A randomised controlled trial of sodium citrate spray for non-conductive olfactory disorders.

OBJECTIVES: Previous research has suggested that sodium citrate improves hyposmia by decreasing mucus calcium levels in the nose. This study aimed to confirm or refute this effect in a single application and assess potential side-effects. DESIGN: Study design was a randomised double-blind controlled trial of sodium citrate nasal spray (intervention) vs sterile water (control). Fifty-five patients with non-conductive olfactory loss were randomised to receive the intervention or placebo. SETTING: Tertiary care clinic. MAIN OUTCOME MEASURES: The primary outcome measure was improvement in measured olfactory thresholds for phenyl ethyl alcohol (PEA) over 2 hours. Other outcome measures assessed were improvement in olfactory thresholds in 1-butanol, eucalyptol and acetic acid; number of responders with a clinically relevant response in each arm; and adverse effects. RESULTS: A significant effect was seen in the intervention arm for PEA and for 1-butanol and eucalyptol when compared to the control arm (P<.05); 32% of the intervention arm responded in terms of improved sensitivity towards some of the odours. Minor adverse effects noted included sore throat, nasal paraesthesia, slight rhinorrhoea and itching. The duration of effect of the citrate is transient, peaking at 30-60 minutes after application. CONCLUSIONS: Sodium citrate yields some potential as a treatment for non-conductive olfactory loss; however, these findings require corroboration in further clinical trials looking at longer term regular use of the spray as a viable therapeutic option for patients where it would be applied at frequent intervals such as before mealtimes.

Does odour cross contamination alter olfactory thresholds in certain odours?

OBJECTIVES: To determine if 1) there is cross contamination between odours tested on thresholds achieved, 2) a delay period is necessary between testing different odours. METHODS: Thirty-five subjects underwent threshold testing with phenethyl alcohol (PEA), ethylmercaptan (MER), acetic acid (ACE), and eucalyptol (EUC) using serial logarithmic dilutions. On separate occasions subjects were exposed to high concentrations of PEA, ACE and EUC in random order for two minutes, and thresholds for all four odours re-tested. Pre- and post-high concentration odour thresholds were compared. RESULTS: Exposure to high concentrations of PEA, ACE and EUC does not alter olfactory thresholds by more than 10-2 for the other odours except in specific circumstances with ACE and EUV. CONCLUSIONS: There is limited cross contamination with ACE and EUC, which is avoided by specifying presentation order as: PEA, MER, ACE, EUC. Odours PEA, MER, ACE and EUC are recommended for olfactory testing.

The presence of ovarian hormone receptors in the nasal mucosa and their relationship to nasal symptoms.

BACKGROUND: There is evidence in the literature showing a link between ovarian hormones and changes to nasal physiology. OBJECTIVES: The aim of this pilot study was to identify and quantify female hormone receptor positive cells in the nasal mucosa and to establish if there is a correlation with rhinitic symptoms. METHODS: Twenty-five adult patients attending a university hospital for routine, elective nonrhinological ENT procedures under general anaesthetic (mainly tonsillectomy) were recruited pre-operatively. Background information about each participant was recorded. Biopsies were taken from the inferior turbinates. These were analysed using immunohistochemistry techniques to assess for the presence of Progesterone, Oestrogen-alpha (ERalpha) and Oestrogen-beta (ERbeta) receptors. The mean number of cells positive for the receptors in each biopsy was deduced using a stratified random sampling technique. RESULTS: All nasal biopsies were negative for progesterone and ERalpha receptors. ERbeta receptors were present in the mucosal glands in 24 out of the 25 biopsies. Using unpaired t-tests to compare the sexes, smoking status and atopic history no statistical difference was shown between any of these groups (p > 0.05). However, the rhinitis quality of life questionnaire score and the mean number of ERbeta receptor positive cells per biopsy showed a positive correlation (Pearson correlation of 0.4, p < 0.05). CONCLUSIONS: The number of oestrogen receptor positive cells appears unaffected by sex, smoking history, hormone status, age or atopy. However, there is a significant positive relationship between the mean number of ERbeta positive cells and nasal symptoms. Pharmacological downregulation of ERbeta positive cells may reduce rhinitic symptoms and is the subject of further research.

Does hormone replacement therapy in post-menopausal women have any effect upon nasal physiology?

BACKGROUND: Previous studies have suggested that the female menstrual cycle, pregnancy and the oral contraceptive pill have an effect upon nasal physiology. OBJECTIVES: This study aimed to assess the effects upon nasal physiology of female hormone replacement therapy in post-menopausal women. This has not been previously studied. METHODS: Twenty post-menopausal women (age range 36 to 70 years; mean age 57.0 years) underwent measurements of the nasal airway, including anterior rhinoscopy, peak nasal inspiratory flow rate, acoustic rhinometry, anterior rhinomanometry, mucociliary clearance time and rhinitis quality of life questionnaire. Measurements of nasal patency were recorded prior to commencing hormone replacement therapy and at a time point 77-195 days (mean 101.9 days) following commencement. RESULTS: There was no statistical difference found for any of the variables, using the paired t-test (p > 0.05 for all). CONCLUSIONS: Female hormone replacement therapy has no discernable effect upon nasal physiology and should not be considered a cause of rhinitic symptoms.

A brief history of olfaction and olfactometry.

The sense of smell has been a cause for speculation and fascination over the centuries. An appreciation of odours has been deeply rooted in many cultures, including ancient civilisations such as the Egyptians. The level of understanding of the anatomy and physiology of olfaction which our ancestors had was slight, and much remains to be discovered. This paper explores the progression of knowledge over the years to the present day. Particular emphasis is placed on odour classification and olfactometry, and on the techniques whereby great scientific minds have sought to quantify that human sense which is arguably least quantifiable. A review of some of the current methods of olfactometry is included within this remit.

The superosmic phenomenon.

BACKGROUND: Olfaction studies in the institution of Department of Otorhinolaryngology at Leicester Royal Infirmary have detected a previously unreported, variable phenomenon--'superosmia'--in which subjects' olfaction threshold concentrations are up to 100,000 smaller than the average value. OBJECTIVES: The aim of this report is to define and quantify this phenomenon. METHODS: Two hundred and thirty subjects, who had been screened for active nasal pathology (age range 20-60 years), underwent individual olfactory threshold tests for phenylethyl alcohol or eucalyptol, using a computer-driven olfactometer in a controlled laboratory setting. Some tests were single tests and others were repeated on a small cohort. RESULTS: Two per cent of subjects demonstrated the superosmic phenomenon on single testing, and 10 per cent demonstrated this phenomenon on variable occasions during repeated testing. The superosmic phenomenon was defined by: (1) confident olfactory perception of a threshold at least equal to if not greater than three threshold levels below the subject's average threshold; (2) repeated perception of the odour at this level for at least 10 responses (1:1024 probability of chance finding); and (3) (where time permitted) a sudden, rapid loss of superosmia. CONCLUSIONS: Superosmia is a distinct phenomenon, the stimulus or mechanism of which is currently the subject of further research. The enhancement of olfactory ability may be possible through activation of an accessory pathway or modulation of the existing olfactory apparatus.

Olfactory clearance: what time is needed in clinical practice?

OBJECTIVE: To determine olfactory adaptation and clearance times for healthy individuals, and to assess the effect of common variables upon these parameters. STUDY DESIGN AND SETTING: Fourteen healthy volunteers were recruited for a series of tests. Their initial olfactory threshold levels for phenethyl alcohol were determined. After olfactory exposure to a saturated solution of phenethyl alcohol (i.e. olfactory adaptation), the time taken for subjects to return to their initial olfactory threshold was then recorded (i.e. olfactory clearance). Visual analogue scale scores for subjective variables were also recorded. RESULTS: The 14 subjects performed 120 tests in total. Despite consistent linear trends within individuals, olfactory clearance times varied widely within and between individuals. The mean olfactory clearance time for phenethyl alcohol was 170 seconds (range 81-750). Univariate analysis showed a relationship between olfactory clearance times and age (p = 0.031), symptoms (p = 0.029) and mood (p = 0.048). CONCLUSIONS: When testing a person's sense of smell in a clinical setting, recent exposure to similar smells should be noted, and a period of 15 minutes needs to be allowed before retesting if using phenethyl alcohol. Other variables need not be controlled, but greater clearance time may be needed for older patients.

What is the short term effect of perfumes on olfactory thresholds?

OBJECTIVES: Body sprays and perfumes are commonly worn by patients attending ENT out-patients clinics. Their effect on performance in olfactory testing is unknown. The aim of this study was to determine whether olfactory thresholds are altered by the presence of such fragrances. MATERIALS AND METHODS: One hundred and sixty healthy volunteers, aged 18 to 65 years, underwent olfactory thresholds testing. Each was then exposed to one of four strong perfumes, applied in a facemask for two minutes, and the thresholds were retested. RESULTS AND ANALYSIS: All olfactory thresholds worsened after being exposed to the strong perfumes of Lynx and Impulse body sprays, with the strongest effect being on olfactory detection of phenylethyl alcohol (p<0.001). CONCLUSIONS: Strong perfumes can have a negative effect on olfactory thresholds. SIGNIFICANCE: Patients attending olfactory threshold testing need to be advised not to wear body sprays or perfumes.

Which variables matter in smell tests in the clinic?

BACKGROUND: Testing of olfactory thresholds in the clinic is becoming more common, with commercially produced tests now available. The effect of common potential variables in the clinic setting on these results is unclear. If many variables must be controlled, tests become more complex and a universally accepted olfactory test becomes less likely. OBJECTIVES: The aim of this study was to determine which potential variables the clinician needs to consider when testing olfaction in the out-patient clinic. METHODS: The study was conducted in a clinic setting at a university hospital, using 103 normal volunteers, comprising staff members and patients and relatives from the ENT clinic waiting room. The subjects recruited had no active rhinological complaints, were not taking any medications and were aged between 16 and 70 years. An olfactory threshold was established for each subject for the odour eucalyptol. Gender, smoking status, age, peak nasal inspiratory flow, ambient temperature and relative humidity were all recorded. RESULTS: For eucalyptol, the distribution of values for olfactory thresholds in the normal population lies around the concentration 10(-3) log vol/vol. There was no significant effect of smoking status, tester, ambient temperature or humidity on the thresholds obtained. CONCLUSIONS: The above variables do not have a significant effect on olfactory thresholds elicited in the clinic. The clinician therefore need not attempt to control these factors when testing olfaction in the out-patient setting. These findings bring the implementation of a universal, reliable and easily administered measurement of olfaction a step closer.

Variability of vascularity in nasal mucosa as demonstrated by CD34 immunohistochemistry.

Regional anatomical variations in the nasal vasculature have not been studied histologically. Immunohistochemistry performed using marker for CD34 antigen on vascular endothelium biopsied from 5 sites on the lateral nasal wall and compared with one septal biopsy. No significant regional variations in microvascular architecture over the lateral wall of the nose were found. * Lateral wall measurements were significantly different to the septal measurements (P = 0.0003, 0.01). Suggests biopsies can be taken from any site on the lateral wall and give a representative sampling of the vascularity for research purposes.

Which solvent for olfactory testing?

The physical properties of any carrier can deteriorate over time and thus alter the results in any olfactory test. The aim of this study was to evaluate clinically potential solvents as a clean odourless carrier for olfactory testing. Sweet almond oil, pure coconut oil, pure peach kernel oil, dipropylene glycol, monopropylene glycol, mineral oil and silicone oil were studied. The experimentation was conducted in two parts. First, an olfactory device was used to conduct air through the solvents on a weekly basis using a cohort of six volunteers to assess the perceived odour of each solvent at weekly intervals. Secondly a cross-reference test was performed using small bottled solutions of phenylethyl-alcohol and 1-butanol in 10-fold dilutions to compare any perceived difference in concentrations over a period of 8 weeks. We concluded that mineral oil is the most suitable carrier for the purpose of olfactory testing, possessing many desirable characteristics of an olfactory solvent, and that silicone oil may provide a suitable alternative for odorants with which it is miscible.

The effect of the steroid sex hormones on the nasal airway during the normal menstrual cycle.

The changes in the nasal mucosa during the menstrual cycle have been little researched and the role of oestrogens debated. The aim of this study was to measure a spectrum of physiological parameters in relation to the peak and trough of these hormonal levels. Ten women underwent measurements at the onset of menses and at the time of ovulation. On each occasion, anterior rhinoscopy, peak inspiratory nasal flow, acoustic rhinometry, anterior rhinomanometry, mucociliary clearance time and rhinitis questionnaire score were recorded. All measurements except anterior rhinoscopy showed a difference between the two readings consistent with nasal congestion at the peri-ovulatory stage of the cycle, of which anterior rhinomanometry and mucociliary time were significant (P

Chronic tonsillar enlargement and cough: preliminary evidence of a novel and treatable cause of chronic cough.

Tonsillar enlargement is sometimes seen in patients with otherwise unexplained chronic cough although its significance is unclear. In this study, the authors set out to test the hypothesis that cough symptoms and cough reflex sensitivity will improve after tonsillectomy in patients with otherwise unexplained chronic cough and enlarged tonsils. Eight consecutive patients with unexplained chronic cough and enlarged tonsils were recruited from 236 patients seen in a cough clinic between 2000 and 2001. Six patients with enlarged tonsils and no cough who were undergoing tonsillectomy for other reasons were recruited as a control group. All patients rated cough severity on a cough visual analogue score (0-100 mm) and had capsaicin cough reflex sensitivity measurement twice before and again 3 months after tonsillectomy. Patients with a chronic cough had heightened cough reflex sensitivity compared with the control group at baseline. There was a significant improvement in mean cough visual analogue score 3 months after tonsillectomy in patients with chronic cough (mean difference 30 mm; 95% confidence interval of difference 8-51 mm). The geometric mean concentration of capsaicin required to cause five coughs increased from 4 to 207 micromol L(-1) after tonsillectomy in patients with chronic cough (mean difference from baseline 5.6 doubling concentrations; 95% confidence interval of difference 3.1-8.2). There was no change in cough reflex sensitivity in control patients after tonsillectomy. These preliminary findings suggest for the first time a possible role for tonsillectomy in patients with enlarged tonsils in whom other causes of cough have been ruled out.

First case of full-thickness palatal necrotizing sialometaplasia.

Necrotizing sialometaplasia is an uncommon, benign, self-limiting condition which can stimulate malignancy. The commonest site of occurrence is the hard palate. We report the first case with full thickness palatal involvement. The clino-pathological features of this condition are discussed.

Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome): otorhinolaryngological manifestations.

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant disorder affecting blood vessels of the skin, mucous membrane and viscera. The otorhinolaryngologist is the commonest clinician involved in management as epistaxis occurs in 93% of the patients. As marked advances have recently been made regarding the pathogenesis and management of the condition, the otorhinolaryngological perspective is reviewed.

First case of surgically corrected puberphonia.

Puberphonia is predominantly a male condition which, normally affecting teenagers, may present in later life. It is defined as the failure to change from the high-pitched voice of the pre-adolescence to the lower pitched voice of adulthood. Patient previously reported have responded to voice therapy alone. We report the first surgically corrected case.

Glossal palpation of the eustachian tube cushion: an unusual cause of globus sensation.

Globus sensation, the sensation of a lump in the throat, is a common symptom which, in its chronic form, accounts for 4% of first-patient visits to ENT clinics. We describe a rare cause of globus sensation and stress the importance of thorough investigation to exclude any possible organic causes.

Is oestrogen therapy justified in the treatment of hereditary haemorrhagic telangiectasia: a biochemical evaluation.

Systemic and topical oestrogen can provoke squamous metaplasia of epithelium. In Hereditary Haemorrhagic Telangiectasia (HHT) the underlying telangiectasia may be protected from trauma and epistaxis reduced. Oestrogens have been advocated but their efficacy is unclear. Recent advances have now identified two oestrogen and one progesterone receptors. The aim of this study is to analyse the sex receptor status of HHT nasal mucosa to determine if oestrogen therapy is biochemically justified. Five HHT patients (three men, two women) and eight controls (four men, four women) underwent nasal mucosa biopsy. Samples were fixed in formalin and paraffin embedded. Alpha oestrogen (ERalpha) and beta oestrogen (ERss) and progesterone (PgR) receptors were identified using mouse monoclonal antibodies by the Streptavidin-biotin peroxidase method. ERss was detected in two HHT subjects (1 M: 1F) and two control subjects. ERalpha and PgR was absent in HHT subjects. This pilot study demonstrated that a subgroup of HHT patients were ERss positive. Oestrogen therapy therefore has a potential therapeutic role on a biochemical basis in these patients. ERss status should be determined before considering oestrogen therapy.

Reversible sensorineural hearing loss after non-otological surgery under general anaesthetic.

Acute sensorineural hearing loss can occur after both otolaryngological and non-otolaryngological procedures. The mechanism of such hearing loss remains unproved; but nitrous oxide has been implicated and where used, attendants should be aware of its potential damage to hearing. It is essential that patients with sudden hearing loss are identified as soon as possible as the recovery rate had been shown to be higher in those who presented early; and as our case demonstrates, complete recovery is possible. Anaesthetists, non-otolaryngological surgeons, and ward nurses must be aware of this early postoperative complication if appropriate treatment is to be instituted.