[The human olfactory system. Anatomy and physiology]

Assessment of COVID-19-related olfactory dysfunction and its association with psychological, neuropsychiatric, and cognitive symptoms

Purpose of review

To provide a detailed overview of the assessment of COVID-19-related olfactory dysfunction and its association with psychological, neuropsychiatric, and cognitive symptoms.

Recent findings

COVID-19-related olfactory dysfunction can have a detrimental impact to the quality of life of patients. Prior to the COVID-19 pandemic, olfactory and taste disorders were a common but under-rated, under-researched and under-treated sensory loss. The pandemic has exacerbated the current unmet need for accessing good healthcare for patients living with olfactory disorders and other symptoms secondary to COVID-19. This review thus explores the associations that COVID-19 has with psychological, neuropsychiatric, and cognitive symptoms, and provide a framework and rationale for the assessment of patients presenting with COVID-19 olfactory dysfunction.

Summary

Acute COVID-19 infection and long COVID is not solely a disease of the respiratory and vascular systems. These two conditions have strong associations with psychological, neuropsychiatric, and cognitive symptoms. A systematic approach with history taking and examination particularly with nasal endoscopy can determine the impact that this has on the patient. Specific olfactory disorder questionnaires can demonstrate the impact on quality of life, while psychophysical testing can objectively assess and monitor olfaction over time. The role of cross-sectional imaging is not yet described for COVID-19-related olfactory dysfunction. Management options are limited to conservative adjunctive measures, with some medical therapies described.

Assessment and Scientific Progresses in the Analysis of Olfactory Evoked Potentials

The human sense of smell is important for many vital functions, but with the current state of the art, there is a lack of objective and non-invasive methods for smell disorder diagnostics. In recent years, increasing attention is being paid to olfactory event-related potentials (OERPs) of the brain, as a viable tool for the objective assessment of olfactory dysfunctions. The aim of this review is to describe the main features of OERPs signals, the most widely used recording and processing techniques, and the scientific progress and relevance in the use of OERPs in many important application fields. In particular, the innovative role of OERPs is exploited in olfactory disorders that can influence emotions and personality or can be potential indicators of the onset or progression of neurological disorders. For all these reasons, this review presents and analyzes the latest scientific results and future challenges in the use of OERPs signals as an attractive solution for the objective monitoring technique of olfactory disorders.

An Overview of Olfactory Displays in Education and Training

This paper describes an overview of olfactory displays (human–computer interfaces that generate and diffuse an odor to a user to stimulate their sense of smell) that have been proposed and researched for supporting education and training. Past research has shown that olfaction (the sense of smell) can support memorization of information, stimulate information recall, and help immerse learners and trainees into educational virtual environments, as well as complement and/or supplement other human sensory channels for learning. This paper begins with an introduction to olfaction and olfactory displays, and a review of techniques for storing, generating and diffusing odors at the computer interface. The paper proceeds with a discussion on educational theories that support olfactory displays for education and training, and a literature review on olfactory displays that support learning and training. Finally, the paper summarizes the advantages and challenges regarding the development and application of olfactory displays for education and training.

Olfaction as a Marker for Dystonia: Background, Current State and Directions

Dystonia is a heterogeneous group of hyperkinetic movement disorders. The unifying descriptor of dystonia is the motor manifestation, characterized by continuous or intermittent contractions of muscles that cause abnormal movements and postures. Additionally, there are psychiatric, cognitive, and sensory alterations that are possible or putative non-motor manifestations of dystonia. The pathophysiology of dystonia is incompletely understood. A better understanding of dystonia pathophysiology is highly relevant in the amelioration of significant disability associated with motor and non-motor manifestations of dystonia. Recently, diminished olfaction was found to be a potential non-motor manifestation that may worsen the situation of subjects with dystonia. Yet, this finding may also shed light into dystonia pathophysiology and yield novel treatment options. This article aims to provide background information on dystonia and the current understanding of its pathophysiology, including the key structures involved, namely, the basal ganglia, cerebellum, and sensorimotor cortex. Additionally, involvement of these structures in the chemical senses are reviewed to provide an overview on how olfactory (and gustatory) deficits may occur in dystonia. Finally, we describe the present findings on altered chemical senses in dystonia and discuss directions of research on olfactory dysfunction as a marker in dystonia.

Olfactory change detection

The human olfactory system is characterized by poor temporal and spatial resolution. When determining changes in the environment, humans rather rely on visual than on olfactory information. Against this background, we developed a test in order to investigate the human capacity to detect changes in the olfactory environment and to determine potential modulators of olfactory change detection. Participants consecutively received four odors (2 odor qualities in 2 concentrations each) which were presented via a computer-controlled olfactometer. The participants' task was to react as soon as they perceived a change of the odor. For control purpose, the same paradigm was also presented with visual instead of olfactory stimuli. A total of 83 healthy participants (aged 18-34 years, 50 women) were included; all of them were screened for attention, olfactory function, chemical sensitivity and the subjective importance of the sense of smell. While visual changes were detected above chance by all participants, olfactory changes were reliably detected by only 24% of the participants. Those were characterized by high subjective importance of olfaction and low chemical sensitivity. Across all participants, changes of olfactory quality were detected more frequently than changes of olfactory concentration. These results suggest that olfaction is imprecise in guiding environmental change detection and may help to explain why humans typically rate the importance of vision higher than the importance of olfaction.

Olfactory functioning in adults with Tourette syndrome

Tourette syndrome is a chronic tic disorder characterized by motor and vocal tics. Comorbidities such as attention deficit hyperactivity disorder and obsessive compulsive disorder can be found. The overlap between neuroanatomical regions and neurotransmitter systems in the olfactory system and the pathophysiology of Tourette syndrome let us hypothesize altered olfactory performance in Tourette syndrome. The main objective of this study was to systematically assess olfactory functioning in subjects with Tourette syndrome and to compare it to healthy controls. We assessed 28 adults with Tourette syndrome (age 33.1±9.4 years, disease duration 23.7±9.7 years) and 28 healthy controls (age 32.9±9.0 years) matched in regard to age, sex, education and smoking habits. The “Sniffin Sticks” test battery was applied to assess odor threshold, discrimination, and identification. Additionally, the combined score of the odor threshold test, the odor discrimination test and the odor identification test of the “Sniffin Sticks” test battery was calculated. Although it was not the primary aim of this study, we assessed whether tics and comorbidity could contribute to olfactory alterations in adults with Tourette syndrome. Therefore, clinical scores were used to assess severity of tics and co-morbidity such as attention deficit hyperactivity disorder, obsessive compulsive disorder, anxiety and depression in subjects with Tourette syndrome. Pathology of the nasal cavities was excluded with rhinoendoscopy. Independent sample t-tests were applied to compare performance in olfactory tests. In the case of statistically significant differences (critical p-value: 0.05), multiple linear regression analysis was carried out to explore whether tic severity, social impairment, co-morbidity or medical treatment had an impact on the differences found. Descriptive values are reported as mean ± standard deviation. Tourette syndrome subjects showed lower combined scores (Tourette syndrome subjects 31.9 ± 5.1 versus healthy controls 35.0 ± 3.1; p = 0.007), odor identification scores (Tourette syndrome subjects 12.4 ± 2.0 versus healthy controls 13.7 ± 1.4; p = 0.008) and odor discrimination scores (Tourette syndrome subjects 12.1 ± 2.1 versus healthy controls 13.2 ± 1.6; p = 0.041) in comparison to healthy subjects, while there was no difference in odor threshold (Tourette syndrome subjects 7.3 ± 2.7 versus healthy controls 8.1 ± 2.2; p = 0.22). Seven out of 28 Tourette syndrome subjects (25%) scored in the range of the age- and sex-dependent combined score for hyposmia, while two of 28 healthy controls (7%) had a similar low combined score. None of the participants were found to have functional anosmia. Multiple linear regression analyses suggest that social impairment may a predictor for low combined score and odor identification score in Tourette syndrome subjects (p = 0.003). Compared to healthy controls, altered olfaction in adults with Tourette syndrome was found in this study. Normal odor threshold level but lower scores at tasks involving supra-threshold odor concentrations point towards a central-nervous alteration in the processing of olfactory information in Tourette syndrome.

Intramodal Olfactory Priming of Positive and Negative Odors in Humans Using Respiration-Triggered Olfactory Stimulation (RETROS)

Priming describes the principle of modified stimulus perception that occurs due to a previously presented stimulus. Although we have begun to understand the mechanisms of crossmodal priming, the concept of intramodal olfactory priming remains relatively unexplored. Therefore, we applied positive and negative odors using respiration-triggered olfactory stimulation (RETROS), enabling us to record the skin conductance response (SCR) and breathing data without a crossmodal cueing error and measure reaction times (RTs) for olfactory tasks. RT, SCR, and breathing data revealed that negative odors were perceived significantly more arousing than positive ones. In a second experiment, 2 odors were applied during consecutive respirations. Here, we observed intramodal olfactory priming effects: A negative odor preceded by a positive odor was rated as more pleasant than when the same odor was preceded by a negative odor. Additionally, a longer identification RT was found for the second compared with the first odor. We interpret this as increased "perceptual load" due to incomplete first odor processing while the second odor was presented. Furthermore, intramodal priming can be considered a possible reason for the increase of identification RT. The use of RETROS led to these novel insights into olfactory processing beyond crossmodal interaction by providing a noncued unimodal olfactory test, and therefore, RETROS can be used in the experimental design of future olfactory studies.

Chemosensory Communication of Gender Information: Masculinity Bias in Body Odor Perception and Femininity Bias Introduced by Chemosignals During Social Perception

Human body odor is a source of important social information. In this study, we explore whether the sex of an individual can be established based on smelling axillary odor and whether exposure to male and female odors biases chemosensory and social perception. In a double-blind, pseudo-randomized application, 31 healthy normosmic heterosexual male and female raters were exposed to male and female chemosignals (odor samples of 27 heterosexual donors collected during a cardio workout) and a no odor sample. Recipients rated chemosensory samples on a masculinity-femininity scale and provided intensity, familiarity and pleasantness ratings. Additionally, the modulation of social perception (gender-neutral faces and personality attributes) and affective introspection (mood) by male and female chemosignals was assessed. Male and female axillary odors were rated as rather masculine, regardless of the sex of the donor. As opposed to the masculinity bias in the odor perception, a femininity bias modulating social perception appeared. A facilitated femininity detection in gender-neutral faces and personality attributes in male and female chemosignals appeared. No chemosensory effect on mood of the rater was observed. The results are discussed with regards to the use of male and female chemosignals in affective and social communication.

Human amygdala activations during nasal chemoreception

This review serves as a comprehensive discussion of chemosensory stimulation of the amygdala in healthy humans. Following an introduction of the neuroanatomy of chemosensory processing in primary and secondary olfactory structures, functional resonance magnetic imaging and positron imaging tomography studies are systematically categorized based on valence of stimuli, stimulus concentration, and paradigm-dependent amygdala activation. The amygdala shows patterns of lateralization due to stimulus valence. Main findings include pleasant odors being associated with bilateral or left amygdala activation, and unpleasant odors being associated with activation of the right amygdala, suggesting a crucial role of the right amygdala in evolutionary preservation. Potentially threatening social stimuli, however, might be processed apart from the olfactory system and tend to activate the left amygdala. Amygdala response to chemosensory stimuli correlated with simultaneous activation in the orbitofrontal cortex (OFC), piriform cortex (PC), and insula, suggesting a close-knit network of these areas during stimulus processing.

[Formula: see text]Olfaction in autism spectrum disorders: A systematic review

Olfactory function is a well-known early biomarker for neurodegeneration and neural functioning in the adult population, being supported by a number of brain structures that could be dysfunctioning in neurodegenerative processes. Evidence has suggested that atypical sensory and, particularly, olfactory processing is present in several neurodevelopmental conditions, including autism spectrum disorders (ASDs). In this paper, we present data obtained by a systematic literature review, conducted according to PRISMA guidelines, regarding the possible association between olfaction and ASDs, and analyze them critically in order to evaluate the occurrence of olfactory impairment in ASDs, as well as the possible usefulness of olfactory evaluation in such conditions. The results obtained in this analysis suggested a possible involvement of olfactory impairment in ASDs, underlining the importance of olfactory evaluation in the clinical assessment of ASDs. This assessment could be potentially included as a complementary evaluation in the diagnostic protocol of the condition. Methods for study selection and inclusion criteria were specified in advance and documented in PROSPERO protocol #CRD42014013939.

Biomarkers for attention-deficit/hyperactivity disorder (ADHD). A consensus report of the WFSBP task force on biological markers and the World Federation of ADHD

OBJECTIVE

Psychiatric "nosology" is largely based on clinical phenomenology using convention-based diagnostic systems not necessarily reflecting neurobiological pathomechanisms. While progress has been made regarding its molecular biology and neuropathology, the phenotypic characterization of ADHD has not improved. Thus, validated biomarkers, more directly linked to the underlying pathology, could constitute an objective measure for the condition.

METHOD

The task force on biological markers of the World Federation of Societies of Biological Psychiatry (WFSBP) and the World Federation of ADHD commissioned this paper to develop a consensus report on potential biomarkers of ADHD. The criteria for biomarker-candidate evaluation were: (1) sensitivity >80%, (2) specificity >80%, (3) the candidate is reliable, reproducible, inexpensive, non-invasive, easy to use, and (4) confirmed by at least two independent studies in peer-reviewed journals conducted by qualified investigators.

RESULTS

No reliable ADHD biomarker has been described to date, but some promising candidates (e.g., olfactory sensitivity, substantial echogenicity) exist. A problem in the development of ADHD markers is sample heterogeneity due to aetiological and phenotypic complexity and age-dependent co-morbidities.

CONCLUSIONS

Most likely, no single ADHD biomarker can be identified. However, the use of a combination of markers may help to reduce heterogeneity and to identify homogeneous subtypes of ADHD.

Invited review article: an odor-sensing system--powerful technique for foodstuff studies

This work examines gas sensor array technology combined with multivariate data processing methods and demonstrates a promising potential for rapid, non-destructive analysis of food. Main attention is focused on detailed description of sensor used in e-nose instruments, construction, and principle of operation of these systems. Moreover, this paper briefly reviews the progress in the field of artificial olfaction and future trends in electronic nose technology, namely, e-nose based on mass spectrometry. Further discussion concerns a comparison of artificial nose with gas chromatography-olfactometry and the application of e-nose instruments in different areas of food industry.

Effects of methylphenidate on olfaction and frontal and temporal brain oxygenation in children with ADHD

OBJECTIVE

Olfaction and attention-deficit-/hyperactivity disorder (ADHD) are mediated by dopamine metabolism and fronto-temporal functioning converging in recent findings of increased olfactory sensitivity in children with ADHD modulated by methylphenidate (MPH) and altered frontal and temporal oxygenation in adults with ADHD.

METHOD

We investigated olfactory sensitivity, discrimination, and identification (Sniffin' Sticks) in 27 children and adolescents with ADHD under chronic MPH medication and after a wash-out period of at least 14 half-lives in balanced order and 22 controls comparable for handedness, age, and intelligence. In addition, inferior frontal and temporal oxygenation was measured by means of functional near-infrared spectroscopy (fNIRS) during the presentation of 2-phenylethanol. Group differences in regard to sex distribution were statistically controlled for by analysis of covariance.

RESULTS

Patients did not differ from controls in any olfactory domain under treatment with MPH. Cessation of medication led to a significant increase in olfactory discrimination. Controls displayed typical inferior frontal and temporal brain activity in response to passive olfactory stimulation, while brain oxygenation was diminished in the patient group when assessed without medication. Under medication ADHD patients showed a trend for a normalisation of brain activity in the temporal cortex.

CONCLUSIONS

The here reported effects of MPH cessation on olfactory discrimination and frontal and temporal oxygenation along with previous findings of increased olfactory sensitivity in medication-naïve ADHD children and its normalisation under chronic MPH treatment lead to the conclusion that MPH exerts differential chronic effects vs. acute cessation effects on altered olfactory function in ADHD. These effects are most probably mediated by modulation of the dopaminergic system.

Trigeminal perception is necessary to localize odors

The human ability to localize odorants has been examined in a number of studies, but the findings are contradictory. In the present study we investigated the human sensitivity and ability to localize hydrogen sulphide (H(2)S), which in low concentrations stimulates the olfactory system selectively, the olfactory-trigeminal substance isoamyl acetate (IAA), and the trigeminal substance carbon dioxide (CO(2)). A general requirement for testing of localization was the conscious perception of the applied stimuli by the participants. Using Signal Detection Theory, we determined the human sensitivity in response to stimulation with these substances. Then the subjects' ability to localize the three different substances was tested. We found that humans can detect H(2)S in low concentration (2 ppm) with moderate sensitivity, and possess a high sensitivity in response to stimulation with 8 ppm H(2)S, 17.5% IAA, 50% v/v CO(2). In the localization experiment, subjects could localize neither the low nor the high concentration of H(2)S. In contrast, subjects possessed the ability to localize IAA and CO(2) stimuli. These results clearly demonstrate that humans, in spite of the aware perception, are not able to localize substances which only activate the olfactory system independent of their concentration, but they possess an ability to localize odorants that additionally excite the trigeminal system.

Activation of olfactory and trigeminal cortical areas following stimulation of the nasal mucosa with low concentrations of S(-)-nicotine vapor--an fMRI study on chemosensory perception

Applied to the nasal mucosa in low concentrations, nicotine vapor evokes odorous sensations (mediated by the olfactory system) whereas at higher concentrations nicotine vapor additionally produces burning and stinging sensations in the nose (mediated by the trigeminal system). The objective of this study was to determine whether intranasal stimulation with suprathreshold concentrations of S(-)-nicotine vapor causes brain activation in olfactory cortical areas or if trigeminal cortical areas are also activated. Individual olfactory detection thresholds for S(-)-nicotine were determined in 19 healthy occasional smokers using a computer-controlled air-dilution olfactometer. Functional magnetic resonance images were acquired using a 1.5T MR scanner with applications of nicotine in concentrations at or just above the individual's olfactory detection threshold. Subjects reliably perceived the stimuli as being odorous. Accordingly, activation of brain areas known to be involved in processing of olfactory stimuli was identified. Although most of the subjects never or only rarely observed a burning or painful sensation in the nose, brain areas associated with the processing of painful stimuli were activated in all subjects. This indicates that the olfactory and trigeminal systems are activated during perception of nicotine and it is not possible to completely separate olfactory from trigeminal effects by lowering the concentration of the applied nicotine. In conclusion, even at low concentrations that do not consistently lead to painful sensations, intranasally applied nicotine activates both the olfactory and the trigeminal system.

Lack of improvement in odor identification by levodopa in humans

Several animal studies demonstrated that olfaction is modulated by dopamine (DA). We examined if such results could be replicated in humans. Thus, we tested olfaction in elderly healthy humans before and after external administration of levodopa in a double-blind, placebo-controlled, randomized cross-over study. Main outcome measure was the sum of correctly identified odors in an odor identification paradigm. In contrast to what had been demonstrated in rats, levodopa did not improve olfaction. We even noted a trend for the reverse. Blood pressure, mood ratings, as well as performance in a simple motor task were comparable between conditions, indicating that levodopa did not induce differences in general arousal, mood, attention, or reaction time. Our findings may be explained by differences in the distribution of dopaminergic receptor subtypes in the olfactory system in animals and humans, by relative differences in dosing regimes, or by subtle differences in the respective paradigms. These hypotheses have to be tested in future experiments, but our study demonstrates that results from animal studies cannot be directly transferred to the human situation.

Reduced olfactory sensitivity in subjects with depressive symptoms

BACKGROUND

Clinical studies suggest that olfactory sensitivity is reduced in major depression. Nevertheless, only little is known about the relationship between depressive symptoms and olfactory functions in healthy subjects.

METHODS

The present study investigated the association between depressive symptoms and olfactory performance in 48 healthy subjects (14 male). First depressive symptoms were assessed using the Beck Depression Inventory, following by olfactory testing. Olfactory threshold and discrimination performance was assessed as well as emotional arousal and pleasantness during the testing procedure.

RESULTS

We observed a significant negative correlation between olfactory sensitivity and depressive symptoms while olfactory discrimination was not related to depressive symptoms.

LIMITATIONS

The degree of depressive symptoms was assessed by questionnaire. A clinical interview might assess depressive symptoms more accurate.

CONCLUSION

We conclude that depressive symptoms are related to a reduced olfactory sensitivity. The observed relation between reduced olfactory sensitivity and depressive symptoms could be mediated by functional deviations within brain structures subserving primary olfactory processing such as amygdala and piriform cortex which is in line with results showing abnormal activity pattern in the amygdala and other brain regions in depression.