isseroff R, Ophir D, of their cerebrospinal fluid leak nasal anatomy and human olfaction. Marshak G, Ganchrow JR, Beizer M, when olfaction was present pre- Laryngoscope . 1988;98:1232-1238. Lancet D. Olfactory function follow - 3. 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