Anosmia 4

Take a history from this 38 year old delivery driver who has suffered with a worsening sense of smell.

History

  • Onset

  • Duration

  • Timing – episodic or constant

  • Severity – is it complete loss of smell (differentiate from hyposmia)? Can they smell strong smells? What can they smell?

  • Progression 

  • Unilateral or bilateral

  • Exacerbating and relieving factors

  • Associated symptoms – phantosmia, parosmia, headaches, visual disturbance, epistaxis, crusting, nasal obstruction, rhinorrhoea, post-nasal drip, memory loss, behavioural change

  • Predisposing events – Recent URTI, trauma/head injury, neurosurgery, exposure to chemical irritants, COVID-19 infection

  • Constitutional symptoms – weight loss, malaise, anorexia, night sweats

  • Past Medical History – cystic fibrosis, HPV infection, nasal polyposis, Previous non Hodgkin’s lymphoma, previous radiotherapy, previous sinonasal surgery, nasal fracture

  • Drug History – nasal steroids, nasal decongestants, aspirin sensitivity

  • Social History – smoking, alcohol, occupation (wood work, nickel, chromium, leather, formaldehyde, cloth fibres), Southeast Asian ethnic origin

  • Family History – Family history of cancer, genetic disorders

  • Systems review

  • Elicit the patient’s ideas, concerns and expectations 

 

Conclusion

  • Summarise consultation

  • Thank patient

  • Offer appropriate differential diagnosis

 

Differential diagnoses to consider*

Inflammatory

  • Chronic rhinosinusitis with nasal polyps

  • Antrochoanal polyp

  • Allergic rhinitis

Infective

  • URTI

  • Sinusitis

Malignancy

  • Primary nasal tumour

  • Frontal lobe tumour

Genetic

  • Cystic fibrosis

  • Kallman syndrome

  • Primary ciliary dyskinesia

Other

  • Chemical irritation

  • Smoking/e-cigarette use

Trauma

  • Olfactory nerve damage secondary to head injury

Neurological

  • Alzheimers 

  • Diabetes

  • Hypothyroidism

*Table not exhaustive

 

Management

 

You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination including nasendoscopy prior to further investigations. In addition, offer a formal assessment of smell using the University of Pennsylvania Smell Identification Test (UPSIT), Sniffin’ Sticks or similar.

 

Further investigations will depend on the history and your examination findings. Some examples are below:-

 

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

Chronic rhinosinusitis with polyposis

Treat first. If no improvement then CT sinuses and plan for surgery (EPOS 2020).

Unilateral nasal polyp or suspected malignancy

CT + MRI (depending on local guidance)

Neurological disorder

Neurological referral

Brain tumour

MR Brain

Genetic disorder

Refer to geneticist

Head trauma

CT/MR brain to rule out space occupying lesion

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