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Gustatory testing for clinicians

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B-ENT, 2009, 5, Suppl. 13, 109-113

Gustatory testing for clinicians

B. Schuster*, E. Iannilli*, V. Gudziol* and B. N. Landis*,**
*Department of Otolaryngology Head and Neck Surgery, University of Dresden Medical School, Dresden, Germany;
**Departments of Otolaryngology Head and Neck Surgery, University of Geneva Medical School and Geneva University
Hospitals, Geneva, Switzerland

Key-words. Taste; taste strips; gustatory event-related potentials; electro-gustometry

Abstract. Gustatory testing for clinicians. By contrast with the evaluation of olfactory function, which has been
standardised for almost two decades, the clinical assessment of gustatory function with psychophysical and objective
testing is still in its infancy. This overview will attempt to summarise the knowledge that is important for clinicians in
the awareness that progress in the field is ongoing. We focus on psychophysical testing but also discuss some recent
achievements in the area of objective taste testing. There are now validated tests available for simple quick scans of
gustatory function but debate continues about the extent to which such tests can be used for medico-legal purposes. In
addition to emerging measures such as gustatory event-related potentials and functional imaging, routine objective
gustatory testing will be needed in the future.

Introduction alter taste. This overview will what is generally called

The gustatory afferent pathway
comprises three of the twelve cra-
nial nerves. These are the facial,
glossopharyngeal and vagal
nerves on each side.1 All gustatory
fibres coming from these nerves
converge within the brain stem to
the nucleus tractus solitarius
(NTS). From there, the ascending
fibres project ipsilaterally to the
thalamus and insula, whereas they
cross at the upper pons or mid-
brain level to a certain extent.2 The
gustatory system therefore has a
predominately ipsilateral projec-
tion with some fibres crossing at
the central level. The exact path
of the peripheral, but also the
central, gustatory fibres has been a
matter of debate for a very long
time, with most findings and the
established knowledge we now
have being based on clinical data.3-6
Consequently, the evaluation of
gustatory function is a key ele-
ment in understanding peripheral
but also central affections that
attempt to present the latest clini-
cal tools for gustatory evaluation.
Although taste fibres supply the
entire tongue, the soft palate, the
epiglottis and the posterior wall of
the oropharynx, the overwhelming
majority of tests and results pre-
sented here investigated the easily
accessible anterior two thirds of
the tongue.7 This region, which is
innervated by the chorda tympani,
is also the region of highest gusta-
tory sensitivity and taste bud den-
sity.8 However, one should bear in
mind that most of our current con-
cepts and knowledge relating to
taste has been validated for these
two-thirds of the tongue.
Symptoms
A clinically useful classification
distinguishes between quantitative
and qualitative taste disorders.
While quantitative disorders
comprise hypogeusia and ageusia,
qualitative disorders consist of
dysgeusia. Dysgeusia is a general
term for any kind of bad or dis-
torted taste sensation without any
further precise description of
whether this condition occurs only
when subjects eat (parageusia) or
is permanently present (phanto-
geusia). While the diagnosis of
dysgeusia relies fully upon patient
descriptions, quantitative taste dis-
orders can be measured. Having
said this, it is also becoming clear
that measurements of qualitative
taste disorders remain to be elabo-
rated.
Patient history
Every patient’s work-up begins
with a thorough patient history.
Since the most prevalent causes of
taste disorders are iatrogenic,
drug-induced, metabolic or post-
infectious it is mandatory to assess
whether the patient has had:
– Recent dental or surgical treat-
ment;
110
– Recent changes in drug intake;
– Newly diagnosed systemic dis-
eases (renal insufficiency, dia-
betes, etc.); or
– Recent infections of the upper
aero-digestive tract (e.g. com-
mon cold, candida, etc.).
In addition to these elements,
questions should also be asked
about neurological or psychiatric
affections, prior head trauma and
general oral perceptual disorders
(dry mouth, burning sensations).
Most causes of taste disorders
become clear after taking a
thorough patient history.
Psychophysical testing
In order to evaluate quantitative
taste disorders, a number of
psychophysical tests have been
developed. In general, there is a
distinction between chemical
(natural) or electrical testing tools.
While the first use basic taste
solutions (sweet, sour, salty, bitter
or umami) to stimulate taste, the
latter apply electrical currents to
the surface of the tongue in order
to elicit taste perceptions. While
both suffer from the same short-
coming of psychophysical tests in
general, which is that patient must
cooperate and must not be suf-
fering from dementia, the major
advantage of both tests is quick
and easy handling and stimulus
presentation. Consequently, both
procedures have been extensively
used in clinical routine practice.
Their usefulness is currently
accepted to be equally good when
it comes to measuring patients’
gustatory function before and after
any interventions. However, it
has been claimed that electro-gus-
tometry co-stimulates trigeminal
fibres to a certain extent, which
probably makes it an unreliable
tool for the measurement of event-
related potentials.9,10 On the other
hand, recent studies suggest that
taste and trigeminal fibres anasto-
mose and act together to a certain
degree at the peripheral level,11-13
which brings into question the
current concept of a clear distinc-
tion between these two modalities
at the oral level.
A) Chemical testing
Whole-mouth testing
-Three-drop method
One of the first standardised tests
was described by Henkin et al.14,15.
It consisted of three consecutive
drops applied to the patient’s
mouth: one with a taste solution
and the two others being blanks.
The patient’s task was to indicate
which droplet contained the taste
solution. This test is very easy to
construct, repeat and is based on
chemical stimulation but its short-
coming is that it is confined to
whole-mouth testing. Since many,
particularly surgically-induced,
taste disorders show locally iso-
lated and lateralised impairment,
lateralised testing tools are
required in the clinic.
-Taste Tablets and Wafers
In order to create tests for
prefabrication and storage, taste
tablets and wafers containing
basic tastants were used with good
test-retest reliability but with the
same drawback of whole-mouth
stimulation only.16,17 However,
these tests are still suitable for
any whole-mouth testing studies.
The three-drop test or the tablets
are also suitable for screening
purposes and can be extended if
necessary for threshold testing.
B. Schuster et al.
Regional tests
-Taste Strips (natural stimuli)
Whole mouth tests can be com-
pleted using regional testing, with
the recently developed18 and vali-
dated19 “taste strips” currently
being a very suitable clinical bed-
side testing tool for the lateralised
testing of the anterior and posteri-
or parts of the tongue.20,21 Isolated
damage to the chorda tympani
or glossopharyngeal innervated
tongue areas can therefore be
easily identified. These taste strips
consist of spoon-shaped filter
papers impregnated with tastant
which are placed onto specific
areas of the tongue. Patients are
presented with a total of 32 tas-
tants (16 a side in different tastant
concentrations). The subjects are
then asked to identify the taste
from a list of four verbal descrip-
tors (sweet, sour, bitter and salty)
in a forced choice paradigm.
While choosing, patients are
required to keep the tongue out-
side the mouth until they have
indicated the perceived quality by
pointing to the descriptor sheet.
Only then are they allowed to
retract the tongue, swallow and
rinse the mouth with tap water. All
correct answers are added up, with
a total possible score of 16 per
side. Values below 9, and dif-
ferences between the sides of 4
and more, are considered to be
outside the normal range and
require further investigation.19
B) Electrical testing
Electro-gustometry (non-natural
stimuli)
This method was first stan-
dardised by Krarup in the 1950s
and he subsequently tested
numerous clinical patient groups
for taste deficits, showing that this
tool was a major advance in the
Gustatory testing for clinicians
clinical assessment of patients
with taste disorders.22-26 In the
meantime, taste testing and this
method have become less wide-
spread in clinical practice in
Europe, but they remain an impor-
tant clinical tool in Asia, and par-
ticularly Japan, which is where the
most important work on middle
ear surgery, and on the damage it
inflicts on taste function and
recovery, has taken place in recent
years.27-31 Electrogustometry is
used for the lateralised assessment
of taste detection thresholds.32 It
involves the use of electrical
mono- (DC anodal) or bipolar
(DC coaxial) stimulation ranging
from 1.5 to 400 µA.33 This range
has been found to measure taste
sensitivity reliably and therefore
to provide information about the
integrity of the taste pathways.34
Since electrical stimulation pro-
duces only a “metallic, sour-like”
taste regardless of the current, this
method is not suitable for studies
investigating selective basic taste
differences (e.g. selective loss of
sweet perception). On the other
hand, regional testing is feasible
and straightforward.
Objective measurements
a) Gustatory event-related poten-
tials
Certain clinical situations,30,31 such
as the examination of dementia
patients, children or possible
malingerers, require objective
testing devices. This became clear
more than three decades ago and
several investigators developed
electrical or chemical taste testing
tools in the hope of obtaining
“objective” measures of human
taste function (for review, see
Ikui35). The major difficulties con-
sist of delivering tastants to the
tongue surface without producing
artefacts such as thermal, tactile or
nociceptive co-activation. In a pio-
neering work, Kobal36 managed to
overcome these technical difficul-
ties with a stimulation device
similar to the one previously used
to record olfactory event-related
potentials.37 In the meantime,
these devices have been used for
the clinical assessment of gusta-
tory function.38 These techniques
give consistent results for sour, but
show certain weaknesses in inves-
tigating the other basic tastes.
Further work is currently in
progress in order to establish more
robust gustatory event-related
potentials for all five taste quali-
ties.
b) Imaging
With the introduction of func-
tional imaging such as PET and
functional MRI, it was possible to
establish an insight into gustatory
processing in healthy and living
humans. These techniques could
confirm or reject observations and
conclusions drawn from patients
with circumscribed anatomical or
neurological lesions and taste dis-
orders. Although gustatory func-
tional imaging is still not widely
used, the current reports clearly
suggest the thalamus, insula and
orbitofrontal cortices are the main
neuronal relays for gustatory pro-
cessing.39-41 However, further work
is required to investigate gustatory
processing in its full extent.
c) Confocal microscopy
This technique, which was
developed in ophthalmology, has
been introduced into gustatory
evaluation by Just, who was able,
for the first time, to visualise and
characterise taste buds in vivo in
humans.42 This technique does not
111
directly measure gustatory func-
tion. However, it does generate a
direct vision of the taste organ,
which allows for the correlation of
morphology with measured taste
function.43,44 By contrast with olfac-
tion, where a direct functional and
morphometric correlation is cur-
rently only possible using MRI
and measurements of the olfactory
bulb, confocal microscopy is a
tool that could, potentially, resolve
many puzzling clinical presenta-
tions. Future work in this very
promising field will establish its
value for routine clinical practice.
Acknowledgements
This work was supported by a grant
from the Swiss National Fund for
Scientific Research (SSMBS grant
n° PASMA-119579/1) to BNL. We
thank Thomas Hummel for valuable
comments on the manuscript.
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 Gustatory testing for clinicians 113

morphology of human fungiform Benno Schuster Fetscherstrasse 74

papillae of healthy subjects and Smell and Taste Clinic 01307 Dresden, Germany
patients with transected chorda tym- Department of Otorhinolaryngology, Tel.: +49-(0)351-458-2268
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