Apparently, there are several drugs on the market that can cause the loss of all or part of your sense of smell.
Q Are any of her medications associated with smell loss or dysfunction?
A Some of them may be described as possibly causing loss of smell in the lists that have been generated.
Q Can you rule out her other medications as playing a causative role in her smell complaints?
A Yes, to a degree of medical probability.
Q And how is that?
A She was taking those medications before she used the product. She is taking them afterward. The change was the use of the Zicam.
Q Well, there was a big increase in dose of one of them right around the time of her complaints, wasn't there?
A Which one was that? I'm sorry. I must have missed that.
Q Pardon me. I think it was her Effexor?
A There were some changes in the Effexor, the BuSpar and the -- it may have been the Effexor. Okay.
Q Assuming that her Effexor was increased in dose around the time of her complaints, can you rule out Effexor as playing a role in causing her smell complaints?
A Yes.
Q How?
A Effexor is one of a group of drugs that have been considered possibly associated with loss of smell. However, it is incredibly uncommon and rare, and she used the others, particularly BuSpar, without changing her loss of smell. Therefore, I think, to a degree of medical probability, it is unlikely that it affects her with the source of her problem.
Q Well, how rare is smell loss in association with Effexor compared to smell loss in association with Zicam?
A I don't have an exact number in that regard.
Q Okay. She has -- this is a woman who has been treated for arthritis, fibromyalgia, headaches related to disc problems, two years of cervical steroid epidural blocks, polymyalgia, depression, laminectomy, foraminotomy, rheumatoid arthritis, osteoarthritis, restless leg syndrome, hiatal hernia, diverticulitis, gastroesophageal reflux disease, irritable bowel syndrome, migraines, incontinence and hypertension, correct?
A This lady has not had an easy life, and I think that's an accurate recording. I didn't write down all those things.
Q Can you rule out her underlying medical conditions, any or all of them, as playing a role in her smell complaints?
A Yes.
Q How?
A She had those before she used the medication. Afterwerds, she had loss of smell therefore, by the temporal association, I think it's more likely, to a degree of medical probability, that the loss of caused by the Zicam.
Q Well, the temporal association was with a pretty severe upper respiratory infection, wasn't it, Doctor?
A That wasn't my impression. It was my impression that she hadn't developed a cold.
A Yes. With the assumption that she did not take Zicam, then I still would begin to put her over into the idiopathic. If we have all the additional information that she lost it in proximity to a cold and that she did not take Zicam, then I would make a diagnosis, instead, of post-viral anosmia.
Q (BY MS. SHARKO) Now, have you in the Hilton case and I gather this is coming in the Lusch case, offered the opinion that you can observe scarring or inflammation in the area of the olfactory epithelium?
A I think in some patients you can. I don't know that that's pertinent to this particular case since I didn't examine these patients.
Q We went through deposition testimony and medical records that you have. Did you get any copies of films, studies, CT scans, MRIs, X-rays, anything like that?
A No, I didn't.
Q Do you know Dr. Susan Schiffman?
A Yes, I do.
Q She is recognized as an expert in the area of olfaction?
?? well as observations in patients that there is a straight pathway from the opening of your nose to the olfactory region.
Q Have you observed Mrs. Hurst's nose?
A You've asked that before, and I have not.
Q And so are you able to say one way or the other whether Mrs. Hurst had a straight pathway on both sides of her nose from the opening to the olfactory epithelium?
A Mrs. Hurst is not described as having septal deviation. I would, therefore, conclude, to a reasonable degree of medical probability, that there is a straight pathway in Mrs. Hurst's nose from the opening of her nose to the olfactory region.
Q Did she have swelling or congestion at the time she used Zicam?
A I don't know.
Q Have you observed Mr. Hans' nose?
A No, I haven't.
Q Are you able to say one way or the other whether Mr. Hans had a straight pathway on both sides of his nose from the opening to the olfactory epithelium?
A I am able to say, to a reasonable degree of medical probability, that there was a straight pathway in Mr. Hans' nose.
Q Based on what?
A Based upon the evaluations of the doctors that looked at him.
Q Which doctors?
A I don't have a specific name written in here.
Q Well, what did you find in the medical records which allows you to conclude that Mr. Hans had a straight pathway on both sides of his nose?
A I found nothing that suggested that he didn't have a straight pathway on both sides. I, therefore, concluded that Mr. Hans, like most people, had a straight pathway from the nasal opening to the olfactory region.
Q What do you know about Mr. Hans' nasal anatomy?
A I didn't examine Mr. Hans.
Q And what do his medical records say about his nasal anatomy?
A They gave no evidence of septal deviation or chronic obstruction.
Q Well, did they -- is there anything anywhere in his medical records which describes his nasal anatomy?
A Not that I specifically can cite for you.
Q Did Mr. Hans have swelling and congestion at the time he used Zicam?
A He described a stuffy nose. He denied a sore throat or cough or fever.
Q So would you expect that Mr. Hans, in fact, had swelling and congestion at the time he used Zicam?
A I don't think so, no.
Q Why?
A Because a stuffy nose is not a very suggestive complaint of congestion of the nose.
Q Well, if a stuffy nose doesn't mean congestion of the nose, Doctor, what does it mean?
A It means stuffy nose.
Q Well, what does it mean? What does “stuffy nose” mean?
A Stuffy nose. That's what he described.
Q Well, if a patient comes in to you and says, “Doctor, I have a stuffy nose,” what does that mean?
A It means they have a stuffy nose.
Q Can you describe “stuffy nose” for me?
A Stuffy nose.
Q Can you define “stuffy nose” without using the phrase “stuffy”?
A No. The patient describes that as a symptom. One then needs to try to further characterize it. As we both said, it is not further characterized in the chart in terms of what he had at that time. It is characterized that he didn't have a sore throat. He didn't have a cough. He didn't have a fever, and he didn't have, quote, anything else, whatever that meant.
Q Did you examine Mr. Thompson's nose?
A No.
Q Are you able to say one way or the other that Mr. Thompson had a straight pathway on both sides of his nose from the opening to the olfactory epithelium?
A Yes. In my opinion, to a reasonable degree of medical probability, he had a straight pathway.
Q What's the basis for that opinion?
A I'm not sure which doctor looked at him, but he said that there was no septal deviation. It's in the medical records.
Q But you don't know who or where?
A I don't remember the name of the doctor that did that.
Q Did Mr. Thompson have swelling or congestion at the time he used Zicam?
A I don't know.
Q Is that something that would be important to know?
A It would have been helpful to be there exactly at that time and observe Mr. Thompson. I was not there exactly at that time, and I had to rely upon the history which I found to be quite thorough.
Q Did Mr.-- did you observe Mr. Myrick's nose?
A No, I didn't.
Q Are you able to say one way or another whether Mr. Myrick had a straight pathway on both sides of his nose from the opening to the olfactory epithelium?
A To a degree of medical probability, he had a straight pathway on both sides of his nose, to the olfactory region.
Q What's the basis for that?
A An examination that said he had no septal deviation.
Q Who did that and when?
A I don't remember. I recorded it from the medical records I received.
Q Did Mr. Myrick have swelling or congestion at the time he used Zicam?
A I don't believe so.
Q What's the basis for that?
A He's characterized as having a mild URI, and he was using the Zicam more on a prophylactic basis.
Q Where does it say that, Dr. Jafek?
A I don't remember whose chart I pulled that out of.
Q Well, what does it mean to use Zicam as a prophylactic?
A I don't think they used the word prophylactic. That was a word that I used in trying to characterize his mild symptoms.
Q And you don't know wlere you got that from?
A What do you mean?
Q Well, I want you to assume that's true, that he testified that his loss was gradual over two to three weeks after he used the product. If that's true, does it make it less likely, in your opinion, to a reasonable degree of medical probability, that his smell complaints were caused by the use of Zicam?
A He may or may not have noticed the loss of smell. That's why I say it depends upon the history. If we could firmly establish, in fact, that he had a gradual loss over a period of two to three weeks following the use of Zicam, then that would suggest that the Zicam is less likely, but certainly that history firmly rules out Parkinson's or other things of that sort in terms of his loss of smell.
Q Why does it rule out Parkinson's disease, in your opinion to a reasonable degree of medical probability?
A Because he had Parkinson's disease -- before he used the Zicam, he had Parkinson's disease. Two to three weeks afterward, you certainly can't say that his Parkinson's progressed at that period of time, therefore, it is very unlikely that Parkinson's was the cause of his loss of smell, for example.
Q Well, how do people with Parkinson's disease report their smell loss? Is it gradual or sudden or when did it occur during the course of the disease?
A It can occur in a variety of times during the course of the disease, if it does occur with Parkinson's disease, and they report that one day they noticed that they had lost their sense of smell, and they document exactly what had happened. Sometimes, as you go back, they describe an additional gradual onset. Other times, they don't.
Q Are you able to rule out Parkinson's disease as playing any role in Mr. Myrick's smell complaints, to a reasonable degree of medical probability?
A That's a very long question. I am able to rule out Parkinson's disease, to a reasonable degree of medical probability, as the cause of loss of smell that he documented in January of '04.
Q How?
A As I mentioned before, because of the longitudinal nature of the Parkinson's, he had had Parkinson's. He had it afterward, but what changes was the use of the Zicam and a loss of smell.
Q What was Mr. Myrick's smell before he used Zicam?
A There was no report of loss of smell on Mr. Myrick before he used the Zicam.
Q There was no report of normal smell in this 81-year old man with Parkinson's disease and diabetes either, was there, Doctor?
A No.
Q What type of smell ability would you expect in an 81-year old man with Parkinson's disease, hypertension, diabetes and congestive heart failure to have?
A I don't think that there is a standard smell. He did not report any loss of smell. I must, therefore, accept his history. He seems like a good historian.
Q What percentage of men who are in their 80s and have Parkinson's disease are aware of any diminution in their ability to smell?
A I don't have a percentage figure on the tip of my tongue.
Q Well, Dr. Murphy reported in her paper damages?
MR. GRAY: Object to form.
A I would be speculating in that particular area. I found Mr. Myrick's deposition to be quite thorough.
Q (BY MS. SHARKO) Are you able to rule out Mr. Myrick's diabetes as playing any role in the cause of his smell complaints?
A Yes, to a degree of medical probability.
Q How?
A He had diabetes before. He had diabetes after. What changed was the use of the Zicam.
Q And of what significance to you is his complaint of phantom smells?
A It suggests that he has some perception of something, but that phantosmia is specific in terms of smells that aren't there. That is certainly not normal sense of smell.
Q Does that suggest that the cause of his smell loss is something other than his use of Zicam?
A No.
Q Is there anything anywhere in the cold for two weeks before he even used the product, correct?
A That's what he said, yes.
Q Given that testimony, can you rule out his cold as being a cause or the cause of his smell complaints?
A The cause was one or the other. It was the Zicam or the post-viral. To a reasonable degree of medical probability, I conclude that it was the viral -- excuse me, the Zicam that caused the problem.
Q Why?
A He describes a stopped-up head. He really had no other cold symptoms, fever or things of that sort. Therefore, I conclude that he had a mild cold, if he had a cold, and, therefore, it is more likely that the Zicam, a known toxin, caused his loss of smell.
Q You said it was either the virus or the Zicam --
MR. GRAY: Objection.
MS. SHARKO: I haven't even finished my question.
MR. GRAY: It is already wrong. I'll let you finish before I object the next time.
Q Well, his area of expertise in the field of neurology is treating people with Parkinson's disease, correct?
A That would be my understanding.
Q And you would agree that he undoubtedly has more experience in the area of Parkinson's disease than you do, correct?
A Parkinson's, but not taste and smell.
Q Do you agree or disagree with Dr. Bhupalam's opinion that the cause of Mr. Myrick's smell complaints were a combination of his age, his Parkinson's disease, and his use of the drug Sinemet?
A I disagree.
Q How do you rule out Mr. Myrick's age as playing any role in the cause of his complaints?
A He was exactly the same age plus two to three weeks before he took the drug. He was exactly the same age plus the two to three weeks after he took the drug. The thing that had changed was the use of Zicam. Therefore, I conclude, to a degree of medical probability, that it was Zicam that caused his loss of smell.
Q How do you rule out Sinemet as playing a role in his loss of smell?
A Same sort of reasoning.
Q When did he start Sinemet in relationship to his smell complaints?
A I don't know the exact date.
Q Well, Sinemet was first prescribed on February 11, 2004, correct?
A If you say so. I didn't find that in the chart.
Q Well, did you have the Veterans Administration Medical Center records?
A I did.
Q Okay. And on February 11, 2004, the notes in the medical record -- medical center record states “the patient was diagnosed with Parkinson's disease by a private neurologist yesterday. He will be starting Sinemet as soon as the prescription is filled.” Do you have any reason to disagree with that?
A No.
Q So do you, therefore, conclude that he started taking Sinemet sometime in February or March 2004?
A You used the word “February or March.” I guess the answer would be yes.
Q Well, I mean the guy is 81. Do you depending upon your definition of several. I believe he saw --$well, your definition of weveral.
Q Dr. Murphy wrote in his records that he couldn't be sure if Zicam was a factor or not, correct?
A That's correct. And we previously mentioned that he may have started on the Sinemet in February or March.
Q What role does his hypertension play in his smell complaints?
A I don't think it plays any.
Q Why?
A Because he had hypertension before he used the Zicam and afterward, and it's not my impression on reviewing the chart that that got out of hand at the time that he used the Zicam and lost his sense of smell.
Q What about issues of HCTZ? Can you rule that out as playing a role in his smell complaints?
A Hydrochlorothiazide is characterized by some as causing loss of smell. It didn't appear to play a role in this particular man.
Q Why?
A Because he used it before he used the Zicam. He used it afterward, therefore, it didn't appear likely that that was the cause of the problem.
Q Would you agree that Mr. Myrick's complaints are completely consistent with post-viral anosmia or hyposmia?
A What complaints are you talking about? We've agreed that post-viral anosmia or loss of smell can occur, and in that sense, he's consistent. On the other hand, I think it was more likely, to a degree of medical probability, that Zicam was the source of his loss of smell.
Q Would you agree that his smell complaints are typical of what one might expect to see in a man in his 80s with Parkinson's disease, diabetes and hypertension?
A No.
Q Why?
A For the reasons we discussed previously.
Q Which are?
A He had those problems before. He had them after. The thing that changed was the use of Zicam, loss of smell.
?? meds,$no ellevgiew, no H/O sinus mnfections, no concussion, VAH, arrow, CT for loss of smell. No toxin exposure, stuffy nose, no sore throat, cough, fever. Anything else? No. Directions read, one quarter-inch into nose, question, prime, quote, tilted to outside, end quote. No pain or discharge, quote, cold lasted one, used again next night again later, No. 3, quote, severe burning in middle of night. Quote, on fire next morning at breakfast,” which is the way I indicated when he noticed his loss of smell and taste.
Q How old was he at the time he allegedly used Zicam?
A Mr. Hans would have been approximately 82 years old.
Q Okay. Can you rule out his age as playing any role in his smell complaints?
A Yes.
Q How?
A He was the same age before and after he used the Zicam. What changed was use of it and the loss of smell. I don't think he aged that quickly.
Q Would you expect someone who is 82 years of age to have normal smell?
A They might or might not. They probably wouldn't be quite as acute as you and I, but I would expect them to notice if they were able to smell things.
Q Has Mr. Hans ever had any objective form of testing?
A Not that I could find in the chart.
Q Is there any way for you to determine objectively what his sense of smell was before and after he used Zicam?
A No.
Q Can you rule out his diabetes as having any effect on his smell complaints?
A Yes.
Q How?
A He had diabetes before and after he used the Zicam. What changed was the use of the Zicam.
Q Can you rule out his hypertension as having -- as playing any role in his smell loss complaints?
A Yes, to a degree of medical probability.
Q How?
Q How?
A Hypothyroidism generally is reported as causing a very slow or almost indetectable loss of smell when it does occur.
Q And so how do you rule that out here?
A I would point out that he had the problem before and after, and this was a very acute loss as he described it.
Q Now, at the time that he was using Zicam, Mr. Hans was having sinus trouble and a lot of drainage and congestion in his sinuses, correct?
A I don't find that. I find the specific description that there is no history of sinus infections.
Q All right. Well, do you have the VA Medical Center records there?
A I believe so.
Q Before we go there, let's go back to the generic nasal spray. Did you see his deposition testimony that --
A I saw --
Q Just a minute. I'm not done with my question.
A Okay.
Q Could you please pass me your copy of it? Now, this lady, Mrs. Hurst, is on a long list of medications, correct?
A That is correct.
Q Are any of her medications associated with smell loss or dysfunction?
A Some of them may be described as possibly causing loss of smell in the lists that have been generated.
Q Can you rule out her other medications as playing a causative role in her smell complaints?
A Yes, to a degree of medical probability.
Q And how is that?
A She was taking those medications before she used the product. She is taking them afterward. The change was the use of the Zicam.
Q Well, there was a big increase in dose of one of them right around the time of her complaints, wasn't there?
A Which one was that? I'm sorry. I must have missed that.
Q Pardon me. I think it was her Effexor?
A There were some changes in the Effexor, the BuSpar and the -- it may have been the Effexor. Okay.
Q Assuming that her Effexor was increased in dose around the time of her complaints, can you rule out Effexor as playing a role in causing her smell complaints?
A Yes.
Q How?
A Effexor is one of a group of drugs that have been considered possibly associated with loss of smell. However, it is incredibly uncommon and rare, and she used the others, particularly BuSpar, without changing her loss of smell. Therefore, I think, to a degree of medical probability, it is unlikely that it affects her with the source of her problem.
Q Well, how rare is smell loss in association with Effexor compared to smell loss in association with Zicam?
A I don't have an exact number in that regard.
Q Okay. She has -- this is a woman who has been treated for arthritis, fibromyalgia, headaches related to disc problems, two years of cervical steroid epidural blocks, polymyalgia, depression, laminectomy, foraminotomy, rheumatoid arthritis, osteoarthritis, restless leg syndrome, hiatal hernia, diverticulitis, gastroesophageal reflux disease, irritable bowel syndrome, migraines, incontinence and hypertension, correct?
A This lady has not had an easy life, and I think that's an accurate recording. I didn't write down all those things.
Q Can you rule out her underlying medical conditions, any or all of them, as playing a role in her smell complaints?
A Yes.
Q How?
A She had those before she used the medication. Afterwerds, she had loss of smell therefore, by the temporal association, I think it's more likely, to a degree of medical probability, that the loss of caused by the Zicam.
Q Well, the temporal association was with a pretty severe upper respiratory infection, wasn't it, Doctor?
A That wasn't my impression. It was my impression that she hadn't developed a cold.
A Yes. With the assumption that she did not take Zicam, then I still would begin to put her over into the idiopathic. If we have all the additional information that she lost it in proximity to a cold and that she did not take Zicam, then I would make a diagnosis, instead, of post-viral anosmia.
Q (BY MS. SHARKO) Now, have you in the Hilton case and I gather this is coming in the Lusch case, offered the opinion that you can observe scarring or inflammation in the area of the olfactory epithelium?
A I think in some patients you can. I don't know that that's pertinent to this particular case since I didn't examine these patients.
Q Doctor, again, I would ask that you just answer my questions, and we'll get through this.
A I thought I did answer it.
Q I'm just laying a foundation.
A Okay.
Q You have in the past testified that where you examined the plaintiff, you were able to observe scarring or inflammation in the area follow an infection of that type?
A I don't think so, no.
Q Why not?
A Bronchitis is an infection of the lung. That's not where loss of smell originates. It is an infection of the nose.
Q And it's your testimony that she had no nasal complaints at that time?
A It is my testimony that she had minor nasal complaints, but I don't find a compelling reason to diagnosis both viral anosmia in this particular case.
Q Well, do you agree that she had a viral problem at that time?
A I don't know. What time are you talking about?
Q April 2, 2003.
A She may or may not have had a viral. It may have been bacterial. I don't know.
Q The doctor specifically noted that her nose was edematous and tender. That doesn't suggest that this was an infection localized in her lung, does it?
A The diagnosis was that of bronchitis, but it is hard to know exactly what goes on.
Q But you would agree that where the doctor writes, “her nose is edematous and tender and she has postnasal drip and her lungs are clear to auscultation,” that this is not an infection that's localized in the lungs?
A It does suggest that it's in the nose, correct. Whether it's infection or allergy is unclear.
Q Well, if it was allergy, he wouldn't be prescribing Zithromax, would he?
A Probably not, but allergy can give you the clinical picture that you described to me.
Q A five-day history of cough, laryngitis, sore throat, right earache, tympanic membrane clear, edematous and tender nose, postnasal drip, lungs clear to auscultation. That's a picture of allergy, Doctor?
A That could be consistent with allergy. It could be consistent with a nasal infection as well.
Q And would you agree that smell loss can follow infections such as this woman presented with on April 2, 2004?
A It can. It is usually not an acute loss, however.
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Q How old was Mr. Thompson at the time he used Zicam?
A Approximately 53.
Q Can you rule out his age as playing any role in the level of smell function that he has?
A Yes.
Q How?
A He was 55 -- 53 before he used medicine. He was 53 afterwards. I don't think he aged during that period of time.
Q He had gastroesophageal reflux disease, increased cholesterol, chronic rhinosinusitis, and he smoked somewhat less than a pack of cigarettes a week. Can you rule out any of those aspects of his underlying history as playing a role in his smell complaints?
A Yes.
Q How?
A None of those are associated with the acute loss of smell.
Q But all of those are, in fact, associated with smell loss, correct?
A All of them are described as producing loss of smell in some people over a period of time.
Q And why do you say that none of them produced smell loss in Mr. Thompson, either independently or collectively?
A His loss was an acute loss. I might add that I'm not aware of good evidence that GERD produces loss of smell. The others have been associated somewhat.
Q Now, his testimony was that he followed the directions on the package, correct?
A Yes.
Q He didn't sniff, correct?
A Yes.
Q He never complained of burning, correct?
A That's correct.
Q He had a cold that lasted for about a week, correct?
A That's correct.
Q And he didn't notice his smell loss for another week to two weeks after the cold, correct?
A That's correct.
Q Under those circumstances, are you able to rule out post-viral anosmia in Mr. Thompson?
A He indicated that it took him a few days to realize that he'd lost his sense of smell, possibly making it a more acute episode. Therefore, I am able to rule out post-viral anosmia and, to a degree of medical probability, it is my opinion that he lost his sense of smell due to the use of the Zicam.
Q Well, he testified at his deposition under oath, and he said in his facts sheet, which I don't think you have, that he first noticed any -- he first noticed an impairment of his sense of smell two weeks after his cold cleared up. Using the facts sheet, which I believe is given under oath and the deposition testimony, which is, in fact, given under oath, assuming those statements to be true, can you rule out post-viral anosmia in this individual?
A Yes.
Q How?
A He indicated that it was two weeks later that he made up his mind, and his description was it had took a few days to realize that he had lost his sense of smell. That is not entirely unusual.
Q Is that consistent with post-viral anosmia?
A It can occur with post-viral anosmia. It's also consistent with Zicam toxicity.
Q In fact, the statement that “As soon as my cold was gone, I noticed I couldn't smell anything,” is completely consistent with post-viral anosmia, isn't it, Doctor?
A It could be consistent with post-viral. It is also consistent with Zicam in that that further shortens up the acute onset of his loss of smell.
Q If Mr. Thompson presented to you as a patient without any history of Zicam use, what would your opinion as to causation be?
A If he had presented with a history that he had not used Zicam and everything else in this particular case is similar, then my diagnosis would be post-viral anosmia.
Q Can you rule out his Lipitor as playing any role in his smell loss?
A Yes.
Q How?
A Lipitor problems are very rare in terms of loss of smell. They're much more common in terms of musculoskeletal problems, and Lipitor may be lethal.
Q You're talking about Lipitor or Baycol?
A Yes.
Q You're talking about Baycol, right?
A I'm talking about all the statin drugs.
Q It's your opinion that statin drugs are lethal?
A They may be lethal in certain cases in terms of the muscle myolysis that occurs.
Q He had a history of seasonal allergies and sinusitis, correct?
A It's my understanding that that was in the collected material that we have. I don't remember.
Q In fact, there is several references to him in the medical records having chronic sinusitis, correct?
A Those words appear elsewhere. It says that he had no nasal symptoms or respiratory symptoms. I'm not sure which is the correct.
Q Well, assuming the references to chronic sinusitis are correct, can you rule that out as playing a role?
A Yes.
Q How?
A It is very unlikely from the medical records that, in fact, he had chronic sinusitis even though the word is there.
Q Why do you say that?
A Chronic rhinosinusitis is a collection of symptoms that persist for longer than three months. I found no documentation of that in the medical records.
Q Given that his treatment medication is consistent with post-viral anosmia and what you consider to be Zicam-induced anosmia, how can you say that it's one or the other?
A It has to be one or the other, and, therefore, to a degree of medical probability, it is my opinion that it's a Zicam-induced problem vather tlan the viral URM in$this case.
Q But why? What is it that causes you to pick one etiology over the other etiology?
A Because of the acute onset of severe loss of smell as occurred in this particular patient with relatively minimal cold symptoms.
Q Well, wait a minute. Why do you say he had relatively minimal cold symptoms?
A Because that's my opinion is that he had relatively minimal cold symptoms.
