Why Do Indians Smell - T-Tees - Your Answers Await, Life's Questions Unraveled

DISCUSSION

Few studies have used quantitative olfactory function testing and/or detailed radiological evaluation of the olfactory apparatus to assess the olfactory phenotypic spectrum in subjects with IHH.[10,11,12] The primary objective of our study was to measure the volume of OBs and dimensions of OSs using dedicated MRI sequences and objective smell testing with a clinical INSIT in patients with nIHH. The INSIT has already been used in Indian study to identify olfactory dysfunction in PD and compared with Sniffin’ sticks test. In this study using a cut-off value of 4 (values ≤4 indicating disease), INSIT showed a sensitivity of 79.2% and specificity of 78%. INSIT is cheap, convenient, and more acceptable in the Indian population.[9] Some studies have used the history of decreased smell as a measure of olfaction.[13] This can underestimate the true prevalence of KS as exemplified in our study. Self-reporting of anosmia correlates well with the smell test, but self-reporting of normal smell is not reliable in all patients. The quantification of olfaction can be done using University of Pennsylvania smell identification test (UPSIT) which is well-validated, easy to use, and a reproducible test that correlates with odor detection thresholds, but is very expensive.[10] In our study, 12 of 32 patients reporting a normal sense of smell were actually found to have hyposmia/anosmia on formal smell testing by INSIT. This is similar to a observation made by Lewkowitz-Shpuntoff et al.[11] This would imply that the self-reporting of normosmia is an inaccurate measure of olfactory function; hence, there is a need to administer a quantitative olfaction test. However, those reporting anosmia need not undergo this test.

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In our study, measurements were done using T2-weighted CISS images. Three-dimensional CISS is a refocused steady-state gradient echo MRI sequence that is flow compensated. CISS sequence plays an important role in evaluating structures surrounded by cerebrospinal fluid with high contrast and spatial resolution.[14] The advantages of CISS are high signal-to-noise ratio, high contrast-to-noise ratio, and intrinsic insensitivity to flow and motion.[15] The limitation includes long image acquisition times. We carried out MRI using this sequence in age- and sex-matched eugonadal controls also. Olfactory finding of control (mean OB volume, OSl, and OSd) is comparable to Koenigkam-Santos et al.[10] There was a statistically significant difference of OB volume between KS, nIHH, and control, and of OSl/OSd between KS and nIHH, but no statistically significant difference of OSl/OSd between control and KS/nIHH; similar findings were reported by Ottaviano et al.[16] We found that all the patients with KS have olfactory abnormalities on MRI. Four of 20 patients with nIHH have olfactory abnormalities. Previous studies have reported that 60%-90% of KS have olfactory abnormalities.[4,12,17,18] But a majority of these studies have defined KS on the basis of history only and did not use objective methods for olfaction testing. Comparison of previous similar study from India and developed countries with our study is shown in Table 3. The presence of bulb aplasia is a specific feature of KS and was not seen in any patient with nIHH; as against this OB/OS, hypoplasia is not specific to KS and is also seen in nIHH, and a similar finding was reported by Lewkowitz-Shpuntoff et al.[11] Vogt et al. also documented olfactory hypoplasia in 3 of 10 patients with nIHH.[6]

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We found a 50% prevalence of KS among patients with IHH. Previous studies reported 60%-65% prevalence of KS among IHH.[4,9] In our study, the male-to-female ratio was 6:1, which was higher than that seen in previous studies, which can be explained by less health-seeking behavior of females in India.[4,16]

We found a good linear correlation between OB volume and the smell test score among all subjects with IHH (r = 0.54, P = 0.013), similar to Jagtap et al. (r = 0.61, P < 0.01) and Ottaviano et al. (r = 0.64; P < 0.001).[4,19] We also noted that there is a moderate agreement between MRI findings and INSIT scores, especially between bulb aplasia and anosmia with a Kappa index of 0.49 (95% CI: 0.10-0.88). Koenigkam-Santos et al. reported a Kappa index of 0.87 (P = 0.001) between bulb aplasia and anosmia.[10] Jagtap et al. also reported Kappa index of 0.49 indicating moderate agreement between MRI olfactory apparatus and UPSIT.[4]

To the best of our knowledge, this is the first detailed study correlating objective smell test by INSIT with structural abnormalities in the olfactory apparatus on dedicated MRI from India in a sizable number of patients. The limitation of our study is that INSIT is not validated with UPSIT in patients with IHH. Although further studies are required to support these findings and clinical utility of INSIT in Indian patients.

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