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 TGFß 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.

The effect of inferior turbinate surgery on nasal symptoms and inferior turbinate contractility.

OBJECTIVES: The aim of this study was to compare radiofrequency ablation (RFA), diode laser, and microdebrider-assisted inferior turbinoplasty (MAIT) in the treatment of chronic nasal obstruction in a one-year follow-up, and to pay special attention to the effect of the procedures on the contractility capacity of the inferior turbinates. METHODS: The patients filled a Visual Analogue Scale (VAS) questionnaire regarding nasal symptoms pre- and postoperatively. Saccharin transit time (STT) evaluation and acoustic rhinometry were also performed. A total of 77 patients attended the one-year control visit and had technically reliable acoustic rhinometry results. RESULTS: All the examined techniques decreased the VAS score for the severity of nasal obstruction statistically significantly. There was no deterioration found in the symptoms of crusting, nasal discharge, and sneezing, nor in mucociliary function in any of the groups. All the three techniques increased the non-decongested total V2-5 cm values and decreased the decongested total V2-5 cm values statistically significantly. The V2-5 cm change (%) values decreased statistically significantly in the RFA, diode laser, and the MAIT groups following the operations, the mean changes being -57 percentage points (pp), -53 pp, and -73 pp respectively. CONCLUSION: All three techniques decreased the severity of nasal obstruction significantly in the one-year follow-up. Although submucosal fibrosis seemed to increase, all the techniques increased the anterior nasal cavity volume significantly. Inferior turbinate contractility decreased to the normal level from the preoperative congested state following the surgery with every examined technique.

An optimization method for surgical reduction of hypertrophied inferior turbinate.

Surgical reductions of the hypertrophied inferior turbinate (HIT) can improve nasal obstruction. However, there is currently a lack of personalized and objective methods to guide surgical operations, which results in the excessive or inadequate resection of HIT. In this study, we proposed an optimizing method based on homotopy deformation to determine the resected amount and shape of the tissue by matching the flow resistance in the two nasal passageways. The simulation results obtained using computational fluid dynamics showed that after such an optimization procedure, the most obstructed nasal side could have a similar air flux as the less obstructed side. A 35% and a 56% less tissue resection in the optimizing operation compared to that in the total turbinectomy could well balance the air flow between the two nasal cavities in the simulations for patients 1 and 2 with unilateral nasal obstruction respectively. Compared with the optimization operation, the total turbinectomy made a more aggressive resection of HIT, which could worsen the air conditioning capacity of the nose. A sensitivity test indicated that in the optimization operation, the most constricted region in the nasal cavity should be adequately enlarged. However, more tissue resection than is required for the optimization operation did not improve the flow in the obstructed side strikingly. Simulations of the optimization operation in both nasal cavities for a patient with bilateral nasal obstruction were also performed. The flow rate could reach the normal level and be well balanced in the two sides after such an optimization procedure.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies.

PURPOSE OF REVIEW: To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS. RECENT FINDINGS: Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials. SUMMARY: The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.

Computational fluid dynamic analysis of aggressive turbinate reductions: is it a culprit of empty nose syndrome?

BACKGROUND: Empty nose syndrome (ENS) remains highly controversial, with aggressive inferior turbinate reduction (ITR) or mucociliary dysfunction frequently implicated. However, the appropriate degree of ITR is highly debatable. METHODS: We applied individual computed tomography (CT)-based computational fluid dynamics (CFD) to 5 patients receiving relatively aggressive ITR but with no ENS symptoms, and compared them to 27 symptomatic ENS patients who all had histories of aggressive ITRs, and 42 healthy controls. Patients' surgical outcomes were confirmed with 22-item Sino-Nasal Outcome Test (SNOT-22) (ITR: 6.40 ± 4.56; ENS: 58.2 ± 15.9; healthy: 13.2 ± 14.9), Nasal Obstruction Symptom Evaluation (NOSE) scores (ITR: 4.00 ± 2.24; ENS: 69.4 ± 17.1; healthy: 11.9 ± 12.9), and Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) (≥11 for ENS). RESULTS: Both aggressive ITR without ENS symptoms and symptomatic ENS patients had significantly lower nasal resistance (ITR: 0.059 ± 0.020 Pa·s/mL; ENS: 0.052 ± 0.015 Pa·s/mL; healthy: 0.070 ± 0.021 Pa·s/mL) and higher cross-sectional areas surrounding the inferior turbinate (ITR: 0.94 ± 0.21 cm2 ; ENS: 1.19 ± 1.05 cm2 ; healthy: 0.42 ± 0.22 cm2 ) than healthy controls. The lack of significant differences among patient groups indicated similar degrees of surgeries between ITR with and without ENS symptom cohorts. However, symptomatic ENS patients have paradoxical significantly less airflow in the inferior meatus (ITR: 47.7% ± 23.6%; ENS: 25.8% ± 17.6%; healthy: 36.5 ± 15.9%; both p < 0.01), but higher airflow around the middle meatus (ITR: 49.7% ± 22.6%; ENS: 66.5% ± 18.3%; healthy: 49.9% ± 15.1%, p < 0.0001) than aggressive ITR without symptoms and controls. Aggressive ITR patients have increased inferior meatus airflow as expected (p < 0.05). This imbalanced airflow produced less inferior wall-shear-stress distribution among symptomatic ENS patients only (ITR: 42.45% ± 11.4%; ENS: 32.2% ± 12.6%; healthy: 49.7% ± 9.9%). ENS patients (n = 12) also had impaired nasal trigeminal function, as measured by menthol lateralization detection thresholds (ITR: 15.2 ± 1.2; ENS: 10.3 ± 3.9; healthy: 13.8 ± 3.09, both p < 0.0001). Surprisingly, aggressive ITR patients without ENS symptoms have better menthol lateralization detection thresholds (LDTs) than healthy controls. CONCLUSION: Although turbinate tissue loss is linked with ENS, the degree of ITR that might distinguish postoperative patient satisfaction in their nasal breathing vs development of ENS symptoms is unclear. Our results suggest that a combination of distorted nasal aerodynamics and loss of mucosal sensory function may potentially lead to ENS symptomology.

Does the reduction of inferior turbinate affect lower airway functions? / A redução da concha nasal inferior afeta as funções das vias aéreas inferiores?

Abstract Introduction: Although the nose and lungs are separate organs, numerous studies have reported that the entire respiratory system can be considered as a single anatomical and functional unit. The upper and lower airways affect each other either directly or through reflex mechanisms. Objective: In this study, we aimed to evaluate the effects of the radiofrequency ablation of persistent inferior turbinate hypertrophy on nasal and pulmonary function. Methods: Twenty-seven patients with bilateral persistent inferior turbinate hypertrophy without septal deviation were included in this study. All of the patients were evaluated using anterior rhinoscopy, nasal endoscopy, acoustic rhinometry, a visual analogue scale, and flow-sensitive spirometry on the day before and 4 months after the radiofrequency ablation procedure. Results: The post-ablation measurements revealed that the inferior turbinate ablation caused an increase in the mean cross-sectional area and volume of the nose, as well as in the forced expiratory volume in 1 s, forced vital capacity, and peak expiratory flow of the patients. These differences between the pre- and post-ablation results were statistically significant. The post-ablation visual analogue scale scores were lower when compared with the pre-ablation scores, and this difference was also statistically significant. Conclusion: This study demonstrated that the widening of the nasal passage after the reduction of the inferior turbinate size had a favorable effect on the pulmonary function tests.

Resumo Introdução: Embora o nariz e os pulmões sejam órgãos separados, numerosos estudos relataram que todo o sistema respiratório pode ser considerado como uma única unidade anatômica e funcional. As vias aéreas superiores e inferiores afetam uma à outra diretamente ou através de mecanismos reflexos. Objetivo: Avaliar os efeitos da ablação por radiofrequência em conchas nasais inferiores com hipertrofia persistente sobre a função nasal e pulmonar. Método: Foram incluídos neste estudo 27 pacientes com hipertrofia persistente bilateral de conchas inferiores sem desvio septal. Todos os pacientes foram avaliados com rinoscopia anterior, endoscopia nasal, rinometria acústica, escala visual analógica e espirometria sensível ao fluxo no dia anterior e quatro meses após o procedimento de ablação por radiofrequência. Resultados: As medidas pós-ablação demonstraram que a ablação das conchas nasais inferiores resultou em um aumento da área transversal média e do volume do nariz, bem como do volume expiratório forçado em um segundo, da capacidade vital forçada e do fluxo expiratório máximo dos pacientes. Essas diferenças entre os resultados pré e pós-ablação foram estatisticamente significantes. Os escores da escala visual analógica pós-ablação foram menores quando comparados com os escores pré-ablação e essa diferença também foi estatisticamente significante. Conclusão: O alargamento da passagem nasal após a redução do tamanho das conchas nasais inferiores teve efeito favorável nos testes de função pulmonar.

Does the reduction of inferior turbinate affect lower airway functions?

INTRODUCTION: Although the nose and lungs are separate organs, numerous studies have reported that the entire respiratory system can be considered as a single anatomical and functional unit. The upper and lower airways affect each other either directly or through reflex mechanisms. OBJECTIVE: In this study, we aimed to evaluate the effects of the radiofrequency ablation of persistent inferior turbinate hypertrophy on nasal and pulmonary function. METHODS: Twenty-seven patients with bilateral persistent inferior turbinate hypertrophy without septal deviation were included in this study. All of the patients were evaluated using anterior rhinoscopy, nasal endoscopy, acoustic rhinometry, a visual analogue scale, and flow-sensitive spirometry on the day before and 4 months after the radiofrequency ablation procedure. RESULTS: The post-ablation measurements revealed that the inferior turbinate ablation caused an increase in the mean cross-sectional area and volume of the nose, as well as in the forced expiratory volume in 1s, forced vital capacity, and peak expiratory flow of the patients. These differences between the pre- and post-ablation results were statistically significant. The post-ablation visual analogue scale scores were lower when compared with the pre-ablation scores, and this difference was also statistically significant. CONCLUSION: This study demonstrated that the widening of the nasal passage after the reduction of the inferior turbinate size had a favorable effect on the pulmonary function tests.

Computational Fluid Dynamics to Evaluate the Effectiveness of Inferior Turbinate Reduction Techniques to Improve Nasal Airflow.

IMPORTANCE: Inferior turbinate reduction (ITR) is a commonly performed procedure for the treatment of nasal obstruction. Which portion of the inferior turbinates should be surgically addressed to improve nasal airflow has yet to be determined. OBJECTIVE: To use computational fluid dynamics (CFD) analysis to evaluate the airflow changes after reduction along different portions of the inferior turbinate. DESIGN, SETTING, AND PARTICIPANTS: Computed tomographic scans of 5 patients were selected. Seven CFD models were created for each patient: 1 unaltered and 6 various ITRs, including 3 one-third ITRs (anterior, middle, and posterior one-third); 2 two-thirds ITRs (anterior and posterior two-thirds); and 1 full-length ITR model. Total airflow rate and nasal resistance was obtained through CFD analysis, and regression analysis was performed on the increased nasal volume, locations, and nasal resistance for all 5 patients. MAIN OUTCOMES AND MEASURES: Total airflow rate and nasal resistance was obtained through CFD analysis, and regression analysis was performed on the increased nasal volume, locations, and nasal resistance for all 5 patients. RESULTS: Full ITR over the whole length was consistently most effective to improve nasal airflow and resistance for all 5 patients (2 men and 3 women), adjusted for the volume. Regression analysis showed a strong linear (R2≥0.79) relationship between nasal volume changes and nasal airflow. However, the most effective location of partial turbinate reduction was not consistent among patients. Surprisingly, for some patients, posterior ITRs were more effective than anterior ITRs. The site of most effective partial ITR differed from 1 side to the other even in the same individual. CONCLUSIONS AND RELEVANCE: The effectiveness of partial ITR and target location likely depends on individual patient anatomy. The fact that full ITRs were consistently most effective and the linear regression between flow and nasal volume changes may indicate that the entire length of the IT has a functional impact on nasal airflow and resistance. LEVEL OF EVIDENCE: NA.

Changes occurring in mucosal contractility of the inferior turbinate and mucociliary clearance following total laryngectomy: A prospective clinical trial.

OBJECTIVE: In this study, changes occurring in the contractility capacity of the inferior turbinate and mucociliary clearance time due to the interruption of nasal air flow were examined. MATERIAL & METHODS: A total of 23 patients undergone total laryngectomy between June 2010 and June 2012 were included in the study. Acoustic rhinometry test was performed in the patients before and after 0.05% oxymetazoline nasal topical decongestant administration. In addition, saccharin test was applied in order to measure mucociliary clearance. The same measurements were repeated at the postoperative months 1, 6 and 12 and the data obtained were statistically compared. RESULTS: In evaluation of the patients' contractility capacity at MCA-1 and MCA-2, contractility capacity was found to be significantly decreased from the postoperative first month compared to the preoperative values. The contractility capacity at the postoperative 6th month was significantly lower than that of the postoperative first month. The contractility capacity at the postoperative 12th month was significantly lower than that of the postoperative 6th month. Mucociliary clearance time did not change significantly at the postoperative first month compared to the preoperative value, while this value was significantly decreased at the postoperative 6th month. No statistically significant difference was observed in mucociliary clearance between the postoperative 6th and 12th months. CONCLUSION: Contractility capacity of the inferior turbinate decrease over time in patients undergoing total laryngectomy. This indicates that the dysfunction developing in the nasal mucosal structure in the chronical absence of nasal air flow may be resulted from the decreased choncal contractility.

Conchal contractility after inferior turbinate hypertrophy treatment:A prospective, randomized clinical trial.

OBJECTIVE: The aim of this study is to evaluate the effects of these two methods (Nasal corticosteroids (NCS) and radiofrequency (RF) application) on conchal contractility utilizing objective rhinologic measurement parameters. METHODS: 82 patients were presented with the complaint of nasal obstruction and diagnosed with inferior turbinate hypertrophy and were included in the study. Patients in Group 1 received NCS for 12weeks. Patients in Group 2 were administered RF to their inferior turbinates. Acoustic rhinometry and rhinomanometry tests with and without decongestant were performed. RESULTS: In the evaluation of the contractility difference of rhinometry parameters, there was not a significant difference among pre and postoperative acoustic rhinometric parameters in Group 1. Whereas in Group 2, postoperative contractility difference was significantly decreased compared to preoperative values. In the evaluation of the contractility difference of rhinomanometric parameters, no significant difference was found between pre and postoperative values in Group 1. However, postoperative contractility difference was significantly decreased compared to preoperative values in Group 2 in terms. CONCLUSION: Because the RF procedure produces fibrosis in the vascular tissues, inferior turbinates do not have a shrinking response to decongestant administration. Administration of NCS administration maintains the contractility function compared to RF application.

Evaluation of Inferior Turbinate Stroma with Ultrasound Elastography in Allergic Rhinitis Patients.

BACKGROUND: Diagnosis of allergic rhinitis is primarily based on history, physical examination and allergy testing. A technique that noninvasively evaluates the soft tissue changes in the nasal mucosa of allergic rhinitis patients has not been defined. AIMS: To assess nasal mucosal changes and measure the submucosal fibrosis in allergic rhinitis patients with sonoelastography. STUDY DESIGN: Case control study. METHODS: Eighty-eight turbinates of 44 patients were included in the study. There were 23 prick test positive allergic rhinitis patients. The control group constituted 21 patients. The rhinitis quality of life questionnaire and the visual analogue scale were applied to the allergic rhinitis patients. A higher visual analogue scale score indicated more severe allergic rhinitis symptoms. Sonoelastographic measurements were made from the lateral nasal wall. The propagation speed of sound waves was recorded in m/s. The presence of asthma and the type of allergic rhinitis (seasonal or perennial) was noted. RESULTS: Ten patients had seasonal allergic rhinitis and thirteen patients had perennial allergic rhinitis. Six patients (26.1%) had accompanying asthma along with allergic rhinitis. The median visual analogue scale score was 7 (3-9) in allergic rhinitis patients. The median symptom duration was 7 (1-24) months. The median quality of life questionnaire score was 3.39 (1.68-5.43) points. The median sonoelastography scores of allergic rhinitis patients and healthy subjects were 2.38 m/s (0.9-4.47) and 2.42 m/s (1.62-3.50), respectively. Sonoelastographic measurements of seasonal and perennial allergic rhinitis patients did not differ significantly (p<0.05). The presence of asthma did not have a significant impact on the elastography measurements (<0.05). However, regression analysis revealed a significant inverse correlation (coefficients: B=0.005, standard error=0.097, beta 0=0.008) between the visual analogue scale and sonoelastography scores (p>0.05). CONCLUSION: Sonoelastography was not suitable as a diagnostic tool in allergic rhinitis. Reduced sonoelastography scores were measured in more symptomatic patients. Higher visual analogue scale scores could be an indicator of disease severity.

Computational fluid dynamics and trigeminal sensory examinations of empty nose syndrome patients.

OBJECTIVE: The precise pathogenesis of empty nose syndrome (ENS) remains unclear. Various factors such as nasal aerodynamics and sensorineural dysfunction have been suspected, although evidence is limited. This study reported the first examination of both nasal aerodynamics and trigeminal sensory factors in actual ENS patients. STUDY DESIGN: Prospective case control. METHODS: We enrolled six patients diagnosed with ENS. Three patients had pre- and post-inferior turbinate (IT) reduction computed tomography scans, which allowed comparison of their nasal aerodynamics changes through computational fluid dynamic (CFD) simulation. Their symptoms were confirmed through Sino-nasal Outcome Test-22, ENS 6-item Questionnaire, acoustic rhinometry, and rhinomanometry findings. Nasal trigeminal sensitivity that potentially mediates their perception of airflow was assessed via menthol lateralization detection thresholds (LDT) and compared with 14 healthy controls. RESULTS: Post-surgical reductions in nasal resistance were observed and significantly lower than normal (P < 0.05). Computational fluid dynamic analysis showed that, paradoxically for all ENS patients, IT reduction did not draw more airflow to the airway surrounding the ITs, but rather resulted in nasal airflow forming into a narrow jet toward the middle meatus region, leaving the airway surrounding the IT with significantly reduced airflow intensity and air-mucosal interactions (inferior region flow percentage reduced from 35.7% ± 15.9% to post-surgery 17.7% ± 15.7%, P < 0.05; inferior wall-shear-stress reduced from 7.5 ± 4.2 × 10-2 Pa to 3.4 ± 3.1 × 10-2 Pa, P < 0.01). Empty nose syndrome patients also had significantly impaired menthol LDT compared to healthy controls (P < 0.005). CONCLUSION: The results indicated that a combinatory of factors, including paradoxically distorted nasal aerodynamic, impaired sensorineural sensitivity, and potential predisposing conditions, may contribute to the development of ENS. LEVEL OF EVIDENCE: 3b. Laryngoscope, 127:E176-E184, 2017.

Update on nonmalignant lesions of the inferior turbinate.

PURPOSE OF REVIEW: The inferior turbinates are routinely examined by otolaryngologists on anterior rhinoscopy and nasal endoscopy. Most lesions of the inferior turbinate are benign but can often be confused with malignancy. This review highlights the broad differential of nonmalignant lesions of the inferior turbinates and their management. RECENT FINDINGS: A variety of infectious, inflammatory, neoplastic, and vascular lesions may affect the inferior turbinates. The most common nonmalignant lesions of the sinonasal region are nasal polyps, inverted papillomas, hemangiomas, and angiofibromas. Early lesions are often asymptomatic and discovered incidentally on routine examination. As these lesions grow they present with nonspecific signs that can be seen in benign, malignant, and infectious etiologies. The most common signs and symptoms are nasal obstruction, rhinorrhea, epistaxis, sinusitis, and hyposmia. Most nonmalignant lesions have characteristic appearances but definitive diagnosis is achieved with biopsy or culture. If the lesions are small the biopsy itself is often curative. SUMMARY: Lesions of the inferior turbinates are rarely isolated to these structures alone. Careful examination can noninvasively assist in early diagnosis of extensive lesions. Once malignancy and processes such as invasive fungal sinusitis or inverted papillomas have been ruled out, treatment of these lesions is ordinarily noncomplicated and definitive.

Effects of partial middle turbinectomy with varying resection volume and location on nasal functions and airflow characteristics by CFD.

The surgical term "turbinectomy" encompasses many variations in the location and extent of removal. As a systemic approach to consider the negative impact of middle turbinectomy(MT), such as the excessive removal of turbinate, airflows inside a pre-surgery model and a series of virtual surgery models were numerically analyzed and compared. These models simulate three variations of partial MT(three bilateral and three unilateral) with varying resection volume and location. Each middle turbinectomy results in alterations of flow and thermal parameters, such as nasal resistance (NR), velocity, temperature, wall shear stress(WSS) and wall heat transfer(WHT). WSS distributions were also considered in connection with mucosal secretion. The tendency of changes in nasal functions and airflow characteristics was identified with respect to resection volume and location. A counter-rotating vortical structure was seen in the region of widened middle airway for the case of total resection of middle turbinate. Maximum velocity and WSS near sphenopalatine ganglion, which was a possible explanation for headache after total resection of middle turbinate, was increased. Changes in NR and WHT for bi-lateral resection cases were greater than those for unilateral resection cases. While the physiological changes in four partial MT models were insignificant, changes in near total resection model was prominent. Although our surgical simulation was done for a single case, we postulate that the removal of the anterior inferior part of middle turbinate while preserving posterior margin will not alter airflow characteristics extensively. These findings will help designing surgical plans for partial MT.

Infected concha bullosa mimicking a malignant lesion on 18F-FDG PET/CT / Concha bullosa infectada imitando una lesión maligna en 18F-FDG PET/TC

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Pathophysiology of empty nose syndrome.

OBJECTIVES/HYPOTHESIS: To review current knowledge on nasal airflow sensation in relation to empty nose syndrome (ENS). STUDY DESIGN: PubMed searches. METHODS: Current literature pertaining to measurement of nasal patency, mechanism of sensory perception of nasal airflow, and ENS. RESULTS: A reliance on pure anatomical analysis of the anatomy in ENS falls short of explaining the disorder. Our understanding of subjective nasal sensation has advanced, as has our understanding of the flow of air through the nose. Neural healing following a surgical insult may not result in a return to a normal physiologic state. Aberrations in neurosensory systems from improper healing may play a major role in the abnormal sensations ENS patients experience. CONCLUSIONS: An evidence-based hypothesis for the development and symptoms of ENS is offered.

Effects of oxymetazoline on nasal flow and maximum aerobic exercise performance in patients with inferior turbinate hypertrophy.

OBJECTIVES/HYPOTHESIS: To determine the effect of topical intranasal oxymetazoline on nasal resistance and aerobic exercise performance in patients with nasal congestion caused by inferior turbinate hypertrophy. STUDY DESIGN: Individual randomized controlled trial. METHODS: Eight patients with inferior turbinate hypertrophy performed a set of exercise tests to exhaustion 1 week apart. They were given oxymetazoline or a placebo before each of the two test sessions according to a random pattern. Changes in nasal airflow were measured as peak nasal flow and ventilatory efficiency parameters, ventilatory equivalents, end-expiratory pressure, oxygen consumption, cardiac efficiency, rate of perceived exertion, and maximal and submaximal mechanical power. RESULTS: Ten minutes after use of the drug or placebo, improvements in maximum nasal airflow were seen in the oxymetazoline group (P < 0.05). However, exercise tests showed improvements in both groups (P < 0.05). After exertion, there was no difference between the two groups in maximum nasal airflow (P > 0.05). There were no differences between groups in oxygen consumption, rate of perceived exertion, respiratory exchange ratio, ventilation, or ventilatory equivalents for oxygen. CONCLUSION: Oxymetazoline increased nasal airflow in patients with turbinate hypertrophy, but this change did not translate into gains in physical exercise parameters or perceived exertion. LEVEL OF EVIDENCE: 1b.

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.