B-ENT, 2007, 3, 101-104

Case report: olfactory loss and unrelated chronic rhinosinusitis

G. Claes and J. Claes
ENT Department, University Hospital of Antwerp, Edegem, Belgium

Key-words. Anosmia; olfactory groove meningioma; sinusitis

Abstract. Case report: olfactory loss and unrelated chronic rhinosinusitis. A case is presented in which a meningioma
of the olfactory region caused olfactory loss as the only presenting symptom. Diagnosis was delayed by the presence of
mild chronic sinusitis, presumed to have been responsible for the presenting hyposmia. The meningioma was initially
not detected on a CT scan of the sinuses. A well conducted anamnesis and objective assessment of total anosmia through
smell identification tests raised the suspicion of a sensorineural olfactory disturbance. The tumour was finally diagnosed
on MR imaging. The paper discusses the practical management of patients presenting with olfactory dysfunction.

Introduction best treatable causes of hyposmia/ Since medical therapy, including

Olfactory disturbances can be
classified into three classes: 1)
Conductive olfactory dysfunction,
caused by compromised nasal
patency, e.g. in patients with
chronic rhinosinusitis or nasal
polyposis, 2) Sensorineural olfac-
tory dysfunction, caused by dam-
age to the olfactory epithelium,
e.g. post-infectious, post-traumatic
or post-surgical, and 3) Central
olfactory dysfunction, caused by
damage to the anterior olfactory
nucleus in the brain, e.g. in
patients with intracranial tumours,
in Parkinson’s or Alzheimer’s
disease.
Rhinitis and rhinosinusitis are
common causes of olfactory dis-
turbances.1 Hyposmia is a com-
olfactory dysfunction. It frequent-
ly resolves after a short treatment
with oral steroids combined with a
nasal steroid spray3; however this
improvement is often transient or
incomplete. Surgical treatment of
patients with rhinosinusitis may
also have a positive effect on the
sense of smell.
If the dysosmia does not fit
within the clinical picture, e.g. if
nasal endoscopy fails to reveal
obstruction of the superior meatus
or a tumour, other causes of olfac-
tory loss have to be excluded. The
olfactory disorder may then be
explained by a neuroepithelial or
central nervous system distur-
bance, in which case further inves-
tigations (assessment of olfactory
function, CT or MR imaging) are
systemic steroids, had not
changed her olfaction and her
symptoms had been present for
over a year, she was referred to the
university clinic. Because of a
striking discrepancy between the
mild findings on CT and on nasal
endoscopy, and her history of total
anosmia, other causes were con-
sidered. Total anosmia was con-
firmed after smell identification
tests using smell diskettes
(Zürcher Geruchstest‚, Dietikon,
Switzerland). This screening test
is designed as a triple forced mul-
tiple choice test of 8 different
odorants. The patient correctly
identified 2 out of 8 smell
diskettes presented, this being
compatible with severe
hyposmia. 4

mon complaint in chronic rhinosi- appropriate. An MRI scan of the brain

nusitis (CRS), and the degree of
olfactory loss is usually propor-
tional to the severity of the rhinos-
inusitis.2 Although very suggestive
of CRS,2 it is rarely the only
symptom. Patients often also
present with nasal obstruction,
rhinorrhoea, a postnasal drip, or
headache as their primary symp-
toms. Rhinosinusitis is one of the
Case report
A 68-year-old female presented
with progressive hyposmia, nasal
congestion and frontal headache.
Initially, her hyposmia was
believed to be related to the eth-
moidal and sphenoidal sinusitis
seen on CT scan (Figure 1a-b).
showed an extra-axially located
bi-frontal sharp mass (diameter
3.1 cm), suggestive of a menin-
gioma. The mass was surrounded
by mild intracerebral oedema and
did not invade the sphenoid or eth-
moidal sinuses (Figure 2a-b). The
CT findings were reviewed and
the tumour, initially not seen by
the radiologist, not by the ENT
102 G. Claes and J. Claes

Figure 1
Coronal CT scan showing total opacification of the left sphe-
noidal sinus with thickening of the bony walls suggestive of
chronic inflammation (a) and a more anterior section showing
a mucosal thickening in the superior part of some ethmoidal
cells and inferiorly in both maxillary sinuses (b). Note that on
the CT, performed with bone windows, the intracranial lesion
was initially not detected.

physician initially consulted nor
by us, was only then identified.
The patient was admitted to the
hospital for removal of the menin-
gioma. Preoperatively, an emboli-
sation of the middle meningeal
artery was performed to occlude
the feeding vessels of the tumour.
The tumour was removed through
a bicoronal incision and sub-
frontal approach. The frontal sinus
was trepanated under neuronavi-
gation control. The tabula interna
of the frontal sinus was removed
and the meningioma was resected
by the neurosurgeon. The dura of
the floor of the anterior fossa was
reconstructed using TissuDura
and a galeal periosteal flap. The
frontal recesses were obliterated
with abdominal fat. All mucosa
was removed from the remaining
walls of the frontal sinus and the
tabula externa was then put back
in place.
Postoperatively the patient
recovered well, although she com-
plained of severe headache, which
was treated symptomatically. The
headaches resolved completely
within a month and a postopera-
tive CT scan showed no residual
meningioma.
Histology revealed a neoplastic
meningothelial meningioma (WHO
grade 1) consisting of uniform
cells with discrete cytonuclear
atypia. Neither mitoses nor
necrosis were seen.
Discussion
Meningiomas are the most fre-
quent type (15-30%) of primary
intracranial tumour, and are
usually benign and attached to
the dura.5 Patients may present
with a gradually worsening focal
neurological deficit, focal seizures
or symptoms of raised intracranial
pressure. Obviously, the clinical
presentation depends on the
localisation of the tumour.
Meningiomas may also be found
incidentally on a CT or MRI scan.
Since they are usually benign
tumours, complete surgical
removal is often possible and in
most cases curative.
In our case, the olfactory distur-
bances were caused by an olfactory
meningioma, while mild chronic
sinusitis coexisted. Olfactory
meningiomas represent about
12% of all basal meningiomas.6
Anosmia is thought to be among
Olfactory loss and unrelated rhinosinusitis
a Figure 2
the first symptoms, although
patients are often unaware of
olfactory loss. Most patients pre-
sent with headache, visual or cog-
nitive disturbances.7 The fact that
meningiomas are slow growing
tumours often results in their late
discovery.
As in the present case, we feel
that – rare as it may be – sen-
sorineural olfactory function loss
must be considered in every case of
severe hyposmia. The evolution of
the olfactory dysfunction, the
response to medication, critical
evaluation of the available data and
olfactory function tests can help
select those cases, in which addi-
tional investigations may be useful.
Smell disturbances are very
suggestive of CRS, but only when
other symptoms of CRS are also
present (headache, postnasal drip,
nasal obstruction, rhinorrhoea).
CT imaging is commonly used in
the diagnosis of CRS, but it is in
fact too sensitive as 27-45% of
Coronal (a) and sagittal (b) T1-weighted gadolinium enhanced
MR images of the same patient, showing the meningioma at
the base of the anterior cranial fossa.
normal subjects show sinus opaci-
fication.8 Furthermore, as in the
present case, the CT scan did not
distinctly show the meningioma,
which caused a delay in the diag-
nosis.
Several authors have designed
algorithms to evaluate olfactory
dysfunction.9-12 The first step is to
take a good history regarding the
nature, timing, onset, fluctuation,
precipitating events and localisa-
tion (left/right) of the disorder. A
correct description has to be
obtained (anosmia, hyposmia,
parosmia, dysosmia ...). A com-
plete otorhinolaryngologic exami-
nation with nasal endoscopy
(visualization of the middle and
superior meati and the olfactory
cleft) has to be performed.
The next step is the evaluation
of the smell disturbance using
psychophysical testing, which gives
a semi-objective measure. A num-
ber of psychophysical tests have
been validated and standardized:
the UPSIT test,13 the Sniffin Stick
103
test,14 the Scandinavian odour-
identification test15 and the alcohol
sniff test.16
Olfactory function can be elec-
trophysiologically assessed using
chemosensory event related
potentials (CSERP).17 These tests
provide objective measures, but
are only available in specialized
centres.
When no evidence of sinunasal
disease is found and the history
of the patient has not revealed
another possible explanation for
the sensory olfactory dysfunction,
brain MR imaging is essential.
This may reveal congenital disor-
ders, post-traumatic brain disor-
ders or tumour lesions (e.g. esthe-
sioneuroblastoma, meningioma
...). However, post-infectious,
toxic or sensorineural olfactory
disorders in the brain are not
always associated with pathologic
changes on MRI. For this reason,
some cases of olfactory dysfunc-
tion remain unexplained (idio-
pathic).
104
Conclusion
Although chronic rhinosinusitis is
a common cause of hyposmia, one
should always consider other (less
common) aetiologies for olfactory
loss, especially when the loss does
not fit with the clinical picture. We
therefore recommend the use of
smell identification tests to objec-
tively assess a smell disorder. MR
imaging of the brain should be
carried out to exclude central or
sensorineural causes of olfactory
loss.
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J. Claes
ENT Department
University Hospital of Antwerp
Wilrijkstraat 10
B-2650 Edegem, Belgium
E-mail: Jos.Claes@uza.be