The intranasal Schirmer test: a preliminary study to quantify nasal secretion.

Adequate secretion of the nasal mucosa is essential for normal nasal physiology. A "dry" nose is a frequent complaint of ENT patients. Measurement of secretion is currently impossible because of the absence of a recognized test. The aim of the present study was to investigate the feasibility of an intranasal Schirmer test in a large number of patients and to define standard values for nasal secretion. The test population comprised 159 healthy, non-smoking volunteers and 30 healthy smoking volunteers. All subjects were examined by nasal endoscopy for anatomic or mucosal disease. A Schirmer test strip was placed on both sides of the mucosa of the anterior nasal septum by anterior rhinoscopy. After 10 min in standardized conditions, the strip was removed and the wetted distance was measured. Active anterior rhinomanometry (ARR) and acoustic rhinometry (AR) were later performed. In the non-smoking group (n = 159), the median wetting distance of the test strip was 10.3 mm (range 3.6-35.0 mm). Age, gender, nasal geometry, and flow (according to ARR and AR) had no significant influence on nasal secretion. The test for normal distribution was negative. In the smoking group (n = 30), the median wetting distance was 8.4 mm (range 2.5-28.0 mm), significantly shorter than the wetting distance in the non-smoking group (p < 0.05). The Schirmer test offers a practical method to quantify mucosal humidification. The test is inexpensive and well tolerated by patients. In healthy people, wetting distances from 6 to 18 mm are considered normal.

Anthropometric Evaluation of Photographic Images Before and After Functional Nasal Surgery in Patients With Deviated Noses.

BACKGROUND: Numerous techniques for correction of deviated noses have been described. Nevertheless, surgical management is challenging even for experienced rhinosurgeons. Often, a "residual deformity" after functional septorhinoplasty (SRP) due to a deviated pyramid syndrome may remain. OBJECTIVE: Therefore, the purpose of this study was to determine how frequent functional SRP in patients with a deviated nose results in "successful" straightening of the external nose based on standardized angle measurements. Possible influences having a positive or negative effect on the surgical success were identified. METHODS: Photo documentation of 607 patients with deviated noses (304 women, 303 men, median age 30 years) before and after nasal surgery were retrospectively analyzed using standardized angle measurements. The pre- and postoperative photos of the faces were anthropometrically measured. The median follow-up was 6 months. RESULTS: A "straight" deviated nose (I-type) was present in 225 patients (37%), a C-shaped nose (C-type) in 382 patients (63%). More than 75% of the patients presented a facial asymmetry. Based on angle measurements alone, a total of 452 (75%) noses were straightened or postoperatively improved. 155 noses (25%) still showed a biometric deviation. The I- or C-type had no relevant influence on outcome. CONCLUSION: A purely biometric analysis of crooked noses is difficult and its importance is limited due to commonly pre-existing facial asymmetries. The risk of a "residual deviation" after rhinoplasty in patients with deviated noses must not be underestimated. This fact should be addressed as part of the informed consent. In particular, it should be mentioned that the surgical outcome can remain well below the patient's aesthetic expectations. Not rarely, a revision surgery may be necessary.

A contemporary review of "realistic" success rates after surgical closure of nasal septal perforations.

OBJECTIVE: The surgical closure of septal perforations is a challenging procedure. Various techniques exist. Each perforation proves that there is not the one precise procedure for all perforations. Nevertheless, success rates of about 90% are reported, although the procedure for closing the defect is challenging. Our goal was to evaluate the existing data. METHODS: We performed a contemporary review of published closure rates of septal perforations on order to compare the present results in the literature. The limitations of the respective studies were analyzed. RESULTS: We found closure rates from 30 to 100%. Numerous procedures were described and combined. Prospective studies comparing different techniques are missing. The follow-up time in studies was quite short or not even specified. Studies on long-term success rates are rare. CONCLUSION: The closure of septal defects is one of the most challenging rhinosurgical interventions. Closure rates ≥90% as described in literature seem relatively high. One reason might be short follow-ups and retrospective study designs. Frequently, precise information on the follow-up and the method of follow up is missing. Thoroughly designed prospective studies are absent. Longer follow-up times are associated with lower complete closure rates. A long-term success rate between 70 and 80% seems realistic.

Nasal air conditioning in patients before and after septoplasty with bilateral turbinoplasty.

OBJECTIVE: Septoplasty is one of the most frequently performed surgical procedures by ear, nose, and throat surgeons. Yet the objective control of success concerning septal surgery still is very difficult and causes controversy. Data concerning one of the main functions of the nose, namely the heating and humidification of inspired air, before and after nasal surgery, are still missing. Therefore, the aim of this study was to compare intranasal air temperature and humidity values before and after septoplasty with bilateral turbinoplasty. METHODS: Sixteen patients were included in this prospective study. Intranasal temperature and humidity were measured in the anterior turbinate area close to the head of the middle turbinate. A miniaturized thermocouple and a humidity sensor were applied for continuous intranasal detection. RESULTS: Significant differences between temperature and humidity values before and after septoplasty could be observed, including absolute temperature, increase in temperature, absolute humidity, and increase in humidity. The postoperative values were significantly higher than the preoperative ones (P < .05). CONCLUSIONS: According to the results of our study, patients seem to profit from septoplasty as heating and humidification as one of the most important nasal functions are restored and even improved after surgery. We therefore conclude that properly performed septoplasty is able to main its importance within the variety of nasal surgical procedures ensuring improved nasal function as well as patient contentment.

Atrophic rhinitis in a patient with anhidrotic ectodermal dysplasia.

We would like to present the rare case of a now 37-year old female patient with autosomal-recessively inherited anhidrotic ectodermal dysplasia being treated in our ENT department for atrophic rhinitis. The clinical appearance very much resembled the picture of an "empty nose" with distinct hypoplasia of the turbinates and extensively wide nasal cavities. We want to point out the possible existence of atrophic rhinitis against the background of an underlying syndromatic disease in adults and also the pediatric patient.

Numerical simulation of intranasal air flow and temperature after resection of the turbinates.

BACKGROUND: Radical surgical resection of the turbinates leads to a reduced intranasal air conditioning. The aim of this study was to determine the effect of turbinate resection on intranasal heating and airflow patterns using a numerical simulation. METHODS: A bilateral model of the human nose with resection of the turbinates on one side based on a CT-scan was reconstructed. A numerical simulation applying the computational fluid dynamics (CFD) solver Fluent 6.1.22 was performed displaying inspiratory intranasal air temperature and airflow patterns. RESULTS: Due to resection of the turbinates the airflow pattern is disturbed resulting in a spacious vortex throughout the entire nasal cavity. Hence, contact between air and surrounding nasal wall is less intense. Consequently, intranasal heating of the inspired air is relevantly reduced. CONCLUSIONS: Surgical resection of the turbinates leads to a disturbed intranasal air conditioning. The presented numerical simulation demonstrates the close relation between airflow patterns and heating.

A numerical simulation of intranasal air temperature during inspiration.

OBJECTIVES/HYPOTHESIS: In vivo measurements of the intranasal air temperature are feasible. The present study was designed to reproduce temperature distributions within the human nasal cavity by means of numerical simulation. STUDY DESIGN: Numerical simulation. METHODS: Based on computed tomography (CT), a steady-state computational fluid dynamics (CFD) simulation was performed displaying the temperature distribution throughout the human nasal cavity during inspiration. The results of the numerical simulation were compared with in vivo temperature measurements. RESULTS: The numerical simulation demonstrated that the major increase of the inspiratory air temperature can be found in the anterior nasal segment, especially within the nasal valve area, which is comparable to in vivo measurements. Intranasal areas of high temperature were characterized by turbulent airflow with vortices of low velocity. The results of numerical simulation showed an excellent comparability to the results of previous in vivo measurements in the entire nasal cavity. CONCLUSION: The anterior nasal segment is the most effective part of the nose in heating of the ambient air. The findings demonstrated the complexity of the relationship between airflow patterns and heating of inspired air. A numerical simulation of the temperature distribution using CFD is practicable.

Numerical simulation of airflow patterns in nose models with differently localized septal perforations.

OBJECTIVES/HYPOTHESIS: The most typical complaints of patients with nasal septal perforation (SP) are nasal obstruction, crusting, and recurrent epistaxis depending on the size and site of the SP mainly due to disturbed airflow patterns. The objective of the study was to determine the influence of differently localized SPs on intranasal airflow patterns during inspiration by means of numerical simulation. STUDY DESIGN: An experimental setup using three dimensional computer models of a human nose was created. Four different models with three differently localized septal perforation allowed an examination of intranasal airflow changes. METHODS: Four high-resolution, realistic, bilateral computer models of the human nose with three differently localized SPs were reconstructed based on computed tomography. A numerical simulation was performed. The intranasal airflow patterns (path lines, velocity, turbulent kinetic energy) during inspiration were displayed, analyzed, and compared. RESULTS: SPs cause a highly disturbed airflow in the area of the SP and behind. A spacious vortex within the perforation, including various localized vortices, was detected. The airflow in the nose was disturbed to varying degrees depending on the location of the perforation. SPs within the anterior caudal septum in area II led to increased negative turbulences and crossflow. CONCLUSIONS: The numerical simulations demonstrate significantly disturbed intranasal airflow patterns due to SPs. This fact may contribute to crusting and nosebleed due to dehydration of the nasal mucosa. The location and size of the SP are crucial for the impact on disturbed airflow pattern and therefore the patients' complaints. Anterior caudal SPs seem to be the worst. Surgical closure of SPs or simply changes in the site and size of the SP if a complete closure is surgically impossible makes sense.

The auricle's cavum conchae composite graft in nasal reconstruction.

BACKGROUND: Autologous transplants consisting of skin and cartilage, so-called composite grafts (CGs), are useful in nasal reconstruction of multilayered defects. A CG from the auricle's cavum conchae serves both functional and esthetic demands. This article outlines the indications and the requirements of the CG, making special considerations to improve wound healing, and discusses our results in consideration with recent publications. METHODS: A retrospective case-control study assessing the functional and esthetic long-term results in the donor and recipient site is presented. RESULTS: Between 2005 and 2011, 91 patients received differently sized CGs of the auricle for nasal reconstruction. In 85/91 cases the donor site defect was closed using a retroauricular pedicled island flap. Six of 91 defects were closed primarily. Indications were multilayered defects of the nasal vestibule, the nasal floor, the inner nasal valve, and the lateral sidewall. The main indication for surgery was skin malignancies. One of 91 major and 14/91 minor complications were observed. Seventy-seven of 91 patients received a custom-made prosthesis to prevent stenotic scarring. The 2.5-year follow-up showed excellent results of stability and shape at the donor and recipient site. CONCLUSION: The auricular inner lining CG is a versatile and reliable autologous transplant, which is ideal for multilayered nasal reconstruction because of easy harvesting, little donor site morbidity, and its convex shape. Septal splints and custom-made prosthesis secure healing and prevent stenotic scarring.

Normal aging does not deteriorate nose-related quality of life: assessment with "NOSE" and "SNOT-20" questionnaires.

OBJECTIVE: Aging causes changes in nasal morphology and function. This study assesses if the age-related nasal changes are detectable with objective measurements and reflected in two validated quality of life outcome tools: the Nasal Obstruction Symptom Evaluation Scale (NOSE) and the Sino-Nasal Outcome Test (SNOT-20) questionnaires. METHODS: Two study groups were included: the "young" group A (n=40) with a mean age of 27 years and the "elder" group B (n=40) with a mean age of 70 years. The subjective nasal complaints and quality of life status were recorded by means of the NOSE and SNOT-20 questionnaires. Objective assessment of intranasal dimensions and nasal airflow in all subjects were performed with the use of acoustic rhinometry and active anterior rhinomanometry respectively. RESULTS: The values obtained from acoustic rhinometry were significantly higher in the older group compared to the younger, presenting wider nasal airway passages for the elderly. However this was not the case with rhinomanometry values as no significant differences between groups were found. In addition no statistically significant difference was demonstrated in both questionnaires scoring between younger and older subjects. CONCLUSION: The outcome of the NOSE and SNOT questionnaires show no deterioration of quality of life in elderly related with changes in nasal function. Acoustic rhinometry confirmed that nasal cavities are becoming larger across the lifespan.

Dynamic nasal infrared thermography in patients with nasal septal perforations.

BACKGROUND: Nasal obstruction is a typical symptom in patients with nasal septal perforations. Rhinomanometry and acoustic rhinometry are not reliable in these cases because the perforations generate incorrect results. Infrared thermography camera (ITC) systems allow contact-free intranasal recordings of the nasal surface temperature and the semiquantification of nasal airflow. The aim of this study was to perform contact-free temperature measurements of the nasal vestibular surface by application of ITC systems in patients with septal perforations to investigate the disturbed intranasal heat exchange and nasal airflow. METHODS: The surface temperature profiles within the nasal vestibules of healthy volunteers (n=10) and patients with septal perforations (n=3) were recorded with an ITC during several breathing cycles. Thermal images were taken (60/s) displaying the surface temperature in degrees centigrade corresponding to a color scale. RESULTS: The temperature recordings showed a disturbed intranasal heat exchange during inspiration and expiration in patients with septal perforations in comparison with healthy subjects. A reduced and irregular inspiratory cooling of the entire surface within the nasal vestibules visualizes a reduced and disturbed airflow volume. CONCLUSION: The study was able to prove the feasibility of intranasal temperature recordings of the surface with an ITC system in patients with septal perforations. Contrary to rhinomanometry and acoustic rhinometry, thermography cameras can be applied to examine airflow in patients with septal perforations. The detected reduced cooling of the surface during inspiration might be a possible explanation for the patients' feelings of nasal obstruction.

Nasal air conditioning in relation to acoustic rhinometry values.

BACKGROUND: Changes of nasal dimensions can influence the air-conditioning capacity of the nose because of alterations of airflow patterns. The goal of this study was to evaluate the correlation between intranasal temperature and humidity values and nasal dimensions, assessed by means of acoustic rhinometry. METHODS: Eighty healthy volunteers (40 men and 40 women; median age, 51 years; range, 20-84 years) were enrolled in the study. In total, 160 nasal cavities were examined. All volunteers underwent a standardized acoustic rhinometry. Additionally, intranasal air temperature and humidity measurements at defined intranasal detection sites within the anterior nasal segment were performed. RESULTS: There was no statistically significant difference between the right and left side of the nose regarding air temperature, absolute humidity, and acoustic rhinometric values. A negative correlation was established between the rhinometric nasal volumes/minimal cross-sectional areas and air temperature and absolute humidity values at the three intranasal detection sites. CONCLUSION: According to our results, nasal volumes and cross- sectional areas relevantly influence nasal air conditioning. A healthy nasal cavity with smaller volumes and cross-sectional areas seems to present a more effective air-conditioning function than a too "wide" open nose because of changes in airflow patterns. This observation should be considered as a limitation for overly extensive nasal surgery especially of the turbinates.

Influence of the turbinate volumes as measured by magnetic resonance imaging on nasal air conditioning.

BACKGROUND: Changes in nasal airflow caused by varying intranasal volumes and cross-sectional areas affect the contact between air and surrounding mucosa entailing alterations in nasal air conditioning. This study evaluates the correlation between nasal air conditioning and the volumes of the inferior and middle turbinates as measured by magnetic resonance imaging (MRI). METHODS: Fourteen healthy volunteers were enrolled. Each volunteer had been examined by rhinomanometry, acoustic rhinometry, intranasal air temperature, and humidity measurements at defined intranasal sites as well as MRI of the nasal cavity and the paranasal sinuses. The volumetric data of the turbinates was based on the volumetric software Amira. RESULTS: Comparable results were obtained regarding absolute humidity values and temperature values within the nasal valve area and middle turbinate area for both the right and the left side of the nasal cavity. No statistically significant differences were found in the rhinomanometric values and the acoustic rhinometry results of both sides (p > 0.05). No statistical correlations were found between the volumes of the inferior (mean, 6.1 cm3) and middle turbinate (mean, 1.8 cm3) and the corresponding humidity and temperature values. Additionally, the air temperature and humidity values did not correlate with the rhinometrical endonasal volumes (0-20 mm and 20-50 mm from the nasal entrance). CONCLUSION: The normal range of volumes of the inferior and middle turbinate does not seem to have a significant impact on intranasal air conditioning in healthy subjects. The exact limits where alterations of the turbinate volume negatively affect nasal air conditioning are still unknown.

Age-related changes in intranasal air conditioning in the elderly.

OBJECTIVES/HYPOTHESIS: Elderly patients frequently complain about the feeling of a dry nose and recurrent crusting probably due to age-related degenerative effects of the nasal mucosa. Data on intranasal air conditioning in elderly patients are missing. The aim of the study was to compare intranasal heating and humidification of respiratory air in elderly subjects and a younger control group. Additionally, rhinomanometrical and rhinometrical data were examined. STUDY DESIGN: The study was conceived as randomized, prospective study. METHODS: Forty study subjects (median age, 70 years; range, 61-84) and 40 control subjects (median age, 27 years; range, 20-40) were included in the study. In vivo air temperature and humidity values were simultaneously measured at defined intranasal sites. Active anterior rhinomanometry and acoustic rhinometry also were performed in every subject. RESULTS: In the study group, the median end-inspiratory air temperature (degrees C)/absolute humidity (g/m3) values were 24.0 degrees C/13.8 g/m3 within the nasal valve region and 24.3 degrees C/14.7 g/m3 anterior to the head of the middle turbinate. In the control group, the corresponding values were 27.0 degrees C/15.5 g/m3 and 26.7 degrees C/17.0 g/m3. Temperature and humidity values were significantly lower in the study group (P < .05). The minimal cross-sectional areas and volumes were significantly higher in the study group (P < .05). CONCLUSIONS: Nasal complaints in elderly patients are a consequence of lower intranasal air temperature and humidity values combined with relatively enlarged nasal cavities due to involution atrophy of the nasal mucosa.

Early influence of bilateral turbinoplasty combined with septoplasty on intranasal air conditioning.

BACKGROUND: Too extensive resection of the inferior turbinates (ITs) during nasal surgery leads to a severely disturbed intranasal air conditioning. Data comparing nasal air conditioning before and after turbinoplasty in nasal surgery are still lacking. The aim of this study was to determine the early effect of bilateral turbinoplasty combined with septoplasty on intranasal heating and humidification. METHODS: Twelve patients were included into this prospective study. In one-half of the patients a bilateral turbinoplasty of the IT during nasal surgery was performed, in the other half no surgery on the IT was performed. Intranasal air temperature and humidity were measured before and after surgery. A combined miniaturized thermocouple and a humidity sensor were used for simultaneous in vivo intranasal measurements. RESULTS: There were no statistically significant differences in temperature and humidity values between the two study groups before surgery (p > 0.05). In both groups, the postoperative temperature and humidity values were statistically significantly higher compared with the preoperative ones (p < 0.05). Regarding the two patient groups, the postoperative increase in temperature and humidity was even more pronounced in patients undergoing additional bilateral turbinoplasty. CONCLUSION: According to the results of this study, patients seemed to overall benefit from nasal surgery, with and without a preserving bilateral turbinoplasty, because intranasal air conditioning was improved after surgery. A carefully performed and conservative reduction of the IT in nasal surgery seems to even improve intranasal air conditioning.

Impact of external nasal strips on nasal geometry and intranasal air-conditioning.

BACKGROUND: The anterior nasal segment is the most effective part of the nasal airways when it comes to warming and humidification of the inhaled air. Any changes in nasal geometry in this segment modifying the airflow could therefore affect nasal air conditioning. The goal of this study was to examine if external nasal strips have an influence on intranasal geometry and air-conditioning. METHODS: Twenty healthy volunteers (mean age, 36 years) were enrolled in the study. All volunteers received active anterior rhinomanometry and acoustic rhinometry before and while wearing commercially available external nasal strips. In addition, in vivo air temperature and humidity were measured with and without nasal strips at the defined intranasal sites. RESULTS: No statistically significant changes in temperature, humidity, and rhinomanometric values were detected during the use of nasal strips (p > 0.05). The statistical analysis of the acoustic rhinometric results showed a significant increase (p < 0.05) in the minimal cross-sectional areas (MCA) 1 (0-2 cm) and MCA2 (2-5 cm) and the nasal volume (Vol) 1 (0-2 cm). On the other hand, the nasal strips did not significantly alter the nasal Vol2 (2-5 cm; p > 0.05). CONCLUSION: Changes in the nasal geometry of the anterior part of the nose by wearing nasal strips did not relevantly alter intranasal air-conditioning. The application of nasal strips entails an increase in MCAs but not in nasal airflow Vol.

Impact of menthol inhalation on nasal mucosal temperature and nasal patency.

BACKGROUND: Menthol is a natural herbal compound. Its isomer l-menthol presents the characteristic peppermint scent and is also responsible for the cooling sensation when applied to nasal mucosal surfaces because of stimulation of trigeminal cold receptors. The aim of this study was to assess the effect of menthol inhalation on end-inspiratory nasal mucosa temperature and nasal patency. METHODS: Eighteen healthy volunteers with a mean age of 30 years were enrolled in this study. Objective measurements included the septal mucosal temperature within the nasal valve area by using a miniaturized thermocouple as well as active anterior rhinomanometry before and after inhalation of l-menthol vapor. All subjects completed a visual analog scale (VAS; range, 1-10) evaluating nasal patency before and after menthol. RESULTS: The mean end-inspiratory mucosal temperature ranged from 27.7 degrees C (+/-4.0) before menthol inhalation to 28.5 degrees C (+/-3.5) after menthol inhalation. There were no statistically significant differences between the temperature values before and after menthol inhalation (p > 0.05). In addition, no statistically significant differences between the rhinomanometric values before and after menthol inhalation were observed. Sixteen of the 18 subjects reported an improvement of nasal breathing after menthol inhalation by means of the VAS. CONCLUSION: Menthol inhalation does not have an effect on nasal mucosal temperature and nasal airflow. The subjective impression of an improved nasal airflow supports the fact that menthol leads to a direct stimulation of cold receptors modulating the cool sensation, entailing the subjective feeling of a clear and wide nose.

Nasal mucosal temperature in relation to nasal airflow as measured by rhinomanometry.

BACKGROUND: The aim of this study was to measure in vivo nasal mucosal temperature and assess its relationship to nasal patency. METHODS: Nasal mucosal temperature of 30 nasal cavities was measured by means of a miniaturized thermocouple within the anterior turbinate area during respiration. Temperature values were compared with corresponding rhinomanometrical data. RESULTS: The median mucosal temperature ranged from 30.2 degrees C (range, 28.9-31.7 degrees C) after inspiration to 32.2 degrees C (range, 31.0-33.9 degrees C) after expiration. The end-inspiratory (r = -0.85) and end-expiratory mucosal temperature values (r = -0.88) negatively correlated with the rhinomanometrical data. CONCLUSION: This study supports the fact that there is a negative correlation between nasal mucosal temperature and nasal resistance. Changes in nasal patency seem to influence nasal mucosal temperature. Within this context, nasal thermoreceptors might play an important role concerning the perception of nasal patency.

Influence of nasal sponges on patients' complaints after nasal and sinus surgery.

BACKGROUND: The goal of this study was to investigate the effect of nasal sponges on the subjective nasal well-being after nasal and sinus surgery. METHODS: The study was designed as a randomized prospective clinical trial comparing four different types of sponges used as nasal passive humidifiers (NPHs). The 40 participants were blinded to the size and pore structure of the NPHs. The NPHs were applied in both nostrils for 1 hour on the 2nd postoperative day. Subjective nasal sensations were evaluated on a visual analog scale. RESULTS: Wearing comfort was rated as satisfactory. Intranasal humidity and feeling of a dry nose were rated as improved after wearing the NPHs. CONCLUSION: The use of NPHs may have a positive effect on the patients' perception of nasal obstruction and intranasal humidity. Additional investigations in patients with intranasal dryness are planned to improve patients' complaints.

Acoustic rhinometry in nasal provocation test in perennial allergic rhinitis.

Acoustic rhinometry is one method to evaluate nasal geometry by an acoustic reflection technique. The aim of this study was to investigate the changes in acoustic rhinometry after nasal provocation in patients with exclusively perennial allergic rhinitis. In 19 patients, acoustic rhinometry and active anterior rhinomanometry were performed before and after nasal provocation test. There was a statistically significant nasal flow reduction measured by active anterior rhinomanometry after nasal provocation (p < 0.05) and a median symptom score of four points, both indicating a positive response to nasal provocation. On the other hand, there was no statistically significant change in the values of acoustic rhinometry after nasal provocation (p > 0.05). In patients with exclusively perennial allergic rhinitis, acoustic rhinometry does not seem to significantly change after nasal provocation. In contrast, active anterior rhinomanometry values decreased significantly after nasal provocation. The presented results indicate that acoustic rhinometry does not seem to be a diagnostic method superior to active anterior rhinomanometry in this context.