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NASAL AIRWAY MEASUREMENT
27. NASAL AIRWAY MEASUREMENT
Nasal obstruction is one of the most common complaints presenting to ear, nose and throat (ENT)
surgeons, but treatment is usually initiated without any objective measurement of nasal airow.
Establishing a normal range of nasal patency is confounded by several factors related to nasal
physiology:
Direct exposure to the external environment where the nose acts as an air conditioner
•
to protect the lungs from infection and variations in environmental conditions.
e nose is subject to spontaneous changes in nasal patency associated with the ‘nasal
•
cycle’.
‘Anatomical’ nasal patency is the nasal patency measured aer decongestion of the nasal
blood vessels by application of a topical nasal decongestant or by standard exercise.
Anatomical nasal patency is a useful measure for the nasal surgeon, as it is determined solely
by the hard tissues of the nose such as cartilage and bone.
Rhinomanometry provides a functional measure of nasal patency, whereas acoustic rhinometry provides an anatomical measurement of cross-sectional area or nasal volume. Nasal
peak inspiratory ow can also provide useful measures of nasal patency.
Rhinomanometry
Rhinomanometry provides a measure of nasal resistance to airow, which is calculated from
two measurements: nasal airow and trans-nasal pressure.
Active rhinomanometry involves the generation of nasal airow and pressure with normal
breathing.
Passive rhinomanometry involves the generation of nasal airow and pressure from an
external source, such as a fan or pump, to drive air through the nose. Passive rhinomanometry involves the direction of an external ow of air through the nose and out of
the mouth.
Acoustic Rhinometry
Acoustic rhinometry consists of generating an acoustic pulse from a spark source or speaker,
and the sound pulse is transmitted along a tube into the nose. e sound pulse is reected
back from inside the nose according to changes in the local acoustic impedance which are
related to the cross-sectional area of the nasal cavity. e reected sound is detected by a
microphone, which transmits the sound signal to an amplier and computer system for processing into an area distance graph.
Acoustic rhinometry cross-sectional measurements correlate very well with computed
tomography (CT) scans, and nasal airway resistance measured by rhinomanometry, but the
accuracy is unreliable in the posterior part of the nose, especially when the nasal passage is
congested.
Peak Nasal Flow
e peak inspiratory or expiratory airow through the nose associated with maximal respiratory eort can be used as a measure of nasal conductance. e measurement is eort
dependent and is less sensitive than rhinomanometry or acoustic rhinometry in determining small changes in conductance. Expiratory measurements are likely to cause expulsion
of nasal secretions into the measuring instrument, and inspiratory ow measurements are
likely to cause nasal alar collapse and ow limitation. Simple peak ow instruments are used
to measure peak nasal inspiratory ow (PNIF) with the use of a face mask.
148 Rhinology and Facial Plastic Surgery
NASAL AIRWAY MEASUREMENT
Subjective
Sensation inuenced b
mood, air temperature
receptors and menthol
Objec
Nasal resistance mainly
inuenced by nasal valve
region
Congestion of
ongestion of ostia
of paranasal sinuses
Subjective Measurements
Nasal sensations are important in the study of nasal disease, as it is the patient’s perception
of nasal sensations (symptoms) that is of primary concern to the patient. Objective measures
of nasal function such as rhinomanometry and acoustic rhinometry do not always correlate
with the patient’s own assessment of the sensation of nasal airow. e reason for the lack
of correlation between the perception of nasal airow and nasal resistance may be because
the resistance to nasal airow is primarily determined by the nasal valve area, whereas the
symptoms of nasal obstruction may be inuenced by other areas of the nose as well as the
nasal valve area, as illustrated in F igure 27.2.
Congestion in the ethmoid region may cause a sensation of pressure and obstruction that has
no relationship to nasal airway resistance. Similarly, pressure changes in the middle ear and
paranasal sinuses may cause a sensation of nasal obstruction and pressure without any eect
on nasal airway resistance. Another factor that may explain the lack of correlation between
objective and subjective measures of nasal obstruction is that the nasal airway consists of two
parallel airways and the total nasal conductance may be near normal even if one nasal passage is completely obstructed. Objective and subjective unilateral measures of nasal obstruction have been shown to have a much better correlation than combined bilateral measures
for the two nasal passages indicating that the nose should be assessed as two separate organs
rather than a single combined airway.
Studies on the eects of menthol on nasal sensation of airow clearly demonstrate the lack
of any correlation between objective measures of nasal airway resistance and subjective
measures of airow. In patients with nasal obstruction associated with the common cold,
ingestion of a menthol lozenge causes a great improvement in the sensation of nasal airow
without any change in nasal airway resistance
Figure 27.2 Factors that inuence the patient’s perception of nasal airow and relationship
to objective and subjective measures of nasal obstruction. Objective measurements are mainly
determined by the cross-sectional area of the nasal valve region at the tip of the inferior turbinate. Subjective measurements are inuenced by the stimulation of cold receptors in the airway.
Congestion in the ethmoid area, ostia of paranasal sinuses and Eustachian tube cause a perception
of congestion and pressure that is unrelated to any change in nasal airway resistance as these areas
are distant from the nasal valve.
tive
y
, cold
ethmoid area
C
Congestion of
Eustachian tube
Rhinology and Facial Plastic Surgery 149
OUTPATIENT ASSESSMENT
KEY POINTS
• Objective and subjective measurements of nasal conductance do not correlate well for
bilateral measures but do correlate for unilateral measures.
• The spontaneous changes in unilateral nasal resistance associated with the nasal cycle
cause great variability in physiological nasal airow.
• Subjective measurements are important as they relate directly to symptoms.
• Decongestion of the nose eliminates the effects of the nasal cycle and allows the
measurement of anatomical nasal airow.
• Acoustic rhinometry provides anatomical rather than functional measurements of the
nasal airway.
• Rhinomanometry is generally accepted as the ‘gold standard’ for measurement of
nasal airway resistance.
Acoustic rhinometry and rhinomanometry in their current forms have not found a routine
place in the day-to-day assessment of patients in the rhinology clinic.
28. OUTPATIENT ASSESSMENT
is chapter covers history taking, clinical examination, nasendoscopy and patient-reported
outcome measures (PROMs).
History Taking
is is best initiated by characterising the index nasal symptoms such as obstruction, rhinorrhoea (anterior or posterior), olfactory dysfunction and pain. Secondary symptoms such
as sneezing, itch, epiphora, taste disturbance and dry mouth should also be elicited, and
characteristics such as duration, periodicity, nocturnal variation, seasonal eects, laterality,
association with trauma or prior surgery and any alleviating or provoking factors may help
to further characterise the problem.
Understanding nasal symptoms and their associations not only helps diagnostically, but
also creates a picture of the quality-of-life (QOL) impairment suered, and recognition of
psychological aspects (prior injury, pain, sleep) that commonly exacerbate perceived nasal
symptoms.
e character of the nasal mucosa, nasal discharge or crusting gives clues to infective (mucopurulent), chronic (rhinosinusitis) or inammatory origins. Increasing unilateral obstruction associated with epistaxis (oen minor) or facial pain and swelling suggests neoplasia
and indicates the need for urgent assessment.
Specic triggers may be recognised, or at least known to the patient in some other form, so
do inquire about allergies, hay fever, exposure to animal dander, asthma (or more general
respiratory symptoms), and nonsteroidal anti-inammatory drug (NSAID) hypersensitivity
(in Samter’s triad: nasal polyposis, asthma and NSAID intolerance).
A history of nasal trauma or surgery (e.g. rhinoplasty, cle palate repair) may suggest
obstruction secondary to septal fracture, dislocation, or failure of support to the internal
nasal valve.
Many systemic diseases have nasal manifestations. Granulomatous polyangiitis (GPA) is
associated with diuse inammation, crusting or necrosis of t he nasal mucosa and structure.
150 Rhinology and Facial Plastic Surgery
OUTPATIENT ASSESSMENT
Table 28.1 Selected examples of the more prevalent and well-validated patient-reported
outcome measures that may be useful in a rhinology clinic
Instrument Validation
The Short Form-36 (SF-36), EQ-5D Generic quality of life
Sinonasal Outcomes Test (SNOT-22) Chronic rhinosinusitis
Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) Allergic rhinitis, non-allergic rhinitis
Nasal Obstruction Septoplasty Effectiveness (NOSE) Septoplasty, functional septorhinoplasty,
nasal valve surgery
Rhinoplasty Outcomes Evaluation (ROE) Rhinoplasty
Sarcoidosis, eosinophilic GPA (EGPA), Behçet’s syndrome, cocaine abuse and excessive nose
picking may have a similar presentation. Cocaine abuse and habitual nose picking can cause
septal crusting, septal perforation and saddle deformity, all of which have the potential to
cause nasal impairments. Immunodeciencies, ciliary defects and smoking are commonly
associated with nasal pathology and symptoms.
Many drugs have common nasal side eects, especially those w ith anti-muscarinic eects, such
as medications for prostatism, epilepsy, hypertension, sedatives, depression, psychiatric illness
and Parkinson’s disease. Nasal obstruction (with vasomotor rhinitis) is a side eect of many
of these drugs as well as oral contraceptives and medicines used to treat erectile dysfunction.
Overuse of sympathomimetic decongestant nasal sprays can cause rhinitis medicamentosa.
Patient-Reported Outcome Measures (PROMs)
Sinonasal disease has a signicant and varied impact on patients’ QOL, which doctors should
measure to evaluate the success of their medical or surgical interventions. is process is
simplied by the routine use of PROMs, such as questionnaires that capture and quantify
the bulk of symptomatology and disease impact (Table 28.1). Unfortunately, ‘simpler’ outcomes like overall patient satisfaction are inuenced by many variables, such as the availability and convenience of health care, the ‘bedside manner’ of the doctor, aability of the
extended team and perceived cleanliness of the hospital that can bias the evaluation. QOL
questionnaires require the patient to rate the impact of their disease across several specied
‘domains’ or areas of interest; reducing this bias. Overall scores can be used to follow patients
with chronic disease, or to compare symptoms/scores before and aer an intervention at an
individual patient level.
Examination
Nasal Structure/Aesthetics
Examination of the external nose should begin with careful inspection and palpation of
the nasal bones, alar cartilages and septum, noting skin type, scars, so tissue envelope
thickness, integrity of the upper and lower lateral cartilages, nasal tip support and conguration, nares shape and integrity of the external and internal nasal valves. ese factors can elicit more subtle causes of dysfunction such as nasal valve insuciency. Saddle
deformity, septal deviation and deciencies of the lateral cartilages are relevant to both
cosmesis and nasal patency.
Functional Assessment/Anterior Rhinoscopy
Nasal patency is assessed through anterior rhinoscopy, which is the examination of the
anterior nose using a udicum’s speculum and headlight illumination. e patient is
asked to breathe normally through his or her nose, noting any diculty or noise. A thumb
is used to gently occlude each nostril in turn and assess unilateral patency, remembering
that many normal subjects are unable to breathe comfortably through a single nasal airway
Any septal deformity should be noted, and the degree of alar margin (external nasal valve)
collapse is observed on normal and on forced inspiration, again noting that some dynamic
Rhinology and Facial Plastic Surgery 151
OUTPATIENT ASSESSMENT
Figure 28.1 Cottle’s areas of the nasal septum and the internal nasal valve region (dotted line).
Deviations of the nasal septum can be classied by location and by severity. 1. Caudal septum.
2. Internal nasal valve. 3. High mid septum. 4. Low mid septum. 5. Posterior septum. Severity is
graded: 0, no deviation; 1, minimal; 2, less than 50% lateralized; 3, more than 50% lateralised and
4, fully lateralised (mucosal contact with lateral wall). (This gure is available free of charge, with
certain provisos; from www.surgtech.net)
narrowing is normal (Figure 28.1). e inferior turbinates should be evaluated for congestion, mucosal thickening and the presence of exudate.
Nasendoscopy
Nasendoscopy is best performed aer the use of a decongestant (oen combined with a local
anaesthetic). e appearances of the nasal mucosa and turbinates should be noted before
and aer application since decongestion will mask some pathological signs (erythema,
congestion).
Endoscopic evaluation using a three-pass technique (Table 28.2). Narrow diameter
(2.5–3.0 mm) angled endoscopes (30–45°) confer greater opportunity to look laterally into
each nasal meatus. Examples of the endoscopic anatomy, and common pathologic ndings,
are provided in Figure 28.2.
Endoscopic Nasal Biopsy
Any nasal masses should be evaluated for colour, consistency, vascularity and origin.
In the absence of unusual appearance, bilateral nasal polyps may not need be biopsied.
Table 28.2 Nasendoscopy technique
First pass: front to back
The endoscope is passed along the nasal oor, visualising the septum and inferior turbinate.
In the post-nasal space, the Eustachian cushion and orice, and the fossa of Rosenmüller are
seen. Any mucopurulent post-nasal drainage can be noted. On withdrawal, the inferior meatus
and, where possible, Hasner’s valve are inspected.
Second pass: medial to the middle turbinate
Passing the endoscope medial to the middle turbinate, the sphenoethmoidal recess, superior
turbinate, and slit-like opening of the sphenoid ostium are often visualised.
The olfactory cleft is seen more anteriorly. Head repositioning may be required, and an angled
endoscope is recommended.
Third pass: the middle meatus
Retracting, rotating the view laterally, and rolling the endoscope into the middle meatus will
medialize the turbinate to expose any middle meatal mucopurulence (sometimes subtle),
accessory ostia or other pathology. The hiatus semilunaris bounded by the uncinate and ethmoid
bulla can be seen, as well as the membranous fontanelles and any associated accessory ostia. An
angled endoscope is recommended.
152 Rhinology and Facial Plastic Surgery
IMAGING IN RHINOLOGY
Figure 28.2 Examples of the endoscopic anatomy, and common pathologic ndings. (A)
Endoscopic view of the right internal nasal valve. (B) Endoscopic view of right middle meatus. (C)
Endoscopic view of the right side of the nasopharynx. (D) Left inferior turbinate hypertrophy in
allergic rhinitis. (E) Right nasal polyp. (F) Severe crusting of the left inferior turbinate and septum in
granulomatous polyangiitis (GPA).
Sinonasal tumours and unusual polyps should be imaged prior to biopsy. In-oce biopsy
can be considered but the possibility of a vascular nature (e.g. juvenile angiobroma) or
meningo(encephalo)coele must be excluded. In such cases, a computed tomography with
contrast or magnetic resonance imaging scan may prevent signicant complications.
KEY POINTS
• Well-developed skills in clinical history and examination are key to correct diagnosis
and management.
• Nasal endoscopy is a necessary investigation for all patients referred for a specialist
rhinologic assessment.PROMs have become an integral component of patient assessment.
29. IMAGING IN RHINOLOGY
Imaging Modalities: Technical Aspects
Computed Tomography (CT)
e mainstay of routine sinus imaging is multidetector row computed tomography (MDCT).
In most instances, intravenous contrast administration is not required.
Advantages
Excellent denition of osseous anatomy and anatomic variants
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Multiplanar reformatting
•
Depicts calcications and high-density secretions
•
Guidance of stereotactic surgery
•
Rhinology and Facial Plastic Surgery 153
IMAGING IN RHINOLOGY
Disadvantages
Ionising radiation. Routine MDCT paranasal sinuses results in a radiation doses of
•
approximately 0.3–0.6mSV (corresponding to 1–2 months of background radiation)
although low-dose approaches and systems may now achieve <0.1 m SV.
Inability to reliably distinguish between inamed mucosa and other tissue types.
•
Magnetic Resonance Imaging (MRI)
Magnetic resonance imaging (MRI) is invaluable in the evaluation of sinonasal neoplasms,
complex infections and rarer inammatory disorders.
Advantages
Excellent so tissue/uid contrast resolution aids dierentiation of inammatory from
neoplastic conditions, cerebrospinal uid (CSF) from secretions and helps detection of
perineural spread and intracranial extension.
Disadvantages
Higher cost (2–4 time) and reduced availability.
•
Unsuitable for claustrophobic patients and those with incompatible metallic implants.
•
Long scanning times.
•
Cone Beam CT (CBCT)
Cone beam CT (CBCT) has well-established uses in dental imaging, but its use can be
extended to image other anatomical regions including the paranasal sinuses.
Advantages
Low cost and compact (can be performed in clinics or intraoperatively).
•
Potentially reduced radiation dose. ere is a 40–80% reduction compared with rou-
•
tine MDCT paranasal sinuses, although now low-dose MDCT may achieve doses
comparable to CBCT.
Excellent depiction of osseous detail.
•
Disadvantages
Longer scanning time (motion artefact)
•
Poor denition of so tissues
•
Limited eld of view
•
18F-uorodeoxyglucose (FDG) Positron-Emission Tomography/Computed
Tomography (PET-CT)
e 18F-FDG PET-CT provides functional information, based on metabolic activity, in
addition to anatomical detail, but it lacks specicity (uptake can be seen in both malignant
and inammatory conditions). Nevertheless, it can be useful in staging (distant disease in
particular) and in detecting disease recurrence (in combination with other modalities).
Imaging: Applications
Depicting Anatomy
Sinonasal anatomy is subject to tremendous variation and can be well delineated on CT
(Figure 29.1). In particular, the components of the ostiomeatal complexes (Figure 1A) and
frontal sinus drainage pathways (Figure 1B), along with clinically relevant anatomical variants, can be depicted.
Notable variants in the nasal cavities include septal deviation and concha bullosa. In the
maxillary antra they include infra-orbital (Haller) cells, which can increase the risk of
orbital injury.
154 Rhinology and Facial Plastic Surgery
IMAGING IN RHINOLOGY
Figure 29.1 Imaging anatomy. CT images depicting anatomical details. (A) Components of the
ostiomeatal complex on a coronal image (red dashed arrow, maxillary sinus ostium; yellow arrow,
ethmoid bulla; dashed line, ethmoid infundibulum; star, middle meatus; dotted line, frontal recess).
(B) Frontal sinus drainage pathway on a sagittal image (dotted line, frontal ostium; red dashed
arrow, frontonasal beak; small yellow arrow, agger nasi cell; large yellow arrow, ethmoid bulla).
(C) Variant frontal sinus drainage pathway with a supra agger cell (large yellow arrow). (D) Coronal
image demonstrating bilateral Onodi (sphenoethmoidal) cells (stars) and their close relationship
with the optic nerve canals (arrows). (E) Coronal image of the anterior skull base demonstrating
asymmetry in the heights of the fovea ethmoidalis (dashed lines) and cribriform plates (dotted
lines); note the left anterior ethmoidal artery ostium (red arrow).
In the frontal sinus drainage pathway variants include:
Agger nasi, supra agger (Figure 1C) and supra agger frontal cells
•
Bulla ethmoidalis, suprabulla and suprabulla frontal cells
•
Other frontoethmoidal cells (e.g. supraorbital and frontal septal cells)
•
In the sphenoethmoidal region, Onodi (sphenoethmoidal) cells (Figure 1D), projecting posteriorly and lateral/above the sphenoid sinus, can put the optic nerves at risk (Keros classication). Variation in the heights of the structures of the anterior skull base (Figure 1E) can
increase the risk of CSF leakage, and variation in the position and dehiscence of the canals
for the carotid and ethmoidal arteries can risk inadvertent vascular injury.
Sinus Inammatory Disease
Incidental
Minor mucosal thickening and retention cysts are common ndings in asymptomatic
•
patients imaged for other reasons.
Incidental mucosal thickening up to 3 mm is usually of no clinical signicance and
•
that in the ethmoid sinuses 1–2 mm of mucosal thickening (related to the nasal cycle)
occurs in most asymptomatic patients.
Retention cysts are common ndings and are recognised as dome shaped, smoothly
•
marginated opacities on CT with high (uid) signal on T2-weighted MRI.
Rhinology and Facial Plastic Surgery 155
IMAGING IN RHINOLOGY
Figure 29.2 Depicting pathology. Examples of the utility of imaging in the depiction of a range
of pathologies. (A) Coronal T2W image demonstrating hyperintense inammatory thickening of
the paranasal sinus mucosa; the signal dropout within the left frontal sinus corresponds with desiccated secretions (star). (B) Axial computed tomography (CT) image demonstrating the utility of CT
in depicting high-density fungal material within the left ethmoid labyrinth and sphenoid hemi-sinus.
(C) Coronal T1W + contrast image of a patient with invasive fungal sinusitis demonstrating intracranial extension (yellow arrow) and turbinate necrosis (red arrow). (D) Coronal CT demonstrating a
dentigerous cyst, expanding into the left maxillary antrum (yellow arrows). (E) Coronal CT revealing
calcied matrix (yellow arrow) within a chondrosarcoma of the nasal septum. (F) Axial fat-saturated
T1W + contrast image revealing the ‘cerebriform’ enhancement pattern (yellow arrow) of a right
maxillary antral inverted papilloma. (G) Coronal T1W + contrast sequence demonstrating an enhancing mass within the left nasal cavity with ow voids, compatible with a juvenile angiobroma. (H)
Axial T1 + contrast sequence demonstrating perineural spread of tumour along the maxillary division of the left trigeminal nerve (yellow arrow). (I), Coronal T1W + contrast at-saturated sequence
demonstrating thin linear dural enhancement (yellow arrows) representing reactive inammation
interrupted by nodular tumour tissue (red arrow), in keeping with intracranial invasion by alveolar rhabdomyosarcoma. (J) Coronal CT demonstrating expansile ground-glass density within the
medial and right lateral aspects of the sphenoid, in keeping with brous dysplasia. (K) Sagittal T1W
sequence from the same case, where the brous dysplasia manifests as low signal (yellow arrow)
(L) Coronal CT demonstrating an osseous defect (yellow arrow) within the sphenoid adjacent to the
right foramen rotundum. (M) An accompanying coronal T2W sequence from the same case demonstrates the intermediate signal brain tissue (yellow arrow) extending through the sphenoid defect,
surrounded by high signal cerebrospinal uid, compatible with an encephalocele.
156 Rhinology and Facial Plastic Surgery
IMAGING IN RHINOLOGY
Rhinosinusitis
e diagnosis of rhinosinusitis is largely a clinical and endoscopic with CT performed
•
to corroborate the diagnosis.
CT has a role in dening the bony anatomy and providing a surgical roadmap, in
•
identifying signicant anatomic variants and in demonstrating patterns of disease
and sinonasal obstruction.
Disease extent can be quantied using one of several staging systems, of which the
•
Lund-Mackay system is perhaps the best known.
CT acquisition is also needed for complex surgical approaches requiring a surgical
•
navigation system.
CT or MRI with contrast is required to assess intraorbital or intracranial complica-
•
tions of rhinosinusitis.
Fungal Sinus Disease
Fungal sinus disease is classied into invasive and non-invasive forms as follows.
Invasive
Acute invasive fungal sinusitis (AIFS) usually occurs in immunocompromised patients
•
and is a rapidly progressive, potentially fatal condition.
In the appropriate clinical setting, unilateral, nasoethmoid mucosal inammatory
•
changes should raise suspicion; however, bony erosion and extrasinus so tissue
extension is more specic.
Chronic (granulomatous) invasive fungal sinusitis (CIFS) aects immunocompetent
•
or mildly immunocompromised patients.
Non-Invasive
Allergic fungal rhinosinusitis (AFRS) typically eects immunocompetent patients
•
with a history of atopy. CT shows unilateral or bilateral opacication of multiple
sinuses, with sinus expansion and bony erosion.
Intrasinus high attenuation is typical in AFRS (due to heavy metals, calcium and
•
inspissated secretions). Although this may also be seen in chronic rhinosinusitis, it
will be associated with wall thickening and sclerosis.
Fungal ball/mycetoma tends to eect older immunocompetent individuals. Usually a
•
single sinus is involved in fungal ball, and on CT, a hyper-attenuating so tissue mass
is seen, oen containing punctate or nodular calcications.
e sinus contents are typically low to signal void on T2-weighted MRI in both forms
•
of non-invasive fungal sinus disease.
Midline Destructive Infectious and Non-Infectious Sinonasal Disease
e dierential diagnosis for septal perforation and midline sinonasal destruction
•
includes granulomatous disorders (e.g. sarcoid, granulomatous polyangiitis [GPA],
neoplasia (e.g. natural killer [NK]-cell/T-cell lymphoma), infection (e.g. syphilis,
tuberculosis) and cocaine misuse.
GPA (Wegener’s granulomatosis) may be marked neo-osteogenesis and have an ‘auto-
•
rhinectomy’ appearance on CT.
Sarcoidosis is suggested by the nding of so tissue nodules on the septum or turbi-
•
nates. Palatal erosion is more suggestive of cocaine misuse, although there is overlap
in appearances with GPA, particularly when a cocaine-induced vasculitis results from
the mixing agent levamisole.
Rhinology and Facial Plastic Surgery 157
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