Clinical Manifestations in Microsoft Office

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Clinical Manifestations
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Testing of Taste Sensation Unilateral gustatory impairment can be identi ed by withdrawing the tongue with a gauze sponge and using a moistened applicator to place a few crystals of salt or sugar on discrete parts of the tongue; the tongue is then wiped clean and the subject is asked to report what he or she had sensed A stimulus that has been used as a surrogate for sour sensation is a low-voltage direct current, the electrodes of which can be accurately placed on the tongue surface If the taste loss is bilateral, mouthwashes with a dilute solution of sucrose, sodium chloride, citric acid, and caffeine may be used After swishing, the test uid is spat out and the mouth rinsed with water The patient indicates whether he or she had tasted a substance and is asked to identify it Special types of apparatus (electrogustometers) have been devised for the measurement of taste intensity and for determining the detection and recognition thresholds of taste and olfactory stimuli (Krarup; Henkin et al), but these are beyond the scope of the usual clinical examination Causes of Loss of Taste Apart from the loss of taste sensation that accompanies normal aging (see above), smoking, particularly pipe smoking, is probably the most common cause of impairment of taste sensation Extreme drying of the tongue from any cause may lead to temporary loss or reduction of the sense of taste (ageusia or hypogeusia), since saliva is essential for normal taste function Saliva acts as a solvent for chemical substances in food and for conveying them to taste receptors Dryness of the mouth (xerostomia) from inadequate saliva, as occurs in the Sjogren syn drome; hyperviscosity of saliva, as in cystic brosis; irradiation of head and neck; and pandysautonomia all interfere with taste Also, in familial dysautonomia (Riley-Day syndrome), the number of circumvallate and fungiform papillae is reduced, accounting for a diminished ability to taste sweet and salty foods If unilateral, ageusia is seldom the source of complaint Taste is frequently lost over one-half of the tongue (except posteriorly) in cases of Bell s palsy (as indicated on page 1181) A permanent decrease in the acuity of taste and smell (hypogeusia and hyposmia), sometimes associated with perversions of these sensory functions (dysgeusia and dysosmia), may follow in uenza-like illnesses These abnormalities have been associated with pathologic changes in the taste buds as well as in the nasal mucous membranes In a group of 143 patients who presented with hypogeusia and hyposmia, 87 were of this postin uenzal type, as determined by Henkin and colleagues; the remainder developed their symptoms in association with scleroderma, acute hepatitis, viral encephalitis, myxedema, adrenal insuf ciency, malignancy, de ciency of vitamins B and A, and the administration of a wide
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DISORDERS OF SMELL AND TASTE
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variety of drugs According to Schiffman, more than 250 drugs have been implicated in the alteration of taste sensation Lipidlowering drugs, antihistamines, antimicrobials, antineoplastics, bronchodilators, antidepressants, and anticonvulsants are the main offenders Little is known about the mechanisms by which drugs induce these effects Distortions of taste and loss of taste are sources of complaint in patients with certain malignant tumors Oropharyngeal tumors may, of course, abolish taste by invading the chorda tympani or lingual nerves Malnutrition due to neoplasm or radiation therapy may also cause ageusia, as pointed out by Settle and colleagues Some patients with certain carcinomas remark on an increase in their threshold for bitter foods, and some who have been radiated for breast cancer or sublingual or oropharyngeal tumors nd sour foods intolerable The loss of taste from radiation of the oropharynx is usually recovered within a few weeks or months; the reduced turnover of taste buds caused by radiation therapy is only temporary An interesting syndrome called idiopathic hypogeusia in which a decreased taste acuity is associated with dysgeusia, hyposmia, and dysosmia has been described by Henkin and coworkers Food has an unpleasant taste and aroma, to the point of being revolting (cacogenusia and cacosmia); the persistence of these symptoms may lead to a loss of weight, anxiety, and depression Patients with this disorder were said to have a decreased concentration of zinc in their parotid saliva and to respond to small oral doses of zinc sulfate The authors have had no opportunity to con rm these observations Another poorly de ned disorder is the so-called burning mouth syndrome, which occurs mainly in postmenopausal women and is characterized by persistent, severe intraoral pain (particularly
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of the tongue) We have seen what we believe to be fragmentary forms of the syndrome in which pain and burning are isolated to the alveolar ridge or gingival mucosa The oral mucosa appears normal and some patients may report a diminution of taste sensation A small number of such patients prove to have diabetes or vitamin B12 de ciency, but in most no systemic illness or local abnormality can be found The few such patients that we have encountered appeared to have a depressive illness, but they responded variably to administration of tricyclic antidepressants Clonazepam may be useful and capsaicin has been tried with uncertain results This disorder is commented on in Chap 10 Unilateral lesions of the medulla oblongata have not been reported to cause ageusia, perhaps because the nucleus of the tractus solitarius is usually outside the zone of infarction or because there is representation from both sides of the tongue in each nucleus Unilateral thalamic and parietal lobe lesions, however, have both been associated with contralateral impairment of taste sensation As indicated above, a gustatory aura occasionally marks the beginning of a seizure originating in the frontoparietal (suprasylvian) cortex or in the uncal region Gustatory hallucinations are much less frequent than olfactory ones Nevertheless, the gustatory sensations were reported in 30 of 718 cases of intractable epilepsy (Hausser-Hauw and Bancaud) During surgery, these investigators produced an aura of disagreeable taste by electrical stimulation of the parietal and frontal opercula and also by stimulation of the hippocampus and amygdala (uncinate seizures) In their view, the low-threshold seizure focus for taste in the temporal lobe is secondary to functional disorganization of the opercular gustatory cortex by the seizure Gustatory hallucinations were more frequent with right-hemisphere lesions, and in half of the cases, the gustatory aura was followed by a convulsion
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