530 Woodard Yappel Sinkko 8 7 12 - SOHN Nurse Disorder… · · 2017-04-28Kathleen Yappel Sinkko,...
Transcript of 530 Woodard Yappel Sinkko 8 7 12 - SOHN Nurse Disorder… · · 2017-04-28Kathleen Yappel Sinkko,...
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Troy Woodard, MDKathleen Yappel Sinkko, CNP
Rhinology, Sinus, and Skull Base Surgery
� Demonstrate knowledge of basic anatomy of
the nose and mouth as it pertains to smell and taste
� Identify causes and treatments of taste and smell disorders
� Provide cases and identify educational needs of a patient with a smell and taste disorder
� Estimated that 2.7 million Americans have olfactory problems� 2/3rd of which report gustatory problems
� 1.1 million Americans have gustatory problems� Approximately 80% of taste disorders are a result of a smell disorder
� Very difficult to diagnose and treat � Lack of knowledge of these diseases
� Secondary problem from another disease state
� Effects of these disorders vary � Minimal � Anxiety provoking
� Depression
� Life Threatening � Poor quality of life
� Smell is a form of chemoreception▪ Chemicals (odorants) absorbed into mucus
▪ Stimulate olfactory receptors
� Purpose
▪ Identify food, mates, predators
▪ Warns of danger
▪ Fire
▪ Spoiled food
▪ Gas Leaks
� Neuroepithelium
� Located in the superomedial and lateral nasal cavity
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� Olfactory receptors
� Bipolar neurons that extend
into the CNS
� Up to 100 million olfactory
neurons on each side
� Generated every 30-60 days
� G-protein mediated
� 300-400 different types
� 1 neuron to only 1 receptor type
� Only body site with exposed neurons to the external environment ▪ More venerable to damage from pathogens, toxins, physical trauma
� Covered by mucus from the Bowman’s Glands▪ Protects against microbial invasion▪ IGA and IGM▪ Lactoferrin
▪ Lysozyme
� Surrounded by supporting cells▪ Sustenacular cells▪ Basal Cells
▪ Bowman’s glands
� Odorant-binding proteins
▪ Transport molecules to olfactory receptors
� Taste is a form of chemoreception
▪ Performed by specialized modified epithelial cells
▪ Ions and molecules dissolved in saliva
▪ Enter taste pore and stimulates taste cells
▪ Taste buds- collection of taste cells
▪ Continuously form by the basal layer
� Role of saliva
▪ Transport medium for tastants
▪ Digestion
▪ Immunity
� 4 primary tastes
� Sweet, Sour, Bitter, and Salty
� Is there a 5th taste?
� Umami (Savory- glutamate) NEW!
� Salty and Sour- Ion (NaCl and H+ dependent)
� Sweet, Bitter - G-protein dependent
� What is Flavor?
▪ Sensation caused by combination of
▪ Smell, taste, touch (trigeminal), sight, temperature, audition
� 4 types of lingual papillae� Fungiform▪ CN VII
� Circumvallate▪ CN IX
� Foliate ▪ CN IX
� Filiform▪ No taste buds
4,600 taste buds on tongue
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� Other locations for taste buds
� Palate
▪ CN IX
� Epiglottis and Larynx
▪ Superior laryngeal branch of CN X
� Pharynx
▪ CN IX and CN X
� Free nerve endings from CN V� Irritants, burning, tickling, stinging
� Sensitive to just about all chemicals if concentrated enough
Is taste regionalized?
� Sweetness- tip of the tongue
� Salty- anterolateral tongue
� Sour- lateral
� Bitter- posterior tongue
� All taste qualities can be detected in all regions of the tongue
� Chemical Stimulation
� G-protein
� Direct neural stimulation
� Millions of neurons
� 1 neuron to 1 receptor type
� 300-400 receptor types
� Develop every 30-60 days
� Chemical Stimulation
� Ions and G-protein
� Indirect neural stimulation
� Thousands of taste buds
� 1 neuron to >1 taste buds
� 4 primary taste types
� Develop every 10 days
� K (Congenital)
� Inflammatory
� Toxins
� Trauma
� Endocrine
� Neoplasia, Neuro
� S (Psychiatric)
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� K congenital� Conductive - Choanal atresia, Vestibular stenosis, Adenoid hypertrophy, Cysts
� Sensorineural - Agenesis of neuroepithelium, I.U. Or Post natal viral infections
� Inflammatory � Conductive– Rhinitis, Sinusitis (bacterial, viral, allergic, fungal
Immune Disorder (Wegners, Sjogren’s, Sarcoidosis, AIDS)
� Sensorineural – URI injury of neuroepithelium, CNS infection
� Toxins and Degenerative � Conductive -- Atrophic Rhinitis
� Sensorineural– Age, CVA, Alzeheimer’s , Parkinson’s , Drugs, ETOH , ZINC
� Trauma � Conductive - Mucosal edema, Foreign body, Nasal deformity, Laryngectomy
� Sensorineural – post surgical (Endoscopic or Open Craniofacial)
� Endocrine and malnutrition � Conductive- Rhinitis of pregnancy, hypothyroidsm
� Sensorineural – Diabetes, Vit. A , B , Zn or Cu deficiency, renal failure, cirrhosis
� Neoplasia Neurologic� Conductive - Benign (papilloma, angiofibroma, osteoma, schwannoma)
Malignant ( SCCA, adenocarcinoma)
� Sensorineural – Benign (meningioma, pit adenoma, craniopharyngioma, glioma) Malignant (esthesioneurolastoma, lukemia, metastastic ), seizures
� S (Psychiatric)� Conductive – Foreign body
� Sensorineural – Depression, psychosis,
� K (Conductive)
� Inflammatory
� Toxins
� Trauma
� Endocrine
� Nasal Neoplasia
� S (Psychiatric)
� K (Conductive )� Xerostomia
� Inflammatory and Infections� Autoimmune- Pemphigus, Sjrogren’ Syndrome
� Infections- Bells palsy, Herpes Zoster, Candida, Gingivitis, Herpes Simplex, Periodontis, Sialadentis
� Toxins� Drugs (abx, physchotropics, chemotherapeutic, anesthetics)
� Trauma� Head Trauma
� Surgery (Cutting the chorda tympani)
� Endocrine and malnutrition� Adrenal cortical insufficiency, Cushing’s, Diabetes,
Hypothyroidsm, panhypopituitarism, Turner’s Syndrome� Vit. B3 and Zn deficiency, renal failure, cirrhosis
� Nasal� Usually decreased flavor
� Neoplasia� Oral Cavity Cancers� Skull Base neoplasm
� S (Psychiatric)� Depression� Schizophrenia
� History
� Timeframe Onset, Fluctuating?
� Recent URI, trauma, sinus problems?
� Neurologic complaints?
� Pain? Nasal congestion?
� Medications?
� Occupational Exposure?
� Smoker? Drinker?
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� Physical Exam
� CN exam
� Nasal endoscopy
� Mirror or flexible endoscopy
� Oral cavity
� Ear exam
� Imaging
� CT scan of sinuses
▪ Best for bony detail
▪ Look for any sinus pathology
▪ Evaluate the anterior skull base/cribriform
� MRI -- Consider if there are neurological deficits
▪ Evaluate olfactory bulbs
▪ Evaluate brain
� Laboratory tests- usually low yield
� Allergy testing
� Electrolytes, Glucose, Vitamin deficiencies
� Renal and LFT’s
� Thyroid and other endocrine function test
� Epithelial Biopsy
� Generally only reserved for research purposes
� Can be risky
� Several tests to measure olfaction
� University of Pennsylvania Smell Identification Test (UPSIT)▪ 40 Scratch and Sniff questions
▪ Scores are compared against age and sex related norms
▪ Not based on threshold
▪ Based on number correct
▪ Normosmia 34-40
▪ Microsmia 19-33
▪ Anosmia is 6-18
▪ Malingering <= 5
� Cross Cultural Smell Identification Test
▪ Shorter Version
� Sniffin’ Sticks
� Reusable pen like instruments
� Test odor identification, discrimination, and threshold
� 3-16 odorants are used
� Butanol Threshold Test
▪ Records concentration at which patient detects butyl alcohol
� Not as common and as developed as smell tests
� All patients should also have a smell test� Only 4 tastes are generally tested
� Quality and Intensity
� Spatial Testing
▪ Tasting functional based on anatomic location
▪ Able to identify which nerve (CN7, CN IX or CN X) is damage
▪ Samples of the basic tastes are randomly placed on 4 quadrants of the tongue and identified and the intensity is rated compared to a whole mouth assessment.
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� Pro’s
� Assess the degree of chemosensory dysfunction
� Cons
� Time consuming
▪ Can slow clinic
▪ May need to have multiple exam rooms to continue while testing is performed
� Difficult to perform
� Must first the identify etiology of abnormality
� Can be VERY difficult
� Important to do a complete H&P
� Remember KITTENS in diagnosing
� 3 most common causes
▪ URI
▪ Nasal/Sinus disease
▪ Head Trauma
� Conductive causes are the most amenable to
correct
� Remove obstruction ( medicine or surgery)
� Sensorineural causes are very hard to correct
� Generally treated with a steroid trial
� Can take weeks to months to return to normal
� Rhinitis/sinusitis � Abx, Saline, Decongestants, Steroids
� Surgical management – polyps, deviation.
� Viral� Steroids
� Alpha Lipoic Acid Hummel et al.
▪ Anti-oxidant
▪ 600 mg/day for 4.5 months
▪ 61% patients demonstrated improvement in smell after URI
� Toxins� Eliminate exposure to toxins
� Endocrine and Malnutrition� Replace hormones
� Replace vitamin deficiency
� Zinc (Systemic …. NOT topical zinc sprays!!!)
� Many cases are UNTREATABLE
� Reassurance
� Education
▪ Life threatening situations
▪ Smoke detectors, natural gas detectors
▪ Check expiration dates on food
� Try to identify etiology▪ Remember KITTENS
� Treat nasal pathology first▪ Abx, Saline, Decongestants, Steroids, Surgery
� Treat any mucosal disorders▪ Infectious
▪ Inflammatory
� Toxins▪ Eliminate exposure to toxins
▪ Consider stopping medication
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� Endocrine and Malnutrition� Replace hormones
� Replace vitamin deficiency
� Neoplasia
� Artificial saliva
� Reduce oral irritants
� Tobacco, mouthwash, ill fitting dentures
� Modify chewing food
� Chew food well
� Switch food regularly to avoid adaptation
� Exhale after swallow to aid in retronasal olfaction
� Difficult to treat
� Very important to our
patients
� Poor quality of life
� Often overlooked
� Multi-factorial Cause
� Complicated Assessment
▪ Measurement is imprecise
� Take steps to discover
etiology
� Treat appropriately
� Potentially Reversible
� Reassure and educate
our patients
Case Presentations
� ID: 65 year old male
� CC: loss of smell and taste for one year
� HPI: loss of smell/taste and nasal obstruction onset did not appear related to acute illness.
Accompanied by nasal congestion and nasal
drainage.
� HPI (cont). Pt had recurrent sinus infections.
Symptoms:- discolored drainage- facial pressure
- pain in upper teeth- increased nasal congestion.
These symptoms were alleviated by antibiotics. (pt
had completed multiple 10 day courses of antibiotics.)
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� Past Medical history:
-Environmental allergies
-Asthma (controlled with meds)
-No history of facial or head trauma
-Nonsmoker
� Past surgical history:-No history of sinus or nasal surgery
� Current nasal medications:
-Veramyst 2 sprays each nostril QD
-Astelin nasal spray 2 sprays each nostril BID
What’s Next?
� Physical Exam
� Physical exam findings:
-Anterior rhinoscopy: left septal deviation and
right sided nasal polyps
-Nasal endoscopy: bilateral polyps filling the nasal cavity
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� K (Congenital)
� Inflammatory
� Toxins
� Trauma
� Endocrine
� Neoplasia, Neurologic
� S (Psychiatric)
� What is the mechanism of this smell
disorder?
� Diagnosis:
-Chronic rhinosinusitis
-Sinonasal polyposis
� Antibiotics
� Oral steroids
� Topical nasal steroid sprays
� Consider Functional Endoscopic sinus surgery
if medical therapy fails
� Outcome:
-Pt failed medical therapy
-Had bilateral FESS (endoscopic sinus surgery)
-Pt had resolution of his sense of smell as well as resolution of nasal obstruction
� Post op
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� ID: 49 yo female
� CC: Phantom smell
So what’ s next?
� Get a thorough history
� Ask what, when , where?� Timeframe Onset,
Fluctuating?
� Recent URI, trauma, sinus problems?
� Neurologic complaints?
� Pain? Nasal congestion?
� Medications?
� Occupational Exposure?
� Smoker? Drinker?
� HPI:
� Past 6 months
� Intermittently smell an odor that is not present to others
� Odor smells of smoke
� She states she does not smoke and no one in her
family smokes
� The odor can be present at different locations
� During the initial onset of this symptom, pt did have a virus from which she recovered
� She has not tried any topical nasal sprays or other medications
� Other symptoms:
-Mild nasal stuffiness
-No nasal drainage
-No nasal facial pain or pressure
� Past Medical history:
-Breast Cancer 2008 treated with surgery/chemo
-No known history of facial or head trauma
-History of depressive disorder
-History of seizure disorder, seizure free on medication
-Nonsmoker
� Past Surgical history:
-L lumpectomy
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� Social history:
- Nonsmoker
- No alcohol or drug use
� Medications:- Zonisamide 100mg 1 po bid
� Physical Exam:
-HEENT –normal
-Flexible laryngoscopy/nasal endoscopy
revealed that the overall appearance of the
nasal lining was healthy
-Olfactory clefts were visualized and patent
-Nasopharynx and larynx were unremarkable
� K (Congenital)
� Inflammatory
� Toxins
� Trauma
� Endocrine
� Neoplasia, Neurologic
� S (Psychiatric)
� What are the possible mechanisms of this
patients smell disorder?� Inflammatory (onset occurred after virus, pt
c/o nasal stuffiness)
- conductive vs. sensorineural
� Neoplasm – (history of breast cancer)
� Psychiatric- (history of depressive disorder)
� Toxin- (history of chemotherapy)
� Neurologic- (history of seizure disorder)
� Assessment:
- Dysosmia (phantosmia)
- H/o breast cancer
- H/o depressive disorder
- H/o seizure disorder
� Initial Treatment Plan:
-Initiate topical nasal steroid spray
-Initiate oral steroid burst and taper
-MRI at return visit
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� Follow up visit:
CC: dysosmia had improved
HPI: smell of smoke went away after treatment with oral steroids and topical nasal steroids. However stopped TNS due to headaches and just noticed a gas odor the day before this visit. Still stuffy but this also improved while on topical nasal steroids.
� Physical Exam – normal
� MRI is normal without evidence of tumor,
metastasis, or sinus disease
� Plan: pt to switch to another topical nasal
steroid spray, if no improvement, can
consider other causes (seizure, psyche)
� Not all patients who present with smell/taste
disorders have happy endings
� Sense of smell and taste:
-is protective. Sense of smell and taste can warn you of chemical dangers, fires,
spoiled food.
-is linked to memories. (Holidays, people,
events, etc.)
-enjoyment of food (social and nutritional
implications.)
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-Can effect patient’s careers � Education:
- Label foods, check expiration dates- Have working smoke detectors
� Consider counseling referral:-Depression
-Pt seems to be having difficulty coping with
loss
Thank you