The Laryngoscope

C 2017 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Chemosensory Function Before and After Multimodal

Treatment in Chronic Rhinosinusitis Patients

Ute Walliczek-Dworschak, MD ; Robert Pellegrino, MD; Franziska Taube, MD; Christian A. Mueller, MD;
Boris Alexander Stuck, MD; Philipp Dworschak, MD; Christian G€
uldner, MD; Silke Steinbach, MD

Objectives/Hypothesis: Olfactory dysfunction is common among the general population, with chronic rhinosinusitis
(CRS) as one of the leading causes. Patients affected by CRS often report changes in taste sensations; however, quantitative
measurements have not been performed to date. Therefore, the present study aimed to investigate gustatory and olfactory
function in CRS patients prior to and after multimodal treatment.
Study Design: Prospective cohort study.
Methods: Twenty-one patients suffering from CRS with nasal polyps (14 male, seven female) with a mean age of
48 6 15 years were included in the study. Chemosensory function was assessed prior to and approximately 190 days after
multimodal treatment, which included endoscopic sinus surgery, oral antibiotics for 5 days, oral steroids for 12 days, and at
least 6 weeks of topical nasal steroids. Olfactory function was tested with the Sniffin’ Sticks test battery, whereas gustatory
function was measured with taste strips. A clinically relevant change in olfactory function was defined as a change of 5
points in the threshold, discrimination, and identification scores.
Results: Compared to normative data, patients baseline gustatory and olfactory function was impaired. After multimodal
treatment, improvements were seen in olfactory function for eight patients (42%), remained stable in 10 patients (53%), and
deteriorated in one patient (5%). Taste function remained unchanged following sinus surgery.
Conclusions: Patients suffering from CRS with polyps exhibit olfactory and taste dysfunctions. Multimodal treatment
leads to an improvement in olfactory, but not gustatory functionality.
Key Words: Chronic rhinosinusitis, taste, nasal polyps, olfaction, endoscopic sinus surgery.
Level of Evidence: 4.
Laryngoscope, 128:E86–E90, 2018

INTRODUCTION Conservative treatment is the first type of medical care

Chronic rhinosinusitis (CRS) is a common disease in
Europe, with approximately 11% of the population being
diagnosed with it.1 Most patients develop CRS without
nasal polyps, with fewer than 18% of the CRS patients
having nasal polyps (CRSwNP). Olfactory functionality is
a well-documented impairment that comes with 15% to
53% of CRS patients.2–6 Dysosmia (or smell impairment)
is more prevalent in CRSWNP patients than patients
without nasal polyps.7,8
From the Department of Otorhinolaryngology–Head and Neck
Surgery (U.W.-D., F.T., B.A.S., C.G.), Center of Orthopedics and Traumatology
(P.D.), Department of Phoniatrics and Pediatric Audiology (C.G., S.S.),
Philipps University Marburg, Marburg, Germany; Department of Otorhi-
nolaryngology–Head and Neck Surgery (C.G.), Chemnitz Hospital GmbH,
Chemnitz, Germany, Smell and Taste Clinic, Department of Otorhinolar-
yngology (U.W.-D., R.P.), Dresden Technical University, Dresden, Germany;
and the Department of Otorhinolaryngology–Head and Neck Surgery (C.A.M.),
Medical University Vienna, Vienna, Austria.
Editor’s Note: This Manuscript was accepted for publication July
28, 2017.
U.W.-D. received generously provided portions of the taste strips
from the Burghart GmbH (Wedel, Germany).
The authors have no other funding, financial relationships, or con-
flicts of interest to disclose.
Send correspondence to Ute Walliczek-Dworschak, MD, Department
of ENT–Head and Neck Surgery, Philipps University Marburg, Baldinger-
strasse, 35043 Marburg, Germany, E-mail: wallicze@staff.uni-marburg.de
DOI: 10.1002/lary.26873
received by CRS patients, and involves topic or systemic cor-
ticosteroids and leukotriene. However, if none to little recov-
ery is shown, endoscopic sinus surgery (ESS) is considered
for CRS patients.9 Olfactory improvements after ESS vary
widely between studies, showing improvement between 0%
to 97%. Some studies even report about deteriorated olfac-
tory function after ESS.10–14
Olfaction is crucial for enjoying food, because it plays
a major role in the perception of flavor.15 For instance,
during the mastication process, food particles are broken
up to dissolve in saliva, transmitting basic tastes to their
respective buds and releasing volatiles through the phar-
ynx toward the olfactory neurons in the nose (retronasal
smell). Due to the integral role smell plays in eating, indi-
viduals have difficulty separating/distinguishing gusta-
tory- and olfactory-mediated sensations, leading to
misreported symptoms of taste and olfactory distortions.16
In fact, only about 5% of patients seen at chemosensory
clinics suffer from isolated taste disorders. Yet, impaired
olfactory function is frequently accompanied by a reduced
taste function,17,18 and patients suffering from CRS often
complain about these chemosensory sensations being
reduced. Therefore, the present study focused on the gus-
tatory and olfactory function in CRSwNP patients.
Changes in these chemosensory systems were measured
before and after multimodal treatment, which included

Laryngoscope 128: March 2018 Walliczek-Dworschak et al.: Taste Function in Chronic Rhinosinusitis
E86
ESS, postoperative antibiotics for 5 days, administration
of oral corticosteroids (for 12 days), and topical corticoste-
roids (for at least 6 weeks).
MATERIALS AND METHODS
This prospective study was conducted from May 2015 to
September 2016 in the Department of Otorhinolaryngology–
Head and Neck Surgery, Philipps University Marburg, and was
approved by the local ethics committee (number 26/15). After
providing detailed information to the patients about the study,
a written consent was obtained. The study was performed
according to the Declaration of Helsinki.
Twenty-one patients (14 male, seven female, mean age
48 6 15 years) suffering from CRSwNP were included in this
study. All patients underwent ESS after being treated with topi-
cal corticosteroids without improvement of their symptoms.
Before surgery, patients were medically examined including a
nasal endoscopy and a computed tomography (CT) scan.
Patients who had documented preexisting olfactory/gustatory
dysfunctions caused by neurologic and psychiatric diseases (e.g.,
Alzheimer disease, Parkinson disease, depression), endocrine
diseases (e.g., diabetes mellitus, thyroid diseases), head trauma,
upper airway infection within the past 3 weeks, aspirin intoler-
ance, allergic rhinitis, and a current history of smoking more
than 10 cigarettes per day were excluded from the study. Indi-
viduals using oral corticosteroids did not participate in the
study until 1 month of discontinued use.
Patients’ olfactory and gustatory function was tested within
1 week prior to ESS and on average 190 days after ESS (range,
58–310 days). Participants were asked to not smoke, eat, or drink
anything except water for approximately 1 hour prior to all test
procedures to avoid chemosensory desensitization.
Gustatory Test
Taste function was assessed by means of the validated
“taste strips,” which are spoon-shaped filter papers impregnated
with different concentrations of sweet, sour, salty, and bitter
(sweet: 0.4, 0.2, 0.1, 0.05 g/mL sucrose; sour: 0.3, 0.165, 0.09,
0.05 g/mL citric acid; salty: 0.25, 0.1, 0.04, 0.016 g/mL sodium
chloride; bitter: 0.006, 0.0024, 0.0009, 0.0004 g/mL quinine
hydrochloride).19 Each taste strip was positioned onto the left
or right side of the tongue, approximately 1.5 cm from the tip in
a posterior direction. Participants were then asked to identify
the taste stimulus from a list of four possible answers (sweet,
sour, salty, and bitter) in a forced choice procedure. Taste func-
tion was tested for the left and the right side of the tongue.
First, one side of the tongue was completely tested, then the
other side followed. Taste strips were presented in increasing
concentrations. Patients were instructed to keep their tongue
protruded during the testing process, and for each correct iden-
tified stimulus the patient was given one point, resulting in a
maximum score of 16 points for each side. Combining the scores
for both sides of the tongue, a maximum total score of 32 points
could be achieved.
Normative Data
To differentiate between normogeusia and hypogeusia, the
10th percentile from subjects between 18 and 40 years was
used.19 Concerning the differences between the left and right
side of the tongue, a score difference of more than 3.3 points
was considered pathological. Similarly, another normative data-
set representing different taste qualities (sweet, sour, bitter,
salty) published by Mueller et al.20 was used to measure taste
Laryngoscope 128: March 2018 Walliczek-Dworschak et al.: Taste Function in Chronic Rhinosinusitis
sensitivity of patients prior to ESS against individuals with
normal taste functionality.
To compare changes of taste sensitivity due to multimodal
treatment, the overall tongue sensitivity (left- plus right-side
scores) for basic tastes was measured before and after surgery.
Olfactory Test
Orthonasal olfactory function was measured by means of
the extended Sniffin’ Sticks test battery (Burghart GmbH,
Wedel, Germany).21 This test comprises three separate tests: n-
butanol odor threshold (THR), odor discrimination (DIS), and a
16-item odor identification test (ID). For the testing, odors were
presented in felt-tip pens when the cap was removed. The felt
tip was positioned approximately 2 cm in front of the partici-
pant’s nostrils for approximately 3 seconds. The kit for measur-
ing the THR contained 48 pens, which were arranged in 16
triplets. One pen was impregnated with n-butanol solution in
16 different concentrations, whereas the remainder were with-
out odor. The participants had to discriminate the odor-
containing pen from the two blanks in a three-alternative forced
choice (3-AFC) method, as previously described.21 The DIS task
comprised 48 pens, arranged in 16 triplets. Participants were
presented three pens, two of which had the same scent, whereas
one contained a different odor. Participants were then asked to
identify the pen that smelled different (3-AFC). The ID test con-
tained 16 pens, which were impregnated with familiar scents.
The patients’ task was to choose the right odor from a list of
four text descriptors for each odorant in a four-alternative
forced choice. Results of all three subtests were summed up for
a composite threshold, discrimination, and identification (TDI)
score that ranged from 0 to 48 points. A postoperative improve-
ment in olfactory function was defined by an increased TDI
score of 5.5points.22
Normative Value
To differentiate between normosmic subjects and those
with impaired olfactory function, the value of the 10th percen-
tile of subjects, matching for sex and age, was chosen.23 With
this information, an individualized comparison between patient
and normative data was performed.
Classification of CRS
Preoperative computed tomography (CT) scans were used
to classify CRS by means of the validated Lund-Mackay score.24
All paranasal sinuses were graded on a scale between 0 and 2
according to their opacification, resulting in a summed score
with a maximum of 24. The mean normative Lund-Mackay
score was defined as 4.26.25 Lund-Mackay grading of each
patient was done by one experienced physician. Nasal polyposis
was defined as the presence of endoscopically visible polyps
growing from the middle nasal meatus into the nasal cavity and
bilateral opacification in more than one paranasal sinus accord-
ing to the CT scans. The extent of nasal polyposis was graded
prior to multimodal treatment by nasal endoscopic examination
using the Malm classification scale with a score between 0 (no
nasal polyps) and 3 (nasal polyps reach the nasal floor).26 The
grading of nasal polyposis of each patient was done by another
experienced physician.
Postoperative Care
To reduce recurrence of nasal polyps, patients were covered
with oral antibiotics (cefuroxime 500 mg 23/d) for 5 days and oral
steroids (prednisolone 50 mg/d) for 12 days. Then topical nasal
E87
 TABLE I.
Comparison Olfactory Function Scores Measured by Means of the
Sniffin’ Sticks Test Between Patients’ Preoperative and Postopera-
tive Score.
Mean Value Mean Value
Patients Score Patients Score
Preoperatively Postoperatively
Threshold part 2.81 6 3.16 2.5 6 2.74
Discrimination part 7.57 6 4.02 10.32 6 3.62
Identification part 8.48 6 5.62 10.11 6 4.55
TDI 17.85 6 11.82 23 6 9.91
TDI 5 threshold, discrimination, and identification.
steroids were prescribed for at least 6 weeks, and the patients were
asked to apply them once a day (budesonide nasal spray). At the
date of the postoperative measurement, none of the patients con-
tinued to apply topical nasal steroids. During the postoperative
period patients were asked to rinse their nose with a physiological
saline solution using a nasal douche 3 to 4 times a day.
Statistical Analysis
Statistical analysis was performed using SPSS 21.0 (IBM,
Armonk, NY). A Wilcoxon matched pairs rank test was used to
compare the taste before ESS to reference values from a
healthy control population.20 To measure chemosensory changes
over time, a repeated measures t test compared chemosensory
variables before and after multimodal treatment. The relation
of olfactory and gustatory measurements and CRS disease
parameters was evaluated with the Pearson product-moment
correlation coefficient. Significance level was set at P <.05.
RESULTS
Patient Characteristics and CRS Staging
From the original 21 patients, 19 (90%) were avail-
able at the follow-up to have their olfactory and gustatory
function measured a second time. Fifteen (71.4%) patients
had no prior sinus surgery, whereas five (23.8%) patients
had been operated on once in the past, and one patient
(5.2%) had two previous sinus surgeries. The mean dura-
tion of the disease prior to surgery was 46.0 6 39.9 months
(range, 5–120 months). Nasal polyps among patients were
classified as Malm grade 1 in one subject (4.8%), grade 2
in 14 subjects (66.7%), and grade 3 in six subjects (28.6%).
The mean Lund-Mackay score was 15.8 6 5.02, which
indicates high opacification in the CT scan.
Analysis of Olfactory Function
According to the TDI score, five patients (26%) were
P Value normosmic, five patients were hyposmic (26%), and nine
patients (47%) were anosmic prior to treatment.
.52
For postoperative changes as a group, olfactory function
<.01
(mean TDI score) significantly improved after treatment
.08
(P 5.02). The significant improvement of the TDI score was
.02 mainly due to significant changes in the DIS subscore
(P <.01), whereas the THR and ID subscores were
improved to a lesser extend (P 5.52, P 5.08, respectively)
(Table I). Eight patients (42%) improved, whereas olfactory
function of 10 patients (53%) remained unchanged, and one
patient (5%) showed olfaction deterioration.
Investigation of Taste Function
Nine patients (43%) were normogeusic, and 12
patients (57%) had an impaired taste function prior to
treatment. Taste scores differed significantly from nor-
mative values (Table II).20 No differences were identified
between the both sides of the tongue (P >.05).
No significant change in taste perception was seen after
treatment compared to baseline for either the left
(8.05 6 4.27 vs. 7.84 6 4.06, P 5.39) or right side (7.52 6 4.55
vs. 7.89 6 4.52, P 5.97) of the tongue (Table III). According to
normative data, 13 patients (68%) were normogeusic and six
patients (32%) were hypogeusic after treatment.19
Analysis of Possible Predictive Factors for
Olfactory/Gustatory Outcome After Sinus
Surgery
Statistical analysis did not reveal any predictive fac-
tor for changes in olfactory/taste function after treatment
(Table IV).
DISCUSSION
The present study aimed to investigate olfactory
and gustatory function in CRSwNP patients before and
after multimodal treatment. According to the definition
of olfactory improvement (TDI > 5.5) published by Gud-
ziol et al.,22 our post-treatment results show that eight
patients (42%) improved, 10 patients (53%) remained

TABLE II.
Comparison of Gustatory Function Scores Between Normative Data and Patients Preoperative Score.
Mean Value Mean Value of Mean Value of
Normative Data Patients Score, P Value Patients Score, P Value
(Whole Mouth Testing)* Left Side of the Tongue (Wilcoxon Test) Right Side of the Tongue (Wilcoxon Test)

Sweet 3.3 6 0.8 2.29 6 1.31 <.001 2.14 6 1.15 <.001

Sour 3.0 6 0.8 1.90 6 1.00 <.001 1.86 6 1.15 <.001
Salty 3.1 6 0.9 2.05 6 1.47 .004 1.95 6 1.63 .007
Bitter 3.0 6 1.1 1.81 6 1.47 .001 1.57 6 1.66 <.001
Summed 12.4 8.05 6 4.27 <.001 7.52 6 4.55 .001
taste score

*From Mueller et al.20

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 TABLE III.
Comparison of Gustatory Function (Summed Taste Score)
Between Patients Preoperative and Postoperative Score.
Mean Value Mean Value P Value
Preoperative Postoperative (Wilcoxon Test)
Sweet 4.47 6 2.43 4.89 6 2.17 .50
Sour 3.84 6 1.95 3.84 6 2.21 .83
Salty 4.05 6 2.56 3.37 6 2.6 .11
Bitter 3.68 6 2.94 4.26 6 4.28 .82
Summed 16.32 6 8.18 16 6 8.39 .41
taste score
unchanged, and one patient (5%) showed deteriorated
olfactory functionality. These results are in line with
other research investigating olfactory function after
sinus surgery via the ID part of the Sniffin’ Sticks
test.11,27,28 For instance, Pade et al. demonstrated, in a
study with 387 CRS patients, that olfactory function
increased in 23%, showed no change in 68%, and
decreased in 9%.11 Similarly, Schriever et al.27 reported
that 17% of CRS patients showed an improvement in
their sense of smell 12 months after sinus surgery,
whereas the olfactory function of 73.6% of the patients
remained stable, and 9.4% observed deterioration com-
pared to presurgical odor ID scores. These two studies
demonstrated a lower improvement rate compared to
our results, which is probably due to our study popula-
tion consisting of CRSwNP patients who have been
shown recently in a meta-analysis to benefit more from
ESS compared to patients without nasal polyps.10,11,27,28
Several reasons exist to help explain olfactory improve-
ment in CRSwNP patients including polyp removal and
reduced inflammation. For instance, the removal of
nasal polyps clears mechanical obstruction of the olfac-
tory cleft to enable odorants access to the olfactory epi-
thelium.18,29 Furthermore, nasal surgery might reduce
inflammatory processes near the nasal neuroepithelium
to help improve olfactory function.30 Yet, the present
study could not reveal any predictive factors for olfac-
tory/gustatory changes after treatment. This might be
due to the homogenous study population, consisting only
of CRSwNP patients.10,11,28 Similarly, possible predictive
factors such as previous sinus surgeries might not be
found predictive in this study due to the small study
population, resulting in difficulty to show statistically
significant differences. In accordance with other
research, this study did not find age as a predictive fac-
tor for olfactory outcome following surgery.11,12,27,31 In
regard to the Lund-Mackay score, other studies have
confirmed our findings that it does not predict olfactory
outcome.10,32 whereas other studies demonstrated the
contrary.12,31,33
Interestingly, the baseline taste function of patients
was significantly worse compared to normative data.19
In accordance, research has demonstrated that chemical
senses closely interact,34 and long-term olfactory impair-
ment, as found in CRS patients, often is associated with
a decrease in taste function.35,36 Similarly, the presence
Laryngoscope 128: March 2018
of olfactory stimuli can modulate, enhancing or sup-
pressing, the perception of a particular taste, even in a
tasteless solution.37 For example, Stevenson and col-
leagues showed that certain odors, such as a caramel,
could simultaneously enhance sweetness while at the
same time suppressing sourness.37,38 These studies sug-
gest that perceptual differences may exist rather than
peripheral ones, in which the altered experience over an
extended time induces cortical variance in the orbito-
frontal cortex. Here gustatory, olfactory, and trigeminal
afferent information converge.36,39,40
Taste receptors (T2R bitter and T1R sweet recep-
tors) are also found extraorally in sinonasal cilia, the so
called solitary chemosensory cells.41 Their function is
not fully understood to the present day, but they are
suggested to be involved in sinonasal innate immunity.
Recently, taste receptors have also been detected in the
lungs.42,43 It has been hypothesized that taste receptors
of this origin are involved in maintaining passage and
promoting clearance of pathogenic bacteria and debris to
fight against infections.42 In this context, extraoral taste
receptors may be associated with oral ones, inducing
suppression to immune responses such as inflammation
or increased mucociliary clearance (for nasal receptors),
which could lead to changes in taste. However, our study
did not reveal any significant differences between preop-
erative and postoperative taste scores, suggesting either
no link exists between receptors or recommunication
requires a longer recovery. Furthermore, it needs to be
kept in mind that the most relevant taste receptors are
located on the tongue, and the tongue was not affected
during ESS.
To the later point, one study looking at smell
improvements following surgery in CRS patients
reported recovery 12 months after surgery, whereas the
follow-up to our study was around 6 months.27 Lastly, it
needs to be kept in mind that chemosensory testing is
dependent on the level of attention and patient’s
mood.44,45 Many studies have demonstrated the hesita-
tion and reluctance to medical and surgical methods,
including ESS,46 thus a focus, and consequential nega-
tive mood, on an upcoming surgery rather than chemo-
sensory testing may have negatively influenced test
scores.
Because this study is a pilot study investigating
taste function in CRSwNP patients, it has some limita-
tions. First, the study population is quite small. Second,
TABLE IV.
Analysis of Possible Predictive Factors for Olfactory/Gustatory
Outcome After Endoscopic Sinus Surgery.
Difference of TDI Difference of Total
Score Pre- and Taste Score Pre- and
Postoperatively Postoperatively
Prior sinus surgery r 5 0.168; P 5.491 r 5 20.26; P 5.910
Malm r 5 20.257; P 5.288 r 5 21.52; P 5.510
LM score r 5 0.449; P 5.054 r 5 0.127; P 5.584
Age r 5 20.255; P 5.324 r 5 20.123; P 5.615
LM 5 Lund-Mackay; TDI 5 threshold, discrimination, and identification.
Walliczek-Dworschak et al.: Taste Function in Chronic Rhinosinusitis
E89
there is high variability in postoperative measure-
ments, as the range of postoperative chemosensory test-
ing scores is large. Last, no control group was defined.
However, this study adds useful information about
chemosensory complaints of CRSwNP patients to the
existing literature, and a future study with a higher
study population is planned to reevaluate the presented
data.
CONCLUSION
In addition to the known impairment of smell,
CRSwNP patients seem to suffer from reduced taste func-
tion. After multimodal treatment, including ESS, olfactory
function improved in approximately half of the CRSwNP
patients, whereas taste function remained unchanged.
Acknowledgments
The authors thank Professor Thomas Hummel, Smell and
Taste Clinic, University of Dresden Medical School, for his
efforts with the statistical analysis, kind suggestions, and
helpful comments on this study. The authors also thank
Ms. Hanna Daniel for her help with statistical planning for
the present study. In addition, the authors thank Susanne
Zapf for her support in linguistic corrections.
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