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a S c i T e c h n o l j o u r n a lResearch Article

Adobamen and Iribhogbe, J Otol Rhinol 2013, 2:3

http://dx.doi.org/10.4172/2324-8785.1000127

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Post-Tonsillectomy TasteDisorders- Review of LiteratureHanna Temporale1*, Krzysztof Zub1, Tomasz Zatoski1and

Tomasz Krcicki1

Abstract

On the basis of the available literature this review shows the

characteristics, possible causes, pathophysiology and treatment

of persistent taste disorders, occurring as a complication after

tonsillectomy. Attention was drawn to the underestimation of the

incidence of these complications and the need to inform patientsassigned to tonsillectomy about the possibility of a decit or

distortion of taste after surgery.

Keywords

Tonsillectomy; Complications; Taste disorders; Dysgeusia

*Corresponding author:Hanna Temporale, Borowska 213, 50-556 Wrocaw,

Poland, Tel: +48 606 831 562; E-mail: hania-qc@o2.pl

Received:May 14, 2013Accepted:August 05, 2013Published:August 15,2013

aste Malfunction (Dysgeusia)

An impairment or dysunction o the sense o taste (dysgeusia)

is the result o damage to the gustatory pathway that may occur

at each stage. Tus epithelial, neural, and central dysgeusia can be

distinguished. Tese disorders, depending on their nature, can be

divided into quantitative (ageusia, hypogeusia, hypergeusia) and

qualitative (parageusia, pseudogeusia, cacogeusia, phantogeusia).

Impaired perception o all tastes is called total dysgeusia and o

some selected tastes partial dysgeusia. According to Janczewski,

the most common cause o reduced sense o taste is rhinitis and

other diseases with nasal blockage or coexisting smell disorders [4].

Other causes might be inflammation o the oral mucosa (e.g. afer

radiotherapy), systemic diseases (diabetic neuropathy, renal ailure,hepatic cirrhosis), hormonal disorder (pregnancy, hypothyreoisis,

adrenal insufficiency), deficiency o micronutrients (zinc, copper),

avitaminosis (deficiency o vitamin A, C, and B), chronic nicotinism,

alcoholism, central nervous system diseases (tumors, vascular diseases,

trauma, meningitis), some mental illnesses (schizophrenia), long-

term use o some medicines (e.g. captopril, metormin, imipramine,

chemotherapeutics), or congenital taste buds malormation [4]. Te

sense o taste is impaired in the elderly. Head and neck surgeries (like

ear, pharyngeal and laryngeal surgery) and tonsillectomy among

them, might also affect the sense o taste.

Post-onsillectomy Dysgeusia

onsillectomy is one o the oldest and most requentlyperormed surgical procedures in otolaryngology. Although

surgical techniques have improved over the years, complications

still happen. Patients mostly suffer rom pain or dysphagia. Lie-

threatening complications like haemorrhage occur in 2-4% o the

patients [5]. Beore tonsillectomy each patient must be inormed

about the risk o taste impairment. ransient post-tonsillectomy taste

dysgeusia (PD) is a common complaint. Long-lasting PD is less

requent but has significant consequences on patients quality o lie.

ransient taste perception changes seem to be relatively requent

afer tonsillectomy [6-8]. Tey are mostly maniested by a metallic

or bitter taste and generally maintain rom 4 days to 2 weeks afer

the procedure. Persistent dysgeusia may last or 2 years or longer and

retreat spontaneously [1,6,7]. Te cause o this complication remainsunknown, although there are several theories, which try to explain its

occurrence.

Nerves Injury

Indirect and direct intrasurgical injury o the lingual or tonsillar

branch o the glossopharyngeal nerve as well as pressure on the

lingual nerve (along with chorda tympani nerve) caused by tongue

retractor during tonsillectomy may lead to taste disturbance [1,2].

Te close anatomic relationship between the palatine tonsil and

the lingual branch o the glossopharyngeal nerve makes the nerve

vulnerable during tonsillectomy. Clamping tonsillar branches o the

lingual or acial arteries to control hemorrhage at the inerior tonsillarpole as well as using electrocautery can injure the nerve [9].

Introduction

As one o the most important senses, correct perception o tastedetermines proper physical and mental unctioning. Some claim thatboth taste and smell are responsible, to a large extent, or the ood

selection, affect human nutritional status, and their dysunction canlead to diseases such as depression [1,2].

Te Sense of aste and its Perception

Tere are our basic types o taste: sweet, salty, bitter, sour and

extra-fifh taste umami (the taste o glutamate). Receptors o taste -the taste buds are mainly located on the tongue, sof palate, epiglottis,upper 1/3 o esophagus, as well as on the lips, cheeks, and they are

scattered in the oral mucosa [3]. Te taste stimulus is transormedinto a nerve impulse and it is carried rom the chemoreceptors o

taste buds afferently by three cranial nerves: the branch o acial nerve(VII) - special sensory fibers o chorda tympani, conducting sense otaste rom the anterior 2/3 o the tongue, the glosso-pharyngeal nerve

(IX) - rom the base o the tongue and the vagus nerve (X) - romthe sof palate, hypopharynx and epiglottis [4]. Next the impulse is

transmitted to the solitary tract, then to the thalamus, neurons projectto the insular cortex, the posterior limb o the internal capsule, andthe operculum (primary gustatory areas).

Te Role of the Glosso-Pharyngeal Nerve

Te glosso-pharyngeal nerve is a mixed nerve: the bigger part

consists o sensory fibers that innervate the throat (including tonsils),middle ear and tongue, the smaller part is ormed by motor fibers orthe throat muscles, tongue, palate and secretory (parasympathetic)

to the parotid gland. erminal branches rom the nerve sensoryinnervate the 1/3 o the tongue.

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Citation:Temporale H, Zub K, Zatoski T, Krcicki T (2013) Post-Tonsillectomy Taste Disorders- Review of Literature. J Otol Rhinol 2:3.

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Volume 2 Issue 3 1000127

In 2004 Goins and Pitovski reported a case study o a patient withpost-tonsillectomy taste disturbance. Using electrogustometry the

lingual branch o the glossopharyngeal nerve (LBGN) was recognised.

Te patient suffered rom ageusia o the posterior one-third o thetongue, which was compensated contralaterally with phantogeusia

maniested by metallic or bitter taste. Te report suggests thatphantogeusia (taste perception despite the absence o the stimulus)

might result rom the release-o-inhibition in the contralateralglossopharyngeal nerve [10].

Inadvertent extension o lingual nerve and its compressionduring tonsillectomymay be prevented by ensuring that the tongue

retractor is not asten too tightly in the mouth, especially in caseswhere the mouth opening is naturally limited [1,9]. Collet et al. notesthat also LBGN may be damaged in the mechanism o stretching

and compression by depression o the tongue [11]. Patients, who aresuspected o taste disorders caused by compression o the tongue,

usually complain o hypogeusia and also o glossodynia o the tip othe tongue. In such cases, the prognosis is considered to be successulbecause there is no permanent damage o the nerve [12]. On theother hand, the researchers did not find that the occurrence o taste

disorders afer tonsillectomy was affected by the length o surgery,including the length o the use o tongue retractor [6].

Neuritis or cicatrisation during postoperative inection is

considered to be another possible cause o the LBGN dysunction[12].

Scinska et al. take into consideration the injury o the sof palate

innervation: the tonsillar branch rom the glossopharyngeal nerve,the palatine nerve (a branch rom the maxillary nerve) or the petrosal

nerve (a branch rom the acial nerve) as a possible cause o dysgeusiaafer tonsillectomy [2]. Te above observations seem to be supportedby cases o taste disorders in patients with the obstructive sleep apneasyndrome (OSAS) afer Uvulopaltopharyngoplasty (UPPP) [13].

Te Role of Zinc in Dysgeusia

Some authors also claim that dietary zinc deficiency plays a rolein the development o PD [1,7]. It is estimated that 25% o tasteand smell disorders is caused by zinc deficiency. Tis deficiency may

lead to parakeratosis o taste buds as well as impaired unction o azinc-dependent enzyme gustin that is responsible or taste perceptionin the taste buds. It is assumed that, apart rom low-level zinc diet,

malnutrition due to postoperative pain and malabsorption, tissueinjury during surgical treatment may lead to release o interleukin-1

(IL-1) and serum-tissue zinc redistribution [3]. Surgery also increasesdemand or zinc due to its participation in blood clotting and woundhealing. Another mechanism o zinc deficiency in post tonsillectomycases is the use o zinc-chelating medications, such as analgesics and

antibiotics administered peri and postoperatively. Tis situationhappens especially i the patient has also been undergoing long-termtreatment with a zinc-chelating drug (eg. antihypertensives) beore

surgery [12].

Serum zinc-level test is cheap and easy to perorm. However,taking into account that over 90% o zinc in the human body is located

intracellularly, the results may not be indicative o the deficiency.

Zinc sulate is used in idiopathic dysgeusia treatment. As no

confirmed side effects o oral zinc supplementation have beenreported such treatment is recommended in all long-lasting post-tonsillectomy dysgeusia. Winduhr et al. report a case o a emale

patient with a 4-year PD who recovered within 2 months afer

an oral intake o zinc sulphate [7]. However, Stathas et al. did not

confirm zinc, copper and errum disorder in serum in patients with

post-tonsillectomy dysgeusia [1].

Other Investigations on Post-onsillectomy Dysgeusia

Drugs interactions are listed as one o taste dysunction causes

[1,12]. Some claim that pathogenesis o those disorders can be

explained by the zinc chelate due to the post-operative drug treatment

(pain killers, antibiotics), whilst non-chelate zinc is responsible or

proper taste perception [2,12,14]. According to the literature, the use

o local anesthesia and adrenaline are mentioned as one o the actors

that lead to post-tonsillectomy dysgeusia [10,12,14].

A type o chosen surgical method has not been ound to

have any influence on the occurrence o taste impairment

[1,6]. Stathas et al. compared the occurrence o taste disorders,

according to two methods o tonsillectomy: the first one:

using scissors and raspatory with electrocautery or coagulation, the

second one: pressure-assisted tissue-welding technology,and ound

no statistically significant difference [1].

Other researchers studied the role o possible actors that might

lead to irregulation o taste afer tonsillectomy such as post-operative

pain, intubation complications, operative time, hemostasis technique,

wound healing. No significant correlation was observed [6]. PD

probably occurs even afer uneventul tonsillectomy [6].

Several reports have pointed out the possibility o linking the

occurrence o taste disorders to depression. A somatic disease and

surgery increase the overall risk o depression. Dysgeusia might cause

anorexia, weight loss, malnutrition, atigue and as a result stressand depressed mood. Te reports draw attention to the act that

post-tonsillectomy taste dysunction with symptoms o depression

may reflect genuine depression, not a postoperative complication.

Tereore, in difficult cases, psychiatric consultation is desirable to

explain the disorders [2].

Diagnostics and Evaluation of aste Disorders

Several methods are used in the qualitative and quantitative

evaluation as well as in the subjective and objective assessment o

dysgeusia. Electrogustometry and specific gustometry are exerted to

measure the taste perception threshold. Intensive studies conducted

lately are aimed at improving the methods o evaluation o gustatory

evoked potentials (GEPs) and gustatory evoked magnetic fields(GEMs) [15,16].

Glossopharyngeal nerve damage can be diagnosed by a thermal

stimulation test. It can explore the thermal and taste sensitivity o

the glossopharyngeal nerve. Cruz and Green induced a bitter or sour

sensation by applying a thermode to the region o the posterior third

o the tongue at a temperature o 15C or 5 to 10 seconds, whereas

at 35C there was no sensation (n=24) [17]. I the glossopharyngeal

nerve is damaged, the taste and thermal sensations caused by cold

disappear. Te induction o a taste sensation by a thermal stimulation

resulted, according to Cruz and Green [17], rom the act that the

neurons sensitive to cold present in the circumvallate papillae

encode according to sodium and hydrogen ion channels, which are

involved in the response to an acid stimulus. In clinical practice,the sensation o cold set off by the application o cold water with a

cotton-tipped applicator to the oliate papillae confirms the integrity

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Citation:Temporale H, Zub K, Zatoski T, Krcicki T (2013) Post-Tonsillectomy Taste Disorders- Review of Literature. J Otol Rhinol 2:3.

Page 3 of 3

doi:http://dx.doi.org/10.4172/2324-8785.1000127

Volume 2 Issue 3 1000127

o the glossopharyngeal nerve, and an absence or a diminution in the

perception o cold is noted in the case o a lesion [ 18]. Tis test isrelatively easy to carry out and is not expensive.

Dysgeusia diagnostics also involves serum zinc-level test as well

as an accurate medical interview, including drug usage.

Post-onsillectomy aste Disorder reatment

Prognosis in dysgeusia afer tonsillectomy is optimistic. In mostcases disturbances retreat spontaneously, however, they may notretreat completely. Complete recovery o the sense o taste depends

on natural healing, the regenerative capacity o the peripheral nervefibers and gustatory pathway [10]. In transient taste malunction it isrecommended to use zinc sulate, e.g. zinc gluconate in a dose o 140

mg daily [16]. It is essential to monitor urther course o the disordersand recovery.

However some researchers underline that meticulous, savingdissection o tonsils and limited use o electrocautery may limitdamage to the throat muscles and consequently reduce the risk odestruction o the surrounding structures, including branches o the

nerves responsible or the reception o taste sensations [9].

Careul fixation o tongue retractor is also emphasized.

Conclusion

Post-tonsillectomy dysgeusia is still underestimated and onlylittle attention is given to it in clinical practise. Te available literature

mentions nerves injury- mainly LBGN as a possible cause o tastedisturbances. Other causes mentioned might be zinc deficiency anddrug interactions. ypically, short-term dysgeusia does not require

treatment. Tere are case reports with the usage o zinc sulate asan effective therapy o persistent taste disturbances, occurring as

a complication o tonsillectomy. Te aim o this publication is toemphasize the problem o dysgeusia afer tonsillectomy and theneed o inorming patients about the possible risk o dysgeusia. It is

essential to take any required steps in order to prevent taste disorderand, in case it does occur, to perorm the appropriate diagnosticprocedures and monitor the treatment.

References

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Taste function evaluation after tonsillectomy: a prospective study of 60

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2. Scinska A, Jodkowska A, Korkosz A , Kukwa W, Sienkiewicz-Jarosz H (2008)

Post-tonsillectomy dysgeusia with weight loss: possible involvement of soft

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3. Konopka W, Dobosz P, Kochanowicz J (2003) Zaburzenia smaku wotolaryngologii. Otolaryngol 2: 145-149.

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Author Afliation Top

1Department of Otolaryngology Head and Neck Surgery, Wrocaw Medical

University, Poland

http://www.ncbi.nlm.nih.gov/pubmed/20229196http://www.ncbi.nlm.nih.gov/pubmed/20229196http://www.ncbi.nlm.nih.gov/pubmed/20229196http://www.ncbi.nlm.nih.gov/pubmed/18047763http://www.ncbi.nlm.nih.gov/pubmed/18047763http://www.ncbi.nlm.nih.gov/pubmed/18047763http://chomikuj.pl/dietetykaCMUMK/rzeczy+od+dziewczyny+z+rocznika+wy*c5*bcej/notatki/zaburzenia+smaku+w+otolaryngologii,2082831964.pdfhttp://chomikuj.pl/dietetykaCMUMK/rzeczy+od+dziewczyny+z+rocznika+wy*c5*bcej/notatki/zaburzenia+smaku+w+otolaryngologii,2082831964.pdfhttp://www.mcgrawhill.ca/professional/products/9780071761475/http://www.mcgrawhill.ca/professional/products/9780071761475/http://www.mcgrawhill.ca/professional/products/9780071761475/http://www.ncbi.nlm.nih.gov/pubmed/19701761http://www.ncbi.nlm.nih.gov/pubmed/19701761http://www.ncbi.nlm.nih.gov/pubmed/20123362http://www.ncbi.nlm.nih.gov/pubmed/20123362http://www.ncbi.nlm.nih.gov/pubmed/20123362http://www.ncbi.nlm.nih.gov/pubmed/20824635http://www.ncbi.nlm.nih.gov/pubmed/20824635http://www.ncbi.nlm.nih.gov/pubmed/20824635http://www.ncbi.nlm.nih.gov/pubmed/17980776http://www.ncbi.nlm.nih.gov/pubmed/17980776http://www.ncbi.nlm.nih.gov/pubmed/17980776http://www.ncbi.nlm.nih.gov/pubmed/15235350http://www.ncbi.nlm.nih.gov/pubmed/15235350http://www.ncbi.nlm.nih.gov/pubmed/15825575http://www.ncbi.nlm.nih.gov/pubmed/15825575http://www.ncbi.nlm.nih.gov/pubmed/15825575http://www.ncbi.nlm.nih.gov/pubmed/12132617http://www.ncbi.nlm.nih.gov/pubmed/12132617http://www.ncbi.nlm.nih.gov/pubmed/17395567http://www.ncbi.nlm.nih.gov/pubmed/17395567http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/18670122https://portal.dnb.de/opac.htm?method=simpleSearch&query=idn%3D571854222https://portal.dnb.de/opac.htm?method=simpleSearch&query=idn%3D571854222http://www.ncbi.nlm.nih.gov/pubmed/10706285http://www.ncbi.nlm.nih.gov/pubmed/8295453http://www.ncbi.nlm.nih.gov/pubmed/8295453http://www.ncbi.nlm.nih.gov/pubmed/8295453http://www.ncbi.nlm.nih.gov/pubmed/8295453http://www.ncbi.nlm.nih.gov/pubmed/10706285https://portal.dnb.de/opac.htm?method=simpleSearch&query=idn%3D571854222https://portal.dnb.de/opac.htm?method=simpleSearch&query=idn%3D571854222http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/18670122http://www.ncbi.nlm.nih.gov/pubmed/17395567http://www.ncbi.nlm.nih.gov/pubmed/17395567http://www.ncbi.nlm.nih.gov/pubmed/12132617http://www.ncbi.nlm.nih.gov/pubmed/12132617http://www.ncbi.nlm.nih.gov/pubmed/15825575http://www.ncbi.nlm.nih.gov/pubmed/15825575http://www.ncbi.nlm.nih.gov/pubmed/15825575http://www.ncbi.nlm.nih.gov/pubmed/15235350http://www.ncbi.nlm.nih.gov/pubmed/15235350http://www.ncbi.nlm.nih.gov/pubmed/17980776http://www.ncbi.nlm.nih.gov/pubmed/17980776http://www.ncbi.nlm.nih.gov/pubmed/17980776http://www.ncbi.nlm.nih.gov/pubmed/20824635http://www.ncbi.nlm.nih.gov/pubmed/20824635http://www.ncbi.nlm.nih.gov/pubmed/20824635http://www.ncbi.nlm.nih.gov/pubmed/20123362http://www.ncbi.nlm.nih.gov/pubmed/20123362http://www.ncbi.nlm.nih.gov/pubmed/20123362http://www.ncbi.nlm.nih.gov/pubmed/19701761http://www.ncbi.nlm.nih.gov/pubmed/19701761http://www.mcgrawhill.ca/professional/products/9780071761475/http://www.mcgrawhill.ca/professional/products/9780071761475/http://www.mcgrawhill.ca/professional/products/9780071761475/http://chomikuj.pl/dietetykaCMUMK/rzeczy+od+dziewczyny+z+rocznika+wy*c5*bcej/notatki/zaburzenia+smaku+w+otolaryngologii,2082831964.pdfhttp://chomikuj.pl/dietetykaCMUMK/rzeczy+od+dziewczyny+z+rocznika+wy*c5*bcej/notatki/zaburzenia+smaku+w+otolaryngologii,2082831964.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/18047763http://www.ncbi.nlm.nih.gov/pubmed/18047763http://www.ncbi.nlm.nih.gov/pubmed/18047763http://www.ncbi.nlm.nih.gov/pubmed/20229196http://www.ncbi.nlm.nih.gov/pubmed/20229196http://www.ncbi.nlm.nih.gov/pubmed/20229196