Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence

Endonasal Thermal Imaging Before and After Nasal Airway Surgery

OBJECTIVE

Nasal airway surgery is often applied when treatment fails to relieve nasal obstruction. However, surgery that improves airflow does not always alleviate the symptoms of nasal obstruction. The perception of nasal breathing is likely more related to changes in mucosal temperature than the mechanical sensation of flow or pressure. This study aims to measure intranasal mucosal temperature pre-and post-surgery using endonasal thermal imaging, exploring its correlation with subjective nasal breathing and objective airflow measurements.

METHODS

A prospective study of adult patients with nasal obstruction managed with nasal airway surgery was performed. Intranasal mucosal temperatures were determined using the thermal endonasal image of the nasal passage produced by the infrared radiometric thermal camera (FILR VS290). A comparison was made between the mean values of mid-expiration (ExT) and mid-inspiration (InT) temperature data (internal nasal valve, nasal cavity, inferior turbinate, and overall airway [mean value]) and visual analog scale (VAS), Nasal Obstruction Symptom Evaluation (NOSE) scale and nasal airway resistance (NAR) before and after surgery.

RESULTS

Seven patients (35.14 ± 16.45 years, 57.14% female) were included. All NOSE, VAS, and NAR improved after surgery (59.29 ± 10.89 vs 17.14 ± 14.64; P < .001, 64.50 ± 26.79 vs 18.57 ± 19.99; P < .001, 0.82 ± 0.48 vs 0.34 ± 0.11 Pa/cm3/s; P = .002, respectively). ExT, InT, and the difference between ExT and InT of three areas and overall airway were similar between pre-and post-surgery. No statistically significant correlations were found between intranasal mucosal temperature, VAS, NOSE, and NAR at pre-and post-surgery except for the difference between ExT and InT of overall airway and NOSE pre-operative (Pearson r = 0.57; 95% CI 0.06-1.09; P = .03).

CONCLUSION

Endonasal thermal imaging can assess the intranasal mucosal temperature of a patient. However, more precise imaging of the nasal passages and data acquisition are required to establish mucosal temperature as an objective measure of nasal obstruction before and after nasal airway surgery in a clinical setting.

Computational analysis of nasal airflow and its alteration by a nasal dilator

Nasal airflow obstruction correlates with several ailments, such as higher patency, increased friction at the mucosal wall or the so-called Little's area, improper air conditioning, and snoring. Nasal dilators are frequently employed, mainly due to their ease of access and use, combined with their non-permanent and non-surgical nature. Their overall efficacy, however, has not been clearly demonstrated so far, with some studies reporting conflicting outcomes, mainly because being based on subjective evaluations. This study employs Computational Fluid Dynamics simulations to analyze the flow inside a real nose, performs an objective assessment of a nasal dilator's effect in terms of airflow and air conditioning, reporting flow paths, friction levels, heat and water fluxes and detailed temperature and humidity distributions. Coincidentally, the studied nose presents a septal deviation, with one nostril being wider than the other. The tubes of the dilator used in both nostrils are identical, as with any standard commercial dilator. Consequently, the dilator widens one nostril, as intended, but results in an obstruction in the other. This allows simultaneously addressing two situations, the nominal function of the dilator, as well as an off-design case. Results indicate a 24 % increase in nasal patency in the design situation. The effect, however, is limited, as quantified by appropriate measures, such as the flow-generated friction at the nose surfaces and the temperature fluxes. Hence, the effect of such a dilator in nominal conditions is perhaps not as large as might be hoped. In the off-design situation, nasal resistance increases by 62 %, an undesirable effect, illustrating the consequences of using an inappropriate dilator.

"Functional Rhinofiller": Improvement of Nasal Airflow with Rhinofiller-A Retrospective Review

INTRODUCTION

Rhinofiller is an aesthetic medical technique that can significantly enhance facial aesthetics by employing hyaluronic acid infiltration. The aim of this study is to review the impact of aesthetic rhinofiller on nasal airflow.

METHODS

This is a retrospective review of 63 consecutive patients. The evaluation of the change in nasal respiratory flow was performed subjectively using a Likert questionnaire and objectively using a rhinomanometer, which enabled active anterior rhinomanometry (AAR). Data were collected at pre-intervention, post-intervention, and at 6-month follow-up.

RESULTS

Among the 63 patients, the questionnaire responses resulted statistically significant both after the treatment and at the 6-month follow-up (p=0.00001). A statistically significant improvement was also observed at the rhinomanometric evaluation between pre-intervention and post-intervention (p=0.006 at 74 Pa, p=0.002 at 100 Pa, and p=0.001 at 150 Pa) and at the 6-month follow-up (p=0.008 at 74 Pa, p=0.003 at 100 Pa, and p=0.002 at 150 Pa). Differences between results were established with a Student's t-test. All p-values were two-tailed, and a value < 0.05 was considered significant.

CONCLUSIONS

Rhinofiller can be a valuable aid in enhancing both nasal airflow and facial aesthetics. Based on our experience, it resulted in an immediate post-operative improvement in nasal airflow that remains stable in the subsequent 6 months.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 . IV: Non-Surgical Procedures.

Impact of posture and CPAP on nasal airflow

Obstructive sleep apnea (OSA) patients who use continuous positive airway pressure (CPAP) often complain of nasal dryness and nasal obstruction as side effects of CPAP. The physiological mechanisms by which CPAP may cause nasal dryness and nasal obstruction remain poorly understood. It has been hypothesized that CPAP interferes with the nasal cycle, abolishing the resting phase of the cycle and leading to nasal dryness. We performed rhinomanometry measurements in 31 OSA patients sitting, laid supine, and supine after 10 min of CPAP at 10 cmH2O. A posture change from sitting to supine led to more symmetric airflow partitioning between the left and right nostrils in the supine position. CPAP did not have a significant impact on nasal resistance, unilateral airflows, or airflow partitioning. Our results suggest that airflow partitioning becomes more symmetric immediately after changing to a supine position, while CPAP had no effect on nasal airflow, thus preserving the nearly symmetric airflow partitioning achieved after the posture change.

Functional and esthetic outcomes of functional rhinoplasty for internal nasal valve dysfunction in Asian patients

OBJECTIVE

This study aimed to use validated measures to evaluate the functional and esthetic outcomes in patients who underwent functional rhinoplasty for Internal Nasal Valve Dysfunction (INVD) in Korea.

METHODS

A retrospective review of consecutive patients who underwent functional rhinoplasty for INVD confirmed by endoscopic findings and the modified Cottle test between 2016 and 2018 was performed. Nasal obstruction was assessed with the Visual Analog Scale (VAS) and nasal obstruction symptom evaluation (NOSE) scale. Acoustic rhinometry was performed pre- and post-operatively. The Minimal Cross-Sectional Area (MCA) of the nose was measured. Objective assessment of the esthetic outcomes was performed with the Objective Rhinoplasty Outcome Score (OROS), which assesses tip rotation, projection, width, dorsal height, width, length, symmetry, and the overall result.

RESULTS

Fifty-seven patients (46 men and 11 women; mean age, 30.5 ± 12.3 years) who underwent functional rhinoplasty were included in this study. The VAS and NOSE scores indicated functional improvement in all cases (all p < 0.001). There were no significant between-group differences (VAS score, p = 0.274; NOSE score, p = 0.952). The objective functional outcomes evaluated using MCA on the concave (p = 0.478) and convex (p = 0.631) sides did not differ significantly pre- and post-operatively. The subjective evaluation of esthetic satisfaction revealed no between-group difference. Moreover, 31 out of 44 patients (70.5%) with static INVD and nine out of 14 patients (64.3%) with dynamic or combined INVD showed excellent outcomes. Regarding objective esthetic outcomes, scores for the eight factors were >3, and there was no significant difference between the two groups (all p > 0.05).

CONCLUSIONS

Functional rhinoplasty, including extracorporeal septoplasty and spreader grafting, may be a viable option for correcting INVD with functional and esthetic improvement. Dynamic INVD is less prevalent among Asians, and there was no significant difference in the surgical outcomes compared with those of static INVD.

LEVEL OF EVIDENCE

Level 4.

Peak Nasal Inspiratory Flow (PNIF) for Nasal Breathing Evaluation

Measuring nasal airflow and nasal breathing has been a major goal of rhinology. Many objective methods for measuring nasal airflow or nasal airway resistance or dimensions provide valuable data but are time-consuming and require expensive equipment and trained technicians, thus making these methods less practical for clinical practice. Peak nasal inspiratory flow (PNIF) measurement is fast, unexpensive, noninvasive, and able to provide an objective evaluation of nasal airflow in real-time. Unilateral PNIF measurements allow separated evaluation of each side of the nasal airway and may prove particularly useful when clinical assessment detects significant asymmetry between both nasal cavities.PNIF measurements are most useful for assessing changes in nasal airflow achieved by any form of therapy, including surgical treatment of the nasal airway. These measurements generally correlate with other objective methods for nasal airway evaluation, but not unequivocally with patient-reported evaluation of nasal breathing. Nevertheless, as low PNIF values prevent the sensation of a suitable nasal breathing, PNIF measurement may also prove useful to optimize the decision of how to best address patients with complaints of nasal airway obstruction.

Quantifying the Subjective Experience of Nasal Obstruction: A Review

Nasal obstruction is an exceedingly common problem and challenging to treat due to its multifactorial etiology. Therefore, measuring treatment outcomes of nasal obstruction can be equally complex yet vital to appropriately assessing symptom improvement or resolution. Both physiologic and anatomic assessments of the nasal airway exist in addition to validated patient-reported outcome measures (PROMs), which objectify subjective nasal obstruction and sinonasal symptoms. Correlation between objective and subjective treatment outcome measures is controversial with clinical guidelines favoring the use of PROMs for surgical treatment of nasal obstruction. In this review, the anatomic and physiologic measurements of the nasal airway and validated PROMs will be discussed, as well as the rationale for implementing PROMs into the rhinoplasty surgeon's practice.

Nasal Patency Measurement: State of the Art of Acoustic Rhinometry

Nasal obstruction is one of the main symptoms of different nasal pathologies. Many physiological and pathological conditions can produce nasal airflow impairment causing nasal obstruction and affecting patients' quality of life. There are different methods for the measurement of nasal obstruction, but in clinical practice the most common used are acoustic rhinometry, rhinomanometry, and peak nasal inspiratory flow. This review describes the fundamentals of acoustic rhinometry, its normal values, the different physiological and pathological conditions that can modify nasal patency, and the utility of this instrument for the measurement of nasal obstruction in clinical practice. Acoustic rhinometry is a simple test, so it is suitable for measurements in the pediatric population, i.e., for evaluating adenoid hypertrophy. Acoustic rhinometry normal values are available, unilaterally and bilaterally for pediatric and adult populations. Acoustic rhinometry has been demonstrated to be reproducible and even superior to rhinomanometry when measuring nasal modifications during challenges. It is possible to use acoustic rhinometry before and after nasal surgery. Measuring nasal cavities volume and cross-sectional area, acoustic rhinometry is particularly indicated in rhinosurgery, especially for the evaluation of spreader grafts. Brief considerations about the correlation between nasal symptoms, in particular the subjective sensation of nasal obstruction, and the acoustic rhinometry results as well as the correlation of acoustic rhinometry with other methods for the measurement of nasal obstruction are also reported. Objective and subjective evaluation of nasal obstruction gives different information that together optimizes the diagnosis and the treatment of rhinologic patients. Acoustic rhinometry alone or in combination of other instruments for the measurement of nasal obstruction or patency should be used regularly in every outpatient clinic that treats patients with nasal obstruction as there is an increasing need of evidence-based therapies.

Chief Complaint: Nasal Congestion

Nasal obstruction is the subjective perception and objective state of insufficient airflow through the nose. Nasal congestion, conversely, describes a state of not just inadequate airflow or obstructive phenomena but also pressure- and mucus-related states to the patient. Nasal receptors belonging to the transient receptor potential (TRP) protein family mediate the sense of nasal patency via the trigeminal nerve. The transient receptor potential melastatin-8 (TRPM8) responds to temperatures around 8°C to 22°C, and is stimulated by menthol and other cooling agents. The radiant effects of airflow create heat loss to activate these receptors and humans perceive this as nasal patency rather than the direct detection of airflow. The thermovascular state of the mucosa, in conditions such as rhinitis, influence TRPM8 activation. Nasal endoscopy can show signs of rhinitis and should be considered an essential part of the workup of nasal congestion. Efforts to relieve nasal congestion need to manage the mucosal state and surgery needs to ensures that the nasal cavity mucosa is exposed to the cooling effects of airflow rather than simply creating a passage to the nasopharynx.

An adjoint-based approach for the surgical correction of nasal septal deviations

Deviations of the septal wall are widespread anatomic anomalies of the human nose; they vary significantly in shape and location, and often cause the obstruction of the nasal airways. When severe, septal deviations need to be surgically corrected by ear-nose-throat (ENT) specialists. Septoplasty, however, has a low success rate, owing to the lack of suitable standardized clinical tools for assessing type and severity of obstructions, and for surgery planning. Moreover, the restoration of a perfectly straight septal wall is often impossible and possibly unnecessary. This paper introduces a procedure, based on advanced patient-specific Computational Fluid Dynamics (CFD) simulations, to support ENT surgeons in septoplasty planning. The method hinges upon the theory of adjoint-based optimization, and minimizes a cost function that indirectly accounts for viscous losses. A sensitivity map is computed on the mucosal wall to provide the surgeon with a simple quantification of how much tissue removal at each location would contribute to easing the obstruction. The optimization procedure is applied to three representative nasal anatomies, reconstructed from CT scans of patients affected by complex septal deviations. The computed sensitivity consistently identifies all the anomalies correctly. Virtual surgery, i.e. morphing of the anatomies according to the computed sensitivity, confirms that the characteristics of the nasal airflow improve significantly after small anatomy changes derived from adjoint-based optimization.

Long-Term Outcomes of Septoplasty With or Without Turbinoplasty: A Systematic Review

BACKGROUND

Septoplasty is used to correct nasal obstruction from nasal septum deviation. However, the long-term efficacy of septoplasty is unclear, and no literature reviews have examined long-term outcomes of septoplasty with or without turbinate modification. This systematic review aimed to evaluate the long-term efficacy of septoplasty with or without turbinate modification in improving nasal obstruction.

DATA SOURCES

PubMed, EMBASE, Cochrane CENTRAL.

METHODS

A systematic review of the literature was conducted using the aforementioned databases. Studies reporting outcomes 12+ months after functional septoplasty with or without turbinate surgery for nasal obstruction were included. Septorhinoplasties, concurrent sinus surgery, pediatric studies, and studies where septoplasty was performed for indications other than nasal obstruction were excluded.

RESULTS

After screening, 35 studies with 4,432 patients were included. Mean weighted post-operative follow-up time was 29.1 months (range 12-120 months). All studies reported significant improvement in subjective and objective outcomes at long-term follow-up compared to baseline. When comparing short-term (<12 months) to long-term (≥12 months) outcomes, four studies noticed that subjective outcomes worsened slightly over time, but no study found a significant change in objective outcomes over time. In addition, 23 studies reported patient satisfaction and/or improvement rates, with 75.4% (2,348/3,113) of patients expressing satisfaction/improvement at an average of 27.0 months after surgery.

CONCLUSIONS

Overall, septoplasty with or without turbinate modification shows significant improvement in obstructive symptoms at long-term follow-up per both objective and subjective measures. Whether outcomes may worsen slightly over time remains indeterminate based on mixed results in the literature.

LEVEL OF EVIDENCE

N/A Laryngoscope, 134:2525-2537, 2024.

Overview of Nasal Airway and Nasal Breathing Evaluation

Several methods are available for evaluating nasal breathing and nasal airflow, as this evaluation may be made from several different perspectives.Physiologic methods for nasal airway evaluation directly measure nasal airflow or nasal airway resistance, while anatomical methods measure nasal airway dimensions. Subjective methods evaluate nasal breathing through several validated patient-reported scales assessing nasal breathing. Computational fluid dynamics evaluates nasal airflow through the analysis of several physics' variables of the nasal airway.Being familiar to these methods is of utmost importance for the nasal surgeon to be able to understand data provided by the different methods and to be able to choose the combination of evaluation methods that will provide the information most relevant to each clinical situation.

Evaluation of Nasal Conditions on Sleep: Integrating Wearable Tech in Surgical Outcomes

Objective: The primary objective of this study was to explore and identify the impacts of nasal septum deviation and turbinate hypertrophy on respiratory function, sleep quality, and overall well-being. Additionally, the study aimed to establish the therapeutic efficacy of surgical intervention and comprehensively analyse the additional advantages of wearable sleep trackers when combined with established diagnostic techniques. Methods: A prospective cohort of 150 participants (75 with nasal septum deviation and 75 with turbinate hypertrophy) underwent surgical intervention. The NOSE scale, PSQI, SF-36, and wearable sleep tracker data were employed for pre- and post-surgical evaluations. Objective measurements, such as nasal airflow and acoustic rhinometry, were also used. Multivariate regression was utilised to identify potential predictors of post-surgical outcomes. Results: The cohort had a mean age of 41 years with evenly balanced gender distribution. Both conditions showed post-surgical improvements in respiratory function, sleep quality, and quality-of-life. Wearable sleep tracker data provided insights into REM sleep duration and interruptions during sleep. The results indicated significant disturbances in sleep patterns in individuals with nasal septum deviation before undergoing surgery. Duration of the nasal condition was found to be a significant factor in predicting outcomes. Conclusion: Nasal septum deviation and turbinate hypertrophy had a significant impact on sleep patterns, overall well-being, and respiratory function. Surgical interventions provided significant relief, and wearable sleep tracker integration provides deeper insights into sleep disorders. The study highlights the importance of early intervention and the benefit of modern technologies in clinical evaluations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04524-y.

Correlation between Subjective Nasal Patency and Nasal Capacity in Young Adults: A Pilot Study with a Prototype Device-A Nasoorospirometer

Background: Nasal airway obstruction (NAO) is characterised by high resistance in the nasal cavity with a collapsible and narrowed upper airway and is an integral part of OSA pathophysiology. The literature demonstrates that the identification of high-risk OSA in the young adult population leads to the prevention of later health consequences. A nasoorospirometer is a prototype device that measures nasal capacity during inspiration. The basis for measurement is a Wheatstone bridge and a thermal anemometer. The parameters are recorded via hot wire anemometry (HTA) with velocity measurements in the airflow field. Therefore, this pilot study aimed to test the feasibility of the device by examining a young adult sample. The secondary aim was to determine whether subjective NAO correlates with nasal capacity and whether NAO corresponds with anthropometric parameters and individual risk of OSA. Methods: A group of 31 participants (mean age 24.9 years) underwent a thorough laryngological examination. The nasoorospirometer was used to measure objective NAO (nasal capacity), the NOSE scale was used to gain subjective NAO evaluation, and the Berlin Questionnaire for the risk of OSA. Results: A correlation analysis confirmed no significant associations between the subjective and objective measures (p > 0.05). Higher BMI and neck circumference are associated with lower NAO and higher nasal patency in the population of young adults (r: 0.32-0.45; p < 0.05). The risk of OSA showed no statistically significant association (p > 0.05). Conclusions: We presented three methods of NAO assessment: subjective participant evaluation, objective nasoosopirometry, and objective laryngological assessment. However, the use of a nasoorospirometer with anthropometric measures in young adults needs to be verified in future studies.

Promising New Diagnostic and Treatment Modalities for Allergic Rhinitis: What's Coming Next?

Novel diagnostic tests may help diagnose patients with local allergic rhinitis (AR) when systemic testing is negative or inconclusive. Surgical approaches including septoplasty, inferior turbinate reduction, nasal swell body reduction, and posterior nasal nerve ablation may improve symptoms in patients whose symptoms are refractory to medical therapy, though high-quality evidence is lacking in the AR population. Intralymphatic and epicutaneous immunotherapy have the potential to improve adherence to allergen immunotherapy, though comparisons with current gold standard treatments are lacking and studies reporting long-term outcomes are needed. Immunomodulatory agents in combination with subcutaneous immunotherapy (SCIT) may improve tolerance of SCIT but reports to date do not demonstrate a clear benefit in symptom alleviation. Future work in these areas may support these options as beneficial for testing and treatment of AR.

CT comparison of the nasal airway anterior and posterior to the piriform aperture in patients with and without nasal obstruction

BACKGROUND

Nasal airway stenosis may lie anterior and/or posterior to the piriform aperture. We intended to compare the nasal airway anterior and posterior to the piriform aperture in patients with and without nasal obstruction.

METHODS

Segmented computed tomography cross-sectional areas of the nasal airway anterior (CT-CSAant) and posterior to the piriform aperture (at the level of the head of the inferior turbinate; CT-CSApost) were compared between patients with nasal obstruction (cases) and trauma controls. CT-CSA were approximately perpendicular to the direction of the nasal airflow. Anterior to the piriform aperture, they were tilted about 30o, 60o and 90o to the nasal floor. Posterior to the piriform aperture, they were tilted about 50o, 80o and 100o to the nasal floor. In cases, we examined the Pearson's correlation of active anterior rhinomanometry with CT-CSAant and CT-CSApost.

RESULTS

Narrow and bilateral CT-CSApost were similarly large between 56 cases and 56 controls (all p > 0.2). On the contrary, narrow and bilateral CT-CSAant were significantly smaller in cases than in controls (all p < 0.001). The ratio of the size of CT-CSAant-30 to that of CT-CSApost-80 was significantly lower in cases (median: 0.84; lower to upper quartile: 0.55-1.13) than in controls (1.0; 0.88-1.16; Mann-Whitney U test; p = 0.006). Bilateral CT-CSAant correlated significantly with total inspiratory flow (all p < 0.026) in contrast to bilateral CT-CSApost (all p > 0.056).

CONCLUSIONS

The nasal airway anterior to the piriform aperture was smaller in patients with nasal obstruction due to skeletal nasal stenosis than that in controls. On the contrary, the nasal airway posterior to the piriform aperture was similarly large between patients with and without nasal obstruction. Furthermore, in patients with nasal obstruction, the anterior nasal airway was narrower compared to that located posterior to it. On the contrary, control patients' anterior nasal airway was as large as the posterior one.

Computational Rhinology: Unraveling Discrepancies between In Silico and In Vivo Nasal Airflow Assessments for Enhanced Clinical Decision Support

Computational rhinology is a specialized branch of biomechanics leveraging engineering techniques for mathematical modelling and simulation to complement the medical field of rhinology. Computational rhinology has already contributed significantly to advancing our understanding of the nasal function, including airflow patterns, mucosal cooling, particle deposition, and drug delivery, and is foreseen as a crucial element in, e.g., the development of virtual surgery as a clinical, patient-specific decision support tool. The current paper delves into the field of computational rhinology from a nasal airflow perspective, highlighting the use of computational fluid dynamics to enhance diagnostics and treatment of breathing disorders. This paper consists of three distinct parts-an introduction to and review of the field of computational rhinology, a review of the published literature on in vitro and in silico studies of nasal airflow, and the presentation and analysis of previously unpublished high-fidelity CFD simulation data of in silico rhinomanometry. While the two first parts of this paper summarize the current status and challenges in the application of computational tools in rhinology, the last part addresses the gross disagreement commonly observed when comparing in silico and in vivo rhinomanometry results. It is concluded that this discrepancy cannot readily be explained by CFD model deficiencies caused by poor choice of turbulence model, insufficient spatial or temporal resolution, or neglecting transient effects. Hence, alternative explanations such as nasal cavity compliance or drag effects due to nasal hair should be investigated.

Usefulness of nasal cavity evaluation before high-resolution esophageal manometry in high-risk patients

BACKGROUND/AIMS

A catheter is inserted through the nasal cavity during high-resolution esophageal manometry (HRM), which may cause adverse events such as pain or epistaxis. Despite these possible safety considerations, studies on this subject are very limited. We aimed to investigate the usefulness of nasal cavity evaluation before HRM to reduce the risk of adverse events and test failure.

METHODS

Patients who underwent HRM after consultation with the ear-nose-throat department for nasal evaluation were retrospectively enrolled between December 2021 and May 2022. The included patients had a previous history of sinonasal disease or surgery or had subjective nasal discomfort. All patients answered the Sino-Nasal Outcome Test (SNOT-22) questionnaire, and subjective nasal discomfort was scored using a visual analog scale. Nasal endoscopy and acoustic rhinometry were performed for disease evaluation and volumetric assessment.

RESULTS

The analysis included 22 patients with a mean age of 58.9 years. The mean SNOT-22 score was 24.2, and 16 patients (72.7%) complained of subjective nasal obstruction. The HRM catheter was successfully inserted in 20 patients (90.9%), without any significant adverse events. The objective measurement outcomes of acoustic rhinometry and sinus endoscopy did not always correspond to subjective symptoms. Narrowed nasal airways unresponsive to decongestants were observed in two patients with failed catheter insertion.

CONCLUSION

To reduce the risk of adverse events and test failure during HRM, a site-specific questionnaire to evaluate nasal obstruction might be helpful. When nasal obstruction is suspected, objective nasal cavity evaluation could be recommended for the safe and successful performance of HRM.

Intranasal trigeminal sensitivity to mechanical stimuli is associated with the perception of nasal patency

PURPOSE

The aim of this prospective study was to examine the characteristics of a clinical test for the assessment of nasal trigeminal sensitivity to mechanical stimuli and its association with the perception of nasal patency.

METHODS

Thirty-two normosmic healthy subjects participated (17 women and 15 men; age = 26 ± 3 years). Precisely defined air puffs were used with a flow rate of 2L/min for mechanical stimulation. They were presented to the nasal vestibule, nasal septum, and inferior turbinate with various stimulus durations. Thresholds were measured by single-staircase stimuli with changes in stimulus duration in steps of 10 ms. Trigeminal suprathreshold intensity was rated by subjects for stimulus durations of 200, 300, 400, and 500 ms. Test-retest reliability was examined by intraclass correlations (ICCs) and Bland-Altman plot with limits of agreement. Pearson's correlations were calculated between self-rated nasal patency and nasal trigeminal sensitivity.

RESULTS

As indicated by trigeminal threshold and suprathreshold intensities, the nasal vestibule is the most sensitive area among the three locations, followed by the nasal septum and the inferior turbinate (p < 0.001). Coefficients of correlations between test and retest were 0.76 for thresholds, and 0.56 suprathreshold intensities (p < 0.001). The Bland-Altman analysis showed a good agreement between test-retest values. In addition, significant positive associations between trigeminal suprathreshold intensities and self-rated nasal obstruction were found at the inferior turbinate (r = 0.4, p < 0.05).

CONCLUSION

Reliable assessment of nasal trigeminal sensitivity for air puffs appears to be possible. Nasal trigeminal suprathreshold sensitivity to mechanical stimuli is associated with the perception of nasal patency at the inferior turbinate. This opens a window into the assessment of the perception of nasal airflow in various clinical purposes, especially for patients with sinonasal diseases.

LEVEL OF EVIDENCE: 3

Computational fluid dynamics calculations in inferior turbinate surgery: a cohort study

PURPOSE

To investigate how the results of nasal computational fluid dynamics (CFD) simulations change due to inferior turbinate surgery and how the results correlate with patient specific subjective assessment and volumetric results in the nasal cavities.

METHODS

The steady inspiratory airflow of 25 patients was studied pre- and postoperatively with heat transfer from the mucous membrane by performing CFD calculations to patient-specific nasal cone beam computed tomography images. These results were then compared to the severity of the patients' nasal obstruction Visual Analogue Scale (VAS) and Glasgow Health Status Inventory assessments, and acoustic rhinometry measurements.

RESULTS

Total wall shear forces decreased statistically significantly (p < 0.01) in the operated parts of the inferior turbinates. Patients' subjective nasal obstruction VAS assessment changes between the pre- and postoperative conditions correlated statistically significantly (p = 0.04) with the wall shear force results.

CONCLUSION

Inferior turbinate surgery lead to decreased total wall shear force values postoperatively. Changes in subjective nasal obstruction VAS results against total wall shear force changes between the pre- and postoperative conditions were statistically significant. CFD data have a potential to be used for the evaluation of nasal airflow.

The long-term effect of maxillary advancement and impaction on subjective and objective nasal patency: A retrospective case-control study

The aim of this study was to investigate the change of nasal patency after maxillary advancement and impaction (MAX_ADV + IMP) in subjects with skeletal class III malocclusion (cases) and after removal of maxillary cysts in close proximity to the nasal floor in subjects that served as controls. NOSE score, volume derived by computed tomography (VOL), and acoustic rhinometry and rhinomanometry were retrospectively evaluated, before and one year after surgery. The movement of specific landmarks was also measured. NOSE score did not change after surgery, neither in 17 cases (p = 0.10) nor in 17 controls (p = 0.14). In cases, VOL_postop (10088 ± 4200 mm³) was significantly higher than VOL_preop (7807 ± 3721 mm³; p = 0.036). Maxillary advancement and inferior displacement of the ventral maxilla were noted by the movement of incisive foramen in the coronal (3.9 ± 5.4; p = 0.011) and Frankfurt Horizontal plane (2.2 ± 2.0; p = 0.001), respectively. In controls, VOL_postop (9749 ± 3654 mm³) was also significantly higher than VOL_preop (8473 ± 2624 mm³; p = 0.050). Cross-sectional areas, nasal flow and nasal resistance changed significantly after surgery in cases (6/30 pairs; p < 0.018), but not in controls (all p > 0.066). MAX_ADV + IMP increased nasal patency, but did not change the feeling of nasal breathing. Physicians should proceed with caution when informing patients about improvement of nasal breathing after MAX_ADV + IMP.

Correlations between objective and subjective tests of nasal patency in patients undergoing septoplasty

OBJECTIVE

This study assessed correlations between pre- and post-operative objective and subjective nasal patency test results in patients undergoing septoplasty to treat nasal septum deviation.

METHOD

Eighty nasal septum deviation patients who underwent septoplasty were prospectively enrolled. Nasal Obstruction Symptom Evaluation questionnaire scores, anterior rhinomanometry and acoustic rhinometry data were compared pre-operatively and three months after surgery. The left, right and total volume and left, right and total minimum cross-sectional area acoustic rhinometry values were compared.

RESULTS

The left volume, total volume, left minimum cross-sectional area and total minimum cross-sectional area differed significantly between the two time-points (all p < 0.05). The total resistance, inspiratory total airflow, expiratory total resistance and expiratory total airflow rhinomanometric data did not differ between the two timepoints (all p > 0.05).

CONCLUSION

This study suggested that subjective tests such as the Nasal Obstruction Symptom Evaluation questionnaire are optimal to identify complaints and assess post-operative satisfaction.

Changes in nasolabial angle may alter nasal valve morphology and airflow: a computational fluid dynamics study

Aim: Nasal valve (NV) dysfunctions are a significant cause of nasal obstruction. Changes in the nasolabial angle (NLA) may also cause changes in NV morphology. The effect of changes in the 3D structure of the nasal valve region (NVR) on nasal airflow has yet to be studied sufficiently. The accuracy of computational fluid dynamics (CFD) simulation results of nasal airflow has been confirmed by in vitro tests. Therefore, this study aimed to evaluate the effect of changes in NV structure and volume on nasal airflow based on the CFD method. Material and Method: We used CT images to create a 3D structural model of the NVR. First, CT images were transferred to MIMICS® software, and the nasal air passage was modeled. A solid reference model of the NVR was then created using SolidWorks software. Five different solid 3D nasal valve models were created with nasolabial angles of 85˚ in Model 1, 90˚ in Model 2, 95˚ in Model 3, 100˚ in Model 4, and 105˚ in Model 5. To simulate breathing during rest and exercise using the CFD method, the unilateral nasal airflow rates were set at 150 ml/s and 500 ml/s, respectively. The CFD method was then used to calculate each model’s airflow properties. Finally, the volumes of the models, pressure at the NV outlet, and airflow velocity were evaluated and calculated to investigate each model’s NV airflow characteristics. Results: Our study found a significant correlation between the nasolabial angle (NLA) and NVR volume (r=-0.998, p=0.000), flow rate and velocity (r=0.984, p=0.000), velocity and maximum pressure (r=0.920, p=0.000), velocity and minimum pressure (r=-0.969, p=0.000), flow rate and maximum pressure (r=0.974, p=0.000), and flow rate and minimum pressure (r=-0.950, p=0.000). There was no correlation between NLA increase and nasal airflow velocity. We determined that the highest pressure and lowest airflow velocity values were in the upper angle region and that the lowest pressure and highest airflow velocity values were at the bottom of the NVR in all models. Conclusion: Using the CFD method, we found a decrease in NVR volume and an increase in airflow velocity with an increase in NLA. In addition, we found that the pressure values in the NVR did not change significantly with the increase in NLA.

Influence of Age and Gender on Nasal Airway Patency as Measured by Active Anterior Rhinomanometry and Acoustic Rhinometry

In this study, we aimed to investigate the influences of age and gender on nasal airway patency, as measured by both active anterior rhinomanometry (AAR) and acoustic rhinometry (AR). The nasal airway patency of healthy subjects was evaluated using AAR and AR. In AAR, the subjects generated airflow actively through inspiration and expiration in repetitions of10, while nasal patency was measured at an inspiratory and expiratory reference pressure of 75 Pa. In AR, we assessed the geometry of the nasal cavity through the analysis of sound waves reflected from the nasal cavities in order to measure both cross-sectional areas and nasal volumes. The subjects were divided by gender, with all males and females then grouped by ages of 20–39 years, 40–59 years and ≥60 years. There were 40 subjects in each group. The mean resistance measured by AAR and the cross-sectional areas and nasal volumes measured by AR were not different between the different age groups; however, the cross-sectional areas and nasal volumes were found to be lesser in females than in males. Our results showed that nasal airway patency was not affected by age, while females were shown to have wider nasal passages than males.

Improvement in Nasal Obstruction and Quality of Life after Nasal Septoplasty with Turbinoplasty: A Pre- and Post-study

Introduction Septoplasty and turbinoplasty are common surgical interventions used to relieve nasal obstructive symptoms. Since it is difficult to measure the degree of nasal blockage, current literature wonders about the frequent performance of these procedures.

Objective To evaluate the perceived change in the nasal obstruction and the quality of life (QoL) of patients that underwent a septoplasty along with a turbinoplasty by applying subjective scales, to describe the correlation between those scales, and to study the impact of clinical factors in the postoperative outcomes.

Methods Prospective observational study. The Nasal Obstruction Symptom Evaluation (NOSE), the Visual Analog Scale (VAS), and the Glasgow Benefit Inventory (GBI) were assessed. The paired sample Wilcoxon test was used to evaluate the difference between the pre- and postoperative surveys. The correlation coefficient between the subjective scales was calculated. A quantile regression was performed to evaluate the effect of surgery on the results adjusted for clinical and demographic variables.

Results A total of 115 patients were interviewed. Postoperative NOSE scores were 45 points lower (95% confidence interval [CI]: - 53.53–- 35.46; p < 0.001) in comparison with the NOSE preoperative scores. Obesity was the only statistically significant factor associated with worse outcomes. Additionally, we found a high correlation between the NOSE and VAS scores and a negative correlation between the GBI and postoperative VAS scores.

Conclusion Nasal septoplasty, when paired with a turbinoplasty, decreases nasal obstruction and improves QoL. Obesity was associated with worse results. There was a strong correlation between the NOSE and the VAS results and between the GBI and postoperative VAS results.

Unmet challenges in septoplasty–nordic studies from a uniform healthcare and geographical area

Purpose

Nasal septoplasty is one of the most common surgical procedures in otorhinolaryngology and optimising both patient selection and the surgery is a challenge. The Nordic countries have similar public healthcare systems and comparable populations in terms of size.

Methods

This is a review of studies of outcome and predictors related to septoplasty from Denmark, Finland, Norway and Sweden, published during the last decade. The aim of this review was to identify areas in need of further research to meet the challenges of septoplasty in the Nordic countries with reference to international data.

Results

Postoperative patient satisfaction at 6–12 months was reported in around 2/3 of the patients and well in line with international data. Patients with more severe symptoms had a higher chance of improvement. Lack of standardisation in patient selection, surgical methods and skills, and follow up procedures, still makes it difficult to explain the 25% failure rate in septoplasty surgery.

Conclusion

This review of the Nordic studies from the last decade shows that septoplasty in general is effective in relieving nasal obstruction. There is a need for studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This includes an awareness of how surgical skills in septoplasty are obtained and maintained.

Structural and functional changes of nasal cavity and maxillary sinus in patients with skeletal class III malocclusion 1 year after bimaxillary surgery

PURPOSE

This study aimed to analyse changes in the nasal cavity and maxillary sinus structure and function in patients with skeletal class III malocclusion 1 year after bimaxillary surgery.

MATERIALS AND METHODS

In this study, cone-beam computed tomography (CBCT) images of 20 patients (10 men and 10 women; mean age 24.3 ± 3.4 years) with skeletal class III malocclusion who underwent Le Fort I osteotomy and bilateral sagittal split osteotomy were obtained before and 1 year after the surgery. CBCT data were stored opened with element 3D (E3D) to establish a nasal airway model (the paranasal sinus includes only the maxillary sinus). Ansys (ANSYS) software is used for simulation and analysis.

RESULTS

The maxillary sinus and nasal cavity volumes decreased significantly 1 year after the surgery. After surgery, the volume of nasal cavity decreased by 13.5%, and the average volume of maxillary sinus decreased by 7.8%. There was no significant difference in the degree of deviation of the septum and nasal cavity resistance, and air distribution in the maxillary sinus did not change. The nasal cavity wall shear stress change was similar to that before surgery.

CONCLUSIONS

The maxillary sinus volume and nasal cavity volume of patients with skeletal class III malocclusion changed significantly after bimaxillary surgery, but there was no significant change in nasal ventilation function 1 year after surgery.

Pharmacology, particle deposition and drug administration techniques of intranasal corticosteroids for treating allergic rhinitis

This review presents an overview of the available literature regarding intranasal corticosteroids (INCs) for the treatment of allergic rhinitis (AR). Various treatment options exist for AR including INCs, antihistamines and leucotriene antagonists. INCs are considered to be the most effective therapy for moderate-to-severe AR, as they are effective against nasal and ocular symptoms and improve quality of life. Their safety has been widely observed. INCs are effective and safe for short-term use. Local adverse events are observed but generally well-tolerated. The occurrence of (serious) systemic adverse events is unlikely but cannot be ruled out. There is a lack of long-term safety data. INC may cause serious eye complications. The risk of INCs on the hypothalamic-pituitary-adrenal axis, on bone mineral density reduction or osteoporosis and on growth in children, should be considered during treatment. Pharmacological characteristics of INCs (e.g. the mode of action and pharmacokinetics) are well known and described. We sought to gain insight into whether specific properties affect the efficacy and safety of INCs, including nasal particle deposition, which the administration technique affects. However, advances are lacking regarding the improved understanding of the effect of particle deposition on efficacy and safety and the effect of the administration technique. This review emphasizes the gaps in knowledge regarding this subject. Advances in research and health care are necessary to improve care for patients with AR.

Can Nose Scale Be Used as a Predictor of Successful Surgery in Patients Undergoing Septoplasty

The complaint of nasal obstruction or difficulty in nasal breathing is highly subjective. The benefits of surgery vary depending upon patient perception and satisfaction. Along with objective methods like nasal endoscopy improvement in subjective score of patients symptoms is definitely an important outcome parameter of management. Assessing the disease specific quality of life outcomes of patients undergoing septoplasty by means of a questionnaire using nose scale and correlating it with diagnostic nasal endoscopic findings and clinical examination thirty patients above 17 years of age, with anatomical deviation of the nasal septum as the sole cause of obstruction and symptoms persisting for more than 3 months, underwent septoplasty. Degree of septal deviation was classified as per Mladina classification. Patients Nasal Obstruction & Symptom Evaluation (NOSE) score were documented preoperatively and postoperatively and analysed. In our study it was found that there was significant improvement in nose scores which correlated with the improvement in nasal endoscopic findings. Use of NOSE score will help in letting the patient know his expected outcome following septoplasty and can be used as a predictor of successful surgery/an adjunct to clinical examination and nasal endoscopy in patients undergoing septoplasty. Disease specific health status instruments like Nose scale are needed along with objective outcome measures to compare disease-specific health status and symptom severity in patients before and after treatment. Similarly it could be used to assess differences in outcome when different surgical techniques are used. These subjective scales like nose scale can be used as along with to clinical examination and nasal endoscopy in the management of patients undergoing septoplasty.

Correlation of Nasal Mucosal Temperature and Nasal Patency—A Computational Fluid Dynamics Study

OBJECTIVES

Recent evidence suggests that detection of nasal mucosal temperature, rather than direct airflow detection, is the primary determinant of subjective nasal patency. This study examines the role of nasal mucosal temperature in the perception of nasal patency using in vivo and computational fluid dynamics (CFD) measurements.

METHODS

Healthy adult participants completed Nasal Obstruction Symptom Evaluation (NOSE) and Visual Analogue Scale (VAS) questionnaires. A temperature probe measured nasal mucosal temperature at the vestibule, inferior turbinate, middle turbinate, and nasopharynx bilaterally. Participants underwent a CT scan, used to create a 3D nasal anatomy model to perform CFD analysis of nasal mucosal and inspired air temperature and heat flux along with mucosal surface area where heat flux >50 W/m² (SAHF50).

RESULTS

Eleven participants with a median age of 27 (IQR 24; 48) were recruited. Probe-measured temperature values correlated strongly with CFD-derived values (r = 0.87, p < 0.05). Correlations were seen anteriorly in the vestibule and inferior turbinate regions between nasal mucosal temperature and unilateral VAS (r = 0.42-0.46; p < 0.05), between SAHF50 and unilateral VAS (r = -0.31 to -0.36; p < 0.05) and between nasal mucosal temperature and SAHF50 (r = -0.37 to -0.41; p < 0.05). Subjects with high patency (VAS ≤10) had increased heat flux anteriorly compared with lower patency subjects (VAS >10; p < 0.05).

CONCLUSION

Lower nasal mucosal temperature and higher heat flux within the anterior nasal cavity correlates with a perception of improved unilateral nasal patency in healthy individuals.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:1328-1335, 2023.

Computational fluid dynamics assessed changes of nasal airflow after inferior turbinate surgery

OBJECTIVE

To demonstrate how Computational Fluid Dynamics (CFD) simulations can reveal important airflow changes in the nasal cavities due to surgical interventions.

MATERIAL AND METHODS

The steady inspiratory airflow of eight patients was studied pre- and postoperatively with heat transfer from the mucous membrane by performing CFD calculations to patient specific cone beam computed tomography (CBCT) images. Eight patients with the largest distance from pre- and postoperative mean changes in inferior turbinate volumetry and Visual Analogue Scale (VAS) results were selected.

RESULTS

Calculated CFD heat transfer results from the anterior parts of the inferior turbinates, where surgical interventions were performed, decreased significantly. The heat transfer results were in line with VAS changes.

CONCLUSION

Surgical interventions reduced heat transfer in the operated parts of the inferior turbinates and were in line with VAS changes. CFD is an option in assessing patient well-being as a function of airflow parameters from mucous membrane with larger data sets. The limitations of the study were the small sample size and the preliminary nature of the study.

Comparative Functional Effect of Alternative Surgical Techniques Used in Rhinoplasty

OBJECTIVE

The purpose of this investigation is to compare the functional effect of the different surgical techniques used for addressing each section of the nose.

METHODS

Prospective study of 57 consecutive rhinoplasty patients. Patients were evaluated with peak nasal inspiratory flow (PNIF), Nasal Obstruction Symptom Evaluation (NOSE), and Visual Analog Scale (VAS) for nasal obstruction before and 1 year after rhinoplasty. Additionally, esthetic evaluation of the nose was obtained with Rhinoplasty Outcomes Evaluation (ROE). According to the surgical technique used to address each portion of the nose, groups of patients were created and the functional improvement of these groups was compared.

RESULTS

Using the TukeyHSD multiple pairwise-comparison test, the estimated difference of the increase of PNIF between using spreader grafts and using spreader flaps was 94.9 (95% CI 24.3, 165.5, P = .004) between spreader grafts and neither grafts or flaps was 79.2 (95% CI 5.8, 152.6, P = .03), between spreader grafts and bilateral spreader flaps plus a unilateral spreader graft was 90.2 (95% CI 22.1, 158.2, P = .005). In all other portions of the nose, no significant difference was found in the functional improvement between different surgical techniques.

CONCLUSIONS

Spreader grafts increase PNIF more significantly than other surgical techniques used for dorsal mid-vault reconstruction. Spreader grafts should be preferred over other techniques whenever an improvement of nasal airflow is required. No significant differences were found between the functional effect of alternative techniques used in other sections of the nose. Additional cohort studies will be necessary to further confirm data from this investigation.

Validation of the traditional Chinese version of the Sinus and Nasal Quality of Life Survey (SN-5) for children

BACKGROUND

Persistent sinonasal symptoms are common in children with chronic rhinosinusitis. The Sinus and Nasal Quality of Life (QoL) Survey (SN-5) was the first validated questionnaire measuring sinonasal-related QoL in populations aged 2-12 years. No norm has been established for Chinese-speaking countries. We translated the SN-5 into traditional Chinese and evaluated validity and reliability.

METHODS

From December 2016 to December 2017, healthy volunteers and children with persistent sinonasal symptoms were enrolled. Guardians of the participants completed the SN-5, a visual analog scale (VAS) of nasal symptoms, and the Obstructive Sleep Apnea-18 (OSA-18); the responses were used to assess internal consistency, discriminant validity, and treatment responsiveness. A nontreatment group was administered the SN-5 1 week later to assess test-retest reliability.

RESULTS

We recruited 31 healthy volunteers and 85 children with rhinosinusitis, 50 and 35 in the treatment and nontreatment groups, respectively. The SN-5 demonstrated good internal consistency (Cronbach's α = 0.86) and test-retest reliability (0.74, p < 0.01). It exhibited good discriminant validity between the healthy and rhinosinusitis groups (p < 0.001). The SN-5 scores were correlated with the VAS scores (0.63, p < 0.001). The effect size of the SN-5 scores was 0.51. The total SN-5 and OSA-18 scores changed significantly after 4-week treatment (p < 0.05) and demonstrated good responsiveness. The SN-5 and OSA-18 scores were significantly and positively correlated (r² = 0.53, p < 0.001).

CONCLUSION

Our traditional Chinese version of the SN-5 is reliable and valid for measuring sinonasal-related QoL in children in Chinese-speaking countries.

TRIAL REGISTRATION NUMBER

NCT04836403.

Assessing the ability of children and parents to rate their nasal patency. A cross sectional study

OBJECTIVE

Nasal obstruction is a common complaint in pediatric otolaryngology. There are several concerns about how nasal obstruction should be measured. This debate is even more important in children, as they can experience difficulties in being sensitive to their symptoms or even expressing them. In this research we aim to explore the ability of children (and their parents) to assess their nasal obstruction.

PARTICIPANTS

AND METHODS: An observational cross-sectional study was performed. Four cohorts of children were consecutively selected from a third level referral Hospital. Cohort A (children suffering solely turbinate enlargement), B (adenoid enlargement only), and C (adenoid and turbinate enlargement), while cohort D were healthy controls. Children and parents were asked to rate nasal patency through a Likert scale from 0 (no patency, complete obstruction of the nose) to 10 (complete patency, it is easy to breathe through the nose). All participants underwent rhinomanometry. Results of nasal resistance were relativized according to pediatric reference values per each age subgroup.

RESULTS

146 participants were included. Cohort A (54), B (40), C (28), D (24). There is a poor but significant correlation between parents' assessment and nasal resistance (rho = -0.28; p = 0.004). In children, there is no significant correlation with nasal resistance (rho = -0.14; p = 0.17). Stratified by severity, only children (and their parents) with good nasal breathing demonstrated good correlation values with the visual analogue score (VAS). Stratified by age, the correlation is only significant for parents of children older than 12 years old.

CONCLUSIONS

This study has demonstrated a good ability to rate nasal patency by healthy children and their parents, but a poor ability for children suffering from impaired nasal breathing. We suggest combining subjective assessment of nasal patency with objective measurements such as rhinomanometry in children.

Efficacy of subcutaneous house dust mite immunotherapy in patients with moderate to severe allergic rhinitis

Aim: To evaluate the efficacy of subcutaneous immunotherapy (SCIT) for the treatment of allergy to house dust mites (HDM) in adults with moderate/severe allergic rhinitis (AR). Methods: Patients sensitized to HDM were randomized to SCIT plus rescue medication (Group A, n = 38) or rescue medication alone (Group B, n = 18), and assessed at baseline and 2, 6 and 12 months. Results: At month 12, Group A presented significant improvement with respect to baseline as evaluated by a visual analogue scale at three concentrations of antigen (0.1, 1 and 10 IR/ml; p < 0.0001). Group A presented significant decreases in symptom scores after 2 months of treatment, which were maintained after 1 year. After 12 months of treatment, Group A showed rescue medication consumption reductions (p < 0.001) and quality of life improvements (p < 0.0001). SCIT elicited a strong immunological response and was well tolerated. Conclusion: SCIT is efficacious for HDM allergy in patients with AR, generating a strong immunological response. Trial Registration Number: EUCTR2009-018155-16-ES (Cochrane Central Register of Controlled Trials).

Accuracy of peak nasal flow to determine nasal obstruction in patients with allergic rhinitis

Objective

Methods

Results

Conclusions

Effects of Functional Rhinoplasty on Nasal Obstruction: A Meta-Analysis

BACKGROUND

Functional rhinoplasty (FRP) is used to improve nasal ventilation by correcting problems with the nasal valves. It has not been systematically reviewed on a large scale.

METHODS

A comprehensive literature search was conducted in the PubMed, EMBASE, and Cochrane Library databases to identify studies evaluating nasal obstruction before and after functional rhinoplasty in patients with nasal valve problems.

RESULTS

A total of 57 cohorts from 43 studies involving 2024 patients were included in the current meta-analysis. The Nasal Obstruction Symptom Evaluation (NOSE) scores indicated significant improvement in nasal obstruction at the 1-month follow-up (WMD = 38.12; 95% CI, 29.15-47.10; I²= 83.6%; P = 0.00), 3-month follow-up (WMD = 48.40; 95% CI, 43.16-53.64; I²= 69.1%; P = 0.00), 6-month follow-up (WMD = 44.35; 95% CI, 36.65-52.04; I²= 96.6%; P = 0.00), 12-month follow-up (WMD=43.07; 95% CI, 26.56-59.58; I²= 97.9%; P = 0.00), and the last follow-up (WMD = 46.90; 95% CI, 43.92-49.88; I²= 95.9%; P = 0.00) with respect to the preoperative baseline. The Visual Analogue Scale (VAS) scores indicated a similar trend at the 1-month follow-up (WMD = 4.68; 95% CI, 3.79-5.57; I²= 86.8%; P = 0.00), 3-month follow-up (WMD = 4.46; 95% CI, 3.19-5.74; I²= 93.3%; P = 0.00), 6-month follow-up (WMD = 4.91; 95% CI, 4.04-5.78; I²= 88%; P = 0.00) and last follow-up (WMD = 4.22; 95% CI, 3.12-5.32; I²= 97.1%; P = 0.00). Nasal obstruction was obviously relieved through rhinomanometry (SMD=0.56; 95% CI, 0.27-0.84; I²= 0.0%; P = 0.00) but not through peak nasal inspiratory flow (PNIF) (SMD=-1.51; 95% CI, -3.10 to 0.07; I²= 98.9%; P = 0.09).

CONCLUSION

FRP may have a positive effect on nasal obstruction caused by nasal valve problems. Broader and well-designed studies are needed to shed more light on the relationships in this area.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pediatric turbinate radiofrequency ablation improves quality of life and rhinomanometric values. A prospective study

OBJECTIVE

turbinate surgery in pediatric patients is gradually increasing in popularity amongst pediatric otolaryngologists. However, despite this, there is scarce information regarding this surgical procedure in children. The present research is designed with the aim of assessing changes in nasal resistance, nasal airflow and quality of life in pediatric patients undergoing turbinate radiofrequency ablation.

METHODS

A prospective uncontrolled intervention clinical trial design was followed. Children between 4 and 15 years old undergoing turbinate radiodiofrequency ablation (TRA) were consecutively selected. Children were examined preoperatively and 1, 3, 6 and 12 months after turbinate surgery. Anterior active rhinomanometry with and without nasal decongestant and examination of the turbinates and adenoid size were carried out in each follow-up visit. The SN5 quality of live survey was answered by parents.

RESULTS

81 children were included, 28 with associated adenoidectomy. A significant improvement in quality of life was demonstrated since the first month after TRA. Regarding nasal resistance, there was an improvement 1 month after surgery, but it only reached statistical significance for the whole sample (p < 0.001)) and for the cohort of isolated turbinate surgery (p < 0.001) at 3 months, while the values for the cohort of children who underwent adenoidectomy reached significance at 6 months after surgery (p = 0.04). The difference in nasal resistance before and after decongestant was compared to the change in nasal resistance after surgery. It demonstrated a strong correlation with the change in nasal resistance at 1 month (R = 0.985; p < 0.001), 3 months (R = 0.995; p < 0.001), 6 months (R = 0.98; p < 0.001) and 12 months (R = 0.98; p < 0.001) after surgery.

CONCLUSIONS

turbinate surgery in pediatric patients seems to be a safe procedure which objectively and subjectively improves the symptoms of children suffering from nasal obstruction.

Evidence of Nasal Cooling and Sensory Impairments Driving Patient Symptoms With Septal Deviation

OBJECTIVES/HYPOTHESIS

About 260,000 septoplasties are performed annually in the US to address nasal septal deviation (NSD). Yet, we do not consistently understand what aspects of NSD result in symptoms.

STUDY DESIGN

Blinded cohort study.

METHODS

Two fellowship-trained surgeons blindly reviewed computerized tomography (CTs) of 10 confirmed NSD patients mixed with 36 healthy controls. All patients were correctly identified, however, 24/36 controls were falsely identified by both surgeons as patients (33.3% specificity), which were grouped as asymptomatic NSD (aNSD), while the remaining controls as non-NSD (healthy). Acoustic rhinometry, rhinomanometry, individual CT-based computational fluid dynamics and nasal sensory testing were applied to address the puzzling questions of why these aNSD had no symptoms and, more fundamentally, what caused symptoms in sNSD patients.

RESULTS

aNSD reported no nasal symptoms - Nasal Obstruction Symptom Evaluation score (sNSD: 60.50 ± 13.00; aNSD: 5.20 ± 5.41; non-NSD: 6.66 ± 7.17, P < .05); 22-item Sino-Nasal Outcome Test score (sNSD: 32.60 ± 14.13; aNSD: 10.04 ± 10.10; non-NSD: 9.08 ± 12.42, P < .001). No significant differences in measured nasal resistance, minimum cross-sectional area (MCA), degree of septal deviation, and nasal airflow distributions were found between sNSD and aNSD groups. Only three variables differentiate sNSD versus aNSD: anterior averaged heat flux on deviated side, inferior turbinate peak heat flux on non-deviated side, and nasal cool sensitivity measured by menthol lateralization threshold, with no significant differences among these variables found between the two healthy groups (aNSD vs. non-NSD). These variables by themselves or combined can differentiate sNSD from controls with higher specificity than the physicians (ROC area under the curve = 0.84 with 70% sensitivity and 91.6% specificity).

CONCLUSIONS

This study sheds light on the potential mechanisms of NSD symptomatology: distorted nasal cooling due to NSD exacerbated by poorer nasal mucosal sensitivity. It further supports our previous hypothesis that nasal obstruction complaints do not result directly from obstruction, rather from the capacity of our nose to subjectively sense airflow cooling.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:509-517, 2022.

Numerical comparison of inspiratory airflow patterns in human nasal cavities with distinct age differences

As a primary determinant of nasal physiological functions, the nasal morphology and its effects on the airflow dynamics have been extensively studied in literature. However, gross flow features reported in literature are mostly obtained from subjects at similar ages, while studies focusing on nasal subjects with distinct age differences are significantly less. To advance current understandings of nasal airflow dynamics in the context of age diversity, this study employed three anatomically accurate nasal cavity models with distinct age features (5-, 24- and 77-year-old models) and numerically compared the physiological nasal airflow fields within these nasal cavity models. To demonstrate the validity of the present numerical models, in vivo rhinomanometry measurement was conducted on the 24-year-old female nasal model, and key anatomical features and pressure-flow curves of all three models were compared with models with similar age features in literature work. Apart from results comparison based on conventional velocity flow fields and wall shear stress distributions, a method for quantifying flow partitions in confined airway spaces was developed to reveal the proportions of fractional flow that enters the olfactory region. Our results revealed dramatic intersubject discrepancies between considered nasal cavity models, especially for the fractional flow that enters the olfactory region. Specifically, the 5-year-old girl nasal model received the highest proportion of fractional flow, which accounts for 13.3% ~ 15% of overall inhalation flow rates under different activity levels. For the 24-year-old female model, on the contrary, the olfactory fractional flow was dramatically reduced (with a local to overall percentage around 4.3%-7.7%). Finally, for the elderly subject-77-year-old male model, minimum level of olfactory flux was observed with a local to overall percentage ranging between 3.1% and 4.9% for considered wide range of inhalation flow rates. Therefore, the local flow intersubject variation can reach nearly fourfold. The vast local flow difference is mainly due to the inherent anatomical features (e.g., immature nasal turbinate structure in the child model, the partial narrowing superior nasal valve in the elder model). The results may further lead to discrepant health effects associated with inhalation exposure to airborne particles.

Detailed Assessment of Nasal Inter-Chamber Anatomical Variations and Its Effect on Flow Apportionment and Inhalation Exposure Patterns

Although many parametric studies have been conducted in developing standardized nasal geometry and analysing associated airflow dynamics, most of them are based on symmetrical nasal chambers assumption, while the inter-chamber variations due to the morphological asymmetry of the two nasal chambers are much less investigated. To address this issue, this paper presents an inter-chamber anatomical variability study by developing a shape comparison method to quantify inter-chamber anatomical differences. Then the anatomical deviation is correlated with the flow apportionment and the associated nanoparticle deposition patterns using CFD method. Results show that noticeable inter-chamber difference is observed especially in the inferior and middle passages where most inhaled flow is distributed to. Additionally, the shape of vestibule notch and septum deviation contributes to the discrepancy flow behaviour between two chambers. Consequently, these differences lead to variations in regional nanoparticle deposition, especially for 1 nm particles in the olfactory region, where the inter-chamber differences can reach up to 400%. Our results suggest that the inter-chamber anatomical variation should be considered when developing standardized nasal models.

Piezo-assisted Turbinoplasty Versus Partial Turbinectomy in External Septorhinoplasty: A Prospective Comparative Study in 100 Patients

OBJECTIVES

The purpose of this study was to compare the outcome of the piezo-assisted turbinoplasty with a partial turbinectomy technique in the treatment of chronic nasal obstruction due to inferior turbinate enlargement.

STUDY DESIGN

This is a prospective randomized single-center study in a cohort of 100 consecutive patients which underwent external septorhinoplasty and concomitant hybrid type of turbinoplasty.

METHODOLOGY

Patients were randomly assigned into two groups. The first group included 50 patients who underwent piezo-assisted outfracturing of the inferior turbinates in combination with bipolar coagulation. The second group included 50 patients who underwent a treatment based on turbinate bipolar coagulation and partial resection of the inferior border of the turbinate. The severity of nasal obstruction was measured in both patient groups with a patient-related outcome questionnaire (NOSE) and objective measures (anterior rhinomanometry and acoustic rhinometry). Assessments were conducted prior to surgery and 3 months after the surgery.

RESULTS

There was a significant improvement in the values of the NOSE questionnaire with no relevant difference between the two study groups. Acoustic rhinometry and rhinomanometry also showed no statistically significant differences between the two study groups. No differences in postoperative healing were found, and postoperative complications were comparable low in both groups. However, the piezo-assisted procedure was quicker to perform with only minimal bleeding.

CONCLUSION

During septorhinoplasty, the combination of thermo-coagulation with piezo-assisted turbinoplasty was as efficient as with partial turbinectomy to establish normal nasal breathing.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Effects of Acute Alcohol Intake on Nasal Patency

BACKGROUND

Acute alcohol intake may influence nasal patency; however, there is lack of objective evidence.

OBJECTIVE

The aim of this study was to evaluate the effects of acute alcohol intake on nasal patency employing both subjective and objective measures.

METHODS

A total of 31 participants were classified into 2 groups of non-heavy drinkers (n = 17) and heavy drinkers (n = 14). Both groups consumed wine in 1 h and were assessed for subjective nasal symptoms and objective nasal patency, using rhinomanometry and acoustic rhinometry, at baseline and at 0.5, 2, and 6 h post-alcohol consumption.

RESULTS

Alcohol consumption significantly increased nasal obstruction from baseline values in both heavy and non-heavy drinking groups. Total nasal volume (TNV) and the minimal cross-sectional area (MCA) were significantly decreased and nasal airway resistance (NAR) significantly increased from baseline values by 2 h post-alcohol consumption for both heavy and non-heavy drinking groups (P < .05). Significant differences were found in TNV, MCA, and NAR between baseline and post-drinking in allergic rhinitis subjects; with no significant differences in MCA and NAR in subjects without allergic rhinitis. Pulse rate (PR) and temperature (T) were elevated, and blood pressure (BP) was decreased after alcohol consumption (P < .05). Blood alcohol concentration (BAC) was not significantly correlated with nasal patency with regard to any subjective or objective measurement.

CONCLUSION

Acute alcohol consumption may impair nasal patency, independent of the amount consumed. Individuals with allergic rhinitis may be more prone to nasal obstruction after alcohol consumption than those without allergic rhinitis.

Toward automatic atlas-based surgical planning for septoplasty

PURPOSE

Surgery for nasal airway obstruction (NAO) has a high failure rate, with up to 50% of patients reporting persistent symptoms postoperatively. Virtual surgery planning has the potential to improve surgical outcomes, but current manual methods are too labor-intensive to be adopted on a large scale. This manuscript introduces an automatic atlas-based approach for performing virtual septoplasties.

METHODS

A cohort of 47 healthy subjects and 26 NAO patients was investigated. An atlas of healthy nasal geometry was constructed. The automatic virtual septoplasty method consists of a multi-stage registration approach to fit the atlas to a target NAO patient, automatically segment the patient's septum and airway, and deform the patient image to have a non-deviated septum.

RESULTS

Our automatic virtual septoplasty method straightened the septum successfully in 18 out of 26 NAO patients (69% of cases). In these cases, the ratio of the higher to the lower airspace cross-sectional areas in the left and right nasal cavities improved from 1.47 ± 0.45 to 1.16 ± 0.33 in the region surrounding the septal deviation, showing that the nasal airway became more symmetric after virtual septoplasty.

CONCLUSION

This automated virtual septoplasty technique has the potential to greatly reduce the effort required to perform computational fluid dynamics (CFD) analysis of nasal airflow for NAO surgical planning. Future studies are needed to investigate if virtual surgery planning using this method is predictive of subjective symptoms in NAO patients after septoplasty.

Comparison of nasal patency after nose-blowing between pinch versus no pinch method: a randomized controlled trial

We proposed that nose-blowing without pinching was safer and able to get rid of mucus and maintain nasal patency as effective as the pinch and blow method. The objective of this study was to evaluate the nasal patency after nose-blowing by pinching the nose versus no pinching. The patients who have nasal discharge such as allergic rhinitis or common cold were recruited. The patients were randomized to perform pinching or no pinching nose-blowing. Fifty patients were enrolled in this study. The objective evaluation using acoustic rhinometry found no difference in nasal patency between the two groups (p > 0.05). The subjective patency score was significantly higher in the pinch one nostril shut group (mean difference 0.88, 95% CI 0.20–1.55). The patency of the two methods were comparable according to the objective test. However, the patients felt that their nose was clearer when pinching and blowing.

Mouth breathing – A predictor for patient satisfaction after nasal septoplasty?

Background: No reliable marker exists to predict septoplasty outcome. Most patients suffering from nasal airway obstruction (NAO) caused by a deviation of the nasal septum report a bothersome mouth breathing and dryness. In this study our aim was to assess, whether mouth breathing could be objectified in these patients and whether mouth breathing could predict septoplasty outcome. Methods: A monocentric, prospective case-control study of 21 patients was conducted. The proportion of mouth breathing was measured in a blinded manner. As a measurement of patient satisfaction, subjective symptoms pre- and postoperatively, were assessed by using VAS, NOSE and SNOT-20 score. In the patient group an additional acoustic rhinometry and a clinical examination of the nose were performed. Results: With a mean of 25% (SD = 20%) the proportion of mouth breathing in patients with NAO did not differ significantly from the proportion in controls without NAO, with a mean of 27% (SD = 23%). Analysis of subjective scores revealed a significant reduction of subjective symptoms after septoplasty. A higher preoperative proportion of mouth breathing correlated with more remaining postoperative NAO. Conclusions: The percentage of mouth breathing is no different in patients with symptomatic septal deviation than in control patients. Mouth breathing in patients with NAO, evaluated for septoplasty, could be a negative predictive factor for patient satisfaction after nasal septoplasty. Mouth breathing in these patients should be observed carefully because more preoperative mouth breathing should make one more hesitant to consider septoplasty.

Quality of Life in Patients with Nasal Obstruction after Septoplasty: A Single Institution Prospective Observational Study

Introduction  Nasal obstruction is a common symptom in otorhinolaryngological practice. It can impact significantly on the quality of life of the individual. Objective  The primary goal of the present study was to evaluate quality of life after septoplasty in adults with nasal obstruction. A secondary goal was to assess the effectiveness of septoplasty. Methods  This was a single institution prospective observational study. Patients had experienced septal deviation and symptomatic nasal obstruction with no benefit from medical treatment. There were 51 patients who completed the Nasal Obstruction Symptom Evaluation (NOSE-POL) scale as well as theVisual Analogue Scale (VAS) before undergoing septoplasty, 3 months later, and finally 7 months after surgery. Patients evaluated changes in their nasal obstruction and changes in their quality of life using the Clinical Global Impression Scale (CGI-S). Results  There was a significant improvement in nasal obstruction after septoplasty. Before septoplasty, the mean score on NOSE was 60.3 ± 20.4; 3 months after surgery, it was 32.9 ± 16.8; and 7 months after surgery it was 39.6 ± 33.2. The VAS results also proved a significant enhancement in nasal obstruction after septoplasty. Patients reported an improvement in nasal obstruction as well as a positive change in quality of life, confirming the effectiveness of septoplasty. Conclusions  In patients with deformed septum, septoplasty contributes to high satisfaction of the patient and a compelling improvement in disease-specific quality of life. The NOSE-POL questionnaire is a useful tool for measuring the outcomes of this procedure.

Laterality and severity of nasal obstruction does not correlate between physicians and patients, nor among physicians

BACKGROUND

Nasal obstruction is a common patient complaint and has a variety of etiologies, and a specific anatomical abnormality can often be found within the nasal cavity on physical examination. In practice, this observed pathology does not always correlate with the laterality, severity, and exact intranasal site of the patients' perceived obstruction.

OBJECTIVES

We seek to answer the following questions: 1) Does a physician's evaluation of nasal obstruction correlate with subjective patient complaints? 2) Is there reasonable correlation between physicians of similar training in the routine evaluation of nasal obstruction?

METHODS

First, we asked patients presenting to the otolaryngology clinic with a primary complaint of nasal obstruction to fill out a modified NOSE survey. Nasal endoscopy was performed on all subjects to assess all potential sites of obstruction. We then determined whether there is an association between patient complaints and findings on physical examination. Second, we determined if there is correlation between similarly trained physicians in their interpretation of a basic nasal examination. Otolaryngologists were shown a series of standardized videos of an endoscopic nasal examination that were recorded with a primary complaint of nasal obstruction. Findings were reported in an anonymous online survey focusing on laterality, severity, and specific site of perceived obstruction.

RESULTS

A total of 38 patients were included in the first part of the study. The Cohen's kappa coefficient was used to determine the interrater agreement between the patient and physician in the degree of nasal obstruction. The kappa coefficient was 0.03 (p value 0.372) for the comparison of the left-sided scores (fair agreement), and 0.16 (p value 0.014) for the right-sided scores (slight agreement). A comparison was also done between the side of the nose the patient felt was most obstructed to the most obstructed side found on physical exam by the otolaryngologist. Thirteen of the 38 patients (34%) had perceived nasal obstruction on the opposite side of that noted to be most obstructed on physical exam. Despite this, the kappa coefficient in this comparison was 0.43 (p value <0.001) revealing moderate agreement between the two groups. Seventeen otolaryngologists participated in the second part of the study. Data extrapolated revealed very little agreement among the physicians in reporting which side of the nose was most obstructed, what anatomical structure contributed to the obstruction the most, and what percentage obstruction was present.

DISCUSSION

Based on our findings, patients can reasonably determine based on their symptoms which side is most obstructed, but symptoms do not correlate with severity of obstruction when compared to physical exam. There is also very little consistency between otolaryngologists in their assessment of the degree of nasal obstruction on exam. The results of this study may have far-reaching implications for patient management, surgical intervention, and medicolegal documentation as it relates to the current surgical treatment of nasal obstruction.