The potential role of peak nasal inspiratory flow to evaluate active sinonasal inflammation and disease severity.

Although the pathophysiology of nasal polyposis is incompletely understood, rhinologists have seldom studied it with rhinomanometry or peak nasal inspiratory flow (PNIF) due to technical limitations and the perception that polyp size might impair reproducibility and the usefulness of recordings. The objective of this study is to assess how measures of rhinomanometry and PNIF relate to disease activity. Nineteen patients with polyps, 15 patients with chronic sinusitis without polyps and 11 negative controls were evaluated with active anterior rhinomanometry and PNIF. Sinusitis and polyp patients were re-evaluated after medical treatment. Polyp patients had the highest median Lund-Mackay score (14) and a median Johansen score of 1. PNIF and its variation after treatment were also lowest in this group (median 90 L/min before and after treatment; median variation of 0 L/min). Nasal resistance was similar between groups, and only correlated with Johansen score (Spearman = 0.517, p = 0.048) after treatment. Our study suggests that evaluating polyp patients using rhinomanometry and PNIF may provide useful and reproducible data. Several findings considered together suggest that polyp size is not the main determinant of nasal functional changes in these patients, warranting further studies to verify whether PNIF changes reflect sinus inflammation or merely airway obstruction.

Aclaración sobre la evaluación de la obstrucción nasal mediante rinomanometría y escalas subjetivas y medición del éxito terapéutico médico y quirúrgico / Comments on the assessment of nasal obstruction with rhinomanometry and subjective scales and outcomes of surgical and medical treatment

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Comparative analysis of velopharyngeal activity assessed by acoustic rhinometry and rhinomanometry.

PURPOSE: To analyze the velopharyngeal (VP) activity of subjects with velopharyngeal dysfunction (VPD) by acoustic rhinometry, as compared to rhinomanometry. METHODS: This was a prospective clinical study conducted in 41 adults, both genders, with repaired cleft palate, with or without a previously repaired cleft lip, and residual VPD on clinical assessment, without compensatory articulations for [p], [t], and [k]. The outcome measures were as follows: (1) on acoustic rhinometry, nasopharyngeal volumetric change (ΔV) during [p], [t], and [k], relatively to rest condition (decreases by <3 cm3 considered as absence of VP activity); (2) on modified anterior rhinomanometry, VP orifice area (areas ≥0.05 cm2 considered as inadequate closure). The plosive [p] was used when comparing the techniques (n=24). RESULTS: (1) A mean ΔV decrease of 18% was observed during [k], which was significantly lower (p<0.05) than the decrease reported for individuals without VPD (30%). ΔV values suggesting VPD were observed in 59% subjects. Similar results were obtained for [p] and [t], which shall be used as stimulus, given that they do not involve the use of the tongue to lift the velum during VP closure, differently from the velar plosive [k]. (2) Inadequate closure was seen in 85% subjects. No correlation was observed between ∆V and VP orifice area. Agreement between techniques was observed in 51% cases. CONCLUSION: Acoustic rhinometry had low accuracy as a diagnostic method of VPD when compared to the gold standard method. Nevertheless, the technique shows potential as a method for monitoring the outcomes of clinical and surgical treatment of VPD aimed at increasing velar and pharyngeal activity.

Análise comparativa da atividade velofaríngea aferida por rinometria acústica e rinomanometria / Comparative analysis of velopharyngeal activity assessed by acoustic rhinometry and rhinomanometry

RESUMO Objetivo: Analisar a atividade velofaríngea (VF) de indivíduos com disfunção velofaríngea (DVF) aferida por rinometria acústica, comparativamente à rinomanometria. Métodos: Estudo clínico prospectivo em 41 adultos, de ambos os gêneros, com fissura de palato±lábio previamente operada e DVF residual ao exame clínico, sem articulação compensatória nas plosivas surdas [p], [t] e [k]. Variáveis analisadas: (1) variação volumétrica da nasofaringe (∆V) na produção das três plosivas, relativamente ao repouso, por rinometria acústica (reduções <3 cm3 foram consideradas como ausência de atividade velofaríngea); (2) área do orifício velofaríngeo (área VF), por rinomanometria anterior modificada; áreas ≥0,05 cm2 foram consideradas como fechamento inadequado. Na comparação das técnicas foi utilizada a plosiva [p] (n=24). Resultados: Observou-se: (1) ∆V médio de 18% no [k], significantemente menor (p<0,05) que a redução relatada para normais (30%); valores de ∆V sugestivos de DVF constatados em 59% dos casos. Resultados similares foram obtidos no [p] e [t], mostrando-se mais apropriados para o exame rinométrico, por não envolverem a participação da língua no fechamento velofaríngeo, diferentemente da plosiva velar [k]; (2) fechamento VF inadequado em 85% dos casos. Não houve correlação significativa entre o ∆V e a área do orifício velofaríngeo. A concordância de diagnóstico entre os métodos ocorreu em 51% dos casos. Conclusão: A rinometria acústica não apresentou boa acurácia como método de diagnóstico da DVF frente ao método padrão. Demonstrou, contudo, potencial como método de acompanhamento dos resultados de intervenções clínico-cirúrgicas que levem à maior atividade velar e faríngea.

ABSTRACT Purpose: To analyze the velopharyngeal (VP) activity of subjects with velopharyngeal dysfunction (VPD) by acoustic rhinometry, as compared to rhinomanometry. Methods: This was a prospective clinical study conducted in 41 adults, both genders, with repaired cleft palate, with or without a previously repaired cleft lip, and residual VPD on clinical assessment, without compensatory articulations for [p], [t], and [k]. The outcome measures were as follows: (1) on acoustic rhinometry, nasopharyngeal volumetric change (ΔV) during [p], [t], and [k], relatively to rest condition (decreases by <3 cm3 considered as absence of VP activity); (2) on modified anterior rhinomanometry, VP orifice area (areas ≥0.05 cm2 considered as inadequate closure). The plosive [p] was used when comparing the techniques (n=24). Results: (1) A mean ΔV decrease of 18% was observed during [k], which was significantly lower (p<0.05) than the decrease reported for individuals without VPD (30%). ΔV values suggesting VPD were observed in 59% subjects. Similar results were obtained for [p] and [t], which shall be used as stimulus, given that they do not involve the use of the tongue to lift the velum during VP closure, differently from the velar plosive [k]. (2) Inadequate closure was seen in 85% subjects. No correlation was observed between ∆V and VP orifice area. Agreement between techniques was observed in 51% cases. Conclusion: Acoustic rhinometry had low accuracy as a diagnostic method of VPD when compared to the gold standard method. Nevertheless, the technique shows potential as a method for monitoring the outcomes of clinical and surgical treatment of VPD aimed at increasing velar and pharyngeal activity.

Validation of polyvinylidene fluoride nasal sensor to assess nasal obstruction in comparison with subjective technique.

OBJECTIVE: The aim of this study is to validate the applicability of the PolyVinyliDene Fluoride (PVDF) nasal sensor to assess the nasal airflow, in healthy subjects and patients with nasal obstruction and to correlate the results with the score of Visual Analogue Scale (VAS). METHODS: PVDF nasal sensor and VAS measurements were carried out in 50 subjects (25-healthy subjects and 25 patients). The VAS score of nasal obstruction and peak-to-peak amplitude (Vp-p) of nasal cycle measured by PVDF nasal sensors were analyzed for right nostril (RN) and left nostril (LN) in both the groups. Spearman's rho correlation was calculated. The relationship between PVDF nasal sensor measurements and severity of nasal obstruction (VAS score) were assessed by ANOVA. RESULTS: In healthy group, the measurement of nasal airflow by PVDF nasal sensor for RN and LN were found to be 51.14±5.87% and 48.85±5.87%, respectively. In patient group, PVDF nasal sensor indicated lesser nasal airflow in the blocked nostrils (RN: 23.33±10.54% and LN: 32.24±11.54%). Moderate correlation was observed in healthy group (r=-0.710, p<0.001 for RN and r=-0.651, p<0.001 for LN), and moderate to strong correlation in patient group (r=-0.751, p<0.01 for RN and r=-0.885, p<0.0001 for LN). CONCLUSION: PVDF nasal sensor method is a newly developed technique for measuring the nasal airflow. Moderate to strong correlation was observed between PVDF nasal sensor data and VAS scores for nasal obstruction. In our present study, PVDF nasal sensor technique successfully differentiated between healthy subjects and patients with nasal obstruction. Additionally, it can also assess severity of nasal obstruction in comparison with VAS. Thus, we propose that the PVDF nasal sensor technique could be used as a new diagnostic method to evaluate nasal obstruction in routine clinical practice.

Measurement tools for the diagnosis of nasal septal deviation: a systematic review.

OBJECTIVE: To perform a systematic review of measurement tools utilized for the diagnosis of nasal septal deviation (NSD). METHODS: Electronic database searches were performed using MEDLINE (from 1966 to second week of August 2013), EMBASE (from 1966 to second week of August 2013), Web of Science (from 1945 to second week of August 2013) and all Evidence Based Medicine Reviews Files (EBMR); Cochrane Database of Systematic Review (CDSR), Cochrane Central Register of Controlled Trials (CCTR), Cochrane Methodology Register (CMR), Database of Abstracts of Reviews of Effects (DARE), American College of Physicians Journal Club (ACP Journal Club), Health Technology Assessments (HTA), NHS Economic Evaluation Database (NHSEED) till the second quarter of 2013. The search terms used in database searches were 'nasal septum', 'deviation', 'diagnosis', 'nose deformities' and 'nose malformation'. The studies were reviewed using the updated Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. RESULTS: Online searches resulted in 23 abstracts after removal of duplicates that resulted from overlap of studies between the electronic databases. An additional 15 abstracts were excluded due to lack of relevance. A total of 8 studies were systematically reviewed. CONCLUSIONS: Diagnostic modalities such as acoustic rhinometry, rhinomanometry and nasal spectral sound analysis may be useful in identifying NSD in anterior region of the nasal cavity, but these tests in isolation are of limited utility. Compared to anterior rhinoscopy, nasal endoscopy, and imaging the above mentioned index tests lack sensitivity and specificity in identifying the presence, location, and severity of NSD.

Evaluation of a single-channel nasal pressure device to assess obstructive sleep apnea risk in laboratory and home environments.

STUDY OBJECTIVES: To evaluate the sensitivity and specificity of a portable single-channel (intra-nasal pressure) sleep apnea device (ApneaLink) in both the laboratory and at home for assessment of sleep apnea risk in comparison with standard polysomnography (PSG). METHODS: Fifty-five participants underwent simultaneous recordings of standard PSG and ApneaLink in the laboratory. Of these, 38 participants also used the ApneaLink device in their own homes for one night. PSG respiratory events were scored using standard criteria. Intra-nasal pressure signals were analyzed using the ApneaLink automated computerized algorithm provided to yield estimates of airflow for detection of apneas and hypopneas. Apnea-hypopnea indices (AHI) were compared. RESULTS: There was high sensitivity and specificity for the ApneaLink AHI when compared to simultaneous PSG at comparable AHI levels (AHI ≥ 15 events/h; sensitivity 100%, specificity 92%; positive and negative predictive values 70% and 100%, respectively). Home-measured ApneaLink AHI sensitivity and specificity were also reliable when compared with PSG (AHI ≥ 5, 81% and 77%, respectively; AHI ≥ 15, 67% and 91%), and improved slightly when two nights' data were used (AHI ≥ 5, 88% and 85%; AHI ≥ 15, 67% and 93%). CONCLUSIONS: The ApneaLink demonstrated good sensitivity and specificity in quantifying AHI when compared to PSG in a population with and without confirmed OSA. This simple, easy-to-use device may be useful in de novo large-scale occupational or underserved community OSA diagnostic programs to identify those with unambiguous disease who need immediate treatment or indicate those who may be at increased risk of OSA.

[An attempt to estimate potentially useful parameters to evaluate the normal range of nasal peak inspiratory flow]. / Próba oceny parametrów przydatnych do wyznaczenia normy dla nosowego szczytowego przeplywu wdechowego.

INTRODUCTION: Measurement of peak nasal inspiratory flow (PNIF, peak nasal inspiratory flow) seems to be a cheap and simple method to assess nasal patency. Unfortunately, due to the lack of reference values a single measurement does not take any information about the degree of nasal obstruction. Therefore, the purpose of this study was to establish parameters useful for estimating PNIF reference values. MATERIAL AND METHODS: 221 respondents, from Wroclaw, answered a questionnaire based on ECRHS II and ISAAC. Sample was randomized based on the personal number, stratified and representative of age and sex. Subjects were divided into three groups on the basis of their age (6-7, 13-14 and 20-45 years). The PNIF was measured using an In-Check portable nasal inspiratory flow meter (In-Check's Clement-Clark). The highest of the five PNIF values was used as the measure of PNIF for each subject in subsequent analyses (PNIF MAX). Patients with rhinitis and/or asthma were withdrawn from the study. RESULTS: Repeated measurements of PNIF were performed in 221 healthy volunteers. PNIF values were higher in males compared to women and this difference was statistically significant. There was a statistically significant correlation between height and PNIF MAX, and there was no such correlation between age and PNIF MAX. Stepwise linear regression that included gender, height, age revealed that only sex and height were independent significant predictors of PNIF. Obtained dependence PNIF MAX = -137.7 - 22.5 x + 1.7 y, where x is the sex (a woman, 0 - male) and the y - height. Coefficient of determination (R(2)) was 0.45 which means that regression equation explains about 45% of the observed PNIF MAX variability. CONCLUSIONS: A correlation was found between PNIF value and sex and height of the patients, while age is irrelevant in this regard. Difficulty of establishing standards for the PNIF parameter are probably due to anatomical differences in the construction of the nose.

The accuracy and reproducibility of rhinospirometry in detecting flow asymmetry in a nasal cavity model.

The objective of this study is to investigate the appropriateness of the NV1 rhinospirometer in the assessment of asymmetrical nasal airflow using a nasal cavity model. The Study is a laboratory-based basic-science study using an artificial model of nasal airflow. It is conducted in Medical Physics Department, Singleton Hospital, Swansea, Wales. A nasal cavity model was created with a series of parallel flow symmetry/asymmetries that were each assessed using standard flow volume measurements. The results were converted into Nasal Partition Ratios (NPRs) for each trial scenario and were examined against a mathematically calculated NPR derived using Pouseille's law. Experimental scenario results were assessed for correlation, accuracy and precision against the mathematically derived result. In this study 300 individual test scenarios were completed using 2 different flow volumes and 15 different symmetry/asymmetry combinations. Correlation of the attained results against the mathematically derived figure gave a very strong correlation, using Spearman's Rho = 0.975. Accuracy was excellent within one Standard deviation of the expected results. It was concluded that the NV1 rhinospirometer is an accurate and precise objective marker of airflow symmetry in the nasal cavity model giving strong correlation, accuracy, precision and reproducibility. The rhinospirometer, as a precision tool, has displayed potential to become an effective objective marker of nasal airflow in the assessment of nasal obstruction; however, clinical trials are required to examine whether the accurate results of this laboratory study are transferable to clinical practice.

Active anterior rhinomanometry in paediatrics. Normality criteria.

BACKGROUND: Active anterior rhinomanometry with a face mask was used to establish the lower age limit for application of the technique, define normality reference standards, and determine the most appropriate pressure for referencing the nasal resistance values. MATERIAL AND METHODS: A total of 409 children of both sexes and aged 5-14 years were studied. The subjects were selected from among healthy children in two primary care centres and one school. The Rhinospir 164 rhinomanometer was used for the tests. Rhinomanometry was performed according to the guidelines of the International Committee on Standardization of Rhinomanometry. The SPSS (Statistical Package for the Social Sciences) was used for the analysis of the results. RESULTS: The study sample was divided into five age groups involving intervals of two years from 5 to 14 years of age, and four body surface groups. The dependent variables studied (resistances and flows at pressure differences of 75 and 100) showed significantly different mean values according to age and body surface. All the mean ratios were over 1.4 units, i.e., the measures of each variable on one side and the other differed between 40% and 44%. CONCLUSIONS: 1.- The lower age limit for rhinomanometry is five years. 2.- The most appropriate pressures for referencing the resistance and flow values are 75 and 100. 3.- The reference standards are established with respect to total resistance and according to subject age and body surface.

Video-rhino-hygrometer: a new method for evaluation of nasal breathing after nasal surgery.

BACKGROUND: Nasal obstruction is one of the most frequent symptoms in the ear, nose, and throat (ENT) setting. It can be evaluated either subjectively or objectively. In a subjective way, a visual analog scale (VAS) and the Sino-Nasal Outcome Test 20 (SNOT 20) can rapidly quantify the degree of obstruction, whereas the most commonly used objective methods are nasal endoscopy and active anterior rhinomanometry (AAR). It is still a matter of controversy to what extent the sense of nasal obstruction is associated with objective measures for nasal space and airflow. The aim of the study was to evaluate nasal breathing before and after functional nasal surgery by video-rhino-hygrometer (VRH) comparing the results with widely accepted methods. METHODS: Twenty patient candidates for septoplasty and inferior turbinate reduction were included in the study. SNOT-20, VAS, nasal endoscopy, and AAR were analyzed and compared with VRH values. RESULTS: Before surgery VRH showed variability of nasal respiratory flow between individuals and between nostrils. After surgery we had an increase (p < 0.05) of airflow in both nostrils. VRH data were found to be correlated with VAS and SNOT-20 values (p < 0.05) both pre- and postoperatively. Despite the statistically significant correlation of AAR with SNOT-20 and VAS, no statistically significant correlation between AAR and VRH was found. CONCLUSION: VRH provides an immediate, easy, and noninvasive assessment of nasal respiration. For these reasons it can be used, in association with rhinoscopic data and other instrumental tests, to evaluate nasal breathing in daily ENT practice.

[The role of active rhinomanometry in the surgical treatment of nasal deformation with concomitant endonasal pathology].

This work was designed to substantiate the necessity of application of active rhinomanometry in rhinoplastic surgery bearing in mind that evaluation of the efficiency of surgical treatment requires the use of such objective methods as the rhinomanometric technique. The authors maintain that it may be helpful not only for the purpose of clinical research but also in practical otorhinolaryngological surgery providing an opportunity to collect objective information for the development of indications for the choice and extent of surgical intervention and the assessment of its outcome. Moreover, under present-day conditions, rhinomanometric measurements may be included in the legal basis on which the results of surgery are estimated if appropriate. The method under consideration serves as a diagnostic standard generally accepted worldwide.

The utility of single-channel nasal airflow pressure transducer in the diagnosis of OSA at home.

RATIONALE: Given the high prevalence of obstructive sleep apnea (OSA) and the demand on polysomnography (PSG), there is a need for low cost accurate simple diagnostic modalities that can be easily deployed in primary care to improve access to diagnosis. STUDY OBJECTIVES: The aim was to examine the utility of single-channel nasal airflow monitoring using a pressure transducer at home in patients with suspected OSA. DESIGN: Cross-sectional study SETTING: Laboratory and home PARTICIPANTS: The study was conducted in two populations. Consecutive patients with suspected OSA were recruited from the sleep disorders clinic at a tertiary referral center and from 6 local metropolitan primary care centers. INTERVENTIONS: All patients answered questionnaires and had laboratory PSG. Nasal airflow was monitored for 3 consecutive nights at home in random order either before or after PSG. RESULTS: Atotal of 193 patients participated (105 sleep clinic patients and 88 from primary care). The mean bias PSG apnea hypopnea index (AHI) minus nasal flow respiratory disturbance index (NF RDI) was -4.9 events per hour with limits of agreement (2 SD) of 27.8. NF RDI monitored over 3 nights had high accuracy for diagnosing both severe OSA (defined as PSG AHI > 30 events per hour) with area under the receiver operating characteristic curve (AUC) 0.92 (95% confidence interval (CI) 0.88-0.96) and any OSA (PSG AHI > 5), AUC 0.87 (95% CI 0.80-0.94). CONCLUSIONS: Single-channel nasal airflow can be implemented as an accurate diagnostic tool for OSA at home in both primary care and sleep clinic populations.

Comparison between a single-channel nasal airflow device and oximetry for the diagnosis of obstructive sleep apnea.

RATIONALE: The most common single channel devices used for obstructive sleep apnea (OSA) screening are nasal airflow and oximetry. No studies have directly compared their role in diagnosing OSA at home. STUDY OBJECTIVES: To prospectively compare the diagnostic utility of home-based nasal airflow and oximetry to attended polysomnography (PSG) and to assess the diagnostic value of adding oximetry to nasal airflow for OSA. DESIGN: Cross-sectional study. SETTING: Laboratory and home. PARTICIPANTS: Sleep clinic patients with suspected OSA. INTERVENTIONS: All patients had laboratory PSG and 2 sets of 3 consecutive nights on each device; nasal airflow (Flow Wizard, DiagnoselT, Australia) and oximetry (Radical Set, Masimo, USA) at home in random order. RESULTS: Ninety-eight of the 105 patients enrolled completed home monitoring. The accuracy of nasal airflow respiratory disturbance index (NF RDI) was not different from oximetry (ODI 3%) for diagnosing OSA (area under the ROC curve (AUC) difference, 0.04; 95% CI of difference -0.05 to 0.12; P = 0.43) over 3 nights of at-home recording. The accuracy of NF RDI was higher after 3 nights compared to one night (AUC difference, 0.05; 95% CI of difference, 0.01 to 0.08; P = 0.04). Addition of oximetry to nasal airflow did not increase the accuracy for predicting OSA compared to nasal airflow alone (P > 0.1). CONCLUSIONS: Nasal flow and oximetry have equivalent accuracy for diagnosing OSA in the home setting. Choice of device for home screening of sleep apnea may depend on logistical and service delivery issues.

The role of single-channel nasal airflow pressure transducer in the diagnosis of OSA in the sleep laboratory.

RATIONALE: Obstructive sleep apnea (OSA) is a common but underdiagnosed disorder. There is a need for validated simpler modalities such as single-channel monitors to assist diagnosis of OSA. STUDY OBJECTIVES: To assess data sufficiency, agreement, and diagnostic accuracy of nasal airflow measured by a single-channel pressure transducer device (Flow Wizard, DiagnoseIT, Sydney, Australia) compared to attended full polysomnography (PSG) on the same night for OSA diagnosis. DESIGN: Cross-sectional study. SETTING: Laboratory. PARTICIPANTS: Subjects with possible OSA referred to the sleep laboratory for PSG were eligible. METHODS: Nasal airflow was measured by a pressure transducer in the laboratory concurrently with PSG. RESULTS: Of 226 eligible subjects who consented, 221 (97.8%; 151 males, 70 females) completed the protocol. With nasal airflow measurement, 5.3% of subjects had insufficient data, compared with 2.2% on PSG. The mean difference between PSG AHI and NF RDI was -6.2 events/h with limits of agreement (+/- 2 standard deviation [SD]) of 17.0 events/hr. The accuracy of the Flow Wizard for diagnosing severe OSA (PSG AHI > 30) was very good (area under the ROC curve [AUC] 0.96; 95% confidence interval [CI] 0.92 to 0.99) and for diagnosing OSA (PSG AHI > 5) was good (AUC, 0.84; 95% CI, 0.77 to 0.90). There was no difference in the rate of data insufficiency and accuracy between males and females. CONCLUSION: Nasal flow measured by a nasal pressure transducer has a low rate of data insufficiency, good agreement, and high accuracy compared to PSG for diagnosing OSA in the monitored sleep laboratory setting.

[Measurement of nasal airflow and aerophonoscopy]. / Mesure du flux nasal et aérophonoscopie.

Diagnosis and treatment of rhinolalia are some of the most important elements in the follow-up of patients presenting with a cleft palate. In order to quantify the nasal airflow, speech therapists use either nasalance-measuring devices or devices related to aerophonoscopy. At the Maxillofacial Surgery Department in the Nantes University Hospital, we are currently trying to evaluate the inter- and intra-individual reproducibility of quantitative values provided by the aerophonoscope. We intend to use this device, originally designed in our department 25 years ago, as a reference tool for the measurement of nasal airflow after cleft surgery.