Critical Role There It Is Again... The Copper on Your Tongue the Very First Thing You Ever Tastes
Smell and Gustation Disorders: A Primary Care Approach
Am Fam Physician. 2000 Jan 15;61(ii):427-436.
Run into related patient information handout on problems with smell or gustatory modality, written by the author of this commodity.
Article Sections
- Abstract
- Aroma
- Taste
- Clinical Evaluation of Odor and Taste
- Treatment
- References
Smell and taste disorders are mutual in the full general population, with loss of smell occurring more frequently. Although these disorders can take a substantial impact on quality of life and may correspond significant underlying illness, they are often overlooked by the medical customs. Patients may have difficulty recognizing odor versus gustation dysfunction and frequently confuse the concepts of "flavour" and "taste." While the virtually common causes of olfactory property disturbance are nasal and sinus illness, upper respiratory infection and head trauma, frequent causes of taste disturbance include oral infections, oral appliances (due east.thou., dentures), dental procedures and Bell'due south palsy. Medications can interfere with scent and sense of taste, and should be reviewed in all patients with reported dysfunction. In addition, advancing age has been associated with a natural impairment of smell and taste ability. A focused history and a concrete exam of the nose and oral fissure are usually sufficient to screen for underlying pathology. Computed tomographic scanning or magnetic resonance imaging of affected areas, as well every bit commercially bachelor standardized tests, may be useful in selected patients. The causes of olfactory dysfunction that are near acquiescent to handling include obstructing polyps or other masses (treated by excision) and inflammation (treated with steroids). Enhancement of food flavour and advent can improve quality of life in patients with irreversible dysfunction.
The senses of smell and taste allow full appreciation of the season and palatability of foods and as well serve as an early alert system against toxins, polluted air, smoke and spoiled nutrient products.1 Physiologically, the chemical senses assist in normal digestion past triggering gastrointestinal secretions.2
Scent or gustatory modality dysfunction can have a significant impact on quality of life. Deficits of these senses tin can adversely touch on food option and intake, specially in the elderly, and have been implicated in weight loss, malnutrition, impaired immunity and worsening of medical disease.iii,4 Patients frequently report increased utilize of sugar and table salt to compensate for macerated senses of smell and gustatory modality,5,6 a practice that is detrimental to those with diabetes mellitus or hypertension.
Subjective complaints exercise not always accurately reflect the chemosensory disturbance experienced past a patient. Although about afflicted patients complain of problems with odor and gustatory modality, testing frequently demonstrates harm that is primarily olfactory in nature7–nine (Figure ane).7 Patients commonly confuse symptoms of flavor loss, which results from smell disturbance, with taste dysfunction. For example, the common cold may distort the flavor of food, but a patient's ability to taste (i.e., salty, sweet, sour, bitter) remains intact. Most flavors depend on retronasal stimulation of the smell receptors.
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Figure one.
Smell
- Abstruse
- Odour
- Taste
- Clinical Evaluation of Smell and Gustation
- Treatment
- References
Beefcake AND PHYSIOLOGY
The human being sense of smell depends on the functioning of not only cranial nerve I (olfactory nerve) only besides portions of cranial nerve Five (trigeminal nerve). Qualitative odor sensations (e.g., the smell of a rose, lemon or grass) are mediated by cranial nerve I (Figures 2a and 2b), whereas somatosensory overtones of odorants (east.g., warmth, coolness, sharpness and irritation) are mediated by the ophthalmic and maxillary divisions of cranial nervus V.
FIGURE 2A.
Anatomy of the olfactory neural pathways, showing the distribution of olfactory receptors in the roof of the nasal crenel.
Figure 2B.
Simplified diagram of cortical regions idea to be involved in the processing of olfactory data as it passes from the olfactory epithelium to the brain.
Smell receptors are located inside the olfactory neuroepithelium, a region of tissue found over the cribiform plate, the superior septum and a segment of the superior turbinate. The free nerve endings of cranial nerve V are located diffusely throughout the nasal respiratory epithelium, including regions of the olfactory neuroepithelium. It is important to remember the distinctive nature of these two neural systems, because some odorants (e.g., ammonia) are sensed largely by the trigeminal nerve.
Once odorants enter the nose, they must move to the nasal vault and dissolve within the covering mucous layer in society to stimulate the olfactory receptors.1,10 Mucous has an important function in dispersing scents to the underlying receptors. The nasal turbinates are also of import because they provide moderate resistance and a moist environment, thereby assuasive optimal stimulation of olfactory neurons by airborne compounds.11,12
NATURAL HISTORY OF Olfactory property DEFICITS
Age-related deficits in the ability to odour are well documented,13,14 and such deficits appear in the majority of elderly patients who are healthy and taking no medications.fourteen However, the complaint of smell loss should never be attributed merely to age, and other causes should be sought.
CAUSES OF Odour LOSS
Olfactory disturbance has many possible causes (Table 1).1,six–8,xv,16 In most instances, loss of smell is caused by nasal and sinus disease, upper respiratory tract infection or head trauma.
TABLE 1.
Selected Possible Causes of Smell Disturbance
| Common causes |
| Nasal and sinus disease (eastward.one thousand., allergic or vasomotor rhinitis, chronic sinusitis, nasal polyps, adenoid hypertrophy) |
| Upper respiratory infection |
| Caput trauma (east.g., frontal skull fracture, occipital injury, nasal fracture) |
| Cigarette smoking |
| Neurodegenerative disease (east.g., Alzheimer's disease, Parkinson'due south disease, multiple sclerosis) |
| Historic period |
| Less common causes |
| Medications (run across Tabular array 2) |
| Cocaine corruption (intranasal) |
| Toxic chemic exposure (e.one thousand., benzene, benzol, butyl acetate, carbon disulfide, chlorine, ethyl acetate, formaldehyde, hydrogen selenide, paint solvents, sulfuric acrid, thrichloroethylene) |
| Industrial amanuensis exposure (eastward.g., ashes, cadmium, chalk, chromium, iron carboxyl, lead, nickel, silicone dioxide) |
| Nutritional factors (e.k., vitamin deficiency [A, B6, B12], trace metal deficiency [zinc, copper], malnutrition, chronic renal failure, liver disease [including cirrhosis], cancer, acquired immunodeficiency syndrome) |
| Radiation treatment of head and neck |
| Built weather (east.g., congenital anosmia, Kallmann's syndrome) |
| Uncommon causes |
| Neoplasm or brain tumor (e.g., osteoma, olfactory groove or cribiform plate meningioma, frontal lobe tumor, temporal lobe tumor, pituitary tumor, aneurysm, esthesioneuroblastoma, melanoma, squamous cell carcinoma) |
| Psychiatric conditions (e.g., malingering, schizophrenia, depression, olfactory reference syndrome) |
| Endocrine disorders (eastward.g., adrenocortical insufficiency, Cushing's syndrome, diabetes mellitus, hypothyroidism, chief amenorrhea, pseudohypoparathyroidism, Kallmann's syndrome, Turner'due south syndrome, pregnancy) |
| Epilepsy (olfactory aura) |
| Migraine headache (olfactory aura) |
| Cerebrovascular accident |
| Sjögren's syndrome |
| Systemic lupus erythematosus |
It is important to have a loftier alphabetize of suspicion for subacute sinusitis, considering decreased smell (hyposmia) can occur without other nasal or sinus symptoms typically associated with sinusitis (e.g., congestion, headache, a "throbbing" force per unit area sensation). Medications are besides an important, frequently overlooked cause of smell impairment (Tabular array 2).one,half-dozen,vii,15 Olfactory damage is estimated to occur in about ten per centum of patients with caput trauma.17 Post-traumatic odor loss is usually caused by shearing injuries to the olfactory nerve fibers at the level of the cribiform plate, just information technology tin also be caused by directly injury to the olfactory bulbs, olfactory tracts or frontal and temporal lobes.18,xix
TABLE 2.
Selected Medications that Reportedly Modify Smell and Taste
| Antibiotics |
| Ampicillin |
| Azithromycin (Zithromax) |
| Ciprofloxacin (Cipro) |
| Clarithromycin (Biaxin) |
| Griseofulvin (Grisactin) |
| Metronidazole (Flagyl) |
| Ofloxacin (Floxin) |
| Tetracycline |
| Anticonvulsants |
| Carbamazepine (Tegretol) |
| Phenytoin (Dilantin) |
| Antidepressants |
| Amitriptyline (Elavil) |
| Clomipramine (Anafranil) |
| Desipramine (Norpramin) |
| Doxepin (Sinequan) |
| Imipramine (Tofranil) |
| Nortriptyline (Pamelor) |
| Antihistamines and decongestants |
| Chlorpheniramine |
| Loratadine (Claritin) |
| Pseudoephedrine |
| Antihypertensives and cardiac medications |
| Acetazolamide (Diamox) |
| Amiloride (Midamor) |
| Betaxolol (Betoptic) |
| Captopril (Capoten) |
| Diltiazem (Cardizem) |
| Enalapril (Vasotec) |
| Hydrochlorothiazide (Esidix) and combinations |
| Nifedipine (Procardia) |
| Nitroglycerin |
| Propranolol (Inderal) |
| Spironolactone (Aldactone) |
| Anti-inflammatory agents |
| Auranofin (Ridaura) |
| Colchicine |
| Dexamethasone (Decadron) |
| Golden (Myochrysine) |
| Hydrocortisone |
| Penicillamine (Cuprimine) |
| Antimanic drug |
| Lithium |
| Antineoplastics |
| Cisplatin (Platinol) |
| Doxorubicin (Adriamycin) |
| Methotrexate (Rheumatrex) |
| Vincristine (Oncovin) |
| Antiparkinsonian agents |
| Levodopa (Larodopa; with carbidopa: Sinemet) |
| Antipsychotics |
| Clozapine (Clozaril) |
| Trifluoperazine (Stelazine) |
| Antithyroid agents |
| Methimazole (Tapazole) |
| Propylthiouracil |
| Lipid-lowering agents |
| Fluvastatin (Lescol) |
| Lovastatin (Mevacor) |
| Pravastatin (Pravachol) |
| Muscle relaxants |
| Baclofen (Lioresal) |
| Dantrolene (Dantrium) |
Sense of taste
- Abstruse
- Odor
- Taste
- Clinical Evaluation of Smell and Taste
- Treatment
- References
ANATOMY AND PHYSIOLOGY
Many nerves are responsible for transmitting sense of taste information to the brain (Figure 3). Because of these multiple pathways, full loss of gustatory modality (ageusia) is rare. Equally in the olfactory system, somatosensory sensations (east.g., stinging, burning, cooling and sharpness) can exist induced past many foods (e.g., hot peppers) through trigeminal nerve fibers in the tongue and oral crenel.
FIGURE 3.
Anatomy of peripheral taste pathways. Multiple fretfulness, including cranial fretfulness Seven, IX and Ten, transmit gustation information from the mouth and pharynx to the brain via the encephalon stem.
Taste receptors are institute within sense of taste buds located not only on the tongue just also on the soft palate, throat, larynx, epiglottis, uvula and first one 3rd of the esophagus.20–22 Taste buds are continually bathed in secretions from the salivary glands, and excessive dryness can distort taste perception.
NATURAL HISTORY OF TASTE DEFICITS
Like olfactory office, sense of taste perception becomes somewhat impaired with normal crumbling.4,15 Compared with younger persons, the elderly tend to perceive tastes as being less intense.
CAUSES OF Gustatory modality LOSS
Common causes of taste loss include oral and perioral infections, oral appliances, Bell's palsy, medications, caput trauma and mass lesions of the taste pathways (Tabular array iii).1,6,7,15,16
TABLE three.
Selected Possible Causes of Gustation Disturbance
| Common causes |
| Oral and perioral infections (e.g., candidiasis, gingivitis, herpes simplex, periodontitis, sialadenitis) |
| Bell's palsy |
| Medications (meet Table 2) |
| Oral appliances (e.k., dentures, filling materials, tooth prosthetics) |
| Dental procedures (e.g., molar extraction, root canal) |
| Age |
| Less common causes |
| Nutritional factors (e.g., vitamin deficiency [B3, B12], trace metal deficiency [zinc, copper], malnutrition, chronic renal failure, liver disease [including cirrhosis], cancer, caused immunodeficiency syndrome) |
| Tumor or lesions associated with taste pathways (e.g., oral fissure cancer, neoplasm of skull base of operations) |
| Caput trauma |
| Toxic chemic exposure (eastward.grand., benzene, benzol, butyl acetate, carbon disulfide, chlorine, ethyl acetate, formaldehyde, hydrogen selenide, paint solvents, sulfuric acid, thrichloroethylene) |
| Industrial agent exposure (e.g., chromium, atomic number 82, copper) |
| Radiations treatment of head and cervix |
| Uncommon causes |
| Psychiatric weather condition (east.yard., depression, anorexia nervosa, bulimia) |
| Epilepsy (gustatory aureola) |
| Migraine headache (gustatory aura) |
| Sjögren's syndrome |
| Multiple sclerosis |
| Endocrine disorders (e.g., adrenocortical insufficiency, Cushing's syndrome, diabetes mellitus, hypothyroidism, panhypopituitarism, pseudohypoparathyroidism, Kallmann's syndrome, Turner's syndrome) |
Alteration of taste can occur considering of the release of bad-tasting materials as a event of an oral medical condition (e.g., gingivitis, sialadenitis). It can likewise occur because of problems with the transport of gustation chemicals to the gustatory modality buds (due east.g., as a result of excessive dryness of the oral cavity or harm to taste pores from a fire) considering of the destruction or loss of taste buds. Another mechanism of gustatory modality loss is damage to one or more than of the neural pathways innervating the gustatory modality buds (e.g., subsequent to viral Bell's palsy or dental or surgical procedures). Rarely, central neural factors (due east.one thousand., tumor or epilepsy) result in loss of taste.
Medications can be responsible for gustatory modality loss and should exist reviewed in all patients with gustatory disturbance1,vi,15,23 (Table ii). Angiotensin-converting enzyme inhibitors (notably captopril [Capoten]) are among the medications virtually normally associated with taste disturbances, including decreased sense of sense of taste (hypogeusia) and a strongly metal, bitter or sweet taste.six Excessive dryness of the oral crenel is a common side effect of a number of medications (e.thousand., anticholinergics, antidepressants, antihistamines) and disease states (e.g., Sjögren's syndrome, xerostomia, diabetes mellitus).
Clinical Evaluation of Smell and Taste
- Abstract
- Aroma
- Taste
- Clinical Evaluation of Smell and Gustatory modality
- Treatment
- References
MEDICAL HISTORY
Because olfactory dysfunction is more common than gustatory modality dysfunction (Effigy 1) and the iii almost common causes of loss of smell are nasal and sinus disease, upper respiratory infection and head trauma, it may be helpful to direct the history and physical examination toward these diagnoses. Intermittent olfactory loss may suggest an inflammatory process rather than a sensorineural lesion (Table 4).
Table 4.
Associated Findings Suggesting a Cause of Smell and Taste Dysfunction
| Findings | Diagnoses to consider |
|---|---|
| History | |
| Sudden loss of function | Head trauma (less probable with taste loss), cerebrovascular blow, astute upper respiratory infection, psychiatric condition |
| Intermittent loss of role | Inflammatory procedure (e.1000., allergy, infection, chemic exposure) |
| Gradual loss of office | Nasal polyps, chronic upper respiratory infection |
| Difficulty passing air through nose | Obstruction secondary to polyps, inflammation or fracture |
| Physical test | |
| Rhinorrhea | Rhinitis (e.k., allergy, infection, irritation) head trauma (fracture of cribiform plate) |
| Intranasal mass lesion | Polyps, tumour or tumor |
| Oral or perioral skin lesion | Viral infection (e.thousand., herpes simplex) |
| White plaque on tongue | Candidiasis, human immunodeficiency virus infection, caused immunodeficiency syndrome, immunocompromised state, leukoplakia |
| Facial droop | Bong'due south palsy |
| Memory damage | Alzheimer's illness |
| Motor findings (e.g., bradykinesia, cogwheel rigidity, akathisia, tremor, instability, ataxia, weakness) | Parkinson's disease, multiple sclerosis |
| Laboratory tests | |
| Depression hematocrit, low hemoglobin level | Anemia, cancer, malnutrition |
| Altered red cell indexes | Nutritional deficiencies (e.m., vitamin B12) |
| Elevated white blood cell count | Infection |
| Elevated blood urea nitrogen level, elevated creatinine level | Renal disease |
| Elevated blood glucose level | Diabetes mellitus |
| Elevated liver enzyme level | Viral hepatitis, liver disease |
| Elevated bilirubin level, elevated alkaline phosphatase level | Liver illness |
| Elevated prothrombin fourth dimension | Malnutrition, liver affliction |
| Altered thyroid function tests | Thyroid disease |
| Elevated erythrocyte sedimentation rate | Sjögren's syndrome, systemic lupus erythematosus |
| Elevated eosinophil count | Allergy |
| Elevated immunoglobulin East level | Allergy |
The patient should be asked about the use of tobacco or cocaine, because these substances can adversely affect the sense of scent. Research into the patient's diet and oral habits may reveal exposure to oral irritants. Specific questions should be asked about dryness of the mouth, periodontal disease, foul breath odor, recent dental procedures, recent radiation exposure, gastric reflux and medication use. Questions should as well be directed at identifying any family history of systemic affliction such as diabetes mellitus or hypothyroidism.
Physical EXAMINATION
A thorough examination of the head and neck should exist performed to look for obstruction, inflammation and infection. Mucous membranes should be evaluated for dryness, leukoplakia and exudate. The patient's teeth and gums should besides exist examined, because severe dental caries, gingivitis and intraoral abscess can result in a malodorous and caustic oral environment that disturbs the senses of smell and gustatory modality.
Oral candidal infections in immunocompromised patients (e.g., those who take received chemotherapy or who have caused immunodeficiency syndrome) can produce white patches or diffuse erythema. Viral infections (e.g., herpes simplex virus, coxsackievirus) tend to cause the evolution of vesicles with surrounding erythema, which then evolve into erosions or ulcers.
The neurologic examination should include a careful evaluation of cranial nerve role. Specific signs of damage to cranial nerve VII may include taste alterations in the anterior two thirds of the tongue, decreased salivation, auditory hyperacusis (resulting from paralysis of the stapedius muscle) and facial paralysis on the ipsilateral side.
LABORATORY TESTS
Clinical laboratory tests may be helpful in ruling out circumstantial medical conditions suggested by the history and physical exam, such equally infection, nutritional deficiency, allergy, diabetes mellitus and thyroid, liver or kidney disease (Tabular array four).
Although the history is routinely used to screen for cranial nervus I impairment, specific olfactory testing may be helpful in evaluating the patient with suspected loss of scent. The almost widely available olfactory test is the Olfactory property Identification Examination.24 This examination evaluates the ability to identify xl microencapsulated "scratch and sniff" odorants. The odors are released by rubbing the microencapsulated strips with a pencil. The patient's test scores are and so compared with norms for the same age and gender.14 It may be useful to examination each side of the nose separately, because unilateral deficits in smell office may suggest a reversible cause (e.g., obstruction by a deviated septum, nasal polyps or some other mass).10
Other commercially available olfactory tests include the three-item forced-choice microencapsulated Pocket Aroma Test,25 the Cursory Smell Identification Test26 and a squeeze-canteen odor threshold test kit.27
Evaluation of taste is more difficult because no convenient standardized tests are soon available. A detailed history is generally the all-time screening tool. Research centers oft use four ready-fabricated solutions containing sucrose (sweet), sodium chloride (salty), quinine (bitter) and citric acid (sour) to obtain data about gustatory modality discrimination.
IMAGING TECHNIQUES
When structural or inflammatory causes of smell or taste loss are suspected, imaging studies may exist helpful in selected patients.18,23,28,29 However, all imaging techniques have limitations, and negative tests cannot rule out structural lesions.
Plain radiographs have substantial limitations. These images do not provide sufficient detail for structures such equally the osteomeatal complex. In particular, more than detailed images are needed when endoscopic surgery is to be performed.
Computed tomographic (CT) scanning is the most useful and toll-effective technique for assessing sinonasal tract inflammatory disorders. Coronal CT scans are particularly valuable in assessing paranasal anatomy. Scanning with thin cuts (5 mm) is useful in identifying bony structures in the ethmoid, cribiform plate and olfactory fissure, as well as the temporal bone in proximity to cranial nervus VII or chorda tympani nerves; however, CT scanning is less effective than magnetic resonance imaging (MRI) in defining soft tissue disease.23,29 The use of intravenous contrast media helps to better identify vascular lesions, tumors, abscess cavities and meningeal or parameningeal processes.
MRI is superior to CT scanning in the evaluation of soft tissues, but information technology poorly defines bony structures. MRI is the technique of selection for assessing the olfactory bulbs, olfactory tracts, facial nerve and intracranial causes of chemosensory dysfunction. It is also the preferred technique for evaluating the skull base for invasion past sinonasal tumors. Gadolinium enhancement is useful for detecting dural or leptomeningeal involvement at the skull base of operations.
Studies such as positron emission tomography and unmarried photon emission computed tomography do not play a significant diagnostic role outside of major academic institutions.
Treatment
- Abstract
- Smell
- Taste
- Clinical Evaluation of Smell and Taste
- Handling
- References
Odor DYSFUNCTION
Olfactory disorders are more likely to be treated successfully when the patient has a reversible cause of intranasal interference such every bit nasal polyps, rhinitis, allergies or mechanical blockage.16 Because inflammatory nasal disease results in swelling of the olfactory clefts and the release of inflammatory mediators that likely alter the olfactory mucosa, the use of corticosteroids topically (e.g., aqueous nasal spray) or systemically (east.g., oral prednisone) may be helpful. However, some investigators have suggested that topical steroids do not reliably restore smell function.xxx A useful dosing regimen for oral prednisone is lx mg per 24-hour interval for 4 days, with the dosage tapered past 10 mg each 24-hour interval thereafter.30
Medical treatments more often than not are non effective in restoring olfactory function in patients with smell dysfunction after an upper respiratory infection.7,31 However, some investigators have suggested that absence of scent function (anosmia) subsequent to an upper respiratory infection may improve over time without specific handling.32
In general, the olfactory system regenerates poorly after a caput injury.seven,17,19 Most patients who recover smell part subsequent to head trauma do and so within 12 weeks of injury.17
Cigarette smoking by itself does not cause complete loss of the sense of odour. Patients who quit smoking typically have improved olfactory part and flavor sensation over time.33
Patients with permanent smell dysfunction need to develop adaptive strategies for dealing with personal hygiene, ambition, condom and wellness. Enhancement of nutrient flavor may make eating more enjoyable. For case, marinating chicken in chicken-flavored bouillon may increase the palatability of the meat. Enhanced flavorings need not be spices and commonly do non cause stomach irritation.
TASTE DYSFUNCTION
Many taste disorders (dysgeusias) resolve spontaneously within a few years of onset.34 However, several immediate steps can exist taken to help correct a gustatory modality disturbance. For example, some drug-related dysgeusias can be reversed with abeyance of the offending agent. Weather such as radiation-induced xerostomia and Bell'due south palsy mostly improve over time. An artificial saliva (due east.g., Xerolube) may be helpful in patients with xerostomia.
Patients should be cautioned not to overindulge as compensation for the bland taste of food. For example, patients with diabetes may need help in avoiding excessive carbohydrate intake as an inappropriate style of improving food taste. Patients with chemosensory impairment should utilise measuring devices when cooking, not "cook by taste." Optimizing food texture, aroma, temperature and color may ameliorate the overall food experience when taste is limited.
REFERRAL
Patients with persistent odor and gustatory modality complaints that are refractory to standard treatment and significantly impair their quality of life may need to exist referred to an otolaryngologist, a neurologist or a subspecialist at a smell and taste eye (Tabular array v). Referral centers specialize in detailed quantitative testing of smell and taste office. Specialized procedures such as functional imaging, endoscopy and biopsy with pathologic evaluation are available.
Table 5.
Referral Centers for the Evaluation and Treatment of Smell and Taste Dysfunction
| Chemosensory Clinical Research Heart |
| 925 Chestnut St. |
| Philadelphia, PA 19107 |
| Telephone: 215-955-5652 |
| Clinical Olfactory Research Center |
| Land Academy of New York Wellness Science Center at Syracuse Higher of Medicine |
| 750 E. Adams St. |
| Syracuse, NY 13210 |
| Telephone: 315-464-5588 |
| Connecticut Chemosensory Clinical Inquiry Eye |
| University of Connecticut Health Middle |
| 263 Farmington Ave. |
| Farmington, CT 06032 |
| Telephone: 860-679-2459 |
| MCV Aroma and Taste Dispensary |
| Medical College of Virginia, Virginia Commonwealth University |
| P.O. Box 980551 |
| Richmond, VA 23298-0551 |
| Telephone: 804-828-9350 |
| Nasal Dysfunction Clinic |
| University of California, San Diego, Medical Center |
| 9350 Campus Point Dr. |
| La Jolla, CA 92037 |
| Telephone: 858-657-8590 |
| Office of Health Communications |
| National Institutes of Health |
| NIH Building 31, Room 3C-35 |
| 31 Center Dr., MSC 2320 |
| Bethesda, Doc 20892 |
| Telephone: 301-496-7243 |
| Rocky Mountain Gustation and Smell Middle |
| University of Colorado Health Science Heart |
| Denver, CO 80262 |
| Phone: 303-315-6600 |
| Academy of Cincinnati Sense of taste and Smell Center |
| University of Cincinnati College of Medicine |
| 222 Piedmont Ave. |
| Cincinnati, OH 45219 |
| Telephone: 513-558-5469 |
| Academy of Pennsylvania Odour and Taste Center |
| Hospital of the University of Pennsylvania |
| 3400 Spruce St. |
| Philadelphia, PA 19104-4283 |
| Phone: 215-662-6580 |
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