Impact of resection of the turbinates and the lateral nasal wall on particle deposition

OBJECTIVES/HYPOTHESIS: The aim of the investigation was to determine the influence of complete resection of the turbinates and the lateral nasal wall on nasal deposition of particulate matter with an aerodynamic diameter of 10 microm or less (pm10) and its relation to nasal patency and geometry. STUDY DESIGN: Retrospective study. METHODS: Eight patients were enrolled in the study after unilateral sinus surgery for a unilateral inverted papilloma of the sinuses. Particle deposition from the inhaled and exhaled air was measured by means of a laser particle counter in the nasal valve area and the nasopharynx during nose-only breathing and nose-in, mouth-out breathing. The data on deposited fraction for the operated side were compared with the data for the untreated, healthy side. Rhinomanometry and acoustic rhinometry were performed. RESULTS: Particle deposition did not differ significantly between the operated and untreated sides of the nose at both detection sites. No correlation between the deposited fraction and rhinomanometric and rhinometric values was found. CONCLUSION: Radical resection of the turbinates does not seem to disturb particle deposition (pm10) measured in the nose to a significant degree. Factors other than impaction and sedimentation onto the mucosal surface of the turbinates seem to be sufficient for effective particle deposition after radical removal of the turbinates.     

Immunohistopathology of allergic rhinitis and conditions allied

Knowledge of nasal physiology and function is necessary for a proper comprehension of nasal symptoms; a short introduction on this topic follows. It is an important task for the nose to filter, humidify and warm the inhaled air. The shape of the nasal cavity and the structure of the nasal lining seem particularly well suited for this purpose. The narrow inlet to the airway (the internal ostium), the bend of the airflow in the nasopharynx and the slit-like cavity provide for effective sedimentation of practically all particles, larger than 10μm, and also of some smaller particles (2–3 μm).¹ Foreign particles deposited in the nasal filter, contact the local immune system. The airway mucosa is equipped with a secretory IgA immune system, which may help to render deposited micro-organisms harmless,² but also IgE producing cells are found in the mucous membrane and in the regional lymph nodes.³ Therefore, the constant sedimentation in the nose of potent allergenic substances (pollen, animal dander, house dust mite) and the consequent risk of allergic rhinitis is a price which has to be paid for nasal filtration and protection of the lower airways against unconditioned ambient air. The nose is also designed for heating and humidification of the inhaled air. Again the slitlike shape of the cavity is of decisive importance, as the intimate contact between the mucosal surface and the inhaled air is necessary for rapid supply of water and heat to the air the nasal cavity. Normally the air passes the nose at a speed of 2 m/sec.⁴ The numerous seromucous glands,⁵ some anterior serous glands⁶ and subepithelial capillaries of the fenestrated type⁷ form the basis for the supply of 500 ml water a day to the inspired air.⁸ The venous sinusoids seem especially designed for maintenance of a slit-like nasal cavity, so important for normal function. More than half of the nasal blood flow is shunted through an abundance of arterio-venous anastomoses.⁹ A comparison with hot water running in a radiator illustrates the importance of this arrangement for heating of the inspired air.     

Septal cartilage graft for nasal valve incompetence associated with deviated septum

BACKGROUND: The nasal valve is one of the major factors contributing to nasal airflow obstruction. Physiologically, the nasal valve offers the greatest resistance to nasal airflow and generally functions as an inflow device controlling nasal airflow and resistance. Many patients who have complaints of breathing impairment are affected by alterations of the nasal septum, the turbinates, the columellar base, the vestibule floor, or the lateral wall of the nose but may have associated incompetence of the nasal valve, which is too often undervalued by nasal surgeons. The aim of this study was to propose a relatively easy surgical technique to correct most nasal valve impairments associated with nasal septum deviation whether or not there also is inferior turbinate hypertrophy. METHODS: Between May 2004 and September 2006, 68 patients (26 women and 42 men; mean age, 37 years; range, 16-71 years) underwent primary or secondary functional nasal surgery, because of a nasal respiratory obstruction caused by nasal septal deviation eventually associated with inferior turbinates hypertrophy, and also demonstrated nasal valvular incompetence. A septal cartilage graft was used to correct the valvular incompetence. RESULTS: On postoperative visits almost all of the patients (with one exception) showed a remarkable improvement in the stiffening of the valvular region and had only minimal depression of the nostril during deep inspiration. CONCLUSION: This study indicated that septal grafts were useful in the surgical management of nasal respiratory impairment because of nasal valve incompetence, where there had been flaccid mobile collapse of the ala of the nose associated with septal alterations.     

Distribution of inhaled aerosol using nasal nebulizer

In this paper, we examined distribution and deposition of inhaled 99mTc aerosols in human respiratory tract, nebulization equipment and expired aerosols. Jet nebulizers were used and aerosols were inhaled through the nose. Results were as follows: 1. On normal breathing, deposition rate of human respiratory tracts in normal subjects were 22% of total dosage and there was no difference from sinusitis group. But, deposition rate of nasal cavity was higher than in sinusitis group normal in group. 2. In normal subjects, there was no influence of breathing pattern to deposition rate of nasal cavity. 3. Distribution of the lung was significantly increased on deep breathing in both groups. 4. Residual volume of nebulizer bottle were about 50% of total dosage.     

Particle deposition in the nose related to nasal cavity geometry

A number of studies have been made to characterise the deposition-pattern of inhaled airborne particles in the nose. Common to all results has been considerable differences in deposition fractions between normal human subjects. It was the aim of the current study to improve our understanding of individual differences in nasal deposition of inhaled particles. Depositions were measured in ten adult normal subjects and were related to dimensional measurements by acoustic rhinometry. Five litres of a polydisperse aerosol (MMAD = 0.7 micron, sigma g = 1.7) were inhaled through one nostril only during 5 inspirations with flows of 10, 20, and 30 L/min with decongested mucosa. Increasing flow was found to increase the fraction deposited in the nose, while there was an inverse correlation between nasal deposition fraction and minimum cross-sectional area of the nasal cavity (Amin). Information based on acoustic rhinometry measurements significantly reduced the amount of unexplained variation between subjects in nasal deposition fraction. We conclude that an estimate of maximum linear air velocity, calculated as airflow divided by Amin, was the best single predictor of nasal deposition fraction, which was found to increase with increasing air velocity raised to a power of approximately 4/3.     

Piriform aperture surgery for alar collapse

The region of maximum resistance in the respiratory tract is in the anterior part of the nose, and this area has been termed the nasal valve.¹ Inspiratory narrowing of this area, known as alar or nasal valve collapse can produce the symptom of obstruction, and may be very difficult to correct. The anatomy and physiology of the nasal valve are discussed followed by the author's technique for correction of a common problem leading to alar collapse; a narrow piriform aperture, which is often associated with a prominent web at the muco-cutaneous junction.     

Detection of particles within the nasal airways before and after nasal decongestion

Cleansing of the air is one of the most important functions of the nose. The aim of this investigation was to determine the influence of decongestion of the nasal mucosa with xylometazoline on the intranasal particle deposition at different sites of the nasal cavity. During respiration of an aerosol of starch particles, the non-deposited particles in the air were laseroptically detected in 10 healthy volunteers by a transnasally placed suction probe at different locations within the nasal cavity. The anterior nasal segment was the main area of intranasal particle deposition before and after decongestion of the nasal mucosa. Particle deposition after nasal decongestion was not significantly different from the values before application of xylometazoline. Decongestion of the nasal mucosa and increase in nasal cavity diameter seems not to influence particle deposition of inhaled and exhaled air within a short period after onset of the maximal decongestive effect of xylometazoline.     

Breath actuated device improves delivery to target sites beyond the nasal valve

OBJECTIVES: The objective was to compare nasal deposition patterns achieved with a conventional hand actuated spray pump and a novel breath actuated bidirectional prototype device housing the same spray pump (OptiMist, OptiNose AS, Oslo, Norway). STUDY DESIGN AND METHODS: The bidirectional delivery device exploits the posterior connection between the nasal passages persisting when the velum automatically closes during oral exhalation. The deposition and clearance patterns achieved with the two devices were compared in nine healthy subjects by scintigraphy after administration of Tc-aerosols. RESULTS: Compared with traditional spray pump delivery, the OptiMist device provided significantly (P < .004) larger initial and cumulative deposition (area under the deposition vs. time curve) in the upper posterior segment of the nasal passage, housing the sinus ostia and the olfactory region, and significantly lower deposition (P < .004) in the anterior segment, lined by nonciliated squamous epithelium. Furthermore, intersubject reproducibility of the initial and cumulative deposition was higher for the OptiMist device both in the upper posterior segment and the entire nose. CONCLUSIONS: Compared with a spray pump, the novel breath actuated bidirectional device provides significantly larger deposition in the clinically important regions beyond the nasal valve and reduced anterior deposition. These striking differences provide new opportunities for improved therapy of chronic rhinosinusitis and polyposis as well as extended use of the nose for delivery of drugs from the nose into the brain.     

Deposition pattern of nasal sprays in man

The intranasal distribution from an aqueous pump spray has been assessed in 13 normal subjects, using insoluble Teflon particles labelled with 99Tcm which were intended to simulate a suspension of drug particles. Three different combinations of metered volume and spray cone angle were compared. The main deposition of particles was in the anterior, non-ciliated, part of the nose, but some particles also penetrated more posteriorly into the main nasal passages and were cleared subsequently to the nasopharynx. No particles were detected in the lungs. With a single puff of 100 microliters volume, 46.5 +/- 4.4 (mean +/- SEM)% of the spray was retained in the anterior part of the nose after 30 minutes, but this was increased to 57.1 +/- 4.5% (P less than 0.05) with two puffs of 50 microliters. The latter were deposited over a significantly (P less than 0.05) smaller area in the nasal cavity. There was a trend towards lower particle retention and a greater area of deposition when the spray cone angle was decreased from 60 degrees to 35 degrees. These results indicate that the drug particles released from nasal pump sprays are distributed both to ciliated and non-ciliated zones, and that the choice of metered volume and possibly spray cone angle may play a role in determining the amount which penetrates to the main nasal passages.     

Morphology and distribution of nasal telangiectasia in HHT-patients with epistaxis

BACKGROUND: Epistaxis in hereditary hemorrhagic telangiectasia (HHT; Rendu-Osler-Weber syndrome) is a frequent symptom that may be caused by a multitude of different genetic and epigenetic phenomena. This investigation analyzes the distribution of nasal telangiectasia in 21 patients with HHT. METHODS: The patients were examined for endonasal telangiectasia by videoendoscopy with rigid endoscopes; in addition, the anterior portion of the nose was examined under the operating microscope. The endonasal findings were recorded on videotape and then evaluated in the media laboratory. RESULTS: Morphology of the nasal telangiectasia showed wide variations: the vessels were shaped like spots, loops, or spiders or they clustered and resembled raspberries. Gender did not have an influence on the phenotype of telangiectasia, whereas advancing age correlated with a higher density of telangiectasia. Patients with an intact nasal septum exhibited the bulk of telangiectasia in the anterior nasal cavity but also on the middle turbinates, the floor of the nose, and within the valve area. Patients with septal perforations displayed the majority of telangiectasia around the edge of the perforations, on the floor of the nose, and on the turbinates. Scattered telangiectasia also could be found in the profound parts of the nasal cavity and in the nasopharynx, especially in patients with septal perforations. CONCLUSION: The shapes of endonasal telangiectasia in HHT patients are very heterogeneous; predilection sites could first of all be found within the anterior portion of the nose. Morphology and distribution of endonasal telangiectasia change as a result of therapeutic interventions, development of septal perforations, and with advancing age. Therefore, repeat endoscopies are recommended to assess the actual stage of the disease before epistaxis therapy.     

A comparative distribution study of two procedures for administration of nose drops

The intranasal distribution of nose drops has been studied in 12 healthy subjects, comparing an administration followed by two rapid inhalations through the nose, with an administration followed by turning the head to five positions. Insoluble particles of human serum albumin labelled with 99Tcm were suspended in the liquid before administration. A significantly larger area (p less than 0.05) in the nasal cavity was covered by the labelled nose drops when the subjects used the turning-the-head procedure. It appears that this procedure gave a larger passive distribution of the particles. The differences were about 10 to 15% between 3 and 45 min after administration. Some particles were rapidly transported into the pharynx. The retention of the particles at the initial site of deposition did not differ significantly between the two procedures and about 50% of the particles seemed to have penetrated to the ciliated region in the main nasal passages and were cleared. The results indicate that the procedure for administration of the nose drops influences the distribution in the nasal cavity, but the clinical relevance should be studied with respect to the efficacy of the active drug in patients.     

Detection of particles within the nasal airways during respiration

This study introduces a new experimental set-up for particle detection within the nasal airways and describes intranasal deposition of particles at various regions of the nasal cavity and the nasopharynx. During respiration of an aerosol of starch particles the nondeposited particles in the air were detected in 11 volunteers by a transnasally placed suction probe at numerous sites of the nasal cavity and nasopharynx. Another, identical suction probe measured the initial number of inhaled particles at the nostril. The two suction probes were connected to two identical laser particle counters and allowed calculation of particle deposition. Particles 1–3 μm in size were deposited to about 60% within the entire nasal cavity, whereas most of the particles 4–30 μm in size were deposited within the entire nasal cavity. Between 80% and 90% of the particles retained in the nasal cavity were deposited at the anterior nasal segment. Studies on deposition of various drugs within the nasal cavity using this experimental set-up are conceivable. Received: 29 May 2000 / Accepted: 10 August 2000     

Electron microscopy findings in the nasal mucosa of a patient with stenosis of the nasal vestibule

The nasal mucosa humidifies, warms and filters inspired air before it passes to the lower respiratory tract. In order to maintain the physiological activity of the respiratory epithelium, a certain amount of airflow is required. This report describes electron microscopy findings in the nasal mucosa of a patient who had decreased airflow through the nose due to stenosis of the nasal vestibule. Electron microscopic examination of the nasal mucosa revealed stratified squamous epithelium composed of markedly degenerated cells. The findings of abnormal mucosal structure highlight another negative consequence of nasal obstruction in addition to abnormal physiological function of the nose. The negative impact of diminished airflow on the nasal mucosa should be considered in any case where the patient has a condition that can lead to partial or total loss of airflow through the nose.     

Ventilation and drug delivery to the paranasal sinuses: studies in a nasal cast using pulsating airflow

BACKGROUND: Although there is a high incidence of nasal disorders including chronic sinusitis, there is limited success in the topical drug delivery to the nose and the paranasal sinuses. This is caused by the nose being an efficient filter for inhaled aerosol particles and the paranasal sinuses being virtually non ventilated METHOD: The objective of this study was to visualize the efficiency of sinus ventilation in a nasal cast using dynamic 81mKr-gas imaging in combination with pulsating airflows. Furthermore, the efficiency of the deposition of radiolabelled aerosol was assessed. RESULTS: Pulsation increased ventilation efficiency of the sinuses more than fivefold and aerosol deposition efficiency more than twentyfold, compared to delivery without pulsation. Furthermore pulsation increased aerosol deposition in the nasal airways by a factor of three. Using pulsating airflow Kr-gas ventilation and aerosol deposition efficiencies increased with increasing sinus volume. Pulsating airflow resulted in a deposition of up to 8% of the nebulized drug within the sinuses compared to 0.2% without pulsation. CONCLUSIONS: The study demonstrates the high efficiency of a pulsating airflow in paranasal sinus ventilation and aerosolized drug delivery. This proves that topical drug delivery to the paranasal sinuses in relevant quantities is possible.     

Clinical aspects and distribution of immunologically active cells in the nasal mucosa of patients with nasal polyps after endoscopic sinus surgery and treatment with topical corticosteroids

Summary Clinical parameters of 72 patients who were operated upon for nasal polyps were evaluated as well as biopsy specimens of the mucosa of the middle and inferior turbinates of 41 of these patients. Biopsies were taken at the time of endoscopic sinus surgery (ESS), after 6 months and after 1 year in 23 patients. During the follow-up period the patients were treated with topical corticosteroids (budesonide). At the time of ESS significantly more CD8+ (suppressor/cytotoxic) cells than CD4+ (helper/inducer) cells were found in the middle and inferior turbinates. At 6 months significantly more CD4+ cells were found than at the time of ESS, whereas at 1 year the number of CD4+ cells had decreased and was lower than at 6 months. These data support the theory that the occurrence of nasal polyps is associated with T-cell-dependent disturbances. Clinical evaluation revealed that most of the patients with chronic airway obstruction had better pulmonary functions postoperatively or required less medication for lung disease. These findings show that ESS combined with topical corticosteroids has a positive effect on upper and lower respiratory tract pathology. Correspondence to: A. E. Stoop     

Asthma,allergische Rhinitis,Sinusitis

Epidemiological studies indicate that allergic rhinoconjunctivitis (ARC) is an important risk factor for bronchial asthma. Both asthma and ARC have now been recognized as inflammatory diseases with similar manifestations in the mucous membranes of the upper (nose and paranasal sinuses) and lower respiratory tract (bronchi). Recent studies show that the deposition of allergen into the lower respiratory tract leads to increased inflammation of the upper respiratory tract, even if the patients are only suffering from ARC. These and other findings indicate that allergic diseases have a systemic component, which might be insufficiently targeted with local therapy.It is currently believed that the impaired function of the upper airways due to ARC causing nasal obstruction, retention of secretions, and disturbed conditioning of the inspired air plays an important role in the development of lower airway symptoms. Studies indicate that treatment of the upper respiratory tract inflammation not only reduces the manifestation of allergen-associated symptoms in the lower respiratory tract, but might also have preventive properties if applied early. ARC should no longer be viewed as a harmless disorder but as the early manifestation of a potentially progressive systemic disease and be treated as such.     

Asthma, allergic rhinitis, sinusitis. Concept of the "unified respiratory tracts"

Epidemiological studies indicate that allergic rhinoconjunctivitis (ARC) is an important risk factor for bronchial asthma. Both asthma and ARC have now been recognized as inflammatory diseases with similar manifestations in the mucous membranes of the upper (nose and paranasal sinuses) and lower respiratory tract (bronchi). Recent studies show that the deposition of allergen into the lower respiratory tract leads to increased inflammation of the upper respiratory tract, even if the patients are only suffering from ARC. These and other findings indicate that allergic diseases have a systemic component, which might be insufficiently targeted with local therapy. It is currently believed that the impaired function of the upper airways due to ARC causing nasal obstruction, retention of secretions, and disturbed conditioning of the inspired air plays an important role in the development of lower airway symptoms. Studies indicate that treatment of the upper respiratory tract inflammation not only reduces the manifestation of allergen-associated symptoms in the lower respiratory tract, but might also have preventive properties if applied early. ARC should no longer be viewed as a harmless disorder but as the early manifestation of a potentially progressive systemic disease and be treated as such.     

Temperature and humidity profile of the paranasal sinuses before and after mucosal decongestion by xylometazolin

BACKGROUND: One of the most important functions of the nose is to warm and to humidify air before it reaches the lower respiratory tract. Nasal decongestants as one of the most common drugs used in otorhinolaryngology are often associated with the feeling of a "dry nose". The purpose of this study was to determine the short-term influence of xylometazoline on temperature and humidity in the nasal airways. METHODS: 15 healthy volunteers were enclosed into the study. A miniaturised humidity sensor and thermocouple was used for detection of humidity and airway temperature in the nasal vestibule, at the nasal valve area and in the nasopharynx at the end of inspiration. Measurements were done before and after topical application of xylometazoline. RESULTS: Temperature and relative humidity increase from the anterior parts of the nose to the nasopharynx at the end of inspiration. The temperature and humidity values after nasal decongestion are not significantly different from the values before application of xylometazoline. As a tendency temperature and humidity values after nasal decongestion are even somewhat higher at the nasal valve area compared to the values before application of xylometazoline. CONCLUSIONS: Widening of the nasal airways by mucosal decongestion did not lead to a significant change of the nasal temperature and humidity profile 20-30 min after application of xylometazoline. The use of xylometazoline seems not to influence humidifying and heating of inspired air within a short period after onset of the maximal decongestive effect of xylometazoline.     

A comparison of anterior and radical trimming of the inferior nasal turbinates and the effects on nasal resistance to airflow

A study of 18 patients with chronic rhinitis who underwent anterior or radical trimming of the inferior turbinates is presented. Radical trimming produced a significant decrease in both total nasal resistance to airflow and subjective nasal obstruction (P less than 0.005). Anterior trimming produced a significant decrease in total nasal resistance to airflow (P less than 0.05), but had no significant effect on subjective nasal obstruction. These results suggest that the main site of nasal resistance in patients with chronic rhinitis is the same as in the normal nose. On the basis of this study, adoption of anterior trimming in place of radical trimming of the inferior turbinates cannot be recommended.     

The nasal distribution of metered dose inhalers

The intranasal distribution of aerosol from a metered dose inhaler has been assessed using a radiotracer technique. Inhalers were prepared by adding 99Tcm-labelled Teflon particles (simulating the drug particles) to chlorofluorocarbon propellants, and scans of the head (and chest) taken with a gamma camera. Ten healthy subjects (age range 19-29 years) each performed two radioaerosol studies with the inhaler held in two different ways: either in a single position (vial pointing upwards) or in two positions (vial pointing upwards and then tilted by 30 degrees in the sagittal plane). The vast majority of the dose (82.5 +/- 2.8 (mean +/- SEM) per cent and 80.7 +/- 3.1 per cent respectively for one-position and two-position studies) was deposited on a single localized area in the anterior one-third of the nose, the initial distribution pattern being identical for each study. No significant radioaerosol was detected in the lungs. Only 18.0 +/- 4.7 per cent and 15.4 +/- 4.1 per cent of the dose had been removed by mucociliary action after 30 minutes, and it is probable that the remainder had not penetrated initially beyond the vestibule. Since the deposition pattern was highly localized and more than half the dose probably failed to reach the turbinates it is possible that the overall effect of nasal MDIs is suboptimal for the treatment of generalized nasal disorders.