How loss of smell is a diagnostic aid in medical conditions

This picture has been used for representational purpose

A family of four entered and positioned themselves strategically in my consultation room. The middle-aged parents took the two seats in front of me, the teenage daughter plonked herself on the examination bed, and the son chose to stand. This was swift. Often, when there are two chairs and more people, the first five minutes are spent deciding who is going to sit where, and most often, one chair remains vacant because people opt to stand out of courtesy. Every culture is different, and every family has a distinct dynamic.

"He can't smell anything," the wife started off after pleasantries were exchanged, and then looked at her husband for him to continue. "My head hurts like hell," he said clasping it with both his palms. He sat there like a stack of circular Russian dolls. His head was perfectly round. His torso was also thoroughly spherical, albeit a voluminously larger version of his head. And the tumour inside his head was the size and shape of a cricket ball, a glowing third eye. It stood there like a road roller, compacting the nerves responsible for smell into the base of the skull.

The olfactory nerves are microscopic versions of spaghetti that line the insides of one's nose and then enter the skull through a sieve in the bone, forming a bundle that resembles a thick flat noodle, one on each side. Now, thanks to the tumour, his nerves were thin flat noodles. The complex connections of the nerves with various parts of the brain via sophisticated networks allows smell to become integrated with emotion, memory and taste.

"He's also becoming very emotional lately," the wife interjected. "We've been married for two decades, and he's told me he loves me twice in 20 years. In the past one month, he's said it a dozen times!" she said with the glimmer of a smile, one tinged with surprise and also concern. The teenage daughter had a bit of a twinkle in her eyes, probably drawing parallels to the affection her dad had also been showering on her. I plugged in the MRI films to show them that the downward pressure of the tumour on the olfactory nerves was causing the dysfunction of smell, and that the swelling of the surrounding frontal lobes was responsible for his emotional effusiveness.

They had all the answers, but didn't know what question to ask next. "We have to remove this with an operation," I helped. "Surgery will relieve the headaches, restore his sentiments, and he will hopefully regain his smell, at least in one nostril," I elucidated. "We'll go ahead with surgery," the son finally spoke as we discussed some more technical nuances related to surgery and its outcome.

A few days later, I walked into the operation theatre at 7 am for his surgery. An early morning OT has a profound and piercing smell that you can feel in your bones. It's ethereal. It is sweet and tangy, zesty and fresh. It has the aroma of mopped floors, buttery walls, sterile packs, warm-pressed linen, and gleaming Keralite nurses - the intense tenderness of whom you can feel even behind the veneer of their triple-layered masks. And when you've operated hard and long enough like I have, the OT also has the smell of joy, grief, gladness, remorse, and hope, with, above all, a fragrance of resilience and compassion.

After fixing the patient's circular head on a clamp, we made a semi-circular incision from ear to ear and reflected the scalp down. We then drilled out a 4 x 4 cm piece of bone above the right eyebrow. The brain was extremely tense as we opened the dura, requiring us to do away with a small and inconsequential part of the frontal lobe to get to the tumour, called the frontal pole. "We're sucking away the ‘I love you' centre of his brain," I told my assistant in jest. "He's now going to say ‘I lobe you' to her!" he retorted, my wit rubbing off on him after the years we've spent chatting under the radiance of the microscope. "Finally, he'll do justice to his Bengali linage," I quipped, before we moved to a more critical stage of the surgery.

Once we got to the tumour we cut off its blood supply first and then cored into its centre so that it could fall on itself. Then, I gently peeled off the right olfactory nerve, followed by the left one, hoping it wouldn't snap at its thinnest point, where it was almost transparent. I often whisper into patients' brains when I operate: "Hang in there," I implored to the cranial nerves, and they did so with tenacity.

A few days later, he was discharged with a smile on his face that met the incision on his head. The sense of smell is the first of all our senses to develop. Even before we are born, our sense of smell is fully formed and functional, although unfortunately, some children are born without the ability to smell, a condition called congenital anosmia. An alteration or loss of smell is a diagnostic aid in many medical conditions. It is a harbinger to Parkinson's in several cases, predicting it several years before the actual onset in some individuals. Often, patients who have seizures report that it started with a disagreeable smell - rotten eggs, pigeon poop, burning rubber, and anything else one can imagine. In some people, strong smells of glue, petrol, or bleach can even trigger a convulsion. The Coronavirus has given the loss of smell an elevated status, and many people have experienced what that feels like to not even be able to taste their meals, because it is smell that gives our food its flavour.

Six months later, the entire Das family was back in my consultation room. They positioned themselves in exactly the same fashion, as if it were home. A fresh MRI showed no tumour and pristine-looking frontal lobes. He was delighted that his sense of smell was back. "I've had to add more spice in his food, though," his wife interjected. "And how is he emotionally?" I asked. "Absolutely fine," she smiled. "In fact, he's become kinder, softer, and still keeps saying he loves me, but I'm not complaining!" she said as they looked into each other's eyes, happy faces all around.

"I'll readily take credit for that, if you don't mind," I signed off with an equally happy face.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.