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| REVIEW ARTICLE |
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| Year : 2012 | Volume
: 2
| Issue : 1 | Page : 10-20 |
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Olfaction following total laryngectomy
Elizabeth Ward1, Anna Rumbach2, Corina J van As-Brooks3
1 The University of Queensland, Division of Speech Pathology, School of Health and Rehabilitation Sciences; Centre for Functioning and Health Research (CFAHR), Queensland Health, Queensland, Australia
2 The University of Queensland, Division of Speech Pathology, School of Health and Rehabilitation Sciences, Queensland, Australia
3 Department of Otolaryngology-Head and Neck Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| Date of Web Publication | 9-Apr-2012 |
Correspondence Address:
Corina J van As-Brooks
Department of Otolaryngology-Head and Neck Surgery, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066CX Amsterdam
The Netherlands
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2230-9748.94728
 Abstract | | |
Total laryngectomy (TL) results in the complete disconnection of the upper and lower respiratory tract, ceasing orthonasal airflow. Hence, olfaction and olfactory acuity are negatively impacted. Prior to the late 1990s, impaired olfaction was simply accepted as a negative consequence of TL surgery. However, a growing body of research conducted within this past decade has demonstrated that rehabilitation is possible with a simple and effective behavioral technique. The current review outlines the literature supporting the negative impact of altered olfaction on quality of life, details of known best practice methods for olfactory assessment both for research and clinical use, and outlines the evidence for interventions known to improve olfactory performance in the TL population. Intervention for olfactory impairment should be part of a holistic, evidence-based rehabilitation process for patients post-laryngectomy. Keywords: Anosmia, assessment, hyposmia, Laryngectomy, Nasal Airflow Inducing Maneuver, olfaction, rehabilitation
How to cite this article:
Ward E, Rumbach A, van As-Brooks CJ. Olfaction following total laryngectomy. J Laryngol Voice 2012;2:10-20 |
| Introduction | |  |
Research conducted this past decade has identified a simple and effective behavioral process for the rehabilitation of olfaction following total laryngectomy (TL). [1] Despite this, routine assessment and rehabilitation of olfactory ability post-laryngectomy has not yet received widespread attention in either literature or clinical practice. [2],[3] The current review outlines the extent of the olfaction deficits post-TL and the evidence supporting the negative impact of this on quality of life. Furthermore, a critique of tools for assessing olfaction and treatment efficacy research will be provided. The intent of this review is to present the current research which supports the implementation of olfactory assessment and rehabilitation as part of a holistic and evidence-based rehabilitation pathway for patients post-TL.
| Olfaction Post-Laryngectomy | | |
The primary mode of olfaction, or the process of smelling, occurs when air is drawn through the nose allowing odor molecules to reach and stimulate the olfactory epithelium located on the roof of the nasal cavity. This is referred to as orthonasal olfaction. To a much lesser degree, odor molecules may reach the nasal cavity through the oral cavity (retronasal olfaction) when inhaling through the mouth or when exhaling through the nose whilst chewing. It is, therefore, to be expected that olfactory ability will be negatively impacted following TL surgery due to the complete disconnection of the upper and lower aerodigestive pathways, with any remaining capacity only possible through the retronasal route. Degenerative changes of the olfactory epithelium over time may further contribute to reduced olfactory acuity due to neurosensorial failure. [4]
The decrement in olfactory performance post-laryngectomy resulting in hyposmia (reduced olfactory acuity) or anosmia (absence of olfactory acuity) has been reported since the early 1960s. [5] Published incidences of olfactory dysfunction post-TL range anywhere from 30% to 100%. [1],[3],[6],[7],[8],[9],[10],[11],[12],[13],[14] A number of methodological differences explain the wide range in incidence rates between studies [Table 1]. One influencing factor is the time post-surgery when patients are assessed. Typically, a higher incidence is noted in studies which assess patients early post-surgery. [7] In comparison, there is some reduction in incidence observed in the long term, when it has been reported some individuals have learnt to compensate with self-taught techniques to assist olfaction post-surgery. [1] Another key factor is the assessment mode. [1],[3],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] The lowest reported incidence was found in a study which assisted passage of vaporized substances up into the nasal cavity, [6] a methodology which essentially replicated the effect of nasal inhalation. Higher rates of impairment are typically noted in studies which use odor detection tests, without assisting nasal inhalation, which is a preferred methodology to determine true functional olfactory ability [Table 1]. Patient report vs direct assessment also accounts for differences in data reported between studies. | Table 1: Studies reporting incidence of olfactory dysfunction after total laryngectomy
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| Impact on Altered Olfaction on Quality of Life | | |
With respect to our senses, olfaction is often reported to be a less important sense. [16],[17] However, the consequences of olfactory dysfunction can have a profound effect on daily functioning and quality of life. [9],[18],[19],[20] Deems et al.[21] demonstrated a higher rate of depression (29%) in those with olfactory dysfunction in comparison with controls. Similarly, Tennen et al.[22] reported moderate depression in 17% of patients with olfactory dysfunction. Furthermore, Miwa et al.[20] conducted a survey of non-surgical patients with olfactory impairment which suggested that overall life satisfaction was positively correlated with smell scores. Reasons for this correlation are many and include significant impairments in the areas of safety, personal hygiene, eating, and social interaction. Personal safety can be impacted as patients are unable to use environmental cues to warn themselves of potentially dangerous situations (e.g., detection of smoke, leaking gas, spoiled food). Poor perception of personal odors can also influence the ability to form and maintain social relationships. [23] Furthermore, sense of smell and memory are closely linked, with certain odors triggering memories from the past to surface. [24-26] This link is severed in those individuals with impaired smell.
As flavor perception is contributed to by input from olfaction, the perception of taste may also be negatively impacted. Aschenbrenner et al.[27] assessed dietary behavior in 176 non-surgical individuals with olfactory dysfunction and found 29% ate less since the onset of their smell loss, 31% ate less in between meals, and 35% to 49% had less social interaction during mealtimes (i.e., went out to dinner or invited or joined others for dinner less frequently). These results were similar to those found by Mattes et al.[28] who reported a decrease in appetite (22%) and food enjoyment (74%), as well as alterations in dietary behavior (59%) for those non-surgical patients with loss of smell (n = 58). Further to this, several studies have linked changes in smell and taste with weight loss, decreased nutrient intake, and malnutrition in individuals with cancer. [21],[29],[30],[31],[32]
To date, only two studies have specifically investigated the impact of altered olfaction on eating behaviors and quality of life post-TL. Van Dam et al.[3] objectively assessed 63 TL patients and divided them into "smellers" and "non-smellers." Non-smellers (68%) reported decreased ability to taste as well as decreases in appetite and an inability to enjoy food subsequent to the post-operative gustatory changes. Similarly, Lennie et al.[33] found that 89% of the cohort studied (n = 34) reported a postoperative reduction in olfactory ability, with 63% reporting changes in the faculty of taste. Of particular clinical importance, both studies identified the need for increased attention to be given to changes in smell and taste during preoperative counseling, with 50% of patients receiving no information regarding potential changes postoperatively in olfaction and gestation. [3]
| Assessment of Olfaction | | |
A large variety of subjective and objective methods for assessing olfactory performance, including assessments of patient perceptions, as well as both the functional and physiological domains, have been described in the literature [Table 2]. [10],[11],[14],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62] Within the TL-specific literature, studies have used a range of different types of assessments with no one tool used consistently [Table 1]. | Table 2: Assessment methods used to assess olfactory performance in patients with total laryngectomy
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Regarding patient perceptions, simple 5-, 7-, or 10-point rating scales with criteria rating from very poor to very good sense of smell can be used to quantify the degree of function/dysfunction. To complement this, there are a range of questionnaires that examine olfactory function [Table 2]. The "Questionnaire concerning Olfaction, Taste and Appetite" first described by De Jong et al.[34] and later modified by Hilgers et al.[1],[11] appears to be the most widely adopted questionnaire for research. It is comprised of 31 multiple choice questions, across 5 subscales (present odor perception, odor perception now in comparison with the past, gustation, appetite, and sensation of hunger) that relate to pre- and postoperative olfactory experience. Although a helpful subjective tool, it has not yet been validated.
Within assessments of functional olfactory ability, there are a range of different tools, each of which incorporates different components of olfactory function (e.g., odor detection, identification, sensitivity, discrimination, memory) [Table 2]. Each has its own merits in terms of administration, cost, and result yielded. However, due to complex preparation, rapid perishability of test substances, lack of standardization of test procedures, poor reproducibility of results across assessment types and cultural regions, and often considerable time to perform the assessment, there is currently no globally accepted gold standard. For assessing olfaction in the normal, non-surgical population, both Doty et al.[63] and Lötsch et al.[64] suggest it is best when a variety of tests (e.g., odor threshold, discrimination, and identification) are used in combination. However, this finding remains controversial, with Lötsch et al.[64] indicating that once olfaction is perturbed, assessment of specificity and sensitivity of olfactory impairment may be achieved with one test (possibly odor threshold). Until research elucidates a consistently sensitive and specific approach to diagnosis of olfactory dysfunction, the most meaningful approach to assess olfactory performance is composite analysis of several components of olfaction.
For objective assessment of functional olfactory ability, the University of Pennsylvania Smell Identification Test (UPSIT) [65] or its down-scaled version, the Cross Cultural Smell Identification Test (CC-SIT), [41] the Connecticut Chemosensory Clinical Research Center (CCCRC) test, [40],[47],[66] and the "Sniffin' Sticks" assessment battery [39] have reached the widest degree of distribution in assessments of olfaction in non-surgical populations. All of these assessments take approximately 30 minutes to administer and have been normed to the general population. The UPSIT, considered clinically as the "gold standard" for assessing olfactory performance by some, [2] is a self-administered "scratch and sniff" test based on odorants which are released from microencapsulated fragrance labels. In this 40-item, multiple choice test, the patient scratches and sniffs a label then tries to identify the odor from four alternatives. Individuals with normal olfactory function achieve a score between 34 (male) or 35 (female) to 40. Individuals with anosmia score less than 20, with hyposmic individuals' scores lying somewhere in between. Although commercially available and validated, the UPSIT has not been described specifically for use with laryngectomized patients to date.
Unlike the UPSIT that solely examines odor identification, the CCCRC test contains both threshold and odor identification components. The stimuli is delivered by means of squeeze bottles, with n-butanol in ascending limits used in the threshold component, and eight bottles containing different real-world odorants with multiple choice from a list of 16 odorants being used for the identification component. The CCCRC differs from the UPSIT in that it is administered by an examiner and the presentation of stimuli is to one nostril at a time, with each nostril receiving a score. Cain and Rabin [47] compared both the UPSIT and CCCRC and found high agreement between the tests, with a correlation coefficient of 0.92. Unsurprisingly, the UPSIT had a higher degree of correlation with the identification component compared with the threshold component (0.95 vs 0.76) of the CCCRC. Although these tests yield comparable net results, each remains diagnostically exclusive.
The Sniffin' Sticks assessment is commercially available, validated, [39],[67],[68] cost-effective, portable, and used to assess multiple components of olfaction performance. Easily administered by any trained health professional, time needed to complete the full test version varies from 25 to 45 minutes, providing information on odor identification, discrimination, and threshold. The full test package consists of 112 sticks that resemble felt-tip pens that are filled with liquid odorants which can be held approximately 2 cm under the nostrils for one to two breaths (i.e., 3 to 4 seconds) for bi-rhinal assessment, but separate testing of each nostril is possible. Normative data derived from a large population sample is available [69],[70] and for these reasons, they have been adopted for clinical use by practitioners across Europe. [71] A screening version of the Sniffin' Sticks assessment has also been validated as a reliable test to screen nasal chemosensory ability. [72] This format of the assessment is quick and simple to perform. It consists of 12 sticks which are used in an odor-detection task. Some normative information is available to assist determining anosmic, hyposmic, and normosmic individuals and it has been used in recent research with patients post-laryngectomy. [14]
Whilst patient perception and functional status assessment are valuable in documenting changes in outcomes post rehabilitation, it is also important to assess the functional status of the olfactory system, i.e., olfactory physiology to determine if patients have the potential to benefit from any intervention. Larynx bypass, a method of reconnecting the nasal passages with the tracheobronchial tree [Figure 1], has been most frequently used to provide a clinical indication of upper airway patency and function of the olfactory epithelium. [14],[52],[53],[56],[58],[73] Other assessments stimulate the olfactory epithelium directly (e.g., Saccharin transit time) or indirectly (e.g., Alinamin test [60] ) through introduction of a chemical agent. Further to these, newer technologies that utilize medical imaging techniques to examine olfactory function are being developed. These include such techniques as rhinomanometry to measure nasal airflow, pressure and resistance in the nostrils, [55] and magnetic resonance imaging to determine degree of olfactory bulb loss [62] [Table 2]. Although the latter are valid objective assessments, these techniques are generally not viable for clinical use due to time, costs, and need for trained personnel. | Figure 1: Schematic drawing of a larynx bypass used to bypass the upper airways to enable orthonasal airflow
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| Intervention to Enhance Olfactory Performance | | |
Two main approaches to enhance olfactory performance after TL have been described in the literature: (1) Prosthetic: use of a prosthetic device to bypass the larynx and reconnect the nose with the lower airway and (2) Behavioral: active use of the muscles in the face and neck to establish a negative pressure in the oropharynx, drawing air into the nose.
Several prosthetic devices have been developed. These instruments, including the "nipple tube," [74] the oral tracheal breathing tube, [75] and the larynx bypass, [52],[53],[56] all act to bypass the larynx, re-establishing orthonasal airflow between the nose and the tracheobronchial tree. This is achieved with a length of plastic tubing, with one end used to seal the tracheostoma and the other placed in the mouth. When the laryngectomee inspires, the air is drawn in through the nose, before passing through the mouth, tubing, and airway [Figure 1]. Research has affirmed larynx bypass as an effective instrument to increase olfactory accuracy in laryngectomized patients, restoring and/or normalizing olfactory performance. [52],[53],[56],[58] However, the applications of these devices as an everyday olfactory aid remains questionable due to issues of practicality. The devices themselves are cumbersome and intrusive, a limitation not highlighted in the aforementioned studies. Furthermore, some patients may find learning to use the device challenging. [3] Therefore, it is likely that these instruments are limited to laboratory use. Despite these limitations, they provide a feasible option to assess olfactory performance post TL in a clinical setting. [14],[73]
A more functionally acceptable behavioral technique designed to restore orthonasal olfaction is the Nasal Airflow Inducing Maneuver (NAIM), or as it is more commonly known, the "polite yawning technique." Described by Hilgers et al., [1] the NAIM aims to establish a negative pressure gradient in the oropharynx to draw air in through the nose, and re-establish orthonasal olfaction. This is achieved by sealing the lips and simultaneously lowering the jaw, tongue, base of tongue, floor of mouth, and soft palate into a "polite yawn," increasing the volume of the oropharynx and creating a vacuum to bring airflow into the nose [Figure 2]. [1] Restoration of orthonasal airflow allows the uptake and transportation of odor molecules to the olfactory bulb, thus restoring sense of smell. Key points of instruction for this technique and its refinement [Figure 3] are outlined in [Table 3]. | Table 3: Process for teaching the Nasal Airflow Inducing Maneuver (NAIM), refining this and using the mater manometer for feedback
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In addition to these two main methods of restoring orthonasal airflow, it is also advocated to blow air into the nose mechanically. This technique is sometimes used for olfaction testing in laryngectomees, [6],[7],[8] or for rehabilitation using a scent-diffusing ventilator. [76]
Efficacy of converting non-smellers to smellers post-TL has been shown, both in the short-and long-term, with success rates ranging from 46% to 88%. [1],[12],[77] Methods of treatment delivery and intensity have varied in the literature [Table 4], [1],[11],[12],[14],[77],[78],[79],[80] but there is a general consensus that although treatment can be effective with a single intervention, [1],[11],[80] further clinician-guided sessions lead to continued and more expeditious improvement in olfactory ability. [14] Research has also established the benefits of utilizing biofeedback to facilitate NAIM training. [12],[14],[81] Water manometry has been used to show both the clinician and the laryngectomee whether the NAIM is executed correctly [Figure 4]. This biofeedback tool can also be utilized as a training tool to further improve and refine the technique [Table 3].  | Figure 4: Schematic drawing of a water manometer used for biofeedback and evaluation during the training process
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 | Table 4: Treatment outcomes following Nasal Airflow Inducing Maneuver therapy
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Although research has shown that patients can restore sense of smell years after TL using this technique, [1],[11],[12],[78],[79] it is preferable to determine patient suitability for NAIM training during preoperative assessment and counseling. [73] Patients may be unsuitable to undergo olfactory rehabilitation with NAIM if they were anosmic prior to TL, or those with anatomical changes that influence adequate orofacial movement to perform the maneuver post-TL. This may include patients with radiation-induced fibrosis leading to reduced jaw mobility (trismus) or mouth opening needed for the movement or those who have difficulty with uni- or bilateral weakness in the lower lip after radical neck dissection, leading to difficulty obtaining a good lip seal. [73] Additional intervention for these deficits may be required prior to undertaking or during NAIM training for it to be most effective.
| Summary and Future Directions | | |
Following the surgical disconnection of the upper and lower respiratory tract post-TL surgery, olfactory function is impaired. However, patients are able to improve their sense of smell with behavioral intervention post-surgery. Olfaction rehabilitation requires minimal equipment and can be taught and learnt easily. Although there is little emphasis in the literature on including assessment and rehabilitation of olfaction post-TL, this is an area that should be addressed as part of standard care.
| Acknowledgement | | |
The authors thank Chris Edghill for his work on the illustrations.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]
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