The “Special Senses,” Special Testing, and the Occupational Health Practitioner

Dennis Shusterman, MD, MPHProfessor of Clinical Medicine, Emeritus

UCSF Division of Occupational & Environmental Medicine

Dwight Bond - https://slideplayer.com/user/9611824/

Disclosures: None

Topics to be covered: Distinction between general & special senses

Review of occupational disorders of the special senses

Distinction between electrophysiology & psychophysical testing

Review of psychophysical tests in the special senses

Definition of “General Senses” “…the general senses …are perceived [through]

receptors scattered throughout the body... rather than tied to a specific [organ]”

Mechanoreception Touch / Pressure / Vibration / Proprioception

Thermoreception

Chemoreception Exogenous & endogenous agents

Nociception

Definition of “Special Senses”

“…the special senses are the senses that

have specialized organs devoted to them”

Vision

Hearing

Vestibular function

Olfaction

Taste

Both general and special sensory systems employ specialized cell structures

Dr. Hugo Heyman - http://www.doctorhugo.org/synaesthesia/receptors.html

Cr. N’s. & Special Senses

https://en.wikivet.net/Cranial_Nerves_-_Anatomy_&_Physiology

Sensory Modality vs. Causal AgentPhysical Chemical Biological

Vision

Hearing

Vestibular function

Olfaction

Taste

Electrophysiology vs. Psychophysics

Electrophysiology PsychophysicsStimuli Physical Physical or ChemicalData type Objective BehavioralPatient effort Passive (mostly) ActivePotential for bias Low High ( “forced choice”)

Credit: James Joe, MBBS Credit: Kohitij Kar, PhD, MIT

Vision

UV-induced corneal “flash burns”

IR-induced cataracts

Source: Hunter D: The Diseases of Occupations (ed. 6) London, Hodder & Stroughton, 1978, p. 842.

Laser-induced retinal injury

https://www.laserlevelhub.net/protecting-your-eyesight-from-laser-injuries-when-using-laser-level/

AcuteMethanol retinopathy

Source: Dr. Anton Vurdaft - Tropical Opthalmology (Blog) - http://tropical-ophthalmology.com/2017/08/18/methanol-optic-neuropathy-rapid-blindness/

(with permission)

Amine-induced glaucopsia

Source: Hwang Y, Cho YK. Two cases of corneal edema due to vaporizedamine. J Korean Ophthalmol Soc 2018; 59(11):1077-81.

O.D. O.S.

Solvent-induced dyschromatopsia

Reference: Gobba F. Color vision impairment in workers exposed to neurotoxic chemicals. Neurotoxicology. 2003 Aug;24(4-5):693-702.

Epidemic kerato-conjunctivitis

Ref: Doyle L, Gallagher K, Heath BS, Patterson WB. An outbreak of infectiousconjunctivitis spread by microscopes. J Occup Med. 1989 Sep;31(9):758-62.

Hearing

Impetus for hearing screening:

Routine periodic surveillance

OSHA-mandated

PEL = 90 dBA as an 8-hour TWA

5 dBA “exchange rate” (havling of time)

85 dBA “Action Level” for hearing conservation

program (warning, IH, PPE & surveillance)

Symptomatic (hearing loss, tinnitus)

Self-reported

Other-reported (typically, spouse / partner)

Types of hearing loss: Conductive

External ear, e.g.: Cerumenous impactoin

Exostosis (“surfer’s ear”)

Middle ear, e.g.,: Otosclerosis; TM perf; Cholesteatoma

Sensorineural Presbyacusis

Ototoxicity (drugs & indust. chemicals)

Noise-related

High-frequency hearing loss

https://www.enteducationswansea.org/hearing-loss Lonsbury-Martin B: Noise-Related Hearing Loss https://clinicalgate.com/noise-induced-hearing-loss/

Age Noise

Asymmetric hearing loss

Asymmetric noise exposureLonsbury-Martin B: Hearing Loss https://

clinicalgate.com/noise-induced-hearing-loss/

Acoustic neuromaJohnson E: Audiological aspects of the diagnosis of acoustic neuromad. J Neurosurg 1966; 24(3):621.

Solvent-noise interaction in hearing loss

Nakhooda F, et al. The effects of combined exposure of solvents and noise on auditory function –

A systematic review and meta-analysis. S Afr J Commun Disord. 2019; 66(1):e1-e11.

Vestibular Function

Characterization & DDX of “dizziness” Lightheadedness

Orthostatic hypotension Hyperventilation (e.g., panic attacks) Intoxication (e.g., solvents) Post-concussive

Vertigo Benign positional Labyrinthitis / Meniere’s Rotation / Acceleration / Opticokinetic Barometric (“alternobaric”)

Caroline Ayinon Yale Scientific Review 12/24/13 12:43http://www.yalescientific.org/2013/12/qa-how-do-

dancers-spin-without-becoming-dizzy/

Aircraft Review: Extra 330SC by Vertigo Design https://xplanereviews.com/index.php?/forums/topic/537-

aircraft-review-extra-330sc-by-vertigo-design/

Vertigo: Rotation / Acceleration / Opticokinetic

“Conveyor-beltvertigo”

https://commons.wikimedia.org/wiki/User:Soljaguar

Vertigo: Alternobaric

Dix-Hallpike Maneuver

Source: Huh Y-E: Bedside evaluation of dizzy patients. J Clin Neurol 2013; 9:203-213

“Miner’s nystagmus”

Source: Fishman RS: The rise and fall of miner’s nystagmus. Arch Opthalmology 2006; 124:1637

Olfaction

Olfaction vs. Trigeminal Sensation

Maxillary N.

Ethmoidal N.

Infraorbital N.

Source: Frasnelli J, Hummel T, Shusterman D. Clinical disorders of the trigeminal systm.In: Welge-Luessen: Management of Smell and Taste disroders. Stuttgart: Thieme, 2014.

Olfactory N.

Source: Ishman SL: Calcification of the olfactory bulb in three patients with hyposmia.Am J Neuroradiol 2003; 24:2097–2101.

Olfactory Disorders

Decreased olfaction

Hyposmia

Anosmia

Dysosmias (distorted olfaction)

Cacosmia

Torquosmia

Phantosmia

DDX of Acquired Olfactory Loss Age / Neurodegenerative disorders

Conductive loss

Allergy, infection, neoplasm

Head trauma

Smoking

Occupational chemical insults Metals (Cd, Ni, Cr, Zn…)

Irritants (NH3, Cl2, SOx…)

Solvents (acetone, benzene, dibasic esters…)

21 y/o/m boatbuilder with OR, hyposmia, OA & ACD

Vapor-phase stimuli

Doty & Kamath, 2014

Olfactory Testing

Qualitative (Odor ID)

Microencapsulated

Felt-tipped pens

Quantitative (Odor detection) Squeeze bottles

Felt-tipped pens

Alcohol Sniff Test

Sci News 9/8/17

Arnold W: Smell Disorders

Taste

Quantitative Disorders Hypergeusia

Hypogeusia

Ageusia

Qualitative Disorders Dysgeusia

Parageusia

Phantogeusia

Gustatory Dysfunction

Special Senses: Causal AgentsPhysical Chemical Biological

Vision IR, UV, lasers; Computer Ergo

Amines, Methanol, Misc. Solvents, CO

Viral conjunctivitis

Hearing Noise Solvents, Pb Viral ?

Vestibular functionAccelerationOpticokinetic

Miner’s nystagmus

Solvents, Organo-phosphates, Hg,

etc?Viral ?

Olfaction Head traumaMetals (Cd, Cr, Ni)Solvents (various)

Acids, CausticsPost-viral

Taste Ionizing radiationCd, Hg, Sb, Cr, Pb, Se, Te, H2Se Bell’s palsy?

ReferencesDavidson T, Murphy C. Rapid clinical evaluation of anosmia: The alcohol sniff test.

Arch Otolaryngol – OHNS 1997; 123:591-4.

Doyle L, et al. An outbreak of infectious conjunctivitis spread by microscopes. J Occup Med. 1989 Sep;31(9):758-62.

Fishman RS: The rise and fall of miner’s nystagmus. Arch Opthalmology 2006; 124:1637

Gobba F, Cavalleri A. Color vision impairment in workers exposed to neurotoxic chemicals. Neurotoxicology. 2003 Aug;24(4-5):693-702.

Huh Y-E: Bedside evaluation of dizzy patients. J Clin Neurol 2013; 9:203-213

Hwang Y, Cho YK. Two cases of corneal edema due to vaporized amine. J Korean OphthalmolSoc 2018; 59(11):1077-81.

Hunter D: The Diseases of Occupations (ed. 6). London: Hodder & Stroughton, 1978, p. 842.

Nakhooda F et al. The effects of combined exposure of solvents and noise on auditory function - A systematic review and meta-analysis. S Afr J Commun Disord 2019; 66(1):e1-e11.

Shusterman D, Sheedy J: Occupational and environmental disorders of the special senses. Occ Med State of Art Reviews 1992; 7(3): 515.

Werner S, Nies E: Olfactory dysfunction revisited: A reappraisal of work-related olfactory dysfunction caused by chemicals. J Occup Med Toxicol 2018; 13:28.