DIAGNOSIS

a) Anamnesis
The first stage in diagnosing is a thorough anamnesis and physical examination.
In the anamnesis it is necessary to ask the length of the complaint, whether it is felt
constantly or disappear and whether it is unilateral. Also note whether there is a history of
trauma, other medical problems, and drugs taken.
b) Physical Examination
Physical examination should include complete examination of the ear, upper
airway, head, and neck. Abnormalities in each head and neck region can cause olfactory
dysfunction. The presence of serous otitis media may indicate the presence of
nasopharyngeal or inflammatory masses.
a. Conductive
Careful nasal examination to look for nasal masses, blood clots, polyps, and
inflammation of the nasal membrane is essential. If present, anterior rhinoscopy
should be supported by endoscopic examination of the nasal cavity and nasopharynx.
The telesantus presence on eye examination may lead to mass or inflammation in the
sinuses. A prominent nasopharyngeal mass into the oral cavity or purulent drainage in
the oropharynx can be found on oral examination. The neck should be palpated to
look for mass or thyroid enlargement. Neurological examination that emphasizes the
cranial nerve and sensorimotor function is essential.
b. Sensoneural
The olfactory examination is divided into two, namely subjective and
objective olfactory examination. On subjective olfactory examination, various
materials are placed in front of the patient's nose separately between the two nostrils
before and after the decongestion of the nasal mucosa. Several types of substances are
used, those with odors that will stimulate only the olfactory nerves (coffee, chocolate,
vanilla, lavender), substances that stimulate the trigeminal component (menthol,
acetic acid), and the substance that also has the tasting component (chloroform
pyridine).
The subjective olfactory examination may also be performed using a ready-
made test kit, such as Sniffin 'Sticks. Sniffin 'Sticks uses a number of n-butanol sticks
that are shaped like pens and contain odors of different concentrations. Through the
use of this tool, the ability to detect odors, distinguish different odors and the ability
to identify smells can be assessed. Patients who tested will be blindfolded, then the
examiner will ask the patient to smell three sticks, where between the three sticks are
only one stick that has a smell. If the patient can not detect any odor or identify the
wrong stick, then a higher concentration sticks are used. The concentration of the
given stick will continue to increase so that the patient can correctly identify at least
twice. Afterwards it is assessed at concentrations in which the patient can detect the
odor correctly. This test only takes 10 minutes and is easy to do.

Figure 8: Tools for the Sniffin 'Sticks test

Figure 9: Procedures using Sniffin 'Sticks

 Objective olfactory examination is much more expensive than subjective
examination and is usually performed in larger centers. Pure smell and trigeminal
nerve stimulant are given to the patient separately, then the response is measured and
analyzed using a computer. Common laboratory tests are blood glucose test, urine
reduction test and others.
c) follow-up examination
A CT scan or MRI of the head is required to exclude neoplasms in the anterior
cranial fossa, anterior fossa anterior fracture, paranasal sinusitis, and neoplasm in the
nasal cavity and paranasal sinuses. Bone abnormalities are best seen through CT, whereas
MRI is useful for evaluating olfactory bulbs, ventricles, and other soft tissues in the brain.
Coronal CT is best for examining anatomy and disease in cribiform plates, anterior
cranial fossa, and sinuses.

Figure 10: Example of a picture of neuroblastoma in an olfactory bulbus

Reference: Clinical Policy Bulletin : Smell and Taste Disorder,Diagnosis, 2007, Available from :
http://www.aetna.com/cpb/medical/data