Intermittent hypoxia induces turbinate mucosal hypertrophy via upregulating the gene expression related to inflammation and EMT in rats

PURPOSE

Chronic intermittent hypoxia (IH) plays a pivotal role in the consequences of obstructive sleep apnea (OSA). It has been demonstrated that IH impairs nasomaxillary complex growth to reduce nasal airway cavity size in rodent models. Although turbinate dysfunction with inflammatory mucosal hypertrophy is related to OSA, the role of IH in turbinate hypertrophy with inflammation-driven fibrosis is unknown. Here, we aimed to clarify the pathogenesis of inflammatory mucosal hypertrophy and epithelial-mesenchymal transition (EMT) in the nasal turbinate under IH.

METHODS

Seven-week-old male Sprague-Dawley rats were exposed to IH (4% O₂ to 21% O₂ with 0% CO₂) at a rate of 20 cycles/h.

RESULTS

Hypertrophy of the turbinate mucosa occurred after 3 weeks, with the turbinate mucosa of the experimental group becoming significantly thicker than in the control group. Immunostaining showed that IH increased the expression of TGFβ and N-cadherin and decreased E-cadherin expression in the turbinate mucosa. Quantitative PCR analysis demonstrated that IH enhanced the expression of not only the inflammatory markers Tnf-a, Il-1b, and Nos2 but also the EMT markers Tgf-b1, Col1a1, and Postn.

CONCLUSIONS

Collectively, these results suggest that IH induced turbinate hypertrophy via upregulation of gene expression related to inflammation and EMT in the nasal mucosa.

Diode laser versus radiofrequency treatment of the inferior turbinate - a randomized clinical trial

BACKGROUND

Laser and radiofrequency induced volume reduction of the inferior turbinates are frequently used treatment modalities. Which of both is superior, however, is not clear to date due to a lack of controlled prospective studies. Here, we compare both methods regarding improvement of nasal breathing, complications, patient comfort and wound healing.

METHODOLOGY

Prospective, randomized, single-blinded clinical trial with intra-individual design. After randomization, one side of the nose was treated with a 940nm diode laser and the other side with bipolar radiofrequency therapy. Pre- and postoperative evaluation was performed using visual analogue scales, nasal endoscopy and objective measurements of nasal patency.

RESULTS

Of 27 enrolled patients, 26 completed the protocol. No severe complications were observed. Intraoperative discomfort was significantly more severe on the radiofrequency side. After three months, a significant reduction of nasal obstruction was observed for laser treatment and radiofrequency therapy with no significant difference between them. Objective parameters did not improve significantly. When asked which treatment modality they would chose again 50 % of the patients decided for radiofrequency treatment, 23 % for laser treatment, and 19 % for both.

CONCLUSION

DLVR and RFVR are well-tolerated treatment modalities and both significantly reduce the degree of nasal obstruction in patients with hypertrophic inferior turbinates. There was no significant difference between both treatment modalities regarding efficiency.

Diode laser versus radiofrequency treatment of the inferior turbinate - a randomized clinical trial

BACKGROUND

Laser and radiofrequency induced volume reduction of the inferior turbinates are frequently used treatment modalities. Which of both is superior, however, is not clear to date due to a lack of controlled prospective studies. Here, we compare both methods regarding improvement of nasal breathing, complications, patient comfort and wound healing.

METHODOLOGY

Prospective, randomized, single-blinded clinical trial with intra-individual design. After randomization, one side of the nose was treated with a 940nm diode laser and the other side with bipolar radiofrequency therapy. Pre- and postoperative evaluation was performed using visual analogue scales, nasal endoscopy and objective measurements of nasal patency.

RESULTS

Of 27 enrolled patients, 26 completed the protocol. No severe complications were observed. Intraoperative discomfort was significantly more severe on the radiofrequency side. After three months, a significant reduction of nasal obstruction was observed for laser treatment and radiofrequency therapy with no significant difference between them. Objective parameters did not improve significantly. When asked which treatment modality they would chose again 50 % of the patients decided for radiofrequency treatment, 23 % for laser treatment, and 19 % for both.

CONCLUSION

DLVR and RFVR are well-tolerated treatment modalities and both significantly reduce the degree of nasal obstruction in patients with hypertrophic inferior turbinates. There was no significant difference between both treatment modalities regarding efficiency.

Peak nasal inspiratory flowmetry for selection of patients for radiofrequency ablation of turbinates

OBJECTIVES

Our goals were to investigate (I) the effectiveness of the topical vasoconstrictor test (TVT) and peak nasal inspiratory flow (PNIF) measurement for the selection of patients with inferior turbinate hypertrophy (ITH) who will benefit from radiofrequency ablation (RFA) of the turbinates and (2) the efficacy of the TVT and PNIF in follow-up of treatment outcomes.

METHODS

Patients with bilateral chronic nasal obstruction due to ITH underwent assessment with a visual analog scale (VAS) and PNIF before and after the TVT. Twenty patients with symptom improvement according to VAS and PNIF results were enrolled in the study. These patients underwent RFA, and PNIF and VAS scores were determined before and I and 6 months after the TVT. These results were compared to evaluate the preoperative prediction of RFA treatment success.

RESULTS

Radiofrequency ablation of the turbinates resulted in significant changes in objective and subjective scores. Preoperative (baseline) subjective and objective responses to decongestant were positively correlated (P = .024 and P < .05, respectively). Preoperative (baseline) objective responses to decongestant were significantly correlated with the objective outcomes of surgery (P = .006 and P < .05, respectively).

CONCLUSION

The combined use of PNIF and the TVT allows for the preoperative prediction of the success of RFA and the selection of patients who will benefit most from RFA.

Mechanical disfunction in the mucosal oedema formation of patients with nasal polyps

BACKGROUND

Nasal polyposis (NP) is characterized by an anomalous tissue growth with oedema and a lack of extracellular matrix. In this study, we investigated whether a mechanical disfunction of the forces that act in oedema formation is present in NP.

METHODS

We compared the interstitial hydrostatic pressure behaviour during a saline solution infusion between healthy nasal mucosa (inferior and middle turbinate from 10 patients) and inflamed nasal mucosa from NP patients (inferior, middle turbinate and a nasal polyp from 6 patients). We used Controlled Disc Stimulation equipment to compare the curve Pressure/Volume created during the saline solution infusion.

RESULTS

The pressure at 0.2 ml infusion was lower in the middle turbinate of NP patients than in the middle turbinate of control patients. The lowest P/V mean assessed was in the polypoid tissue.

CONCLUSIONS

The interstitial hydrostatic pressure showed different behaviour during liquid infusion in nasal mucosa from NP patients when compared with healthy nasal mucosa. This study allows us to cogitate on a new pathophysiological mechanism contributing to the development of the NP.

The efficacy of radiofrequency volumetric tissue reduction of hypertrophied inferior turbinate in simple snoring

BACKGROUND

Simple snoring represents a social problem, not only because it could affect the patient's married life, but it often goes along with sleep-disordered breathing. Chronic nasal obstruction has many sequel including snoring and the inferior turbinate hypertrophy (ITH) is its most common cause. The aim of the study is to evaluate the efficacy of video-assisted endoscopic radiofrequency volumetric tissue reduction (RFVTR) to reduce snoring in patients affected by chronic nasal obstruction due to ITH.

PATIENTS AND METHODS

This prospective study was conducted over 48 habitual snoring with persistent nasal obstruction due to bilateral ITH refractory to medical management received one time RFVTR of both it. Nasal symptoms were assessed both subjectively, by Visual Analog Scale (VAS) and NOSE Scale, and objectively by videorhinohygrometer. Snoring was measured by Snoring severity rated by the bed partner, in a longitudinal fashion, using VAS. All patients were evaluated pre-operatively, and after 45th day (range 35-50 days) post-operatively.

RESULTS

Thirty-two subjects completed study. All patients had significant symptomatic improvement in nasal breathing (5.53 ± 2.88 vs 1.87 ± 1.75; p < 0.05), confirmed by videorhinohygrometer values (p < 0.05). We had a significantly improvement of snoring in all patients (5.62 ± 2.80 vs 1.86 ± 1.43, p < 0.001) with a mean snoring Visual Analog Scale improvement of 77.4%.

CONCLUSIONS

Based on this study and literature review, it seems that RFVTR represents a safe, minimal invasive, easy performed, and time and cost effective surgery, which may decrease symptoms of snoring in patients with ITH, at least, in short-term follow-up.

[The state of palatine tonsils in the patients presenting with the deviation of the nasal septum]

The objective of the present study was to further improve diagnostics and treatment of chronic tonsillitis (ChT). It included 100 patients presenting with disturbances of the nasal breathing that resulted in the deviation of the nasal septum and hypertrophy of the inferior turbinate bones. The signs of the simple form of chronic tonsillitis were detected in the 87 patients enrolled in the study. The patients who enjoyed the normalization of the nasal breathing after the surgical intervention had a more favourable clinical course of chronic tonsillitis compared with the patients given no such treatment. The results of the study provide an additional information concerning the relationship between the disturbances of the basal bleeding and the development of changes in palatine tonsils; moreover, they allow determining early indications for the surgical treatment for the correction of the deviation of the nasal septum.

[Certain peculiarities of rhinoseptoplasty in children]

This paper reports the results of examination and treatment of children presenting with deviation of the nasal septum. All of them underwent septoplasty simultaneous with rhinoplasty, vasotomy of inferior nasal concha, and correction of bullous middle nasal concha (if indicated). It is recommended that the data obtained be taken into consideration during rhinoseptoplastic surgey in children.

The evidence for reducing inferior turbinates

Nasal obstruction is commonly due to enlargement of the inferior turbinate. This review discusses the pathophysiology of turbinate enlargement, the indications for, and methods and outcome of turbinate reduction. All techniques are successful but vary in their long-term efficacy, their propensity for complications and the degree to which they may adversely affect nasal function. Newer techniques under local anaesthetic and often endoscopic control offer outpatient treatment with satisfactory outcomes. However selecting a particular technique should take account of the individual patient's features, the surgeon's experience and judgement and informed patient choice.

[A computational fluid dynamics study of inner flow through nasal cavity with unilateral hypertrophic inferior turbinate]

OBJECTIVE

To investigate the anatomical influence of the hypertrophic inferior turbinate on computational fluid dynamics (CFD) model of unilateral hypertrophic inferior turbinate nasal cavity, and to analyze the bilateral detailed nasal airflow simulations under both inspiratory and expiratory phases in CFD model.

METHOD

One male volunteer troubled with unilateral hypertrophic inferior turbinate accepted CT scan. CFD model was built by CT scans through Simplant 10.0 and ANSYS ICEM. Fluent 6.3.26 simulated the airflow of both nasal cavity in breathing rates 200 ml/s.

RESULT

1) In infraturbinal region, the cross-section area (CSA) of the nasal cavity with hypertrophic inferior turbinate was smaller than that in healthy side and the average area difference between two sides was 1.62 cm2. 2) In both inspiration and expiration phases, the hypertrophic infraturbinal produced a markable reduction in intranasal pressures drop along the full length of the infraturbinal region. The volumetric flow rate in the hypertrophic infraturbinal side was 50 ml/s, which equalled to one third of that in healthy side; Mean air speed in the anterior valve region was estimated to be 0.57 m/s at hypertrophic infraturbinal side and 1.83 m/s at healthy side during inspiration; More vortices happened in the hypertrophic infraturbinal side.

CONCLUSION

The unilateral hypertrophic infraturbinal change the normal anatomy and influence the aerodynamic of nasal cavity, which is harmful to the functions of human nasal in ventilation, temperature accommodation and olfactory sensation.

Variations in paranasal sinus anatomy: implications for the pathophysiology of chronic rhinosinusitis and safety of endoscopic sinus surgery

OBJECTIVES

To study the radiologic anatomy of the paranasal sinuses in patients with and without chronic rhinosinusitis to assess whether anatomic variations are associated with disease pathology, and to identify those variants that may impact operative safety.

SETTING

Tertiary referral otolaryngology unit.

MAIN OUTCOME MEASURES

Incidence and nature of anatomic variants with potential impact on operative safety, and the presence or absence of sinus mucosal disease and its correlation with anatomic variants with a potential impact on mucociliary clearance.

METHODS

We reviewed 278 computed tomographic scans from patients with rhinosinusitis symptoms to investigate anatomic variations that may predispose to sinusitis or impact on operative safety. The incidence of variants with potential impact on sinus drainage was compared between patients with and without sinus mucosal disease with logistic regression.

RESULTS

A closed osteomeatal complex was identified in 148 patients (53%), followed by concha bullosa in 98 patients (35%). Closed osteomeatal complex and nasal polyposis were independent risk factors for sinus mucosal disease. Anatomic variants with a potential impact on operative safety included anterior clinoid process pneumatization (18%), infraorbital ethmoid cell (12%), sphenomaxillary plate (11%), and supraorbital recess (6%). In 92% of patients, the level difference between the roof of the ethmoid cavity and the cribriform plate was Keros I.

CONCLUSIONS

Bony anatomic variants do not increase the risk of sinus mucosal disease. However, anatomic variants with a potential impact on operative safety occur frequently and need to be specifically sought as part of preoperative evaluation.

Comparative study on the long-term effectiveness between coblation- and microdebrider-assisted partial turbinoplasty

OBJECTIVES

Various surgical methods have been tried to relieve the symptoms of nasal obstruction in patients with inferior turbinate hypertrophy. Recently, coblation that uses the radiofrequency and microdebrider is being increasingly used in turbinate surgery. The aim of this study was to compare the long-term postoperative outcome between the coblation- and microdebrider-assisted partial turbinoplasty.

METHODS

We selected 60 patients for this prospective study who had nasal obstruction and hypertrophied turbinate mucosa that was refractory to medical treatment. Thirty patients were treated with coblation (group 1) and 30 patients were treated with microdebrider (group 2). Postoperative changes in degree of nasal obstruction were evaluated prospectively at 3, 6, and 12 months after the procedure. A cross-sectional area of second notch and volume of nasal cavity were compared at 12 months after operation. Operation time, duration of crust formation, postnasal drip, and postoperative bleeding were also compared.

RESULTS

Nasal obstruction was improved significantly in both groups at 3, 6, and 12 months after the procedure. However, when compared between two groups, symptom improvement was statistically significant in group 2 at 12 months after surgery. Acoustic rhinometry performed at 12 months demonstrated a significant increase of cross-sectional area of second notch and volume of nasal cavity in group 2 in comparison with group 1. There were no significant differences in degree of postnasal drip, operation time, or duration of crust formation between the two groups.

CONCLUSION

This study suggests that microdebrider-assisted partial turbinoplasty is more effective and satisfactory in long-term relief of nasal obstruction and reduction in mucosal volume of anterior head of inferior turbinate.

Acoustic rhinometry predicts tolerance of nasal continuous positive airway pressure: a pilot study

BACKGROUND

Nasal continuous positive airway pressure (nCPAP) is usually the first-line intervention for obstructive sleep apnea, but up to 50% of patients are unable to tolerate therapy because of discomfort-usually nasal complaints. No factors have been definitively correlated with nCPAP tolerance, although nasal cross-sectional area has been correlated with the level of CPAP pressure, and nasal surgery improves nCPAP compliance. This study examined the relationship between nasal cross-sectional area and nCPAP tolerance.

METHODS

We performed acoustic rhinometry on 34 obstructive sleep apnea patients at the time of the initial sleep study. Patients titrated to nCPAP were interviewed 18 months after starting therapy to determine CPAP tolerance. Demographic, polysomnographic, and nasal cross-sectional area data were compared between CPAP-tolerant and -intolerant patients.

RESULTS

Between 13 tolerant and 12 intolerant patients, there were no significant differences in age, gender, body mass index, CPAP level, respiratory disturbance index, or subjective nasal obstruction. Cross-sectional area at the inferior turbinate differed significantly between the two groups (p = 0.03). This remained significant after multivariate analysis for possibly confounding variables. A cross-sectional area cutoff of 0.6 cm2 at the head of the inferior turbinate carried a sensitivity of 75% and specificity of 77% for CPAP intolerance in this patient group.

CONCLUSION

Nasal airway obstruction correlated with CPAP tolerance, supporting an important role for the nose in CPAP, and providing a physiological basis for improved CPAP compliance after nasal surgery. Objective nasal evaluation, but not the subjective report of nasal obstruction, may be helpful in the management of these patients.

Does the use of the combined oral contraceptive pill cause changes in the nasal physiology in young women?

BACKGROUND

Changes in nasal physiology have been observed during pregnancy and the menstrual cycle. The role of female hormones in these changes is unclear. The aim is to investigate the effect of the modern combined oral contraceptive pill (COCP).

METHODS

Eleven women were recruited from a family planning clinic. Anterior rhinoscopy, peak inspiratory flow rate, acoustic rhinometry, anterior rhinomanometry, mucociliary clearance time, and rhinitis quality-of-life questionnaire (RQLQ) scores were recorded at days 1 and 14 pre- and post-COCP.

RESULTS

Increased nasal obstruction midcycle pre-COCP, with significant differences for anterior rhinoscopy (p = 0.001) and peak inspiratory flow rate (p = 0.022), was found. No statistical difference was shown between pre- and post-COCP results apart from day 1 anterior rhinoscopy findings (p = 0.05).

CONCLUSION

The modern COCP has no significant effect on nasal physiology.

Craniofacial pain and anatomical abnormalities of the nasal cavities

The causal relation between anatomical variations of the nose and headaches and facial pain is analyzed through literature review of the topic. The pathogenesis that can be involved in this relation proves to be wider than simple alteration of nasal septum and turbinates that can cause mechanical stimulus through contact between these structures, which covers infectious factors, neurogenic inflammation, correlation with migraines and the role of nasal obstruction. The clinical findings of a lot of authors including the test with topical anesthetic to prove this causal relation, the indication of surgical treatment, in addition to good results of this treatment, are reported. The mechanism of pain relief obtained through surgical correction of nasal septum and turbinate is discussed. These data make us conclude that there are multiple etiologic factors involved, which makes us question the fundamental role of the mechanical aspect.

Relationship between pediatric sinusitis and middle turbinate pneumatization--ethmoidal sinus pyocele thought to be caused by middle turbinate pneumatization

OBJECTIVE

To investigate whether the presence of pediatric middle turbinate pneumatization causes narrowing of the ostiomeatal complex (OMC) and is associated with the development of paranasal sinusitis.

METHODS

CT scans of 190 nasal sides of 95 children (1-15 years old) were analyzed for the presence of middle turbinate pneumatization and mucosal thickness in the paranasal sinus.

RESULTS

Middle turbinate pneumatization was detected in nine (4.6%) of the nasal cavities. Only one of these sides was in a patient younger than 10 years of age, while the other eight sides were in patients at least 13 years old. In six of those nine sides with pneumatization, paranasal sinusitis was also found. However, the images showed that in five sides the middle turbinate pneumatization itself did not obstruct the OMC. In addition, the mean +/- standard deviation (S.D.) of the total score for the paranasal sinus opacification on the side which had the middle turbinate pneumatization was 5.67 +/- 2.95. The corresponding value for the 76 sides without pneumatization was 5.29 +/- 2.53, and the difference between these mean total scores was not statistically significant. However, in one side, the OMC was obstructed or narrowed due to the middle turbinate pneumatization, and an ethmoidal sinus pyocele formed on this side.

CONCLUSION

A causal relationship was not found between middle turbinate pneumatization and the mechanism of development of paranasal sinusitis in children. However, in the event that the OMU becomes obstructed at some time, frequent cycles of improvement and aggravation of pediatric paranasal sinusitis may occur and lead to the development of a serious condition.

Secure endoscopic sinus surgery with partial middle turbinate modification: a 16-year long-term outcome report and literature review

The efficacy of functional endoscopic sinus surgery for the treatment of chronic sinusitis is well established. Two contrasting European techniques were introduced to North America in the 1980s: that espoused by Wigand, which included endoscopic isthmus modification of all sinus ostia and cavities with modification of the middle turbinates, and that developed by Messerklinger, who practiced only minimal opening of the narrow osteomeatal tract at the anterior ethmoid sinus to achieve physiologic reversal of sinus disease. These techniques were additionally modified recently by the introduction of power resection techniques by Setliff and Christmas and stereotactic computer navigation by Anon and Fried. In 1986, after exposure to both original techniques, I developed a middle-ground approach that lies between the extremes of the two European schools. The benefits of this middle-ground multimodal secure technique include a high success rate, maximal safety, and the ability to be performed as an adjunct to any other indicated functional nasal surgery. Since its inception, a key feature of this technique has included partial modification of the bulky inferior portion of the middle turbinates. This has contributed markedly to successful long-term outcome and safety rates.

Comparison of the effects of radiofrequency tissue ablation, CO2 laser ablation, and partial turbinectomy applications on nasal mucociliary functions

OBJECTIVES

One of the major causes of chronic nasal airway obstruction is disease of the inferior turbinate. However, there is no agreement on how to deal with this problem. Comparison was made of the nasal functions after treatment by radiofrequency tissue ablation, laser ablation, and partial turbinectomy using subjective symptom scores and objective tests.

STUDY DESIGN

Prospective, randomized clinical trial.

METHODS

The study was conducted on three groups of 45 adult volunteer patients with symptoms and signs of nasal obstruction and stuffiness related to enlarged turbinates. In group A, laser ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group B, radiofrequency tissue ablation was applied to the inferior turbinate on one side and partial turbinectomy to the inferior turbinate on the other side. In group C, patients who were not treated by any surgical techniques were the control subjects. Clinical examinations, visual analogue scales, rhinomanometry, and isotopic study of nasal mucociliary transport time were used to assess treatment outcomes.

RESULTS

At 12 weeks after surgery, the nasal mucociliary transport time results were compared in the same patients. The average time was 25.60 minutes on the side where laser ablation was applied and 11.40 minutes on the side where partial turbinectomy (PT) was applied. In the patients on whom radiofrequency tissue ablation and partial turbinectomy were applied, the average nasal mucociliary transport time was 10.33 minutes on the radiofrequency tissue ablation side, whereas it was 11.33 minutes on the partial turbinectomy side. Rhinomanometric measurements demonstrated a significant decrease in nasal resistances at 12 weeks in both sides in groups A and B.

CONCLUSIONS

In the study it was demonstrated that radiofrequency tissue ablation to the turbinate is effective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary function significantly. With the partial turbinectomy technique, results obtained were similar to the results with the radiofrequency tissue ablation technique.

[The inferior turbinate: dysregulation and surgical reduction]

Nasal obstruction may be caused by individual anatomy, a dysregulation of the nasal mucosa or, frequently, a combination of both. Persistent allergic inflammation deserves special attention, as initial therapy should not be surgical. The plethora of surgical techniques for the reduction of inferior turbinate volume is a good indicator of unresolved controversies regarding the ideal technique. This review analyses our current knowledge about success and complication rates of different surgical techniques. Many of these techniques have a distinct pro and contra-profile which is acceptable for both the patient and the surgeon. This is a good starting point for randomised clinical trials. The definition of the anterior turbinoplasty as a gold-standard for future trials is proposed.

[Current views of surgical procedures in the treatment of hypertrophic nasal conchae]

Surgical treatment aiming at decreasing the size of the nasal conchae is controversial and it should be performed only after all alternative kinds of therapy have appeared unsuccessful. The incision of hypertrophic nasal conchae can also be performed together with the operation of the nasal septum. The excision of the entire concha is performed very infrequently. Usually, only the soft tissue of the concha is excised, but the excision of the hypertrophied tissue is most desirable. Some patients may undergo the cryotherapy.

Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution

To achieve success in rhinoplasty, the plastic surgeon takes advantage of numerous intraoperative techniques designed to manipulate nasal soft tissue and the osseocartilaginous framework. Although the postoperative result may meet preoperative aesthetic goals, an element of nasal airway obstruction can persist from failure to acknowledge the role of inferior turbinates. Surgically responsive inferior turbinate hypertrophy is frequently not addressed secondary to inadequate history taking, incomplete physical examination, and/or surgeon reluctance to handle these sensitive structures. The goal of this article is to discuss the anatomy and physiology of the inferior turbinates, to present the role for inferior turbinate surgery during rhinoplasty, and to delineate the evolution of the current technique of submucosal resection of the inferior turbinates. Over the past 14 years, the senior author (R.J.R.) has performed inferior turbinates surgery on 648 patients as part of a rhinoplasty.

Total inferior turbinectomy: operative results and technique

The internal nasal structures, including the turbinates, regulate the nasal airflow. The surgical treatment of turbinate hypertrophy remains controversial. A wide variety of surgical procedures is performed, with universally unsatisfactory results. Interference with nasal physiology and possible postoperative complications have been the main reasons for the objection to total inferior turbinectomy. Over a 6-year period, 357 total inferior bilateral turbinectomies were performed at our institution. We present the results of these procedures and describe our surgical technique. We conclude that even in a hot and dusty climate, total inferior turbinectomy is an effective and relatively safe procedure.

Anatomic correlates of acoustic rhinometry as measured by rigid nasal endoscopy

Acoustic rhinometry (AR) evaluates the cross-sectional areas and volume of the nasal cavity through acoustic reflections. Successive valleys displayed on an AR graph are believed to correspond to anatomic landmarks. To assess the anatomic accuracy of AR, we performed AR and endoscopic measurements with a rigid endoscope in 85 normal human subjects after topical decongestion. Endoscopic measurements were recorded for distances between the midcolumella and the nasal valve, the anterior end of the inferior turbinate, the anterior end of the middle turbinate, the midportion of the middle turbinate, and the posterior nasopharynx. The first AR valley most closely corresponded with endoscopic measurements of the nasal valve. The second valley had a mean value that corresponded with the anterior end of the inferior turbinate. The third valley matched best with the values of the anterior end of the middle turbinate. Nasopharyngeal measurements by each modality yielded a good agreement. AR appears to correspond to nasal anatomic landmarks but not in an exact point-to-point manner.

Alterations of nasal mucociliary transport in patients with hypertrophy of the inferior turbinates, deviations of the nasal septum and chronic sinusitis

Mucociliary transport (MCT) represents the first barrier of the nasal fossae and paranasal sinuses against various biological and physical insults. We studied the nasal MCT time using a mixture of vegetable charcoal powder and 3% saccharin in three groups of patients suffering from hypertrophy of the inferior turbinates, deviations of the nasal septum or chronic sinusitis. The mean values of the nasal MCT in the first two groups were practically identical to the normal ones. In contrast, significantly delayed times were found in patients with chronic sinusitis (P < 0.01). Findings indicate that this delay is determined by an increase in viscoelasticity of the mucus following the acute release of mediators of inflammation, together with a reduction in the periciliary stratum, which slows down the metachronous wave of the MCT.

A dynamic and direct visualization model for the study of nasal airflow

OBJECTIVE

To evaluate nasal airflow characteristics during physiologic breathing in normal and pathologic conditions.

DESIGN

The choana of an anatomical human model was connected to a pump that simulated physiological pressure changes in the upper airway system. Normal ambient air was used as medium. The airstream was marked with aerosolized water particles, and was observed through an exact but translucent replica of the original nasal septum.

RESULTS

In physiologic conditions the airflow is mixed. Turbulence is clearly visible even with low flow velocities. There is less turbulence with lower flow rates. The nasal airflow follows a triphasic pattern of acceleration, near-steady state, and deceleration. Turbulence is prominent in the first and third phases. The main flow stream passes through the middle meatus at all rates. Hypertrophic mucosal membranes and turbinates increase the proportion of air passing the middle meatus. With decongested turbinates, flow distribution is more even. After turbinectomy there is a significant amount of airflow passing along the floor of the nose. The olfactory region is aerated only toward the end of inspiration and during the entire expiration phase.

CONCLUSIONS

This model allows the investigation of airflow distribution and turbulence under physiologic conditions and the examination of the influence of pathologic conditions on these parameters. Overzealous trimming of turbinates results in an unphysiologic distribution of airflow.

[Nd:YAG laser treatment of the lower turbinates with contact in hyperreflexic and allergic rhinopathy]

BACKGROUND

Nasal obstruction caused by mucosal swelling due to hyperreflectory or allergic rhinitis is a very frequent disorder. We would like to report about our first results (ENT department, University of Göttingen) in the reduction of hyperplastic inferior turbinates by Nd:YAG Laser treatment.

PATIENTS AND METHOD

One hundred seventeen patients with nasal obstruction were treated by Nd:YAG laser between October 1993 and February 1997. We used the laser in "contact mode" and all outpatients were under local anaesthesia. Follow-up was possible in 83 cases. A subjective scale was used to evaluate our results. One quarter of the patients suffered from an allergic rhinitis.

RESULTS

For 80% the nasal airflow was increased. Sixty percent had excellent or good results without any nasal obstruction after therapy. The patients with allergic rhinitis performed as well as the patients with hyperreflectory rhinopathy. This improvement appeared as early as four weeks after treatment and was permanent in 37 of 40 cases with long-term observation of at least one year. Side effects: 14% reported a dry nasal mucosa for two weeks; 31% had a bloody nasal secretion for two days after treatment, but did not bleed. Fifteen percent complained of pain during the procedure.

CONCLUSION

The reduction of the inferior turbinates by Nd:YAG laser is an effective treatment of equal value in symptomatic therapy of the hyperplastic turbinates due to hyperreflectory and allergic rhinopathy. Seventy-three percent of these patients would like to be treated in this way again if necessary.

Transport phenomena in the human nasal cavity: a computational model

Nasal inspiration is important for maintaining the internal milieu of the lung, since ambient air is conditioned to nearly alveolar conditions (body temperature and fully saturated with water vapor) on reaching the nasopharynx. We conducted a two-dimensional computational study of transport phenomena in model transverse cross sections of the nasal cavity of normal and diseased human noses for inspiration under various ambient conditions. The results suggest that during breathing via the normal human nose there is ample time for heat and water exchange to enable equilibration to near intraalveolar conditions. A normal nose can maintain this equilibrium under extreme environments (e.g., hot/humid, cold/dry, cold/humid). The turbinates increase the rate of local heat and moisture transport by narrowing the passageways for air and by induction of laminar swirls downstream of the turbinate wall. However, abnormal blood supply or mucous generation may reduce the rate of heat or moisture flux into the inspired air, and thereby affect the efficacy of the process.

Chronic sinusitis: a sequela of inferior turbinectomy

Inferior turbinectomy has generated a great deal of controversy among rhinologic surgeons. Proponents of partial and total inferior turbinectomy cite numerous studies of large numbers of patients with subjective relief of nasal obstruction after turbinectomy. Clinical studies critical of turbinectomy have focused on complications such as hemorrhage, crusting, adhesions, and atrophic rhinitis. Our study was undertaken to evaluate the incidence of chronic sinusitis post inferior turbinectomy. Postoperative evaluation by history, physical examination, and computerized tomography of the paranasal sinuses revealed that a significant number of patients who underwent inferior turbinectomy developed sinusitis. Patients evaluated in our clinic for nasal obstruction underwent a detailed history, physical examination along with nasal endoscopy and coronal computerized tomography of the paranasal sinuses. Those patients with nasal obstruction not responsive to medical treatment and without evidence of sinusitis underwent submucous resection and inferior turbinectomy. The incidence, cause, and possible prevention of post inferior turbinectomy sinusitis is discussed in this article.

Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis

Mucosal changes have been well described in chronic sinusitis, yet little is known about the underlying bone, despite clinical and experimental evidence suggesting that bone may be involved in chronic sinusitis. Techniques of undecalcified bone analysis were used for detailed histologic examination of ethmoid bone in chronic sinusitis compared with controls. Bone synthesis, resorption, and inflammatory cell presence were specifically assessed. Additionally, histomorphometry techniques were used to determine ethmoid bone physiology in individuals undergoing surgery for chronic sinusitis. Overall, individuals undergoing surgery for chronic sinusitis were found to have evidence of marked acceleration in bone physiology with histologic changes including new bone formation, fibrosis, and presence of inflammatory cells. These findings are compared with osteomyelitis in long bone and the jaw. The suggestion that underlying bone may serve as a catalyst for chronic sinusitis is supported and implications for therapy are discussed.

[Presumed physiopathology of the nasal wall surgery and contemporary techniques of the inferior turbinates surgery]

The lateral wall of the nasal cavity is anatomically complex and covers several nasal functions: ventilation, conditioning of the air, protection. This region also plays a prime role in maintaining nasal-sinus homeostasis through dynamic regulation of the two-way exchange between the nasal cavity and paranasal sinuses. In light of the most recently acquired information, physio-pathological aspect of the lateral wall are discussed in terms of ventilation mechanisms and mucociliary clearance of the paranasal sinuses. In this light, the key to nasal-sinus physiology is clearly the perviousness of the side wall ostium and, above all, the status of the structures making up the "ostiomeatal complex". The anatomo-functional integrity of the lateral wall is fundamental for sinus ventilation 90% of which depends on passive diffusion of air through ostium. It is also a key to mucociliary clearance, always directed toward the main ostium. This rationale provides the basis for the so-called functional surgery of the lateral wall aimed at restoring ostium permeability. One structure in the lateral wall is a key to nasal physiology: the lower turbinate. Anatomical or functional alterations of the lower turbinate is one of the major causes of nasal stenosis. Pharmacological treatment of this pathologies is not always satisfactory, hence one leans toward surgical treatments. Nevertheless, the wide range of techniques available attests to the fact that there is still great deal of uncertainty in this regard. After having analysed the data available in the literature, the authors propose a comparison of some of the most frequently used forms of surgery: electrocauterization, cryotherapy, laser therapy, submucosal decongestion with or without luxation, turbinectomy. Follow-up based on rhinomanometric evaluation, rhinometry, TTMC, IgA assay and symptom scoring has been performed for 4 years. The results show that the submucosal decongestion technique, particularly the variation with lateral luxation, is considered most effective in resolving obstruction while respecting nasal physiology.

Morphological variability of smooth muscle cells in human nasal swell bodies

The complex functional behavior of nasal swell bodies is still not completely understood. In the present study the histology of the vessels involved in the swelling mechanism is examined and the ultrastructural appearances described of the different types of smooth muscle cells located in the vascular wall of swell bodies in the human inferior turbinate. Even though the majority of smooth muscle cells of the nasal swell bodies showed a normal, elongated appearance comparable to other smooth muscle cells elsewhere in the body, a variety of cells with atypical shapes could be detected that have not been described previously in vessels of the nasal mucosa. The diameters of the smooth muscle cells in general were strikingly variable. The individual smooth muscle cells were surrounded by a basal lamina that was occasionally disrupted or doubled. Myoblasts were separated by a connective tissue space containing collagen fibrils, mature elastin fibers and bundles of microfibrils. The latter two types of fibers and fibrils occurred mainly in the outer parts of the muscular coat. The endowment of cytoplasmic components was similar in all smooth muscle cells of the vascular wall in the swell bodies. These findings indicate that the specific feature of smooth musculature presumably resides in the unusual morphological variability of the single cells present, as well as in the striking heterogeneity of the arrangement of bundles of these cells in the vascular wall.

The place of endonasal endoscopy in the relief of middle turbinate sinonasal headache syndrome

Middle turbinate sinonasal headache syndrome is a rare but not uncommon treatable cause of headache. The true incidence of headache from this cause is unknown. Pneumatization (concha bullosa) or hypertrophy of the middle turbinate can result in it contacting the septum or the lateral nasal wall and may give headaches in the periorbital region. It may occur in the absence of inflammatory sinus disease. The clinical history, nasal endoscopic examination and, coronal CT-scan should point towards the diagnosis and a local anaesthetic challenge test should confirm the diagnosis. Treatment is by relieving the contact point by medical or surgical means. Twenty-one cases of middle turbinate sinonasal headache syndrome refractory to medical treatment are presented with emphasis on the results of endonasal endoscopic surgical treatment.

[Comparative study of most recent surgical techniques for the treatment of the hypertrophy of inferior turbinates]

The choice among the several techniques carried out to treat the hypertrophy of inferior turbinates is still difficult and matter of great interest. In the present study the Authors evaluated the efficacy and sequelae of the most common operations suitable for this pathology. The surgical procedures taken into consideration were (1) electrocautery; (2) cryotheraphy; (3) lasertherapy; (4) submucosal decongestion without lateral outfracture; (5) sub-mucosal decongestion with lateral outfracture; (6) turbinectomy. The six groups of patients (total 382) have been followed up for 4 years after surgery. At this aim the rhinomanometry, acoustic rhinometry, MCTt and SIgA dosage have been checked up together with the symptomatologic score. The conclusion was that the submucosal decongestion with lateral outfracture was the most effective technique for the chronic nasal obstruction, able to respect all the nasal functions.

Piriform aperture surgery for alar collapse

The region of maximum resistance in the respiratory tract is in the anterior part of the nose, and this area has been termed the nasal valve. Inspiratory narrowing of this area, known as alar or nasal valve collapse can produce the symptom of obstruction, and may be very difficult to correct. The anatomy and physiology of the nasal valve are discussed followed by the author's technique for correction of a common problem leading to alar collapse; a narrow piriform aperture, which is often associated with a prominent web at the muco-cutaneous junction.

An in vitro model for measuring tryptase release from nasal mucosa in response to allergen challenge

A simple in vitro nasal mucosal culture model has been developed to measure release of the mast cell specific enzyme tryptase in response to allergen challenge. Patients who were undergoing inferior turbinectomy were skin-tested for commonly inhaled allergens. The mucosa from the inferior turbinates was kept viable using Minimal Essential Medium. Tryptase release into the medium was measured using the Pharmacia Riact Assay. There was a significant increase in tryptase release in response to allergen challenge from the mucosa harvested from skin-test positive patients. Mucosa from skin-test negative patients failed to demonstrate an increase in tryptase release. This could prove to be a useful research model for the study of nasal type I hypersensitivity and drugs that affect it.

[Model studies of nasal turbinate surgery]

The improvement of nasal air flow often requires, in addition to septoplasty, surgery of the turbinates. In order to broaden our knowledge of the influence of turbinate surgery on nasal function, the authors investigated nasal models with different lateral walls by visualisation of flow patterns and rhinoresistometry. Anterior turbinoplasty and turbinectomy reduce the nasal resistance to air flow, but the respiratory function of the nose deteriorates. As the result of these experiments, a trimming of hyperplastic turbinates must create a normal shape of lateral nasal wall, because the respiratory function is based on nearly regular narrow cavities.

Laser treatment of rhinitis--1 year follow-up

Laser cautery of the inferior turbinates for the treatment of rhinitis has been shown to be as effective as sub-mucosal diathermy in the short-term and to produce less morbidity. However, the long-term effects are unknown. A cohort of patients who were treated by either of these methods were reviewed 1 year after treatment. Subjective and objective measurements of airway obstruction were performed using a linear analogue scale and a nasal peak inspiratory flowmeter. The results obtained were compared with those recorded pre-operatively, 3 days post-operatively and 6 days post-operatively. In contrast to the results of sub-mucous diathermy of the inferior turbinates for the treatment of rhinitis, the reduction in subjective nasal airway obstruction obtained by laser cautery to the inferior turbinates is maintained 1 year after surgery. Neither method of turbinate reduction was associated with a sustained objective improvement in nasal airway patency as measured by peak nasal inspiratory flow rate determinations.

Inferior turbinectomy: comparison of four techniques

As yet, there is not totally satisfactory means for treating hypertrophied turbinates and the proper management of turbinate dysfunction remains in question. In the present series, four of the widely practiced surgical procedures for the reduction of the size of the inferior turbinates were evaluated and compared. In all cases turbinectomy was performed as an isolated procedure. Eighty patients with chronic non-allergic rhinitis and hypertrophied inferior turbinates were selected, randomly divided into four groups, and followed up post-operatively for one year. Study of the results indicated that the beneficial effect of the operation is mainly mechanical by reduction of the resistance to nasal airflow. The post-operative improvement in smell acuity correlated positively with the increased patency of the nasal airway. None of the procedures had a deleterious effect on olfactory acuity. In contrast, the operation failed to enhance the mucociliary clearance rate or significantly decrease nasal drainage. Partial inferior turbinectomy and laser turbinectomy improved nasal breathing in 77 per cent of patients, and enhanced olfactory acuity in 78 per cent of patients who had pre-operative hyposmia. The results of turbinoplasty and cryoturbinectomy were less favourable. The surgical technique, advantages, and drawbacks of each of these procedures are discussed.

Activation of an apical Cl- conductance by Ca2+ ionophores in cystic fibrosis airway epithelia

Cystic fibrosis (CF) airway epithelia express a defect in adenosine 3',5'-cyclic monophosphate (cAMP)-dependent regulation of apical membrane Cl- channels. Recent patch-clamp studies have raised the possibility that Ca2+ -dependent mechanisms for the activation of Cl- secretion may be preserved in CF airway epithelia. To determine 1) whether intact normal (N1) and CF airway epithelia exhibit a Ca2+ -dependent mechanism for activation of Cl- secretion and 2) whether Ca2+ -dependent mechanism for activation of Cl- secretion and 2) whether Ca2+ -dependent mechanisms initiate Cl- secretion via activation of an apical membrane Cl- conductance (GCl-), nasal epithelia from N1 and CF subjects were cultured on collagen membranes, and responses to isoproterenol or Ca2- ionophores [A23187 10(-6) M; ionomycin (10(-5)M)] were measured with transepithelial and intracellular techniques. Isoproterenol induced activation of an apical membrane GCl- in N1 cultures but was ineffective in CF. In contrast, in both N1 and CF amiloride-pretreated cultures, A23187 induced an increase in the equivalent short-circuit current that was associated with an activation of an apical membrane Gc1- and was bumetanide inhibitable. A23187 addition during superfusion of the lumen with a low Cl- (3 mM) solution reduced intracellular Cl- activity of CF cells. A Ca2+ ionophore of different selectivity properties, ionomycin, was also an effective Cl- secretagogue in both N1 and CF cultures. We conclude that 1) the A23187 induced Cl- secretion via activation of an apical GCl- in N1 human nasal epithelium, and 2) in contrast to an isoproterenol-dependent path, a Ca2+ -dependent path for GCl- activation is preserved in CF epithelia.