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Aug. 23, 2018 -- Some say they bite into a sandwich that suddenly smells like a burnt cigarette. Others report smelling burnt rubber and can't figure out where the stench is coming from. In a better-case scenario, the smell of peaches fills their nose 24/7, proving that too much of even a pleasant odor can make you feel a little wacky.

It all may sound like a Saturday Night Live skit in the making.

But doctors and those affected say these phantom odors are real -- and troubling. The medical term is phantosmia.

It's not life-threatening, but there are no reliable treatments, and it can make your life much worse. There isn't even good information on how many people are walking around asking co-workers or spouses: “What is that smell?”

So the National Institutes of Health nosed into the topic further, concluding that one in 15 Americans have phantosmia.

Most likely affected are women 40 to 60, says lead author Kathleen Bainbridge, PhD, a researcher with the National Institute on Deafness and Other Communication Disorders (NIDCD). The problem is less likely in those 60-plus. In most cases, it tends to go away after a year or less, but while it’s happening, it can be upsetting and distracting.

Survey Details

To get to the one in 15 estimate, Bainbridge and her colleagues used data collected from 2011 through 2014 as part of the National Health and Nutrition Examination Survey. This sample included 7,417 adults ages 40 years and older. They found 534 men and women in the survey were affected. That translates to 6.5% of the U.S. population. The group most likely to be affected: women 40 to 60.

Most people with phantom odor issues, about 89%, don't broach the problem with their health care provider, the researchers found. Anyone can get this condition, but lower-income people -- researchers aren’t sure why that is -- as well as those with dry mouth problems or anyone with a history of head injury is more likely to.

As for why more women than men? 'Women are more in tune with their chemical world,' says study co-author Donald Leopold, MD, an ear, nose, and throat specialist and professor of surgery at the University of Vermont Medical Center, Burlington. They buy fragranced products more often than men, for instance, he suspects.

The study is published in JAMA Otolaryngology -- Head & Neck Surgery.

A Patient's Story

Mike Gonzales, 41, an auto mechanic in Loveland, CO, has had phantom odor issues since 2015, he says. First was the hotel room that he describes as smelling of rotting fast food. 'I wrote it off at first that it was just the hotel,' he says. But 'it followed me home.'

Then came the dirty feet smell around the computer desk at home. A dinner his wife prepared smelled burned, but it wasn't, she assured him. 'Around this time, I also started getting a smell of burnt plastic, seemed to be mostly when I'd wake up in the morning.'

The phantom odor affects him at least once a day and sometimes as many as three times, he says. He's tried nasal sprays and washes, among other suggested remedies, he says, but nothing seems to work. He saw a therapist for a while to deal with the depression that has resulted, he says.

'I've been trying to laugh about it some, best way for me to deal with the depression,' he says.

Causes and What to Do

People should mention the phantom odor problem to their health care provider, experts say. It's been linked with medical conditions such as epileptic seizure, depression, head trauma, and migraine. So ruling those out is wise.

Those affected often try finding the source for days or weeks before seeing their doctor, Leopold says. At that point, any sense of humor about the issue that may have been there originally has dissipated, he says. People want relief. 'I've had people rip up carpets,' he says, to try to uncover the source of the smell.

'It's an unrecognized problem,' says Nina Shapiro, MD, a professor of head and neck surgery at the UCLA David Geffen School of Medicine and a co-author of Hype: A Doctor's Guide to Medical Myths, Exaggerated Claims and Bad Advice. She was not involved in the NIH study.

She understands that people don't bring it up but agrees they should. 'It can certainly affect quality of life.'

The problem is, doctors can't really say what causes it. 'It's somehow related to airflow,' Leopold says. He has had patients report to him that they wake up without smelling anything unusual. But then they sniff or sneeze, and the odor without a source is back.

'The biologic cause of phantom odor remains unknown,' Bainbridge says. Overactive nerve cells in the nasal cavity may play a role, she says, or something may be miswired with the central nervous system related to how odors are interpreted in the brain. Leopold's money is on the brain theory.

Some success has been reported, Leopold says, with using anti-seizure medications or antidepressants.

A simple at-home treatment may work, too, he says. Patients get a squeeze bottle and fill it with salt water. They 'get on their hands and knees, forehead to the floor.' They squeeze the bottle to inject saltwater into each nostril. 'That will unclog the upper nasal cavity.' And sometimes the phantom odor disappears.

Leopold used to perform an operation to destroy the sense of smell. 'I have stopped doing it,' he says. 'I don't think it's very good therapy.'

Time alone may solve the problem. 'I will often advise people to live with it, deal with it,' he says. 'It's a huge hit to their quality of life.'

Azure SQL Database is an automatically managed data service that constantly monitors your queries and identifies the action that you can perform to improve performance of your workload. You can review recommendations and manually apply them, or let Azure SQL Database automatically apply corrective actions - this is known as automatic tuning mode.

Automatic tuning can be enabled at the server or the database level through the Azure portal, REST API calls and T-SQL commands.

Note

For Managed Instance, the supported option FORCE_LAST_GOOD_PLAN can be configured through T-SQL only. Portal based configuration and automatic index tuning options described in this article do not apply to Managed Instance.

Note

Configuring Automatic tuning options through ARM (Azure Resource Manager) template is not supported at this time.

Enable automatic tuning on server

On the server level you can choose to inherit automatic tuning configuration from 'Azure Defaults' or not to inherit the configuration. Azure defaults are FORCE_LAST_GOOD_PLAN is enabled, CREATE_INDEX is enabled, and DROP_INDEX is disabled.

Important

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As of March, 2020 changes to Azure defaults for automatic tuning will take effect as follows:

• New Azure defaults will be FORCE_LAST_GOOD_PLAN = enabled, CREATE_INDEX = disabled, and DROP_INDEX = disabled.
• Existing servers with no automatic tuning preferences configured will be automatically configured to INHERIT the new Azure defaults. This applies to all customers currently having server settings for automatic tuning in an undefined state.
• New servers created will automatically be configured to INHERIT the new Azure defaults (unlike earlier when automatic tuning configuration was in an undefined state upon new server creation).

Azure portal

To enable automatic tuning on Azure SQL Database logical server, navigate to the server in Azure portal and then select Automatic tuning in the menu.

Note

Please note that DROP_INDEX option at this time is not compatible with applications using partition switching and index hints and should not be enabled in these cases. Dropping unused indexes is not supported for Premium and Business Critical service tiers.

Select the automatic tuning options you want to enable and select Apply.

Automatic tuning options on a server are applied to all databases on this server. By default, all databases inherit configuration from their parent server, but this can be overridden and specified for each database individually.

REST API

Find out more about using REST API to enable Automatic tuning on a server, see SQL Server Automatic tuning UPDATE and GET HTTP methods.

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Enable automatic tuning on an individual database

The Azure SQL Database enables you to individually specify the automatic tuning configuration for each database. On the database level you can choose to inherit automatic tuning configuration from the parent server, 'Azure Defaults' or not to inherit the configuration. Azure Defaults are set to FORCE_LAST_GOOD_PLAN is enabled, CREATE_INDEX is enabled, and DROP_INDEX is disabled.

Tip

The general recommendation is to manage the automatic tuning configuration at server level so the same configuration settings can be applied on every database automatically. Configure automatic tuning on an individual database only if you need that database to have different settings than others inheriting settings from the same server.

Azure portal

To enable automatic tuning on a single database, navigate to the database in Azure portal and select Automatic tuning.

Individual automatic tuning settings can be separately configured for each database. You can manually configure an individual automatic tuning option, or specify that an option inherits its settings from the server.

Please note that DROP_INDEX option at this time is not compatible with applications using partition switching and index hints and should not be enabled in these cases.

Once you have selected your desired configuration, click Apply.

Rest API

Find out more about using REST API to enable Automatic tuning on a single database, see SQL Database Automatic tuning UPDATE and GET HTTP methods.

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T-SQL

To enable automatic tuning on a single database via T-SQL, connect to the database and execute the following query:

Setting automatic tuning to AUTO will apply Azure Defaults. Setting it to INHERIT, automatic tuning configuration will be inherited from the parent server. Choosing CUSTOM, you will need to manually configure automatic tuning.

To configure individual automatic tuning options via T-SQL, connect to the database and execute the query such as this one:

Setting the individual tuning option to ON, will override any setting that database inherited and enable the tuning option. Setting it to OFF, will also override any setting that database inherited and disable the tuning option. Automatic tuning option, for which DEFAULT is specified, will inherit the automatic tuning configuration from the server level settings.

Important

In case of active geo-replication, Automatic tuning needs to be configured on the primary database only. Automatically applied tuning actions, such are for example index create or delete will be automatically replicated to the read-only secondary. Attempting to enable Automatic tuning via T-SQL on the read-only secondary will result in a failure as having a different tuning configuration on the read-only secondary is unsupported.

Find our more abut T-SQL options to configure Automatic tuning, see ALTER DATABASE SET Options (Transact-SQL) for SQL Database server.

Disabled by the system

Automatic tuning is monitoring all the actions it takes on the database and in some cases it can determine that automatic tuning can't properly work on the database. In this situation, tuning option will be disabled by the system. In most cases this happens because Query Store is not enabled or it's in read-only state on a specific database.

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Permissions

As automatic tuning is Azure feature, to use it you will need to use Azure's built-in RBAC roles. Using SQL Authentication only will not be sufficient to use the feature from Azure portal.

To use automatic tuning, the minimum required permission to grant to the user is Azure's built-in SQL DB contributor role. You can also consider using higher privilege roles such are SQL Server Contributor, Contributor and Owner.

Configure automatic tuning e-mail notifications

See automatic tuning e-mail notifications guide.

Next steps

• Read the Automatic tuning article to learn more about automatic tuning and how it can help you improve your performance.
• See Performance recommendations for an overview of Azure SQL Database performance recommendations.
• See Query Performance Insights to learn about viewing the performance impact of your top queries.