Nasal gel and olfactory cleft

OBJECTIVE: To evaluate whether a nasal gel, administrated using a radial-hole inhaler, reaches the olfactory cleft and if a different administration method influences distribution. MATERIAL AND METHOD: Sixteen healthy volunteers underwent a nasal endoscopy at 1 and 7minutes after the administration of a intranasal gel, with a different method in each fossa. RESULTS: No dye deposition was identified at the olfactory cleft, middle turbinate or middle meatus. In all cases the gel was identified at the nasal vestibule. On the right side, the second most frequent dye identification area was the inferior turbinate, with a rate of 87% at the first minute and 75% at 7 minutes. It was followed by the septum (75 and 62%) and the inferior meatus (6.2 and 12.5%). On the left side, the second most frequent stained area was the septum (18.7 and 13.5%), followed by the inferior meatus (6.5 and 65%). No inferior turbinate staining was found in the left side. There was a significant difference in the deposition rate at the septum (P<.01) and inferior turbinate (P<.001), when both administration methods were compared. CONCLUSIONS: No nasal gel, administrated using a radial-hole inhaler, was found at the olfactory cleft, middle turbinate or middle meatus. Gel distribution was located at the anterior and inferior portion of the nose, independent of the administration method used. Significantly different gel distribution rates were found at the septum and inferior turbinate when the 2 administration methods were compared.     

The effect of inferior turbinate hypertrophy on nasal spray distribution to the middle meatus

The distribution of topical nasal sprays is suboptimal, the main obstruction to adequate delivery in normal volunteers being the nasal valve. We aimed to test the hypothesis that, in patients with rhino-sinusitis, hypertrophy of the inferior turbinate also limits the distribution of administered drug to the middle meatus. We modelled the effect of inferior turbinate hypertrophy and reduction by effecting congestion (by ipsilateral isometric exercise) and decongestion (topical oxymetazoline) in normal volunteers. The method chosen to estimate drug delivery to the middle meatus used endoscopic photography after the administration of dyed aqueous spray. A randomized cross-over study design was used and 20 nasal cavities were studied. The congestion/decongestion manoeuvres significantly altered nasal airflow, as measured by peak inspiratory nasal flow (P < 0.001). Congestion diminished significantly drug delivery to the middle meatus, as compared with decongestion (P = 0.026). This may support a clinical role for inferior turbinate reduction to improve the efficacy of topical nasal therapy, as well as improving nasal airflow.     

下鼻道后穹窿鼻出血的临床特点及综合治疗

目的：总结下鼻道后穹窿鼻出血的临床特点并分析其综合治疗措施。方法：212例鼻出血住院患者中23例（10．8％）确诊为下鼻道后穹窿鼻出血,1例在全身麻醉下行鼻内镜鼻腔探查＋电凝止血术,其余22例在局部麻醉下行鼻腔探查＋电凝止血术。所有患者在术中排除了嗅裂、蝶筛隐窝及中鼻道出血,术中行下鼻甲骨折内移位后见下鼻道后穹窿活动性出血,立即给予双极电凝止血。术后电凝区域及鼻黏膜糜烂处填塞少量纳吸棉组织。结果：所有患者术中均发现明确的出血点并成功止血;术后1周内未再出血。随访6～12个月患侧鼻腔无再发鼻出血,无鼻腔粘连。结论：难治性鼻出血如排除嗅裂、蝶筛隐窝及中鼻道出血,则应考虑下鼻道后穹窿出血的可能。术中将下鼻甲往内侧骨折移位彻底暴露下鼻道后穹窿并仔细探查是发现和治疗下鼻道后穹窿鼻出血的关键。     

Responses of resistance and capacitance vessels in human nasal mucosa to beta-receptor agonists

To investigate the responses of nasal vessels, divided into resistance and capacitance vessels, to a beta-receptor agonist in human, mucosal blood flow of the inferior turbinate and nasal airway resistance were measured when 1.5 mg terbutaline was applied topically. Mucosal blood flow was measured by the hydrogen clearance method just beneath the site where terbutaline in physiological saline (0.02 ml) was applied on an extremely localized area of the nasal mucosa. Nasal airway resistance of the ipsilateral and contralateral nasal cavities was measured separately by anterior rhinomanometry when terbutaline in normal saline (0.1 ml) was sprayed in the unilateral nasal cavity. Topical application of terbutaline elicited neither a significant increase of mucosal blood flow of the inferior turbinate nor an increase of nasal airway resistance. beta-Receptors seem not to be as densely distributed both in the resistance vessels and in the capacitance vessels as to cause vasodilatation by their activation in the nasal mucosa.     

烟雾示踪剂在显示鼻腔呼气相气流变化中的研究

目的 研究鼻腔呼气相气流曲线及不同解剖部位气流的变化。方法 对10例鼻内镜检查鼻腔黏膜及结构正常的吸烟志愿者,采用吸烟的方式将电子烟的烟雾吸入,储存于口咽及以下气道内,以1、1.5、2s一个呼气周期均匀呼气,观察鼻腔气流变化。 结果 咽部气流在鼻咽顶部气流由垂直直线上升变为曲线前移,大部分以层流方式进入总鼻道,少量气体由下鼻甲后端进入下鼻道以湍流方式运动,极少量气体以层流的方式进入嗅裂及中鼻道, 鼻阈以湍流为主。 结论 鼻咽顶与鼻腔交界的坎阻挡气流导致呼出气流改变运动方向,使气流压低主要经总鼻道底部流出,极少经上鼻道流出,下鼻道气流以湍流为主。呼出气流对中鼻道及嗅裂影响较小。     

Why we should avoid using inferior turbinate tissue as control to Nasal Polyposis studies

Conclusion: The authors are aware that inferior turbinate mucosa presents different properties from middle turbinate mucosa and any data generated using inferior turbinate as control in Nasal Polyposis (NP) should be analysed very carefully. Objective: This study aims to compare the mechanical properties of inferior turbinate mucosa vs middle turbinate mucosa. Materials and methods: The interstitial hydrostatic pressure behaviour was compared during a saline solution infusion between healthy nasal mucosa from inferior turbinate with middle turbinate (four patients). Results: A significant difference, p?=?0.02, was found in the response of interstitial hydrostatic pressure during the saline injection when the inferior turbinate vs middle turbinate was compared.     

Expression patterns of galectin-1 and galectin-3 in nasal polyps and middle and inferior turbinates in relation to growth regulation and immunosuppression

BACKGROUND: The term nasal polyposis describes benign growth processes in the nasal and sinus mucosa, which are mainly located in the middle meatus and never in the inferior meatus. As a step to define the biochemical determinants relevant for growth regulation, we focused on endogenous lectins known for anti-apoptotic (galectin-3) and immunomodulatory (galectin-1) activities. DESIGN: Using computer-assisted microscopy, we performed an immunohistochemical investigation defining the quantitative parameters of expression of galectin-1 and galectin-3 in 10 nasal polyps, 10 middle turbinates, and 10 inferior turbinates, all of which were obtained from surgical resection. RESULTS: Our data show that galectin-3 expression is markedly (P<.001) higher in nasal polyps than in turbinates. No relation to the allergic status was discovered. Galectin-1 expression is higher in nasal polyps than in middle turbinates (P<.001) in nonallergic patients compared with allergic ones (in glandular epithelium, P =.009; in connective tissue, P =.006). The lowest galectin-1 expression was observed in the middle turbinate. CONCLUSIONS: These data are in line with a positive influence of galectin-3 on growth and an immunoregulatory role of galectin-1, mimicking an increased expression dependent on glucocorticoid.     

Diagnostic value of acoustic rhinometry: patients with allergic and vasomotor rhinitis compared with normal controls

By means of the acoustic reflection technique, termed acoustic rhinometry, cross-sectional areas along the whole upper airway can be measured by an acoustic click. This paper describes the normal values obtained from 134 probands. The normal curve shows the minimal cross-sectional area (I-notch) to be located at the isthmus nasi. The second narrowest segment of the nasal cavity is located at the head of the inferior concha (C-notch). In patients with turbinate hypertrophy due to allergic or vasomotor rhinitis the minimal cross-sectional area is sited at the head of the inferior turbinate. Furthermore, acoustic rhinometry allows exact measurements of size and location of the congested mucosa following challenge with allergens in patients affected with allergic rhinitis. After anterior turbinoplasty of patients with turbinate hypertrophy improved nasal breathing was associated with an enlargement of the cross-sectional areas at the head of the anterior inferior turbinate. Acoustic rhinometry not only enables to distinguish the various deviations of the nasal structures from normal (valve stenosis, septal deviation, turbinate hypertrophy, tumour masses) concerning their location and size, but also allows to demonstrate exactly the efficacy of rhinosurgical techniques.     

Infected inferior turbinate pneumatization

With the widespread utilization of endoscopic nasal surgery, the interest in nasal structures has increased. Inferior turbinate pneumatization is among the most rare causes of nasal obstruction. In the current literature, there are only ten reported cases of inferior turbinate pneumatization. A 52-year-old male patient presented with nasal obstruction, purulent nasal discharge, facial pain and headache. Anterior rhinoscopic examination showed bilateral middle and inferior turbinate hypertrophy and edema of the nasal mucosa. Computed tomography (CT) revealed bilateral frontal, anterior and posterior ethmoidal and maxillary sinusitis with bilateral concha media bullosa and right infected inferior turbinate pneumatization. In this report, infection of this rare anatomical abnormality is presented for the first time and documented with acoustic rhinometry, CT and peroperative photography.     

Nasal polyps in the olfactory cleft

Objectives: Nasal polyps frequently arise from the middle meatus in patients with nasal polyposis, but caution is required when polyps are seen protruding from the olfactory cleft. The purpose of this study was to evaluate a method to achieve effective and safe access to the olfactory cleft, and to determine the actual incidence of polyps arising from the olfactory cleft in patients with nasal polyposis. Patients: Eighty-four patients with bilateral or unilateral nasal polyps (n = 143) ranging in age from 16 to 72 years underwent endoscopic sinus surgery in the period from January 1994 to December 1996. Methods: To observe and gain access to the olfactory cleft, septoplasty combined with endoscopic sinus surgery was needed in patients with nasal polyposis. Results: The endoscopy during the combined septoplasty and endoscopic sinus surgery revealed that 36.4% (n = 52) of bilateral or unilateral nasal polyps (n = 143) arose from the olfactory cleft. Of 52 polyps of olfactory cleft origin, 45 (86.5%) arose from the superior turbinate and/or superior meatus, 32 (67.3%) from the medial side of the middle turbinate, 24 (46.2%) from the anterior face of the sphenoid sinus, and 17 (32.7%) from the mucosa of the nasal septum. Conclusions: These findings suggest that for surgeries of nasal polyposis an approach to the olfactory cleft as well as to the middle meatus is required.     

The septal mucosa decongests with naphazoline: a study of mucosal dynamics with sonography

A new method using B-mode and power-Doppler-mode (pD) sonography for the investigation of changes in nasal mucosa swelling and perfusion was developed. The effect of naphazoline (0.25 mg/mL) on the nasal mucosa was visualized and recorded in 1-minute intervals in 40 patients. The effect of normal saline solution was studied in 27 healthy volunteers. The decongestant and normal saline were applied by flooding the anterior nasal cavity. A computer program automatically quantified pD color information. Normal saline solution induced a 4.8 +/- 2.4% increase in perfusion (+/- SEM, n.s.) after 5 minutes. In the naphazoline group, changes in stereometry were measured on B-mode-sequences in 24 (60%) and perfusion changes in 24 participants (60%). In 16 of 40 patients (40%), both stereometry and perfusion were analyzed. After 10 minutes, the septum and inferior turbinate mucosa thickness were reduced by 17 +/- 2.8% (p < 0.001) and 25 +/- 2.6% (p < 0.001). Perfusion of the septum and inferior turbinate mucosa as visualized with pD-sonography decreased by 33 +/- 3.3% (p < 0.001). The reduction of bloodflow induced by naphazoline as visualized with pD-sonography is within the range of perfusion changes found in LDF and Xenon clearance studies. Decongestion of the septum mucosa demonstrates erectile properties of the septum, which may contribute to the increase of nasal patency after nasal decongestion.     

Parameters of nasal airway anatomy on magnetic resonance imaging correlate poorly with subjective symptoms of nasal patency.

Forty-four patients undergoing magnetic resonance imaging (MRI) head scans for non-nasal disease were asked to complete a questionnaire immediately after the scan. Subjective patency was scored for each nasal airway, patients were also asked about other nasal symptoms, hay fever, upper respiratory tract infections, medication and any history of nasal surgery or trauma. The following measurements from MRI scans were made: the cross-sectional area of the nasal airway at the anterior end of the middle turbinate, the horizontal width of the inferior turbinate and maximum septal mucosal thickness. In addition the presence of any septal deviation and the thickness or the mucosa of the paranasal sinuses was assessed. Correlation between subjective airway patency and the anatomical parameters studied was generally very weak. However, patients with sinus mucosal thickening on MRI scanning had significantly lower subjective patency scores (left P = 0.003, right P = 0.029) for both nasal airways. Assessment of the nasal airway on MRI correlates poorly with symptoms of nasal obstruction. However, patients with sinus mucosal thickening (> 5 mm) had significantly more symptoms of nasal obstruction on both sides.     

Parameters of nasal airway anatomy on magnetic resonance imaging correlate poorly with subjective symptoms of nasal patency

Forty-four patients undergoing magnetic resonance imaging (MRI) head scans for non-nasal disease were asked to complete a questionnaire immediately after the scan. Subjective patency was scored for each nasal airway, patients were also asked about other nasal symptoms, hay fever, upper respiratory tract infections, medication and any history of nasal surgery or trauma. The following measurements from MRI scans were made: the cross-sectional area of the nasal airway at the anterior end of the middle turbinate, the horizontal width of the inferior turbinate and maximum septal mucosal thickness. In addition the presence of any septal deviation and the thickness or the mucosa of the paranasal sinuses was assessed. Correlation between subjective airway patency and the anatomical parameters studied was generally very weak. However, patients with sinus mucosal thickening on MRI scanning had significantly lower subjective patency scores (left P= 0.003, right P= 0.029) for both nasal airways. Assessment of the nasal airway on MRI correlates poorly with symptoms of nasal obstruction. However, patients with sinus mucosal thickening ( > 5 mm) had significantly more symptoms of nasal obstruction on both sides.     

Epithelioid haemangioendothelioma arising in the nasal cavity

We report here the case of an epithelioid haemangioendothelioma (EHE) arising in the nasal cavity which is, to the best of our knowledge, the first ever described example in the world literature in that particular site. The patient is a 23-year-old male who presented with repeated episodes of epistaxis from the nasal cavity and with a 1.5 cm reddish, polypoid, smooth, spontaneously bleeding nodule in the right middle meatus. This lesion was histologically diagnosed as epithelioid haemangioendothelioma. Immunohistochemically the neoplasm displayed striking positivity for CD31, CD34 and vimentin. A surgical approach was performed by 'facial degloving', removing the right inferior turbinate, the anterior two-thirds of the middle turbinate and the medial wall of the ethmoid bone. After 12 months follow-up the patient is disease-free, without any local or distant recurrence.     

Simulated septal deviations

Effects of simulated septal deviations on nasal airflow resistance were measured in two healthy young adults by computer-assisted rhinomanometry. Within the decongested bony cavum, simulated deviations, 30 x 5 x 5 mm perpendicular to the maxillary crest, elevated resistance only slightly, but severely when the mucosa was not decongested. Caval resistance was unaffected by simulated maxillary crest spurs, 30 x 5 x 5 mm, in either vascular state. Between inferior turbinate and anterior naris, 5-mm septal protrusions from floor to roof increased resistance severely, but when shortened by one third, their resistive effects were markedly decreased, especially when positioned near the roof. The cavum can accommodate large septal spurs, deviations, and congested mucosa with little effect on airflow resistance. By contrast, resistance of the anterior nasal airway beyond the inferior turbinate bone is acutely responsive to changes in mucosal congestion and to septal protrusions, especially when they are situated near the floor of the nose.     

微波组织凝固法治疗变应性鼻炎的研究

目的 评价微波组织凝固治疗变应性鼻炎的效果。方法 我们用微波组织凝固法治疗我科在1998－2000年间收治的94例患者。利用微波产生的热能凝固中鼻甲、对应鼻中隔粘膜以及下鼻甲前端等筛前神经支配区域，阻断神经传导，治疗变应性鼻炎。对微波在不同条件下的治疗效果做了仔细的观察。结果 微波的治疗效果显著。结论 微波凝固法是一种治疗变应性鼻炎较好的辅助治疗方法。     

Dehiscence of the greater palatine nerve. A risk factor in inferior turbinectomy?

Inferior turbinectomy, often combined with septal surgery, is frequently performed in the surgical treatment of nasal obstruction. A patient with post-operative greater palatine anaesthesia occurring after this procedure prompted a study of the anatomy of the greater palatine nerve in the region of the inferior turbinate. Sixty-four lateral nasal walls were examined in cadavers. A dehiscence rate of 22% was noted, and in an additional 55% there was only a minimal bony covering to the nerve. Dehiscences occurred exclusively in the inferior meatus, anterior to the posterior bony end of the inferior turbinate. The narrow antero-posterior extent of the dehiscence, the hard dense lateral nasal wall bone and the lateral position of the nerve in the canal help to protect the nerve from surgical trauma during turbinate surgery.     

How can hyperreactive rhinopathy be modified surgically? II: Acoustic rhinometry and anterior turbinoplasty

By means of the acoustic reflection technique, or acoustic rhinometry, all cross-sectional areas of the upper airway can be measured by an acoustic signal. In this paper, the normal mean curve of 134 normal probands is determined. This normal curve shows the minimum cross-sectional area (I-notch) to be located at the Isthmus nasi. The second narrowest segment of the nasal cavity is located at the head of the inferior concha (C-notch). In patients with turbinate hypertrophy due to allergic or vasomotor rhinitis the minimum cross-sectional area is sited at the head of the inferior turbinate. Furthermore, acoustic rhinometry allows the exact size and location of the congested mucosa to be determined following provocation with allergens in patients with allergic rhinitis. Acoustic rhinometry could further demonstrate why nasal breathing in patients with turbinate hypertrophy improves in the long term after anterior turbinoplasty: in this operation the narrow cross-sectional areas at the head of the inferior turbinate are enlarged. Acoustic rhinometry not only allows the location and size of the various deviations of the nasal structures to be distinguished from normal (valve stenosis, septal deviation, turbinate hypertrophy, tumor masses), but also allows an exact demonstration of the efficacy of rhinosurgical techniques.     

Decreased nasal mucosal sensitivity in older subjects

BACKGROUND: The sensitivity of the human nasal cavity mucosa to touch is not well understood. The site of receptors and mode of action responsible for the sensation of the nasal airflow is a topic of controversy. Previous studies have suggested that the skin-lined nasal vestibule is more sensitive to airflow than the mucosa of the nasal cavity. A possible decline in nasal sensitivity to airflow in older subjects has not been studied. METHODS: The threshold of the mucosal sensitivity to jets of air was assessed in 76 subjects with healthy nasal cavities. A total of 141 nostrils were tested, 67 in younger patients and 74 in older patients. RESULTS: Statistically significant (p < 0.001) increases in thresholds were found for all points tested for older patients compared with the younger patients. In general, the more sensitive locations were in the nasal vestibule. The nasal cavity mucosa in the inferior meatus was slightly more sensitive than the middle meatus. CONCLUSION: We have measured the threshold to touch (air jet sensitivity) in nine places in each of 141 nasal cavities and determined that the variability and sensitivity of these measurements among people varies by age and the distance from the nostril. Older subjects were found to have a higher threshold for the sensation of airflow, and the nasal vestibule was found to be more sensitive than the rest of the nasal cavity mucosa with the inferior meatus slightly more sensitive then the middle meatus.