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Levi L, Yang A, Tsai EF, Ma Y, Ibrahim N, Dholakia SS, Rao VK, Renteria A, Cao X, Chang MT, Nayak JV. Stepwise Empty Nose Syndrome Evaluation (SENSE) test-A modified cotton test for reduced bias in office diagnosis of empty nose syndrome. Int Forum Allergy Rhinol 2024. [PMID: 39373717 DOI: 10.1002/alr.23442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/25/2024] [Accepted: 08/20/2024] [Indexed: 10/08/2024]
Abstract
INTRODUCTION Diagnosis of empty nose syndrome (ENS) relies on the ENS six-item questionnaire (ENS6Q) with a score of ≥11, followed by a "positive" cotton test yielding seven-point reduction from baseline ENS6Q score via cotton placement to the inferior meatus (IM). Given the intricacies of diagnosing ENS and the propensity for false positives with the standard cotton test, we modified the classic single-step cotton test into a four-part Stepwise Empty Nose Syndrome Evaluation (SENSE) cotton test to reduce bias and evaluate the placebo effect. METHODS Individuals diagnosed with ENS underwent the SENSE test, a single-blinded, four-step, office-based cotton test, without topical anesthesia or decongestants. Conditions included: (1) placebo/no cotton placed; (2) complete cotton-blockade of nasal vestibule; (3) cotton placed medially against the nasal septum; and (4) cotton placed laterally in the IM (site of inferior turbinate tissue loss). With each condition, patients completed an ENS6Q. RESULTS Forty-eight ENS patients were included. Twenty-nine percent demonstrated a placebo effect (p < 0.001), 40.4% had a positive response to complete cotton-blockade (p < 0.001), 64.4% to septum-placed cotton, and 79.1% to IM-placed cotton (p < 0.001), corresponding to a mean ENS6Q reduction of 11.9 points (p < 0.001). Notably, the mean difference in ENS6Q scores between septum and IM placement was 1.7 (p < 0.001). CONCLUSIONS The SENSE test offers further insight into subtleties of nasal breathing experienced by ENS patients. The placebo effect can be prominent and important to consider with individual patients. While most ENS patients prefer any intranasal cotton placement over baseline, blinded testing reveals these patients can accurately discriminate minimal changes in nasal aerodynamics.
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Affiliation(s)
- Lirit Levi
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel
| | - Angela Yang
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Esmond F Tsai
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yifei Ma
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nour Ibrahim
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sachi S Dholakia
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vidya K Rao
- Divisions of Cardiothoracic Anesthesiology and Critical Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Axel Renteria
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Xueying Cao
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael T Chang
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jayakar V Nayak
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
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Seresirikachorn K, Png LH, Do TQP, Kalish L, Campbell RG, Rimmer J, Alvarado R, Raji N, Choy C, Snidvongs K, Sacks R, Harvey RJ. Endonasal Thermal Imaging Before and After Nasal Airway Surgery. Ann Otol Rhinol Laryngol 2024:34894241287003. [PMID: 39356545 DOI: 10.1177/00034894241287003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2024]
Abstract
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.
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Affiliation(s)
- Kachorn Seresirikachorn
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Doctor of Philosophy Program in Medical Sciences (International Program), Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Lu Hui Png
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore
| | - Timothy Quy-Phong Do
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Larry Kalish
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Raewyn G Campbell
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Department of Otolaryngology, Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Janet Rimmer
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Woolcock Institute, University of Sydney, Sydney, Australia
- Faculty of Medicine, Notre Dame University, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | - Nelufer Raji
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Christine Choy
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
| | - Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Endoscopic Nasal and Sinus Surgery Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Raymond Sacks
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- Department of Otolaryngology, Head and Neck Surgery, Concord General Hospital, University of Sydney, Sydney, Australia
| | - Richard J Harvey
- Rhinology and Skull Base Research Group, St Vincent's Centre for Applied Medical Research, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
- School of Clinical Medicine, St Vincent's Healthcare Clinical Campus, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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Gwak JW, Kim DH, Jang YJ. Application of a Novel 3D-Printed Nasal Plug as a Conservative Treatment for Empty Nose Syndrome. Laryngoscope 2024; 134:3935-3940. [PMID: 38544462 DOI: 10.1002/lary.31414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE Empty nose syndrome (ENS) is commonly treated by surgery, albeit with limited success. Herein, we introduce our experience of applying a newly developed "3D-printed nasal plug" as an alternative conservative treatment modality. METHODS This retrospective study included 20 patients (14 males, 6 females; mean age 46.5 ± 13.5 years) with ENS who underwent the application of the 3D-printed nasal plug at Asan Medical Center between June 2022 and May 2023. Symptom improvement was assessed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) before and after applying the nasal plug. Clinical results, such as duration and frequency of plug use, discomfort, and level of satisfaction, were investigated. RESULTS The mean follow-up duration was 40.3 ± 24.2 weeks. The average duration of nasal plug usage was 10.8 h per day and 5.3 days a week. The ENS6Q scores improved from 19.6 ± 4.6 to 6.8 ± 5.1 (mean reduction 12.8 ± 5.9) after 30 minutes of wearing. Symptom "nose feelings too open" was improved most by a score of 3.0 ± 1.5 (p < 0.001). Thirteen patients (65.0%) reported that the effectiveness of the plug, initially confirmed at the first wearing, was well maintained during the entire follow-up. Four patients (20.0%) wore the nasal plug uninterruptedly throughout the week, whereas nine patients (45.0%) wore it intermittently as needed. Frequently reported complaints with plug usage were 'displacement of the plug' and 'cosmetic concerns' about the visible hook portion. CONCLUSION A 3D-designed nasal plug can be a useful conservative treatment option for ENS patients. LEVEL OF EVIDENCE 4 Laryngoscope, 134:3935-3940, 2024.
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Affiliation(s)
- Jang Wook Gwak
- Department of Otolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Don-Han Kim
- Department of Digital Content, University of Ulsan, Ulsan, Republic of Korea
| | - Yong Ju Jang
- Department of Otolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Hussain S, Hayat J, Almhanedi H, Alherz M, Ebrahim M, Lari A, Thamboo A. A Systematic Review and Meta-Analysis of Management Options for Empty Nose Syndrome: A Proposed Management Algorithm. Otolaryngol Head Neck Surg 2024. [PMID: 39126290 DOI: 10.1002/ohn.929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 06/27/2024] [Accepted: 07/20/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Empty nose syndrome (ENS) is an acquired condition characterized by paradoxical nasal obstruction and sensation of nasal dryness often accompanied by psychological disorders such as depression or anxiety, typically occurring after the loss of inferior turbinate tissue or volume in the setting of prior sinonasal surgery. This review aims to identify and evaluate the reported management options. DATA SOURCES PubMed, Scopus, and Web of Science. REVIEW METHODS The terms "empty nose syndrome" OR "atrophic rhinitis" were used in a systematic search of original articles since the year 1990, yielding 1432 individual studies. These were screened on the Covidence platform for inclusion if any intervention was reported for the treatment of ENS. A pooled analysis of standardized mean differences (SMDs) combined with a random effects model was employed to report outcomes in Empty Nose 6-Item Questionnaire (ENS6Q), Sino-Nasal Outcome Test (SNOT), anxiety, and depression scores. RESULTS A total of 35 articles were included, comprising 957 individual ENS patients. Surgical interventions mostly in the form of meatus augmentation implants accounted for 26 out of the 36 articles. The remaining ten articles included medical and psychological management options. SMD in SNOT, ENS6Q, anxiety, and depression scores were reported and demonstrated statistically significant improvements in follow-up periods of up to 1 year. All articles reported favorable outcomes following their chosen interventions. CONCLUSION There is a paucity of evidence on the management of ENS and an absence of randomized controlled trials. Surgical intervention appears to be the current mainstay of treatment, but there is a potential role for psychological and medical management.
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Affiliation(s)
- Salman Hussain
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jafar Hayat
- Faculty of Medicine, University of Manchester, Manchester, UK
| | - Hamad Almhanedi
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Canada
| | - Mohammad Alherz
- Department of Anatomy, Trinity College Dublin, Dublin, Ireland
| | - Mahmoud Ebrahim
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Canada
| | - Ali Lari
- Department of Orthopedic Surgery, Alrazi Hospital, Kuwait
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, St. Paul's Sinus Centre, University of British Columbia, Vancouver, British Columbia, Canada
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Nakamura T, Tomomatsu N, Takahara N, Kurasawa Y, Sasaki Y, Yoda T. Morphological changes in the inferior nasal passage associated with superior repositioning of the maxilla with/without horseshoe osteotomy or turbinectomy. Int J Oral Maxillofac Surg 2024:S0901-5027(24)00251-0. [PMID: 39127572 DOI: 10.1016/j.ijom.2024.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 07/21/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024]
Abstract
Superior repositioning of the maxilla during Le Fort I osteotomy (LFI) may narrow the inferior nasal passage. This retrospective study was performed to investigate morphological changes in the inferior nasal passage following LFI with/without additional procedures performed for nasal ventilation (horseshoe osteotomy or inferior turbinate partial resection). Three groups of patients were compared: those undergoing conventional LFI (Conv, 63 patients), LFI with horseshoe osteotomy (Hs, eight patients), and LFI with inferior turbinate partial resection (Turb, 21 patients). Coronal computed tomography images were used to evaluate the degree of stenosis of the inferior nasal passage. The soft tissue and bony tissue volumes in the inferior turbinate were also calculated three-dimensionally. The rate of obstruction of the inferior nasal passage postoperative was 65.9%, 50%, and 11.9% in the Conv, Hs, and Turb groups, respectively (Fisher's exact test, P < 0.001). Patients in the Turb group had significantly less nasal obstruction regardless of the pitch direction of the maxillary movement or volume of the bone in the inferior turbinate (all P < 0.001). In conclusion, for patients with high superior repositioning and well-developed bony tissue in the inferior turbinate, additional procedures are recommended to maintain the ventilation of the nasal passage postoperatively.
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Affiliation(s)
- T Nakamura
- Department of Maxillofacial Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - N Tomomatsu
- Department of Maxillofacial Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan.
| | - N Takahara
- Department of Maxillofacial Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Y Kurasawa
- Department of Maxillofacial Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - Y Sasaki
- Department of Maxillofacial Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
| | - T Yoda
- Department of Maxillofacial Surgery, Tokyo Medical and Dental University, Bunkyo-ku, Tokyo, Japan
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Snoeks S, Velasco E, Talavera K, Hellings PW. Nasal Obstruction: Overview of Pathophysiology and Presentation of a Clinically Relevant Preoperative Plan for Rhino(Septo)plasty. Facial Plast Surg 2024; 40:275-286. [PMID: 38224694 DOI: 10.1055/s-0043-1777850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024] Open
Abstract
Impairment of nasal breathing is a highly prevalent and bothersome symptom that affects daily functioning and/or sleep quality. Those surgeons dealing with patients seeking rhinoplasty need to carefully analyze the preoperative nasal breathing capacity and predict the positive or even negative impact of rhino(septo)plasty on nasal breathing. Given the lack of correlation between the subjective feeling of suboptimal nasal breathing and the objective measurements of nasal flow and nasal resistance, a critical and mainly clinical evaluation of all anatomical, mucosal, and sensory mechanisms involved in nasal obstruction is mandatory. Indeed, thermo-, mechano-, and chemosensory receptors on the nasal mucosa, airflow, and respiratory dynamics might all contribute to the overall perception of nasal breathing capacity. In this review, we provide an overview of the factors determining suboptimal nasal breathing including different diagnostic and experimental tests that can be performed to evaluate nasal flow and nasal resistance and current limitations in our understanding of the problem of nasal breathing in an individual patient. An algorithm for the preoperative or diagnostic workup for nasal obstruction is included that might be useful as a guide for clinicians dealing with patients seeking nose surgery.
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Affiliation(s)
- Simon Snoeks
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals, Leuven, Belgium
| | - Enrique Velasco
- Department of Cellular and Molecular Medicine, Catholic University of Leuven Faculty of Medicine, Leuven, Belgium
| | - Karel Talavera
- Department of Cellular and Molecular Medicine, Catholic University of Leuven Faculty of Medicine, Leuven, Belgium
| | - Peter W Hellings
- Department of Otorhinolaryngology-Head and Neck Surgery, University Hospitals, Leuven, Belgium
- Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
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Harvey RJ, Roland LT, Schlosser RJ, Pfaar O. Chief Complaint: Nasal Congestion. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1462-1471. [PMID: 38677589 DOI: 10.1016/j.jaip.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 04/22/2024] [Indexed: 04/29/2024]
Abstract
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.
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Affiliation(s)
- Richard John Harvey
- Rhinology & Skull Base, University of New South Wales and Macquarie University, Sydney, Australia.
| | - Lauren T Roland
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis, St. Louis, Mo
| | - Rodney J Schlosser
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery, Section of Rhinology and Allergy, University Hospital Marburg, Philipps-Universität Marburg, Marburg, Germany
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Huang CC, Sun PH, Wu PW, Huang CC, Chang PH, Fu CH, Lee TJ. Computed Tomographic Evaluations in Patients with Empty Nose Syndrome. Laryngoscope 2024; 134:2105-2110. [PMID: 38009472 DOI: 10.1002/lary.31204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE We aimed to evaluate computed tomography (CT) images of patients with empty nose syndrome (ENS), investigate the impact of reconstruction surgery on sinus inflammation, and identify the optimal airspace diameter after surgery. METHODS We conducted a retrospective case series analysis, identifying and enrolling patients with ENS with perioperative CT findings. The clinical characteristics of the participants were collected, and the modified Lund-Mackay (mLM) CT scores were determined. The anterior airspace diameter was evaluated by measuring the distance between the septum and the lateral nasal wall on the coronal plane at the level of the nasolacrimal duct. RESULTS Twenty patients with ENS and perioperative CT images were enrolled. The mean total mLM CT score and all subsite scores showed no significant changes after surgery. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) score, Sino-nasal Outcome Test-25 (SNOT-25) score, sleep symptoms domain, psychological domain, and empty nose symptoms domain were significantly associated with anterior airspace diameter in the regression analysis. CONCLUSION There was no significant difference in sinus inflammation between preoperative and postoperative CT evaluations. The anterior airspace diameters were significantly associated with ENS6Q and SNOT-25 scores. LEVEL OF EVIDENCE 4 Laryngoscope, 134:2105-2110, 2024.
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Affiliation(s)
- Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ping Hsueh Sun
- Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsiang Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China
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Patel S, Mahr G, Deeb R, Craig JR. Numerous unsuccessful surgeries for empty nose syndrome in a patient with somatic symptom disorder. Am J Otolaryngol 2024; 45:104149. [PMID: 38070377 DOI: 10.1016/j.amjoto.2023.104149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/02/2023] [Indexed: 03/16/2024]
Affiliation(s)
- Shivali Patel
- Department of Psychiatry, University of Michigan, 1500 E Medical Center Dr., Ann Arbor, MI 48109, United States of America
| | - Gregory Mahr
- Department of Behavioral Health, Henry Ford Health, 1 Ford Place Suite 1C, Detroit, MI 48202, United States of America
| | - Robert Deeb
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, 2799 W Grand Blvd, Detroit, MI 48202, United States of America
| | - John R Craig
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, 2799 W Grand Blvd, Detroit, MI 48202, United States of America.
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Park MJ, Bae M, Kim JH, Chung Y, Jang YJ, Yu MS. Impact of long-term nasal airflow deprivation on sinonasal structures and chronic rhinosinusitis in total laryngectomy patients. Laryngoscope Investig Otolaryngol 2024; 9:e1214. [PMID: 38362182 PMCID: PMC10866595 DOI: 10.1002/lio2.1214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/02/2023] [Accepted: 01/02/2024] [Indexed: 02/17/2024] Open
Abstract
Objective Total laryngectomy (TL) patients are good models in which to evaluate the effects of nasal airflow cessation on the sinonasal tract. Here, we evaluated changes in sinonasal structures and association with sinus opacification in the computed tomography (CT) images 3 years post-TL. Methods Patients who underwent TL from 2005 to 2017 in a teaching academic center were reviewed retrospectively. Patients with a final follow-up CT taken less than 3 years after TL, tracheoesophageal puncture, inadequate CT image, or history of sinonasal surgery were excluded. The control group included patients who underwent a partial laryngectomy or hypopharyngectomy without requiring a tracheotomy for more than a month. Altogether, 45 TL patients and 38 controls were selected. The volume of all four paranasal sinuses, inferior turbinate soft tissue volume (ITSTV), maxillary sinus natural ostium (MSNO) mucosal width, and Lund-Mackay scores (LMS) were measured on preoperative and postoperative CT scans. Results The mean duration between surgery and the final CT scan was 6.3 ± 2.4 and 5.5 ± 2.3 years for the TL and control groups, respectively. Neither group showed significant changes in the four paranasal sinuses' volume or MSNO mucosa width. The ITSTV decreased significantly, from 4.6 ± 1.3 to 2.8 ± 1.1 mL (p < .001), in the TL group, regardless of the presence of nasal septal deviation, showing ITSTV reduction on both concave and convex sides. By contrast, the control group showed no significant changes in ITSTV. Postoperative LMS changes in both groups were insignificant. The number of patients with LMS aggravation or alleviation was the same in both groups, regardless of preoperative sinus opacification. Conclusions Paranasal sinus structures and sinus opacification are not affected significantly by nasal airflow cessation; however, the inferior turbinate mucosa is affected by long-term discontinuation of nasal airflow. Level of Evidence 4 (case-control study).
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Affiliation(s)
- Marn Joon Park
- Department of Otorhinolaryngology—Head and Neck Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
- Department of Otorhinolaryngology—Head and Neck SurgeryInha University School of MedicineIncheonKorea
| | - Mirye Bae
- Department of Otorhinolaryngology—Head and Neck SurgeryBundang Jesaeng General Hospital, Daejin Medical CenterSeongnamKorea
| | - Ji Heui Kim
- Department of Otorhinolaryngology—Head and Neck Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Yoo‐Sam Chung
- Department of Otorhinolaryngology—Head and Neck Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Yong Ju Jang
- Department of Otorhinolaryngology—Head and Neck Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
| | - Myeong Sang Yu
- Department of Otorhinolaryngology—Head and Neck Surgery, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulKorea
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11
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Yan X, Menzel S, Zhao K, Kim K, Hummel T. Intranasal trigeminal sensitivity to mechanical stimuli is associated with the perception of nasal patency. Eur Arch Otorhinolaryngol 2023; 280:5391-5399. [PMID: 37561188 DOI: 10.1007/s00405-023-08126-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 07/12/2023] [Indexed: 08/11/2023]
Abstract
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
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Affiliation(s)
- Xiaoguang Yan
- Department of Otorhinolaryngology, Smell and Taste Clinic, TU Dresden, Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Susanne Menzel
- Department of Otorhinolaryngology, Smell and Taste Clinic, TU Dresden, Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Kai Zhao
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Kanghyun Kim
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH, USA
| | - Thomas Hummel
- Department of Otorhinolaryngology, Smell and Taste Clinic, TU Dresden, Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Jankowski R, Mathis-Marçon C, Fieux M, Barron M, Legré M, Favier V, Tiotiu A, Saroul N. Chronic nasal dysfunction: A clinical case illustrating the concept in practice. Eur Ann Otorhinolaryngol Head Neck Dis 2023; 140:305-308. [PMID: 37980265 DOI: 10.1016/j.anorl.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
INTRODUCTION We illustrate the diagnostic method for chronic nasal dysfunction by an observation in which the clinical history was compared to preoperative responses on the DyNaChron self-administered questionnaire, with ENT interpretation of the sinonasal CT scan preceding and guiding nasal endoscopy. CASE REPORT The initial suspicion of rhinitis medicamentosa was transformed by the radiological and endoscopic findings of chronic respiratory rhinitis signs. Prick tests showing sensitivity to dust mites then suggested an allergic origin of the mucosal inflammation, which affected neither the olfactory nose nor the paranasal sinuses. A septal deviation hampering visualization of the right ethmoidal reliefs completed the clinical picture. Inferior turbinate hypertrophy secondary to allergic inflammation could have been aggravated by prolonged daily use of nasal vasoconstrictors. Failure of medical treatment combining nasal lavage, topical corticosteroids and an attempt at weaning led to effective medical and surgical management combining septoplasty, bilateral inferior turbinoplasty, continuation of topical corticosteroids and initiation of allergen immunotherapy. In addition to complete relief of nasal obstruction and abandonment of nasal vasoconstrictors, improved sense of smell completed the restoration of nasal comfort. DISCUSSION It is helpful to conceive the nose as being anatomically and pathophysiologically a triple organ and to evaluate therapy in terms of improvement in each symptom.
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Affiliation(s)
- R Jankowski
- Service d'ORL, CHRU Nancy, université de Lorraine, 54500 Vandœuvre-lès-Nancy, France.
| | - C Mathis-Marçon
- Service d'ORL, CHRU Nancy, université de Lorraine, 54500 Vandœuvre-lès-Nancy, France
| | - M Fieux
- Université de Lyon, université Lyon 1, 69003 Lyon, France; Hospices civils de Lyon, hôpital Lyon Sud, service d'ORL, d'otoneurochirurgie et de chirurgie cervico-faciale, 69310 Pierre-Bénite, France
| | - M Barron
- Service d'ORL, CHRU Nancy, université de Lorraine, 54500 Vandœuvre-lès-Nancy, France
| | - M Legré
- Service d'ORL, institut Arthur-Vernes, 75006 Paris, France
| | - V Favier
- Université de Montpellier, CHU de Montpellier, département d'ORL, CCF et CMF, hôpital Gui-de-Chauliac, Montpellier, France
| | - A Tiotiu
- Service de pneumologie, CHRU Nancy, 54500 Vandœuvre-lès-Nancy, France
| | - N Saroul
- Université Clermont Auvergne, CHU Clermont-Ferrand, INRAE, UNH, équipe ASMS, 63000 Clermont-Ferrand, France; CHU de Clermont-Ferrand, service d'oto-rhino-laryngologie et chirurgie cervico-faciale, 63003 Clermont-Ferrand, France
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13
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Sumaily IA, Hakami NA, Almutairi AD, Alsudays AA, Abulqusim EM, Abualgasem MM, Alghulikah AA, Alserhani AA. An Updated Review on Atrophic Rhinitis and Empty Nose Syndrome. EAR, NOSE & THROAT JOURNAL 2023:1455613231185022. [PMID: 37449389 DOI: 10.1177/01455613231185022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Objective: Atrophic rhinitis (AR) is a rare clinical condition affecting the nasal mucosa. It is characterized by progressive nasal congestion and thick, bothersome nasal secretions. In this narrative review, pathogenesis, differences between the 2 types of AR, new management modalities, and the impact of management on lifestyle have been highlighted. Materials and Methods: An extensive literature search was conducted using PubMed, Web of Science, Google Scholar, and Saudi Digital Library databases. The articles were investigated to extract information on the pathogenesis, types, new treatment modalities, and the impact of management on lifestyle. Results: AR has primary and secondary types that affect different populations and have specific clinical presentations. Primary AR is common in women and countries with long, warm seasons. Secondary AR is the most common disease in the industrialized world. It is more common among adults who have systemic disease, have undergone extensive nasal surgery, and have experienced nasal trauma. Certain infections, autoimmune disorders, chronic sinusitis, hormonal imbalance, poor nutritional condition, and iron deficiency anemia have been suggested as etiological factors. Conservative treatment is safe, inexpensive, and effective. Hygiene, a well-balanced diet, smoking cessation, and early detection and treatment of nasal pathology can help prevent AR. Some interventions shown to improve quality of life was explained in detail. Conclusions: This paper reviewed published relevant literature on AR related to pathogenesis, types, new treatment modalities, and the impact of treatment on lifestyle, thus, providing a comprehensive view of the management and prevention of AR.
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Affiliation(s)
| | | | - Anwar Dhawi Almutairi
- Department of Otolaryngology-Head and Neck Surgery, Maternity and Children's Hospital, AL Qassim, Saudi Arabia
| | | | | | | | - Abdulrahman Ahmad Alghulikah
- Department of Otolaryngology-Head and Neck Surgery, Security Force Hospital, Ministry of interior, Riyadh, Saudi Arabia
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14
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Agarwal M, Lobo R, Srinivasan A. Postoperative Imaging Appearances of the Paranasal Sinuses. Semin Roentgenol 2023; 58:248-260. [PMID: 37507167 DOI: 10.1053/j.ro.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/13/2023] [Accepted: 03/19/2023] [Indexed: 07/30/2023]
Affiliation(s)
- Mohit Agarwal
- Department of Radiology, Froedtert and Medical College of Wisconsin, Milwaukee, WI.
| | - Remy Lobo
- Department of Radiology, Division of Neuroradiology, Michigan Medicine, Ann Arbor, MI
| | - Ashok Srinivasan
- Department of Radiology, Division of Neuroradiology, Michigan Medicine, Ann Arbor, MI
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15
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Wise SK, Damask C, Roland LT, Ebert C, Levy JM, Lin S, Luong A, Rodriguez K, Sedaghat AR, Toskala E, Villwock J, Abdullah B, Akdis C, Alt JA, Ansotegui IJ, Azar A, Baroody F, Benninger MS, Bernstein J, Brook C, Campbell R, Casale T, Chaaban MR, Chew FT, Chambliss J, Cianferoni A, Custovic A, Davis EM, DelGaudio JM, Ellis AK, Flanagan C, Fokkens WJ, Franzese C, Greenhawt M, Gill A, Halderman A, Hohlfeld JM, Incorvaia C, Joe SA, Joshi S, Kuruvilla ME, Kim J, Klein AM, Krouse HJ, Kuan EC, Lang D, Larenas-Linnemann D, Laury AM, Lechner M, Lee SE, Lee VS, Loftus P, Marcus S, Marzouk H, Mattos J, McCoul E, Melen E, Mims JW, Mullol J, Nayak JV, Oppenheimer J, Orlandi RR, Phillips K, Platt M, Ramanathan M, Raymond M, Rhee CS, Reitsma S, Ryan M, Sastre J, Schlosser RJ, Schuman TA, Shaker MS, Sheikh A, Smith KA, Soyka MB, Takashima M, Tang M, Tantilipikorn P, Taw MB, Tversky J, Tyler MA, Veling MC, Wallace D, Wang DY, White A, Zhang L. International consensus statement on allergy and rhinology: Allergic rhinitis - 2023. Int Forum Allergy Rhinol 2023; 13:293-859. [PMID: 36878860 DOI: 10.1002/alr.23090] [Citation(s) in RCA: 92] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 09/13/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.
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Affiliation(s)
- Sarah K Wise
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Cecelia Damask
- Otolaryngology-HNS, Private Practice, University of Central Florida, Lake Mary, Florida, USA
| | - Lauren T Roland
- Otolaryngology-HNS, Washington University, St. Louis, Missouri, USA
| | - Charles Ebert
- Otolaryngology-HNS, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joshua M Levy
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Sandra Lin
- Otolaryngology-HNS, University of Wisconsin, Madison, Wisconsin, USA
| | - Amber Luong
- Otolaryngology-HNS, McGovern Medical School of the University of Texas, Houston, Texas, USA
| | - Kenneth Rodriguez
- Otolaryngology-HNS, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ahmad R Sedaghat
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elina Toskala
- Otolaryngology-HNS, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Baharudin Abdullah
- Otolaryngology-HNS, Universiti Sains Malaysia, Kubang, Kerian, Kelantan, Malaysia
| | - Cezmi Akdis
- Immunology, Infectious Diseases, Swiss Institute of Allergy and Asthma Research, Davos, Switzerland
| | - Jeremiah A Alt
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fuad Baroody
- Otolaryngology-HNS, University of Chicago, Chicago, Illinois, USA
| | | | | | - Christopher Brook
- Otolaryngology-HNS, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raewyn Campbell
- Otolaryngology-HNS, Macquarie University, Sydney, NSW, Australia
| | - Thomas Casale
- Allergy/Immunology, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Mohamad R Chaaban
- Otolaryngology-HNS, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio, USA
| | - Fook Tim Chew
- Allergy/Immunology, Genetics, National University of Singapore, Singapore, Singapore
| | - Jeffrey Chambliss
- Allergy/Immunology, University of Texas Southwestern, Dallas, Texas, USA
| | - Antonella Cianferoni
- Allergy/Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Anne K Ellis
- Allergy/Immunology, Queens University, Kingston, ON, Canada
| | | | - Wytske J Fokkens
- Otorhinolaryngology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | | | - Matthew Greenhawt
- Allergy/Immunology, Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amarbir Gill
- Otolaryngology-HNS, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashleigh Halderman
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Jens M Hohlfeld
- Respiratory Medicine, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover Medical School, German Center for Lung Research, Hannover, Germany
| | | | - Stephanie A Joe
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Shyam Joshi
- Allergy/Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jean Kim
- Otolaryngology-HNS, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam M Klein
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Helene J Krouse
- Otorhinolaryngology Nursing, University of Texas Rio Grande Valley, Edinburg, Texas, USA
| | - Edward C Kuan
- Otolaryngology-HNS, University of California Irvine, Orange, California, USA
| | - David Lang
- Allergy/Immunology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Matt Lechner
- Otolaryngology-HNS, University College London, Barts Health NHS Trust, London, UK
| | - Stella E Lee
- Otolaryngology-HNS, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Victoria S Lee
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Patricia Loftus
- Otolaryngology-HNS, University of California San Francisco, San Francisco, California, USA
| | - Sonya Marcus
- Otolaryngology-HNS, Stony Brook University, Stony Brook, New York, USA
| | - Haidy Marzouk
- Otolaryngology-HNS, State University of New York Upstate, Syracuse, New York, USA
| | - Jose Mattos
- Otolaryngology-HNS, University of Virginia, Charlottesville, Virginia, USA
| | - Edward McCoul
- Otolaryngology-HNS, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Erik Melen
- Pediatric Allergy, Karolinska Institutet, Stockholm, Sweden
| | - James W Mims
- Otolaryngology-HNS, Wake Forest University, Winston Salem, North Carolina, USA
| | - Joaquim Mullol
- Otorhinolaryngology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Jayakar V Nayak
- Otolaryngology-HNS, Stanford University, Palo Alto, California, USA
| | - John Oppenheimer
- Allergy/Immunology, Rutgers, State University of New Jersey, Newark, New Jersey, USA
| | | | - Katie Phillips
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael Platt
- Otolaryngology-HNS, Boston University, Boston, Massachusetts, USA
| | | | | | - Chae-Seo Rhee
- Rhinology/Allergy, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | - Sietze Reitsma
- Otolaryngology-HNS, University of Amsterdam, Amsterdam, Netherlands
| | - Matthew Ryan
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Joaquin Sastre
- Allergy, Fundacion Jiminez Diaz, University Autonoma de Madrid, Madrid, Spain
| | - Rodney J Schlosser
- Otolaryngology-HNS, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theodore A Schuman
- Otolaryngology-HNS, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcus S Shaker
- Allergy/Immunology, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Aziz Sheikh
- Primary Care, University of Edinburgh, Edinburgh, Scotland
| | - Kristine A Smith
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | - Michael B Soyka
- Otolaryngology-HNS, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Masayoshi Takashima
- Otolaryngology-HNS, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Monica Tang
- Allergy/Immunology, University of California San Francisco, San Francisco, California, USA
| | | | - Malcolm B Taw
- Integrative East-West Medicine, University of California Los Angeles, Westlake Village, California, USA
| | - Jody Tversky
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew A Tyler
- Otolaryngology-HNS, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria C Veling
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Dana Wallace
- Allergy/Immunology, Nova Southeastern University, Ft. Lauderdale, Florida, USA
| | - De Yun Wang
- Otolaryngology-HNS, National University of Singapore, Singapore, Singapore
| | - Andrew White
- Allergy/Immunology, Scripps Clinic, San Diego, California, USA
| | - Luo Zhang
- Otolaryngology-HNS, Beijing Tongren Hospital, Beijing, China
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Huang CC, Wu PW, Huang CC, Chang PH, Fu CH, Lee TJ. Identifying Residual Psychological Symptoms after Nasal Reconstruction Surgery in Patients with Empty Nose Syndrome. J Clin Med 2023; 12:jcm12072635. [PMID: 37048718 PMCID: PMC10095541 DOI: 10.3390/jcm12072635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/11/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Empty nose syndrome (ENS) is a syndrome of paradoxical nasal obstruction that is thought to be mostly caused by inappropriate turbinate procedures. This study aimed to investigate depression- and anxiety-associated psychological symptoms in patients with ENS before and after surgical reconstruction, and to compare them with those of control subjects. Methods: Patients with ENS were prospectively enrolled. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item questionnaire (ENS6Q), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate the participants before and after reconstruction surgery with submucosal Medpor implantation (Stryker, Kalamazoo, MI), as well as control subjects at enrollment. Results: Forty patients with ENS and forty age- and sex-matched controls were recruited. Patients with ENS experienced significant improvement in SNOT-25, ENS6Q, BDI-II, and BAI scores after surgery, but all were significantly greater than those in the control group. Nine patients with ENS (22.5%) had postoperative residual psychological symptoms. Preoperative BDI-II and BAI scores were significant predictors of postoperative residual psychological symptoms. The optimal cut-off value was BDI-II > 28.5 (sensitivity, 77.8%; specificity, 77.4%) in receiver operating characteristic curve analysis. Conclusions: The nasal and psychological evaluations in patients with ENS significantly improved after nasal reconstruction surgery, but both were significantly greater than those in the control group. Identifying individuals who may experience postoperative residual symptoms and providing a multimodal approach, including surgical reconstruction and psychiatric treatment, are suggested.
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Affiliation(s)
- Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
| | - Chia-Hsiang Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen 361000, China
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17
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Lee DW, Kim JY, Kwon JH. Platelet-rich plasma injection for empty nose syndrome: A case report. Am J Otolaryngol 2023; 44:103750. [PMID: 36630732 DOI: 10.1016/j.amjoto.2022.103750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 12/14/2022] [Indexed: 01/11/2023]
Abstract
Empty nose syndrome (ENS) is a relatively rare disease found in patients who have undergone sinonasal surgery, characterized by excessive reduction of the turbinate, causing intranasal turbulence and loss of receptors within the nasal mucosa. Patients diagnosed with the disease usually experience symptoms including dryness of the nose, nasal pain, paradoxical nasal obstruction, and crusts in the nasal cavity. ENS can be treated with conservative care such as nasal irrigation or nasal moisturizers. Accurate efficacy of surgical treatment of ENS is often difficult to predict and is accompanied by operational obstacles and complications. Platelet-rich plasma (PRP) has recently gained attention as a regenerative therapy in several medical fields. We present two cases of ENS treated by injection of PRP as a simple and less invasive method, and describe its efficacy with nasal endoscopy and subjective questionnaires.
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Affiliation(s)
- Dong Woo Lee
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, Republic of Korea
| | - Joo Yeon Kim
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, Republic of Korea
| | - Jae Hwan Kwon
- Department of Otolaryngology-Head and Neck Surgery, Kosin University College of Medicine, Busan, Republic of Korea.
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18
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Huang CC, Lee CC, Wei PW, Chuang CC, Lee YS, Chang PH, Huang CC, Fu CH, Lee TJ. Sleep impairment in patients with empty nose syndrome. Rhinology 2023; 61:47-53. [PMID: 36306524 DOI: 10.4193/rhin22.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Empty nose syndrome (ENS) is characterized by paradoxical nasal obstruction that usually occurs after turbinate surgery. Patients with ENS may also experience significant psychiatric symptoms and sleep dysfunction, which negatively affect the quality of life of affected subjects. This study aimed to evaluate sleep impairment and sleepiness in patients with ENS. METHODS Patients with ENS and control participants were recruited prospectively. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Epworth Sleepiness Scale (EpSS), and modified sleep quality index (MSQI) were used to evaluate the participants before and after nasal surgery. RESULTS Forty-eight patients with ENS and forty-eight age- and sex-matched control subjects were enrolled. The SNOT-25, ENS6Q, EpSS, and MSQI scores in the ENS group were all significantly higher than those in the control group before and after surgery. After surgery, ENS patients all exhibited significant improvements in SNOT-25, ENS6Q, EpSS, and MSQI scores. Regression analysis revealed that SNOT-25 score was a significant predictor of EpSS and MSQI in preoperative evaluations. ENS patients experiencing daytime sleepiness suffered from significantly more "dryness of nose" and "suffocation" than those not experiencing daytime sleepiness. CONCLUSIONS Patients with ENS experienced significantly impaired sleep quality and sleepiness. Nasal reconstruction surgery improved the sleep quality of ENS patients. The severity of sleep dysfunction is associated with the severity of ENS symptoms. Recognizing individuals with significant sleep impairment and sleepiness and providing appropriate management are critical issues for ENS patients.
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Affiliation(s)
- C-C Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-C Lee
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taiwan; Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - P-W Wei
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwan
| | - C-C Chuang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taiwan
| | - Y-S Lee
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Biotechnology, Ming Chuan University, Taoyuan, Taiwan
| | - P-H Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan
| | - C-C Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-H Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - T-J Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China
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Tănase MI, Bulmaci M, Stan C, Doinel RG, Cosgarea M, Pop SS, Maniu AA. Laser nasal surgery (Review). Exp Ther Med 2023; 25:108. [PMID: 36778045 PMCID: PMC9909775 DOI: 10.3892/etm.2023.11807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 01/05/2023] [Indexed: 01/26/2023] Open
Abstract
Laser nasal surgery has been an elusive subject in the last 10 to 15 years It was considered as a potential surgical staple for nasal surgery in the 1980s; however, it did not become one due to technical difficulties. Laser therapy has reemerged as an alternative to classical endoscopic surgery, and otorhinolaryngology surgeons are considering the benefits that it can offer. The advantages of this procedure are shorter hospitalization time, lack of nasal packing, high procedural precision with tissue sparing, and the unique capability of reducing both bacterial and fungal colonization at the level of the paranasal sinus. Therefore, laser therapy appears to be an invaluable tool for clinical practice. Due to the absence of a guaranteed cure for reoccurring nasal polyposis, laser therapy is worth investigating. For this therapy to evolve, an improved understanding of laser types and the effects that they produce is required. By investing in further developments of the equipment, the technique may become more widely used. With the current accelerated rate of technological evolution and robotic capabilities, laser nasal surgery may become a gold standard in future years. The aim of the present review is to evaluate whether it is worth investing in nasal laser surgery as a future alternative to current treatment standards.
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Affiliation(s)
- Mihai Ionuț Tănase
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Mara Bulmaci
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Constantin Stan
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania,Department of Clinical Surgery, Dunărea de Jos University, Faculty of Medicine and Pharmacy, 800008 Galați, Romania
| | - Rădeanu Gheorghe Doinel
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania,Correspondence to: Dr Rădeanu Gheorghe Doinel, Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
| | - Marcel Cosgarea
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Septimiu Sever Pop
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Alma Aurelia Maniu
- Department of Otorhinolaryngology, Iuliu Haţieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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20
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Lee SJ, Choi YS, Bae CH, Song SY, Kim YD, Na HG. Autologous Costal Cartilage Augmentation Technique for Treatment of Empty Nose Syndrome. KOREAN JOURNAL OF OTORHINOLARYNGOLOGY-HEAD AND NECK SURGERY 2022; 65:843-847. [DOI: 10.3342/kjorl-hns.2022.00584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 07/13/2022] [Indexed: 07/25/2023]
Abstract
Empty nose syndrome is a rare complication caused by excessive removal of normal tissues after nose surgery. The main symptoms of empty nose syndrome are paradoxical nasal obstruction, dryness, crust and dyspnea. Medical treatments such as irrigation, humidification, and ointment are not very effective, so surgical treatments to reconstruct the normal nasal cavity using implant materials are often considered. If the implant is not properly inserted, the symptoms persist and the implant must be removed again, resulting in the only donor site complications. Therefore, it is essential to treat the implant well and insert it precisely. Here we describe a surgical procedure to manage implant materials using autologous costal cartilage in the form of block, diced, and crushed cartilage for augmentation technique.
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Schmidt N, Behrbohm H, Goubergrits L, Hildebrandt T, Brüning J. Comparison of rhinomanometric and computational fluid dynamic assessment of nasal resistance with respect to measurement accuracy. Int J Comput Assist Radiol Surg 2022; 17:1519-1529. [PMID: 35821562 DOI: 10.1007/s11548-022-02699-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Computational fluid dynamics (CFD)-based calculation of intranasal airflow became an important method in rhinologic research. Current evidence shows weak to moderate correlation as well as a systematic underprediction of nasal resistance by numerical simulations. In this study, we investigate whether these differences can be explained by measurement uncertainties caused by rhinomanometric devices and procedures. Furthermore, preliminary findings regarding the impact of tissue movements are reported. METHODS A retrospective sample of 17 patients, who reported impaired nasal breathing and for which rhinomanometric (RMM) measurements using two different devices as well as computed tomography scans were available, was investigated in this study. Three patients also exhibited a marked collapse of the nasal valve. Agreement between both rhinomanometric measurements as well as between rhinomanometry and CFD-based calculations was assessed using linear correlation and Bland-Altman analyses. These analyses were performed for the volume flow rates measured at trans-nasal pressure differences of 75 and 150 Pa during inspiration and expiration. RESULTS The correlation between volume flow rates measured using both RMM devices was good (R2 > 0.72 for all breathing states), and no relevant differences in measured flow rates was observed (21.6 ml/s and 14.8 ml/s for 75 and 150 Pa, respectively). In contrast, correlation between RMM and CFD was poor (R2 < 0.5) and CFD systematically overpredicted RMM-based flow rate measurements (231.8 ml/s and 328.3 ml/s). No differences between patients with and without nasal valve collapse nor between inspiration and expiration were observed. CONCLUSION Biases introduced during RMM measurements, by either the chosen device, the operator or other aspects as for example the nasal cycle, are not strong enough to explain the gross differences commonly reported between RMM- and CFD-based measurement of nasal resistance. Additionally, tissue movement during breathing is most likely also no sufficient explanation for these differences.
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Affiliation(s)
- Nora Schmidt
- Department of Otorhinolaryngology and Facial Plastic Surgery, Park-Klinik Weissensee, Schönstraße 80, 13086, Berlin, Germany.
| | - Hans Behrbohm
- Department of Otorhinolaryngology and Facial Plastic Surgery, Park-Klinik Weissensee, Schönstraße 80, 13086, Berlin, Germany
| | - Leonid Goubergrits
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Hildebrandt
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Brüning
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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22
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Huang CC, Wu PW, Lee YS, Huang CC, Chang PH, Fu CH, Lee TJ. Impact of sleep dysfunction on psychological burden in patients with empty nose syndrome. Int Forum Allergy Rhinol 2022; 12:1447-1450. [PMID: 35665478 DOI: 10.1002/alr.23040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Chien-Chia Huang
- Department of Otolaryngology, Division of Rhinology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Wen Wu
- Department of Otolaryngology, Division of Rhinology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Shien Lee
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Biotechnology, Ming Chuan University, Taoyuan, Taiwan
| | - Chi-Che Huang
- Department of Otolaryngology, Division of Rhinology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan
| | - Po-Hung Chang
- Department of Otolaryngology, Division of Rhinology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan
| | - Chia-Hsiang Fu
- Department of Otolaryngology, Division of Rhinology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ta-Jen Lee
- Department of Otolaryngology, Division of Rhinology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China
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