Current advances in rhinomanometry

Current advances in rhinomanometry were reviewed in this paper. Active posterior rhinomanometry with a “head-out” body plethysmograph may be the least invasive method currently available for measuring nasal patency. In general, active anterior rhinomanometry with a face mask or a nasal nozzle has been employed in various studies throughout the world. Nasal resistance as calculated from the equationR = 0.78 (ΔP/V)^1.33 at any points on a pressure/flow curve, or averaged nasal resistance may be the most suitable expression for nasal patency. Values for nasal resistance at ΔP 100 Pa in Japanese patients or ΔP 150 Pa in Caucasians have been widely employed as standard objective data for nasal obstruction, although rhinomanometric results sometimes do not agree with subjective evaluation of nasal obstruction. Nasal airflow acceleration or peak flow index during nasal breathing at rest can be applied as warranted to confirm an objective diagnosis of symptomatic nasal obstruction. Further, nationality and anthropological characteristics can be related to the severity and type of stuffiness.     

Perceptual and physiologic effects of histamine challenge on nasal breathing

The purpose of this study is to determine the effect of histamine-induced nasal congestion on nasal airflow and the perception of externally applied resistance to nasal breathing. Nasal cross-sectional area and nasal airflow during free breathing were measured in 15 adult subjects before and after histamine challenge. The threshold for perception of resistance to nasal breathing was determined using a dynamic perturbator device, with both free breathing and controlled nasal air-flow. The average threshold for perception of nasal resistance was 0.383 Pa/cm3/s at baseline. After histamine application, there was a significant decrease in nasal cross-sectional area (p = 0.0001), associated with a decrease in nasal airflow (r = 0.6). The average threshold of perception increased to 1.373 Pa/cm3/s (p < 0.0001). When nasal airflow was controlled at the baseline rate, the threshold of perception improved to 0.638 Pa/cm3/s (p = 0.024). These findings indicate that nasal congestion causes a reduction in both nasal airflow and the perception of resistance to nasal breathing. The ability to detect nasal airway impairment is improved with increased nasal airflow. An improved understanding of the physiology of the subjective perception of nasal patency may lead to innovative methods for the treatment of nasal obstruction.     

Patency of the maxillary sinus ostium in healthy individuals

In a group of 20 healthy subjects the patency of the maxillary ostium has been evaluated in 35 maxillary sinuses with three different techniques: simultaneous pressure recording in the sinus and the ipsi- and contralateral nasal cavity; simultaneous recording of differential pressure between the sinus and the ipsilateral nasal cavity and air-flow through the ostium during nasal breathing; recording of the pressure rise in the sinus with an artificial air-flow of 1 litre per minute applied to the sinus. The tests were carried out in sitting and recumbent positions. In 5 persons (10 sinuses) a retest was performed after 2 months. These subjects were also tested with an inflatable neck cuff in order to obtain an increased venous pressure. Rhinomanometry at rest and after physical effort was also performed. The pressure relationship between the maxillary sinus and the ipsilateral nasal cavity was 1:1 in both the sitting and the recumbent position, but less than 1 when the contralateral nasal cavity was measured. Pressure recording alone gives no quantitative information about the patency of the ostium. Determination of the ostial resistance during nasal breathing could be performed in 13 sinuses, but in the remaining 22 the ostia were too wide to give a measurable resistance. The equivalent ostial diameter during inspiration could be estimated in 12 of the sinuses from a diagram constructed from known ostial diameters in model experiments. With an artificial air-flow applied into the sinus, the equivalent ostial diameters could be estimated from the diagram in all cases. No statistical difference was found in comparable cases between the mean equivalent ostial diameters estimated with the two methods. The equivalent ostial diameters showed a statistically significant reduction in the recumbent position and after application of the neck cuff. A statistically significant relationship was also found between the airway resistance of the nasal cavity and the equivalent diameter of the ostium in sitting and recumbent positions. Such a relationship could not be found between the equivalent ostial diameters measured at rest and the nasal resistance recorded after physical effort.     

The effects of nasal massage of the "yingxiang" acupuncture point on nasal airway resistance and sensation of nasal airflow in patients with nasal congestion associated with acute upper respiratory tract infection

The aim of our study was to determine whether nasal massage of the "yingxiang" acupuncture point in patients with nasal congestion had any effect on nasal airway resistance (NAR) measured by posterior rhinomanometry and sensation of nasal airflow measured on a visual analog scale (VAS). Twenty patients were randomized into two groups; one group self massaged the yingxiang point for 30 seconds, while the other group acted as control group without nasal massage. NAR and VAS were measured at baseline, and at 2 and 10 minutes after massage. At the end of the study, patients were asked to score any change in their nasal congestion. There was no statistically significant difference between the two groups in percentage change in NAR or VAS from baseline at any time during the study, although the massage group showed trends toward decongestion and relief from congestion. At the end of the study, more patients in the massage group than the control group felt their nasal congestion was improved (p < 0.005). It is interesting that all three measures (NAR, VAS, and end question) showed that the nasal massage group had greater relief from nasal congestion than the control group. The results of this study, when taken together, indicate that nasal massage may provide some relief from nasal congestion and that further studies involving a larger patient population are warranted to determine whether nasal massage has a significant effect on NAR.     

Nasal airway measurements in children treated by rapid maxillary expansion

BACKGROUND: Rapid maxillary expansion is an orthodontic procedure that is commonly used to widen the maxilla. It is generally admitted that this technique is effective to correct palate narrowing, whereas there has not been agreement on the effect of this procedure in nasal parameters. The availability of a reliable and objective technique to assess the geometry of nasal cavities, such as acoustic rhinometry, stimulated the present investigation. METHODS: Twenty-seven children, undergoing rapid maxillary expansion, were evaluated by rhinomanometry and acoustic rhinometry. Postero-anterior radiographs were taken in 15 patients for cephalometric measurements. Examinations were performed before expansion treatment and after 12 month follow-up and compared to the measurements obtained from an untreated control group. RESULTS: With regard to rhinomanometry, we recorded a significant reduction in nasal airway resistance (NAR) after the orthodontic procedure only in decongestion. Using acoustic rhinometry, we found a significant increase in total minimum cross-sectional areas (TMCA) and total nasal volume (TNV) after the expansion both in basal and decongested conditions. Also, nasal cavity width and interzygomatic distance had a significant mean increase after the treatment. Comparison of measures between the control group and the treated group showed that the increase in TMCA and TNV, as well as the decrease in NAR, were significantly greater in the treated group in both basal and decongested conditions. CONCLUSION: We demonstrated that rapid maxillary expansion is an effective procedure in widening nasal cavities with respect to an untreated control group and that the reported improvement in nasal breathing after palatal expansion, is a consequence of an increase in nasal size.     

Smoking and improvement after nasal surgery in snoring men

BACKGROUND: The aim of this study was to compare subgroups of smokers and nonsmokers undergoing nasal surgery and to evaluate improvement of nasal stuffiness, snoring, and symptoms related to sleep-disordered breathing after nasal surgery. METHODS: A cross-sectional prospective study was performed. The study population included 40 consecutive snoring men scheduled for surgical treatment of nasal obstruction. The patients completed nasal and sleep questionnaires, an Epworth sleepiness scale, and a visual analog scale of snoring intensity. They underwent polysomnography, anterior rhinomanometry, acoustic rhinometry, and cephalometric analysis. RESULTS: The smokers were younger, they snored longer and louder, and they had higher nasal resistance with decongestion and longer soft palates than the nonsmokers. Nasal stuffiness improved well after surgery, but a decrease of nasal resistance was not related to improvement of subjective snoring. CONCLUSION: Smoking was associated with increased snoring, nasal obstruction, and pharyngeal soft tissue volume. Expectations of patients may influence subjective assessment of snoring after nasal surgery.     

Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence

Background: There is no consensus about the value of objective measurements of nasal patency. Objective: To assess the correlation between the subjective sense of nasal patency and the outcomes found with rhinomanometry and acoustic rhinometry. Type of review: Structured literature search. Search strategy and evaluation method: Review of English‐language articles in which correlations were sought between subjective nasal patency symptoms and objective scores as found with rhinomanometry [nasal airway resistance (NAR)] and acoustic rhinometry [minimal cross‐sectional area (MCA)]. Correlations were related to unilateral or combined assessment of nasal passages and to symptomatic nasal obstruction or unobstructed nasal breathing. Results: Sixteen studies with a level of evidence II‐a or II‐b fit the inclusion criteria and were further analysed. Almost every possible combination of correlations or lack thereof in relation to the variables included was found. However, when obstructive symptoms were present, a correlation between the patency symptoms with nasal airway resistance and minimal crosssectional area was found more often than in the absence of symptoms. In cases of bilateral assessment a correlation was found almost as often as it was not between patency symptoms and total nasal airway resistance or combined minimal crosssectional areas, while in the limited amount of studies in which unilateral assessment was done a correlation was found each time between patency symptoms and nasal airway resistance. Conclusions: The correlation between the outcomes found with rhinomanometry and acoustic rhinometry and an individual’s subjective sensation of nasal patency remains uncertain. Based on this review, it seems that the chance of a correlation is greater when each nasal passage is assessed individually and when obstructive symptoms are present. There still seems to be only a limited argument for the use of rhinomanometry or acoustic rhinometry in routine rhinologic practice or for quantifying surgical results. Clin. Otolaryngol. 2009, 34 , 518–525.     

The effect of lignocaine on nasal resistance and nasal sensation of airflow

The effect of lignocaine on nasal sensation of airflow and nasal resistance was assessed in twenty-five subjects. A randomised crossover trial was conducted with lignocaine as the active drug and saline as the placebo. Both substances were delivered to the nasal mucosa as a nasal spray. Lignocaine caused a sensation of increased nasal patency in twenty-two of the twenty-five subjects studied. Saline had no such effect. The difference between this subjective effect of the two substances was highly significant (p less than 0.001). Neither spray had any significant effect on nasal resistance to airflow assessed objectively by rhinomanometry.     

Rhinomanometry: do the anterior and posterior methods give equivalent results?

Nasal resistance to airflow was measured by both anterior and posterior rhinomanometry in 15 healthy volunteers. It was found that the posterior method gave values on average 16% higher than the anterior method. This difference was statistically significant. We propose that this is due to posterior rhinomanometry measuring the resistance of the nasopharynx as well as the resistance of the nose. In the past a discrepancy between the 2 methods has been claimed to be due to an error in the standard form of the parallel resistance equation. This hypothesis was tested by measuring total nasal resistance by posterior rhinomanometry and comparing this with a total nasal resistance value derived from posterior rhinomanometric measurements of the resistance of the individual nasal cavities. The standard form of the parallel resistance formula was used to derive the total nasal resistance. There was no significant difference between the 2 values for total nasal resistance. We conclude that if measurements are made at the same pressure gradient then the use of this equation is valid.     

The effect of aromatics on inspiratory and expiratory nasal resistance to airflow

Unilateral inspiratory and expiratory nasal resistance to airflow were measured in 35 subjects using active anterior rhinomanometry. No significant difference was found between inspiratory and expiratory resistance. Inhalation of a mixture of aromatics, camphor, menthol, oil of pine needles and methyl salicylate had no effect on inspiratory or expiratory nasal resistance. Factors influencing inspiratory and expiratory resistance and the actions of aromatics are discussed.     

鼻阻塞的主观评价与客观鼻测量的相关性研究

目的 探讨鼻阻塞时检查者和患者的主观评价与客观鼻测量之间是否有相关性.方法 检查者和患者均采用视觉模拟量表(visual analog scale,VAS)对鼻阻塞程度进行评价.客观鼻测量采用主动后鼻测压仪和鼻声反射测量仪进行.以配对t检验分析检查者的临床评价和患者VAS均数的差异,以Spearman等级相关分析评价客观鼻测量结果单侧鼻气流阻力与单侧鼻道容积、单侧鼻腔最小横截面积的关系,以及检查者的临床评价、患者VAS与上述客观鼻测最结果的相关性.结果 本组病例经统计学分析,316例患者中,减充血前后单侧鼻气流阻力与单侧鼻道容积、单侧鼻腔最小横截面积间呈负相关(r值分别为-0.430、-0.554、-0.373、-0.600,P值均＜0.001).减充血前后,检查者的临床评价与患者VAS均数呈正相关,差异均有统计学意义(r值分别为0.630、0.526,P值均＜0.001),二者均与鼻气流阻力有一定的正相关关系(减充血前:检查者的临床评价与鼻气流阻力r=0.530,P=0.000,患者VAS与鼻气流阻力r=0.351,P=0.000;减充血后:检查者的临床评价与鼻气流阻力r=0.452,P=0.000,患者VAS与鼻气流阻力r=0.216,P=0.000),与鼻道容积和鼻腔最小横截面积均有一定的负相关关系(减充血前:检查者的临床评价与鼻道容积r=-0.411,P=0.000,患者VAS与鼻道容积r=-0.325,P=0.000,检查者的临床评价与鼻腔最小横截面积r=-0.507,P=0.000,患者VAS与鼻腔最小横截面积r=-0.384,P=0.000;减充血后:检查者的临床评价与鼻道容积r=-0.391,P=0.000,患者VAS与鼻道容积r=-0.209,P=0.000,检查者的临床评价与鼻腔最小横截面积r=-0.471,P=0.000,患者VAS与鼻腔最小横截面积r=-0.286,P=0.000).检查者的临床评价与客观鼻测量参数的相关系数大于患者VAS与客观鼻测最参数的相关系数.结论 鼻阻力测压与鼻声反射测量的结果有一定的相关性.检查者的临床评价与患者VAS存在一定的正相关关系.两者均与客观鼻测量参数存在一定的直线相关关系.     

Accuracy of measurement and comparability of anterior rhinomanometry and whole body plethysmography in determination of nasal resistance. Studies with a mechanical model

The degree of accuracy of anterior rhinomanometry and the plethysmographic method in determining nasal resistance was examined in a mechanical model. The plethysmographic method allows a precise estimation of nasal resistance. It was found that the absolute variation of the plethysmographically measured values is not greater than 5%. Anterior rhinomanometry as described by Bachmann (2) allows a valid estimation of the pressure-flow relation. Here, too, inaccuracy remains within a range of 5% if the values are recorded with an X-Y-plotter. With the system developed by EVG, a microprocessor-controlled analysis is also possible. The flow rate is measured at pressure rates of 75, 150, and 300 Pa. Inconstancies in respiratory flow cause deviations from the correct pressure-flow graph. Should these deviations accidentally coincide with the predefined points of evaluation these erroneously achieved results will be assumed to be representative for the whole graph. This analytical fault has meanwhile been corrected by interpolating the points at the predefined pressure rates. Due to the differences in analytic techniques the methods of determining nasal resistance are not comparable in practice. The authors therefore recommend that, in addition to the usual results of analysis, average value of nasal resistance be determined for each measuring procedure. Today, this can be done without any problem by using microprocessors.     

Human nasal mucosa reaction during chilling of the feet

As rhinostereometry, an optical measurement method, allows meticulous studies of changes in nasal mucosa congestion, the mucosal reaction in eight healthy volunteers was studied with this technique before, during and after 20 minutes' chilling of the feet in cold water. In five volunteers there were no observable mucosal reactions. In three volunteers the mucosal congestion changed but not uniformly, and not in such a way that the change could be explained as an effect of chilling of the feet. In four volunteers there was a clearly observable increased nasal secretion. This gives a possible explanation of the increased nasal breathing resistance observed in similar studies using rhinomanometry as the measuring method.     

Reliable and reproducible anterior active rhinomanometry for the assessment of unilateral nasal resistance

Unilateral nasal resistance is now thought to be more important than total resistance in promoting obstructive symptoms. We assessed the reproducibility of anterior active rhinomanometry in measuring unilateral nasal resistance. Ten baseline readings of unilateral nasal resistance were made over a 30-min period in seven healthy subjects (14 nostrils) using anterior active rhinomanometry performed according to the International Committee for the Standardization of Rhinomanometry (ICSR) guidelines. Baseline readings revealed that measurements using anterior active rhinomanometry had an unacceptably high coefficient of variation (19%-60%). With a more time-consuming revised protocol involving multiple recordings and the identification and exclusion of erroneous data, coefficients of variation of 7%-15% were obtained. We conclude that single anterior active rhinomanometry readings are potentially prone to large errors and each researcher using such equipment must satisfy his/herself that their methodology has an acceptable coefficient of variation in their hands. The ICSR guidelines are not always sufficient to allow reproducible measurement and specially designed protocols may be necessary to produce reliable results.     

The adrenaline contraction test with rhinomanometry

The relationship between the sensation of nasal obstruction as a subjective symptom and nasal resistance was examined, and the adrenaline contraction test combined with rhinomanometry was evaluated. The nasal resistance was determined by the oscillation method using a rhinomanometry. As the sensation of nasal obstruction advanced, the nasal resistance tended to be increased. The group with a (-) sensation of nasal obstruction included patients with a high nasal resistance who corrected their first statement to a (+) sensation as a result of the adrenaline contraction test. The test indicated the sensation of nasal obstruction more accurately. In the 26 patients who underwent septoplasty and conchotomy, the rate of change in BNR by the adrenaline contraction test was 30-40%. The eight patients whose preoperative rate was less than 20% all showed a rate of more than 40% in unilateral rhinomanometry. Indications of reconstructive surgery for nasal obstruction may be present if the rate of change in BNR is 30-40% or the rate of change in unilateral rhinomanometry is more than 40%. Since the test predicted the postoperative nasal resistance, it can also be used in evaluating the results of surgical therapy.     

A clinical follow-up of septal surgery with special attention to the value of preoperative rhinomanometric examination in the decision concerning operation

A consecutive series of 57 patients who had undergone an operation on the nasal septum was followed up 1.5–3.5 years postoperatively. Rhinomanometric measurements, a clinical examination of the exterior of the nose, and rhinoscopy were performed. These same examinations had been carried out preoperatively and the results recorded preoperatively. The results of the preoperative rhinomanometry were not known to the surgeon and the indication for surgery was based on clinical examination alone. At follow-up the patients also answered a questionnaire. According to the findings at rhinomanometry 52 of the 57 patients had a better airway after the operation. In 11 patients who subjectively did not consider the nasal airway to have been improved by the operation, an allergy or vasomotor rhinitis was found and in some cases the results of preoperative rhinomanometry (total nasal resistance) were normal. To measure the error of the method, a separate series of duplicate measurements was performed on 50 subjects. The standard deviation of the difference between duplicate measurements was found to be 15% of the mean value and the error of the method was considered small enough to justify rhinomanometry as a method for inter-individual comparisons, provided the laboratory standard is well known.     

Clinical effect of bipolar radiofrequency thermotherapy on allergic rhinitis

The clinical effect of bipolar radiofrequency thermotherapy on allergic rhinitis was evaluated. A bipolar radiofrequency system (CelonLab ENT) was used to treat 16 patients suffering from allergic rhinitis between February 2003 and August 2003. The thermotherapy was performed under local anesthesia at the otolaryngology outpatient clinic of St. Marianna University Toyoko Hospital. Data were collected by questionnaire and rhinomanometry preoperatively and 2 months postoperatively. The mean visual analogue scale (VAS) score for intraoperative pain was 31 mm (range, 0-100), and nearly all the patients felt no or a subtle pain during the thermotherapy. Postoperative pain was also well tolerated, with nearly all the patients not requiring analgesic drugs. Postoperative bleeding was minor, and none of the patients required additional treatment for bleeding. Nearly all the patients reported an improvement in their nasal patency, rhinorrhea, headaches, and sleeping. Statistically significant improvements were observed for all the measured VAS scores: nasal patency, rhinorrhea, headache, and olfactory function. Nasal resistance, as measured by anterior rhinomanometry, significantly improved after treatment. The effect of decongestion was also measured using anterior rhinomanometry. The ratio of nasal resistance before and after decongestion was significantly higher after thermotherapy, suggesting that nasal decongestion had a smaller effect on nasal patency after treatment. The current results suggest that the CelonLab ENT device is an effective and safe treatment for allergic rhinitis.     

鼻内镜手术疗效综合评价

目的 探讨鼻内镜手术对慢性鼻窦炎及鼻息肉疗效的综合评价方法.方法 采用声反射鼻腔测量系统、前鼻测压计、T＆T嗅觉计定量检查法和术区黏膜评分法,对46例慢性鼻窦炎及鼻息肉患者鼻气道阻力、嗅觉、鼻腔术区黏膜形态进行测试.结果 鼻内镜手术后患者的鼻气道通气、嗅觉有明显好转;术后鼻腔、黏膜状况与功能恢复有显著相关性.结论 鼻气道阻力、嗅觉功能测试、鼻声反射检查、术区黏膜评分检测作为手术前后鼻功能的检测手段,可对术后疗效进行客观的综合评价.     

Studies of transnasal pressure and airflow values in a Japanese population

The proportions of subjects who attained transnasal pressure and flow values of different magnitudes during spontaneous nasal breathing at rest were determined. Several co-ordinate points on transnasal pressure: flow curves generated by 77 (34 M, 43 F) healthy Japanese subjects aged 15-65 years were examined. By posterior rhinomanometry the proportion approximated 100% at Brom's radii R1 and R2 and 80-90% at 0.25 l/sec flow and at 0.5 cm H2O (50 Pa) pressure when both nasal cavities were patent. When one nasal cavity was occluded the results were 100% at radius R1 and 80-90% at radius R2 and 0.5 cm H2O (50 Pa) pressure. By anterior rhinomanometry, the proportion approximated 100% at radius R1 and 0.5 cm H2O (50 Pa) pressure and was quite high at radius R2 and 1.0 cm H2O (100 Pa) pressure. Pressure and flow are more representative at points where the pressure: flow curve includes the turbulent flow component than at radius R1 and 0.5 cm H2O (50 Pa) pressure. Calculation of total nasal resistance from unilateral resistances at 1.0 cm H2O (100 Pa) appears a suitable compromise and this point is recommended for a Japanese population.     

Pre- and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery

Functional endoscopic endonasal sinus surgery (FESS) is at present the surgical method of choice for many clinicians treating chronic sinusitis and nasal polyposis. Postoperatively, patients have felt that patency of the nasal airway is improved, although all previous studies have failed to objectively measure changes produced. By using anterior active rhinomanometry, decreased unilateral and total nasal resistance was measured. Although improvement in total resistance was not statistically significant, reduction in unilateral resistance was. All patients demonstrated subjective improvements in unilateral and total nasal patencies. The reduction in nasal resistance was more pronounced in baseline resistance values than after decongestion, indicating that FESS had a positive effect on mucosal edema but did not alter the structural anatomy of the main nasal passages.