Permanent anosmia after topical nasal anaesthesia with lidocaine 4%

* E-mail: f.agro{at}unicampus.it

Editor—A 62-yr-–old male patient presented with nasal breathing impairment, cough and facial pain without olfactory discomfort. Fibreoptic flexible endoscopy of the nasal passages was performed, preceded by endonasal topical local anaesthesia (ETLA) with lidocaine 4% spray (two puffs in each nostril), using a plastic dispensing apparatus, with no propellant gas. Inferior turbinate hypertrophy and nasal septal deviation were found. About 10 min later the patient mentioned the onset of anosmia. Olfactory impairment was confirmed by a Sniffin'SticksTM test battery1 score <16. Head computed tomography (CT) scan was performed to rule out tumour, infection and obstruction. Three months later the patient was still anosmic and the Sniffin'Sticks test battery confirmed previous findings.

Establishing a direct relationship between drug exposure and anosmia is often difficult, and it is frequently hard to determine with certainty the causative role of specific drugs in the development of such a disorder. In this case lidocaine seems the likely cause of the patient's anosmia, as no other substance either included in the original lidocaine solution or coming from the dispensing apparatus came into contact with the nasal mucosa. Mitochondrial dysfunction with activation of apoptotic pathways2 is the likely mechanism of lidocaine neurotoxicity. Furthermore, ETLA in the supine position and/or in a head-down position can favour contact of the anaesthetic to the olfactory cleft with consequent higher risk of anosmia.3 Smell disorder after ETLA, though usually reversible,4 is a cause of dissatisfaction and fears for the patient and the clinician, with possible legal consequences.5

In conclusion, we suggest performing ETLA with the subject in the sitting position and the head upwards to reduce contact of the anaesthetic with the olfactory cleft. Written informed consent should be obtained from each patient, considering that ETLA will render the procedure more comfortable but may cause transient or, as in this unique case, permanent olfactory dysfunction.

F. Salvinelli, M. Casale, J. F. Hardy, L. D'Ascanio and F. Agrò*

Rome, Italy

References

1 Hummel T, Sekinger B, Wolf SR, Pauli E, Kobal G. ‘Sniffin’ sticks': olfactory performance assessed by the combined testing of odor identification, odor discrimination and olfactory threshold. Chem Senses 1997; 22: 39–52[Abstract/Free Full Text]

2 Johnson ME, Uhl CB, Spittler KH, Wang H, Gores GJ. Mitochondrial injury and caspase activation by the local anesthetic lignocaine. Anesthesiology 2004; 101: 1184–94[CrossRef][ISI][Medline]

3 Cain AJ, Murray DP, McClymont LG. The use of topical nasal anaesthesia before flexible nasendoscopy: a double-blind, randomized controlled trial comparing cophenylcaine with placebo. Clin Otolaryngol 2002; 27: 485–8[CrossRef][ISI][Medline]

4 Welge-Lussen A, Wille C, Renner B, Kobal G. Anesthesia affects olfaction and chemosensory event-related potentials. Clin Neurophysiol 2004; 115: 1384–91[CrossRef][ISI][Medline]

5 Wienke A. Damage to sense of smell and taste following xylocaine administration? Process before the expert evaluation committee for medical malpractice of the North Rhine Physicians Organization in 1995 (Az. 91/588). Laryngorhinootologie 1996; 75: 109–10[Medline]





This Article
Full Text (PDF)
E-Letters: Submit a response to the article
Alert me when this article is cited
Alert me when E-letters are posted
Alert me if a correction is posted
Services
Email this article to a friend
Similar articles in this journal
Similar articles in ISI Web of Science
Similar articles in PubMed
Alert me to new issues of the journal
Add to My Personal Archive
Download to citation manager
Disclaimer
Request Permissions
Google Scholar
Articles by Salvinelli, F.
Articles by Agrò, F.
PubMed
PubMed Citation
Articles by Salvinelli, F.
Articles by Agrò, F.