Deviated nasal septum. 3. Its influence on the physiology and disease of the nose and ear. I

The Nose as a Route for Therapy: Part 1. Pharmacotherapy

This article reviews nasal structure and function in the light of intranasal pharmacotherapy. The nose provides an accessible, fast route for local treatment of nose and sinus diseases, with lower doses than are necessary systemically and few adverse effects. It can also be used for other medications as it has sufficient surface area protected from local damage by mucociliary clearance, absence of digestive enzymes, responsive blood flow, and provides a rapid route to the central nervous system.

Nasal Polyps: Epidemiology, Pathology, Immunology, and Treatment

Nasal polyps frequently are associated with aspirin intolerance, intrinsic asthma. Young's syndrome, cystic fibrosis, and Kartagener's syndrome. Children 16 years or younger with nasal polyps should be evaluated for cystic fibrosis. Nasal polyps are frequently bilateral, multiple, freely movable, and pale-gray and arise from the middle meatus of the nose. Histologically, they classically have pseudostratified ciliated columnar epithelium, thickening of the epithelial basement membrane, high stromal eosinophil count, mucin with neutral pH, few glands, and essentially no nerve endings. Cells consist of a mixture of lymphocytes, plasma cells, and eosinophils. Polyps from patients with Young's syndrome, Kartagener's syndrome, and cystic fibrosis have predominately neutrophils with insignificant eosinophils. Chemical mediators found in nasal polyps are as follows: histamine, serotonin, leukotrienes [(SRS-A or LTC4, LTD4, LTE4), LTB4], ECF-A, norepinephrine, kinins, TAME-esterase, and possibly PGD2. There is more histamine in nasal polyps than in normal nasal mucosa, and norepinephrine is present in greater concentration in the base of nasal polyps than in normal mucosa. The concentrations of IgA and IgE and, in some cases, IgG and IgM are greater in polyp fluid than in serum. IgE-mediated disease is not the cause of nasal polyps, but when present, may contribute to episodes of exacerbation. Despite medical or surgical management, a significant number of nasal polyps are recurrent. For treatment, systemic corticosteroids should be tried before surgical polypectomy. Polypectomy does not increase the risk of developing asthma or making asthma worse. At the present time, the pathogenesis of polyp formation is unknown.

Chronic Sinusitis and Nonallergic Rhinitis

Syndromes of chronic sinusitis (CS) and nonallergic rhinitis (NAR) are poorly defined. There is a paucity of epidemiologic studies and long-term treatment outcome remains based mainly on anecdotal evidence. Clinical diagnoses must be differentiated from those made solely on radiographic criteria. The role of allergic disease in CS is undetermined. Many factors such as vascular reactivity, cellular infiltration, modifications of nasal secretions, anatomic abnormalities, deficiency of mucociliary clearance, immunodeficiency, and nasal reflexes contribute to symptom pathogenesis. The question whether NAR is a disease or an exaggerated physiologic response is controversial and is addressed in this contribution. Ultimately, enhanced knowledge of the pathophysiology of CS and NAR may lead to novel therapeutic approaches. Patients readily attribute a variety of symptoms such as postnasal drainage, facial fullness or swelling, head pressure, and nasal congestion to the paranasal sinuses. Unfortunately, many practitioners do not adopt a critical attitude to diagnosing sinus pathology and differentiating it from exaggerated physiologic responses to environmental factors. In this paper I will try to highlight some of the difficulties in this area.

The ontogeny of nasal floor shape variation in extant humans

Variation in nasal floor topography has generated both neontological and paleontological interest. Three categories of nasal floor shape (Franciscus: J Hum Evol 44 (2003) 699-727) have been used when analyzing this trait in extant humans and fossil Homo: flat, sloped, and depressed (or "bi-level"). Variation in the frequency of these configurations within and among extant and fossil humans has been well-documented (Franciscus: J Hum Evol 44 (2003) 699-727; Wu et al.: Anthropol Sci 120 (2012) 217-226). However, variation in this trait in Homo has been observed primarily in adults, with comparatively small subadult sample sizes and/or large age gradients that may not sufficiently track key ontogenetic changes. In this study, we investigate the ontogeny of nasal floor shape in a relatively large cross-sectional age sample of extant humans (n = 382) ranging from 4.0 months fetal to 21 years post-natal. Results indicate that no fetal or young infant individuals possess a depressed nasal floor, and that a depressed nasal floor, when present (ca. 21% of the sample), does not occur until 3.0 years postnatal. A canonical variates analysis of maxillary shape revealed that individuals with depressed nasal floors were also characterized by relatively taller anterior alveolar regions. This suggests that palate remodeling at about 3.0-3.5 years after birth, under the influence of tooth development, strongly influences nasal floor variation, and that various aspects of dental development, including larger crown/root size, may contribute to the development of a depressed nasal floor. These results in extant humans may help explain the high frequency of this trait found in Neandertal and other archaic Homo maxillae.

Anatomical and histological factors affecting intranasal drug and vaccine delivery

The aim of this review is to provide an understanding of the anatomical and histological structure of the nasal cavity, which is important for nasal drug and vaccine delivery as well as the development of new devices. The surface area of the nasal cavity is about 160 cm², or 96 m² if the microvilli are included. The olfactory region, however, is only about 5 cm² (0.3 m² including the microvilli). There are 6 arterial branches that serve the nasal cavity, making this region a very attractive route for drug administration. The blood flow into the nasal region is slightly more than reabsorbed back into the nasal veins, but the excess will drain into the lymph vessels, making this region a very attractive route for vaccine delivery. Many of the side effects seen following intranasal administration are caused by some of the 6 nerves that serve the nasal cavity. The 5^th cranial nerve (trigeminus nerve) is responsible for sensing pain and irritation following nasal administration but the 7^th cranial nerve (facial nerve) will respond to such irritation by stimulating glands and cause facial expressions in the subject. The first cranial nerve (olfactory nerve), however, is the target when direct absorption into the brain is the goal, since this is the only site in our body where the central nervous system is directly expressed on the mucosal surface. The nasal mucosa contains 7 cell types and 4 types of glands. Four types of cells and 2 types of glands are located in the respiratory region but 6 cell types and 2 types of glands are found in the olfactory region.

[A study of the Eustachian tube function in patients with a scuba diving accident]

The scuba diving population has increased very much recently, bringing with it a rise in barotrauma. Ninety-seven patients with scuba diving-related accidents (34 males and 63 females; mean +/- SD: 36.6 +/- 10.3 years) and 39 healthy volunteers (9 males and 30 females; mean +/- SD: 41.1 +/- 16.9 years) without a history of Eustachian tube dysfunction participated in this study. All patients underwent audiometric measurements, including hearing testing, tympanometry, and Eustachian tube function testing (sonotubometry and impedance test). The tympanometry results of the majority of the patients were normal (Jerger A type), however, 83 of 97 patients (85.6%) were diagnosed as having Eustachian tube dysfunction: all patients had tubal stenosis. Compared with healthy volunteers, the Eustachian tube function in scuba diving patients was significantly lower. According to whether the affected parts were one ear or both ears, we classified these patients into 2 types, that is, the unilateral group and the bilateral group. The symptoms in the unilateral group were more serious than those in the bilateral group. In the unilateral group, the Eustachian tube functions of the affected ear did not always show lower than those of the healthy ear, so we thought that excessive positive pressure at the mesotympanum caused by the Valsalva maneuver might have affected not only the affected ear but also the healthy ear and have resulted in healthy ears being severely impaired by excessive positive pressure. To prevent scuba divers from pressure injury, we think that divers should have their Eustachian tube dysfunction accurately evaluated and any problems should be treated well.

Bilateral sinonasal polyposis in a patient with unilateral choanal atresia

Sinonasal polyposis is a disorder of hyperplastic mucosal inflammation that subsequently leads to the development of smooth, pale, non-neoplastic masses. The theories on its pathogenesis are diverse and remain debated within the medical community. A distinct, widely accepted, and unifying theory is absent, and probably unrealistic given the varying possible causes. The case reported here, which demonstrates nasal polyp formation within an atretic nasal cavity, suggests that nasal airflow or aerodynamics may have little to no effect on its etiology. It also seems to provide evidence that at least in some individuals nasal polyps appear to be due to an inflammatory disorder independent of inhalant allergen challenge.

Considerations in the etiology, treatment, and repair of septal perforations

Nasal septal perforations present a distinct challenge to the facial plastic surgeon. A clearcut causal factor must be established from a long, diverse list of potential causes. Surgical repair presents a complex technical challenge, because a septal perforation is a hole in three distinct contiguous layers composed of both right and left septal mucoperichondral flaps and the intervening cartilage, all three of which must be separated from each other and repaired individually. This article describes presenting symptoms and findings for septal perforations, the history and physical examination, causes, helpful hints for prevention of perforations, and surgical and nonsurgical treatment options and outcomes.

Septal perforation repair

Nasal septal perforations present a distinct challenge to the otolaryngologist-head and neck surgeon, and a problem to the patient. The techniques for repairing septal perforations that have the best physiologic result, the highest success rate, and the best long-term patient acceptance and comfort, require the use of bilateral intranasal mucosal advancement flaps with the interposition of a connective tissue graft. The presenting symptoms and findings, the history and physical examination, the causes of septal perforations, helpful hints for prevention, and surgical and nonsurgical treatment options and outcomes are discussed in this article.

The relationship between nasal airway resistance and middle ear pressure in subjects with acute upper respiratory tract infection

Middle ear pressure and nasal airway resistance were measured over 7 1/2h in 8 subjects (age 18-32) with symptomatic acute upper respiratory tract infection. The mean middle ear pressure was -13 +/- 1.5 daPa (s.e.m.) with a range between 65 to -140 daPa. The mean total nasal resistance was 0.4 +/- 0.02 Pa/cm3/s (s.e.m.) with a range between 0.20 to 1.28 Pa/cm3/s. Unilateral nasal airway resistance exhibited reciprocal fluctuations with a range between 0.18-3.60 Pa/cm3/s. The mean difference between the highest and lowest unilateral nasal resistance values for each subject was 1.48 +/- 0.22 Pa/cm3/s (n = 16). No correlation was found between unilateral nasal airway resistance and middle ear pressure. Total nasal airway resistance had an inverse correlation with middle ear pressure r = 0.32, r2 = 0.11, n = 176 (p < 0.001). The results indicate that the generation of a negative middle ear pressure in acute upper respiratory tract infection occurred in a manner consistent with intermittent obstruction of the Eustachian tube and gradual middle ear gas absorption. Rapid increases in middle ear pressure and the generation of a positive middle ear pressure were associated with nose blowing. No evidence was found to support the hypothesis that negative middle ear pressures are associated with sniffing.

Seasonal allergic rhinitis and its effects on eustachian tube function and middle ear pressure

Middle ear pressure was recorded from 396 ears and aural symptoms inquired of 198 adult subjects with seasonal allergic rhinitis. Evidence of eustachian tube dysfunction was found in 24% of subjects. Increased duration of exposure to pollen over a further 2 weeks increased the incidence of eustachian tube dysfunction to 48%. The development of eustachian tube dysfunction did not correlate with the severity of nasal symptoms.

Middle ear as a gas pocket

An analysis of 45 adult ears that underwent a modified radical mastoidectomy for cholesteatoma and remained with an intact unperforated pars tensa is described. 1) While in practically all these ears some air was present behind the tympanic membrane, its amount varied considerably. 2) The air present behind the tympanic membrane was always in communication with the eustachian tube. 3) The regions in the middle ear devoid of air presented a deep atelectasis that was found predominantly in the posterior-superior part of the middle ear. Topographically the regions of air and atelectasis corresponded to the distribution of ciliated and flat epithelia in the middle ear, respectively. The presence of air in the middle ears obliges us to view these ears as being aerated gas pockets. The aeration difference between such an atelectatic ear and one in a physiologic state is probably a difference of degree. This difference can result from reduction in aeration through the eustachian tube or from excessive absorption of gases into the circulation, or from deficient normal diffusion of carbon dioxide or nitrogen from the circulation into the middle ear, or from a combination of these factors. The analogy with the respiratory system is emphasized.

Eustachian tube function following adenoidectomy: an evaluation by sniffing

Recent investigations have demonstrated an association between sniff-induced negative middle ear pressure and otitis media with effusion. This is taken as evidence of Eustachian tube malfunction. Adenoidectomy is frequently performed as part of the surgical management for otitis media with effusion, but whether this affects Eustachian tube function is uncertain. The aim of this study was to investigate the hypothesis that if adenoidectomy improved Eustachian tube function, children who had undergone adenoidectomy would show less tendency to generate a high negative intratympanic pressure by sniffing. Eustachian tube function was studied actively in 40 children with otitis media with effusion. Twenty children, selected at random, underwent adenoidectomy and all 40 had a unilateral grommet inserted. Eighty-five percent of the children could create a negative middle ear pressure by sniffing, but there was no difference in the number of 'sniff + ve' children between the adenoidectomy and control groups (P greater than 0.5), or in the magnitude of the negative pressure induced. It is concluded that a high percentage of children with otitis media with effusion are capable of inducing a negative middle ear pressure by sniffing, but this parameter of Eustachian tube function is not affected by adenoidectomy.

Septal manipulation in the neonate: method and results

The septal configuration at birth may be straight (type A) which occurs in 42% cases, bent to one side (type B), or deformed to both sides (type C). There is a close correlation of these types, immediately with nasal obstruction and feeding problems and later with the development of dental abnormalities and respiratory infections of the throat and ear. These symptoms occur most in type B cases and least in type A cases. A total of 284 babies was assessed at birth and then when aged about 5 years. A total of 105 babies, who had minimal trouble and were used as controls and not manipulated, were compared with 179 who had troublesome symptoms and were manipulated. Manipulation greatly reduced the incidence of these problems at a statistically significant level. The physiological reason why type B causes more ear disease than types A or C is described. This involves the normally occurring Bernouilli's phenomenon in the nose. The external nasal deformity which causes minimal physiological changes, and occurs in 4% of births, can be successfully straightened by manipulation.

The relationship between the 'superior constrictor swallow', clicking of the ears and ear disease

A normal modified type of swallow is described, the function of which is to open the pharyngotympanic tube. It is associated with clicking of the ears. The tensor veli palatini, the levator palatini and the superior constrictor muscles appear to be the muscles involved, as it can occur without swallowing or movement of the tongue, or speaking. This modified swallow has been called the 'superior constrictor swallow', and it is demonstrated by productions of typical frames from a cine film. Sniffing, yawning and normal swallowing can occur with or without opening of the pharyngotympanic tubes, but this normal modified swallow (SCS) must be initiated to produce opening of the tubes. The change in middle-ear pressures with clicking is well shown with tympanometry. Modified swallow, largely involving the inferior constrictor muscle, may also occur.

The development and significance of septal and dental deformity from birth to eight years

The septa of a series of 145 babies at birth was assessed into 3 types: type A--in the midline, type B--unilateral bending or kinking at the vomerine junction, type C--deformed to both sides. These were reassessed aged 5-6 years with the primary dentition present, and 90 cases reassessed aged about 8 years. In some there was a change to types B and C, but none changed to type A. Of 15 cases of external deformity of the nose at birth, 10 (66%) had irregularity of the columella. The children had dental examination and plaster casts made, an ear, nose and throat examination, and were photographed. The chances (which were statistically significant) of developing dental abnormalities and malocclusion, palatal asymmetry, upper respiratory tract infections and ear disease were found to be mostly in type B cases, less in type C cases and least in type A cases. Thus ear troubles were found in 45% type B, 25% type C and only 10% of type A cases. The palatal height was not related to any septal deformity.

Pressure opening and closing functions of the Eustachian tube by inflation and deflation in children and adults with normal ears

Different inflationary (e.g. Valsalva's) and deflationary (e.g. sniffing) manoeuvres were studied in 58 children and 61 adults, all otologically healthy, in order to evaluate qualitatively and quantitatively the pressure opening and closing functions of the Eustachian tube. Only 71% of the normal children could voluntarily increase the middle ear pressure compared with 100% of the adults. The corresponding figures for evacuating the middle ear by deflation were 24% and 34%, respectively. The rhinopharyngeal pressure levels during the manoeuvres were age-dependent and decided the response rate in children. Tubal factors also determined the response rate since low pressure opening and closing levels were related to successful deflation. Negative middle ear pressures found in the normal children were due to poor muscular opening function of the tube rather than successful deflation. The pressure closing level seems to be a reliable tool in grading tubal closing ability.

Experimental study of velocity fields in a human nasal fossa by laser anemometry

Velocity fields were mapped in a model of a human nasal fossa by laser doppler velocimetry, an innovative, quantitative and noninvasive method of optical anemometry, and by computerization. Other pertinent parameters were also calculated. Studies made at different cross sections of the nasal fossa showed the very definite influence not only of shapes and dimensions but also of direction of flow on velocity fields. The turbinates had a streamlining effect on the velocity fields while the liminal valve had a directional effect. Flow was usually greater in the lower half of the fossa and closer to the septum. The flow was generally turbulent. Velocity fields appear to give more information on intranasal aerodynamics than the calculated flow and Reynolds number for the sections studied, and this allows one to at least theorize that there may be an aerodynamic basis to certain pathological conditions of the nasal airway and its adjoining cavities, the paranasal sinuses, and the eustachian tubes.

Sniff-induced negative middle ear pressure: study of a consecutive series of children with otitis media with effusion

Sniff-induced negative pressure in the middle ear space has recently been demonstrated in patients with the retraction type of middle ear disease. In the present study pressure recordings were performed in a consecutive series of 50 children treated with ventilating tubes for otitis media with effusion. It was found that a majority of the patients were able to induce negative pressure in the middle ear by sniffing. The ability to equalize negative pressure was found to be poor. These findings suggest a causal relationship between sniff-induced negative pressure in the middle ear space and the development of middle ear effusion.

On the origin of the high negative pressure in the middle ear space

It has generally been assumed that a high negative pressure in the middle ear space results from obstruction of the eustachian tube and the subsequent gas resorption through the middle ear mucosa. There is clinical evidence that quite a different mechanism is operating. The present experimental study verifies, with direct pressure recordings in cases of the retraction type of cholesteatoma and related conditions, that a high negative pressure can be generated by an active evacuation of air through the eustachian tube. The high negative pressure induced may explain the development of tympanic membrane retraction and pocketing, and the subsequent development of cholesteatoma.

Bilateral Antrochoanal Polyps

Unilateral antrochoanal polyps are quite common, but reports of bilateral incidence are very rare.

Deviated nasal septum. Incidence and etiology

Septal deformity is of two kinds, which may occur independently, or together: 1) anterior cartilage deformity of the quadrilateral septal cartilage, caused by direct trauma or pressure at any age; and 2) combined septal deformity involving all the septal components, caused by compression across the maxilla from pressures occurring during pregnancy or parturition. This is part of a facial deformity. The incidence of septal deformity was investigated in 2,380 Caucasian infants at birth, 2,112 adult skulls of five ethnic groups (European, Indian [Asian], Chinese, African and Australian Aborignal), 918 mammals (266 higher and lower apes, 457 other placental mammals and 185 marsupials). The method of nasal testing of infants by passage of special testing struts (6 by 2 mm) is described. Forty-two percent of septa of infants were straight, 27% deviated and 31% kinked. A similar pattern was found in adult skulls, namely 21% straight, 37% deviated and 42% kinked. Anterior cartilage deformity occurred in about 4% of births. The maxillary molding theory of transmitted pressures during pregnancy or partitution, causing septal deformity, is described. The findings show that varying degrees of septal deformity occur at a constant rate at birth and in the adult. These may vary slightly for each ethnic type. Birth molding pressures are a major cause of dental malocclusion. The shape and strength of the skull and the erect posture appear to be major factors, for septal deformity did not occur in the lower animals, but occurred in 37% of the higher apes and also in a skull of a hominid 1,750,000 years old. This concept enables easy recognition at birth, and the carrying out of a rational method of treatment by manipulation and rapid maxillary expansion.

Nasal polyposis

A review of 313 cases of nasal polyposis indicates that there is a high incidence of recurrence in this disease. Other nasal pathology affects a significant number of these patients. Simple surgical removal of the polypi by a transnasal route is the common mode of treatment.