BackTable / ENT / Podcast / Episode #122
Evaluation & Management of Patients with Olfactory Dysfunction
with Dr. Zara Patel
In this episode of BackTable ENT, Dr. Zara Patel, director of endoscopic skull base surgery and professor of otolaryngology at Stanford, joins Dr. Shah to discuss the physiology behind olfactory dysfunction and evidence-based cutting-edge therapies.
BackTable, LLC (Producer). (2023, August 1). Ep. 122 – Evaluation & Management of Patients with Olfactory Dysfunction [Audio podcast]. Retrieved from https://www.backtable.com
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Dr. Zara Patel
Dr. Zara Patel is director of endoscopic skull base surgery and a professor of otolaryngology and neurosurgery at Stanford in California.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
First, Dr. Shah and Dr. Patel outline different patterns of olfactory dysfunction and their etiologies. Damage to the olfactory system can result from inflammation, trauma, or neurodegeneration affecting olfactory bulb neurons. However, smell-based symptoms are common in migraine and seizure auras, so taking a thorough medical history is important in all patients. Also, they review “red-flag” medications contributing to smell loss.
Next, Dr. Shah asks Dr. Patel about the workup of patients with olfactory disturbance. Dr. Patel recommends rigid nasal endoscopy with and without decongestion for all patients with olfactory complaints. Unless another medical issue is suggested from the patient’s history, Dr. Patel does not routinely order labs for smell disturbance. The role of imaging is addressed, including use of MRIs for prognostication.
The doctors then cover evidence-based management of olfactory dysfunction. In cases where inflammation causes olfactory disturbance – such as post-viral etiologies – steroid therapy can help restore smell. To have effect, the drug must reach the olfactory cleft, so Dr. Patel prefers nasal rinses with budesonide over intranasal or oral steroids. Then, Dr. Shah shares her experience treating patients with olfactory training. Dr. Patel explains the neural basis of training and instructs clinicians on how to counsel patients for best outcomes.
Finally, Dr. Patel shares her expertise on hot topics in olfactory research, like the science behind platelet-rich plasma (PRP) for smell loss. She also reviews situations in which dietary supplements can improve symptoms. They end the episode with insights regarding equitable care of patients with smell-based symptoms.
Dr. Patel’s Stanford profile
JAMA Patient Handout on Olfactory Training:
International Consensus Statement on Allergy and Rhinology:
[Dr. Zara Patel]
There's functional MRI evidence showing that before you do olfactory training, if you give someone with smell loss an odor, there's just this kind of disparate chaotic array of connectivity lighting up in the brain. If you do training and then again present that odor and functional MR, just the olfactory cortex lights up right where it's supposed to, and that really shows that you are changing synaptic connectivity by doing this. It's not just some silly woo-woo aromatherapy type thing that's happening.
We are actually exercising the smell system, and I explain it to patients, and I think this actually resonates very well with people. They can understand this intuitively much better when you say this. If you had a stroke and you lost function of your arm, you would go to physical therapy and exercise that arm until you got that function back. You're doing the same exact thing with your smell system when you do olfactory training, so people really understand that. They say, "Oh, yes, that makes a lot of sense," then they're motivated to actually do it. As far as the odors, you start with those four, and then yes, at one month and then again at three months, I have people switch up these odors.
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