ONLINE EXCLUSIVE
Significance of imaging in the
diagnosis of olfactory disorder
Teemu Harju, MD; Markus Rautiainen, MD, PhD; Ilkka Kivekäs, MD, PhD
Abstract
The aim of this retrospective analysis was to examine olfactory
disorders among the patients in the Ear, Nose, and Throat Clinic
of Tampere University Hospital, Finland, from 2001 to 2011,
and to evaluate the necessity of imaging in the examination of
patients with olfactory disorders. Charts of 143 consecutive pa-
tients with a primary olfactory disorder were examined, and 69
patients who had undergone the necessary testing were included
in the study. The most common causes of olfactory disorder
were upper respiratory infection (23%), chronic rhinosinusitis
(19%), head trauma (17%), and allergic or nonallergic rhinitis
(6%). In 25% of the patients, no obvious cause for the symptoms
was found. Computed tomography (CT) scans were normal in
37 of 52 (71%) patients and magnetic resonance imaging was
normal in 21 of 25 (84%) patients. No intracranial or intranasal
tumors were found in the overall cohort. Of the patients with
additional symptoms (facial pain, headache, nasal discharge,
or stuffiness), 58% had chronic rhinosinusitis. Of the patients
with no additional symptoms or signs associated with chronic
rhinosinusitis on clinical evaluation, only 2% had chronic rhinosi-
nusitis on imaging. Only the detection of chronic rhinosinusitis
and head trauma had clinical value in the determination of the
etiology. A sinonasal CT scan should be considered in patients
who have at least one symptom associated with sinusitis in
addition to an olfactory disorder to confirm the etiology and
to find those patients who may benefit from medical therapy
or surgical treatment.
From the Department of Otorhinolaryngology, the University of
Tampere; and the Department of Ear and Oral Diseases, Tampere
University Hospital, Tampere, Finland.
Corresponding author: Ilkka Kivekäs, MD, PhD, Department of
Otorhinolaryngology, Tampere University Hospital, Teiskontie 35,
33521 Tampere, Finland. Email: ilkka.kivekas@fimnet.fi
Volume 96, Number 2
Introduction
Olfactory disorders are disorders of the chemosenses
that can severely alter quality of life, personal safety,
interpersonal relations, and eating habits and nutri-
tional intake.1 The prevalence of olfactory disorders is
quite high in population-based studies in which odor
identification has been assessed.2-4 In a Swedish study,
19% of the adult population was found to have some
kind of olfactory dysfunction.2
Identification of the etiology of olfactory disorder
is important to determine which patients may benefit
from therapy. Furthermore, correct diagnosis helps in
the counseling of patients.5,6 Conservative therapy with
corticosteroids and surgical therapy has been proven to
be effective in the treatment of sinonasal-disease–related
olfactory disorders but not non-sinonasal disease.7,8
When evaluating a patient who has a smell disorder,
obtaining a detailed patient history is important. The
physical examination should include a complete ear, nose,
and throat examination,5,9 as well as nasal endoscopy.10 A
neurologic examination with emphasis on assessment of
cranial-nerve function should be performed.5 Accurate
olfactory testing is essential to establish the validity of
the patient´s complaint and the degree of chemosenso-
ry loss.5,11 Imaging studies of the brain and paranasal
sinuses are often obtained in an effort to determine the
site and nature of the underlying pathology. Sinonasal
computed tomography (CT) is the technique of choice
for the study of sinonasal structures. Head magnetic
resonance imaging (MRI) is useful in the evaluation of
the central causes of an olfactory dysfunction.12
The clinical value of imaging in patients with ol-
factory loss has been controversial. Busaba concluded
that imaging was not needed in a patient with isolated
olfactory loss if clinical examination was normal.13
Mueller et al, however, concluded that CT scans are
useful to diagnose conductive/inflammatory olfactory
loss in patients suspected of non-sinonasal disease.6
The aim of this retrospective analysis was to examine
olfactory disorders among the patients of the Ear, Nose,
and Throat Clinic of Tampere University Hospital, and
www.entjournal.com E13
 HARJU, RAUTIAINEN, KIVEKÄS
to evaluate the need for imaging studies in the exam-
ination of patients suffering from olfactory disorders.
Patients and methods
The study was carried out at Tampere University Hos-
pital, Tampere, Finland, and the review board of our
institute (R11587) approved the study design. A ret-
rospective review of 143 consecutive patients with a
primary complaint of olfactory disorder that had been
treated at the Tampere University Hospital Ear, Nose,
and Throat (ENT) outpatient department between
2001 and 2011 was conducted.
All patients were identified from their ENT clinic
discharge codes (R43.0 and R43.1, according to the
International Classification of Diseases, 10th Revision,
ICD10). Information on etiologies and types of olfactory
disorders, ages at onset of disorder, and other possible
symptoms was collected. Data on examination methods
and their findings were also collected and evaluated.
Results
The main reason for exclusion from this study was de-
ficiency of olfactory testing. From the total cohort of
143 patients, only 69 patients had the necessary imag-
ing and olfactory testing records available. Of these, 50
(72%) were women and 19  (28%) men, with a mean
age of 49 years at onset of symptoms (range: 18 to 76
years). The most common types of olfactory disorder
were anosmia (45%; n = 31) and hyposmia (45%; n =
31). Five (7%) of the patients had parosmia and hypos-
mia and 2 (3%) had only parosmia. Nineteen patients
(28%) complained of additional symptoms such as fa-
cial pain, headache, nasal discharge, and stuffiness.
Upper respiratory infection (URI) was the cause of
olfactory disorder in 16 (23%) patients, chronic rhinosi-
nusitis was the etiology in 13 (19%), and allergic or non-
allergic rhinitis in 4 (6%). In 12 (17%) patients, olfactory
disorder was caused by head trauma. Two patients had
congenital olfactory loss, 2 had rheumatoid arthritis, 1
had Sjögren syndrome, 1 had a history of occupational
exposure to toxic chemicals, and in 1 patient, olfactory
dysfunction was related to medication.
In 17 (25%) patients, no obvious cause for the symp-
toms was found. In this group, 2 patients complained of
partial memory loss but no neurodegenerative disease
was diagnosed, 2 suffered from depression, 1 had dia-
betes, and 1 had neuropathy of unknown origin. These
complaints, however, were not considered undisputed
causes of their symptom.
A limited odor test (ammonia, anise, coffee, and tar)
was carried out in 43 (62%) patients and an extensive
odor test (Sniffin’ Sticks) in 26 (38%). Nasal endoscopy
was performed in 32 (46%) patients, with findings in 5
(16%): mucosal inflammation was present in all 5, and
E14 www.entjournal.com
mucosal polyposis was present in one.
CT imaging of the brain and paranasal sinuses was
performed in 52 (75%) patients, head MRI in 25 (36%),
and both CT imaging and head MRI in 8 (12%). CT was
normal in 37 of 52 (71%) patients. Findings in 15 (29%)
patients included chronic rhinosinusitis in 12 (23%);
changes due to trauma (hemorrhage, skull base fracture)
in 2, for which CT imaging was done in acute situations;
and degenerative brain changes (atrophy) in one.
Correspondingly, MRI was normal in 20 of 25 (80%)
patients and pathology was discovered in 5 (20%). Find-
ings included degenerative brain changes (atrophy) in
2 patients, chronic rhinosinusitis in 1, change due to
trauma (brain contusion) in 1, and multiple sclerosis
plaques in 1 patient, in whom the olfactory disorder was
thought to be caused by acute URI. Multiple sclerosis
had been diagnosed earlier in this patient, and the
plaques had been found in older MRI examinations,
as well. The plaques were in brain areas not critical for
olfaction function.
No intracranial or intranasal tumors were found in
any patient. Three patients (2 on CT, 1 on MRI) had
degenerative brain changes that were not considered
to be the cause of the disorder. In this group, the eti-
ologies were URI, chronic rhinosinusitis, and Sjögren
syndrome.
Of the 19 patients with additional symptoms, 11
(58%) were diagnosed with chronic rhinosinusitis: 10
by CT and 1 by MRI. Among patients with olfactory
dysfunction as their only symptom (n = 50), chronic
rhinosinusitis was diagnosed by imaging in only 2 (4%),
both by CT. Of these 2 patients, 1 was found to have
polyposis and discharge on nasal endoscopy. Therefore,
only 1 (2%) patient who was found to have chronic
rhinosinusitis on imaging had no symptoms or signs
of sinonasal disease.
There was a statistically significant correlation be-
tween the presence of additional symptoms (facial pain,
headache, nasal discharge, and stuffiness) and chronic
rhinosinusitis on imaging (p < 0.0001; chi-square test).
All patients who had an olfactory disorder caused by
allergic or nonallergic rhinitis (n = 4) had additional
symptoms (stuffiness in most cases) (table).
Discussion
The subjective complaint of the patient is not a reli-
able assessment of olfactory function, and therefore
assessment by smell testing is recommended.5,11 Sev-
eral olfactory tests are commercially available,14,15 but
experience has shown that they are not widely used in
a clinical setting outside major centers.9 The situation
seems to be similar at our clinic, as only 38% of the
patients in our study were tested using extensive odor
tests (Sniffin’ Sticks). In the remainder, a limited odor
ENT-Ear, Nose & Throat Journal February 2017
 SIGNIFICANCE OF IMAGING IN THE DIAGNOSIS OF OLFACTORY DISORDER
test was used. Deficiencies in objective olfactory test-
ing, therefore, were the main reason for patient exclu-
sion.
In our retrospective study, nasal endoscopy was per-
formed in 46% of patients, a possible explanation being
that the examination strategy of the clinicians relied
strongly on imaging. CT was performed mainly when
chronic sinusitis was suspected (or to exclude it). Head
MRI was used mainly when the etiology was otherwise
unclear, to exclude other possible intracranial causes.
The determination of URI or head trauma as the cause
of the smell disorder was based mainly on the patient’s
description and how the disorder first appeared during
the URI or after the head trauma. In 3 of 12 patients
with head trauma, changes in imaging also supported
the determination.
The determination that chronic rhinosinusitis was
the cause of the disorder was based on the patient’s
symptoms and findings on imaging. In cases in which
rhinitis was the cause of the disorder, the evaluation
was based on the patient’s symptoms, possible history
of allergy, clinical findings of the nasal mucosa, and
the exclusion of chronic rhinosinusitis with imaging.
In cases of other, rarer causes, the determination was
based mainly on the patient’s history.
In the present study, olfactory disorder was not
caused by either brain or nasal mucosal tumor. The
sample size of 69 patients is too small to conclude that
the exclusion of brain tumors by imaging is not useful
in the examination of patients with olfactory disorder.
Olfactory disorder induced by brain tumor, however, is
rare. In an American study of 750 consecutive patients
with chemosensory disorders, only 2 (0.3%) cases were
induced by brain tumor.16
Volume 96, Number 2
According to recent studies, the major symptoms of
olfactory groove meningiomas are headache, anosmia/
hyposmia, mental disturbances, visual deficits, and sei-
zures.17,18 Based on these studies, in most of the olfactory
groove meningioma cases, other symptoms are present
in addition to olfactory dysfunction.
Olfactory loss can also be secondary to the com-
plete obstruction of the airflow by intranasal tumors,
such as inverting papilloma, hemangioma, squamous
cell carcinoma, esthesioneuroblastoma, or sinona-
sal-undifferentiated carcinoma.5 The most commonly
observed symptoms of such tumors are unilateral
nasal obstruction and recurrent epistaxis, in addition
to anosmia.19 Such masses are readily visualized with
nasal endoscopy.13
Olfactory bulb sizes were not measured systematically
in this study. Olfactory bulb volume is decreased in
patients with olfactory loss caused by trauma, infec-
tions, or sinonasal disease, as well as in patients with
idiopathic olfactory loss.20-22 Olfactory bulb volume
has been shown to change with the degree of olfactory
dysfunction and decreases with the duration of the
olfactory loss.23 An enlargement of the olfactory bulb
due to an improvement in peripheral olfactory function
has also been described.24 Bulb size has recently been
shown to have prognostic value for recovery,20 which
supports the routine use of MRI in the examination of
patients with olfactory disorder.
Stankiewicz and Chow25 found that 47% of the pa-
tients who had at least two major symptoms or at least
one major and two minor symptoms, according to the
symptom-based definition of chronic rhinosinusitis,26
had a positive CT scan indicating chronic rhinosinusitis.
In the present study, 58% of the patients who had at
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 HARJU, RAUTIAINEN, KIVEKÄS
least one symptom (facial pain, headache, nasal dis-
charge, or stuffiness) in addition to olfactory disorder
were found to have chronic rhinosinusitis on imaging,
a finding in line with those of Stankiewicz and Chow.
Olfactory disorder as an isolated symptom does not
seem to be a strong predictor of chronic rhinosinusitis.
When the symptoms suggest chronic sinusitis, nasal
endoscopy alone can miss the signs of sinonasal disease
in 9% of suspected cases,10 prompting consideration of
a sinonasal CT scan to confirm the diagnosis.
Olfactory cleft is a topic that has been explored
extensively. Moderate or severe opacification of the
olfactory cleft in the preoperative CT seems to predict
worse postoperative olfactory results than mild findings
in the treatment of chronic rhinosinusitis with nasal
polyposis.27 This prognostic aspect also supports the use
of sinonasal CT in the diagnosis when the symptoms
suggest chronic rhinosinusitis.
Mueller et al concluded that CT scans are useful in
the diagnosis of conductive/inflammatory olfactory
loss in patients suspected of non-sinonasal disease.6
They found that 7% of patients without symptoms or
signs of sinonasal disease on clinical evaluation had
sinonasal disease on CT scans. In the present study,
only 2% of such patients had chronic rhinosinusitis on
imaging. Based on the findings of this study, therefore,
CT imaging of patients suspected of non-sinonasal
disease is not indicated.
Conclusion
The significance of imaging in the diagnosis of olfac-
tory disorders is controversial, especially regarding the
use of MRI. Only chronic rhinosinusitis and head trau-
ma seemed to have clinical value in the determination
of the etiology. Severe causes of olfactory disorders,
such as brain tumors, are rare and present with oth-
er symptoms, which supports the notion that imaging
should be targeted to patients selected based on the
history and clinical examination.
In the cases in which URI is the cause of olfactory
disorder, a thorough patient history and clinical ex-
amination with nasal endoscopy are often sufficient to
make a diagnosis. If the patient has a history of head
trauma and no imaging has been done in the acute
situation, head imaging should be considered. Head
MRI should be performed if the patient has additional
symptoms that suggest brain tumor or neurologic dis-
orders. On the other hand, the olfactory bulb size could
have prognostic value for recovery, which supports the
routine use of MRI in the examination of patients with
olfactory disorder.
If a patient has at least one symptom associated with
chronic rhinosinusitis in addition to olfactory disorder,
a sinonasal CT scan should be considered to confirm
E16 www.entjournal.com
the etiology and to identify those patients who may
benefit from the medical therapy or surgical treatment.
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