Добавил:
kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз: Предмет: Файл:

Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4473_Библиотеки_им_академика_М_И_Перельмана

.pdf
Скачиваний:
0
Добавлен:
30.08.2026
Размер:
42 Мб
Скачать
18 Sinus Pain
https://t.me/medicina_free
209
18.8 Causes Removed fromtheOrofacial Area
A history of neck injury can often be over­looked. The nerve supply to the upper neck and head overlaps in the upper spinal cord. Using rst principles, neck pain could be referred to the head. Alternatively, by sensitizing the spinal cord to incoming pain messages, neck pain could lower the pain threshold to other sensory messages being received from the face and head. After a whiplash injury to the neck, areas well away from the original injury site—from the head to the feet—are hypersensitive to normal sensory messages [3]. Migraine and TTH have been associated with food intolerances [53, 54]. The microbiota-gut-brain axis is receiving increasing attention, and the role of gut micro­biota in headache and facial pain is an emerging research area [55].
18.9 Psychological Well-Being
Anxiety and depression have signicant associa­tions with migraine, TTH, CRS and TMJ disor­ders [4, 56]. Systems review of the patient often reveals issues with poor short-term memory, pal­pitations, shortness of breath, irritable bowel symptoms, poor sleep quality, cold hands and feet as well as tingling of the hands in an ulnar nerve distribution. Depressive symptoms are important in deciding on treatment, and in pre­dicting treatment outcomes.
18.10 History Taking
Clinical diagnosis is largely dependent upon an accurate history. The initial differential diagnoses generated depend upon the clinician’s experi­ence, the patient’s age and gender, and the time course and site of the pain. The differential diag­nosis for headaches is extensive. Acute inam­matory causes are usually relatively obvious. Many patients may have symptoms reecting a sensitized nervous system, such as night sweats, unexplained itch, tinnitus, irritable bowel or blad-
der symptoms, heavy painful periods and altered sensation on combing their hair, as well as pain problems elsewhere in the body [3]. Poor sleep and sleep quality have been implicated in THH and TMJ dysfunction [44, 45]. The interactions are probably bidirectional [9].
Neuralgias are characterized by sudden, intense, lancinating, burning or stabbing pain lasting only from a few seconds to less than two minutes. This pain is often triggered by sensory or mechanical stimuli. Trigeminal neuralgia is typically seen in older females, unilateral and in the second and/or third divisions of the trigemi­nal nerve. Rarely, pontine tumours, the base of tongue tumours or multiple sclerosis need to be considered as a secondary cause. If a cough or sneezing makes the headache worse, a posterior fossa lesion may need to be considered.
18.11 Examination
After routine otolaryngological examination, pal­pation for muscle tenderness and excessive red­dening afterwards provides important physical information about the state of the CNS [8]. Many of these tender areas (or trigger points) corre­spond to traditional Chinese acupuncture points. Acupuncture is effective in the management of TTH [57, 58]. Sometimes there are subtle differ­ences in swelling and redness between the two sides of the face. The pectoralis minor muscle as it inserts into the coracoid process, the mid-point of the upper trapezius muscle (Fig.18.1), sterno­cleidomastoid (Fig. 18.2), masseter, temporalis and the suboccipital muscles are usually tender when examined using appropriate palpation tech­niques [59]. Jaw joint and associated muscle ten­derness together with limited and jerky jaw movements and clicking of the jaw joint may be found on clinical examination. The teeth can be examined for excessive wear (bruxism) or per­cussion tenderness. Alterations in facial sensa­tion are best detected by comparing moving light touch between the two sides of the face in the three divisions of the trigeminal nerve. Posture and cervical range movement should be assessed [9]. An examination of areas away from the head
210
https://t.me/medicina_free
Fig. 18.1 The tender area in the superior midpoint of the shoulder in the trapezius muscle is located if one palpates the superior aspect of the muscle between thumb and fore­nger [59]
J. Bartley
and neck often provides useful, additional infor­mation. People who are highly stressed tend to take small irregular breaths, largely in their upper chest. The low back, extensor forearm muscles and calves are often tender to palpation in pain patients as well [3]. Clinically, patients with uni­lateral facial pain are often tender down that side of the body. The muscle tenderness reects the underlying status of the nervous system.
18.12 Investigations
18.12.1 Radiology
Further urgent investigation and neurological evaluation are warranted for patients presenting with facial pain together with other signicant symptoms/signs (Table 18.3). Diagnostic imag­ing tests (e.g. plain X-rays, dental X-rays, MRI, axial CT scan) may help determine or exclude a cause of pain. The choice and timing of the test vary according to clinical suspicions and the nd­ings on physical examination.
Fig. 18.2 To examine the sternocleidomastoid muscle for tenderness, the muscle needs to be examined up and down its length in a gentle pincer-like grip between thumb and forenger [59]
18.12.2 Blood Investigations
Certain blood tests may be useful in evaluating patients presenting with facial pain [60]. Some females will have an iron deciency. Vegetarians and the elderly can have undiagnosed vitamin B12 deciencies. People living in countries with temperate climates, who have dark or brown skin,
Table 18.3 Red ags requiring further investigation
• The pain is new or has signicantly changed
• There is signicant associated nausea and vomiting
• The pain is unusually severe or persistent
• There is accompanying fever
• The pain is made worse by coughing, sneezing or a change in position
• There is a change in strength, coordination or senses
• There is drowsiness, difculty thinking or concentrating
• The headache is progressively getting worse
• The headache wakes the patient from sleep
• The headache occurs for the rst time in childhood or after age 50
18 Sinus Pain
https://t.me/medicina_free
211
often have a signicant vitamin D deciency. Thyroid function needs checking in TTH patients [44]. Granulomatosis with polyangiitis (Wegener’s) may need exclusion. In a person aged over 50 years with a rapidly developing headache, an erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) test is mandatory.
18.13 Management
Depending on the clinical diagnosis, a wide range of treatment options is available.
Many of these interventions are outside the conventional knowledge base of many otolaryn­gologists, but some knowledge is useful if an oto­laryngologist wished to provide comprehensive care and diagnosis. Psychological interventions such as cognitive behavioural therapy and relaxation work can be extremely useful for migraine, TTH and TMJ disorders [8, 44, 51]. Attention to diet, sleep patterns, posture and exercise can be important. Simple analgesics and non-steroidal anti-inammatory drugs are rec­ommended for the treatment of episodic facial pain. Drugs that are commonly useful are Gabapentin or low-dose Amitriptyline at night. Mirtazapine and Venlafaxine are second-choice drugs.
18.14 Conclusions
The otolaryngologist should be equipped to eval­uate, treat or appropriately refer patients present­ing with facial pain. Migraine, TTH, TMJ pain and sinus pain share a common underlying patho­physiology. Around the head and neck, other pathologies apart from sinus disease can also be related to facial pain. These factors also need consideration in the diagnostic work up. Because facial pain may involve a range of medical/surgi­cal subspecialties, a multidisciplinary approach is often needed.
References
1. De Corso E, Kar M, Cantone E, Lucidi D, Settimi S, Mele D, et al. Facial pain: sinus or not? Acta Otorhinolaryngol Ital. 2018;38:485–96.
2. Headache classication Committee of the International Headache Society. The international classication of headache disorders, 3rd edition. Cephalalgia. 2018;38:1–211.
3. Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152:S2–S15.
4. Jacobson S, Folstein M.Psychiatric perspectives on headache and facial pain. Otolaryngol Clin N Am. 2003;36:1187–200.
5. Woolf C.Evidence for a central component of post­injury pain hypersensitivity. Nature. 1983;306:686–8.
6. Diener HC, Holle D, Solbach K, Gaul C.Medication­overuse headache: risk factors, pathophysiology and management. Nat Rev Neurol. 2016;12:575–83.
7. Burstein R, Noseda R, Borsook D.Migraine: multi­ple processes, complex pathophysiology. J Neurosci. 2015;35:6619–29.
8. Bendtsen L, Fernandez-de-la-Penas C. The role of muscles in tension-type headache. Curr Pain Headache Rep. 2011;15:451–8.
9. Jay GW, Barkin RL. Primary headache disorders ­part 2: tension-type headache and medication overuse headache. Dis Mon. 2017;63:342–67.
10. Milligan ED, Watkins LR. Pathological and protec­tive roles of glia in chronic pain. Nat Rev Neurosci. 2009;10:23–36.
11. Guo W, Wang H, Watanabe M, Shimizu K, Zou S, LaGraize SC, etal. Glial-cytokine-neuronal interac­tions underlying the mechanisms of persistent pain. J Neurosci. 2007;27:6006–18.
12. Scholz J, Woolf CJ. The neuropathic pain triad: neurons, immune cells and glia. Nat Neurosci. 2007;10:1361–8.
13. Lee S, Zhao YQ, Ribeiro-da-Silva A, Zhang J.Distinctive response of CNS glial cells in oro-facial pain associated with injury, infection and inamma­tion. Mol Pain. 2010;6:79.
14. Hossain MZ, Unno S, Ando H, Masuda Y, Kitagawa J. Neuron-glia crosstalk and neuropathic pain: involvement in the modulation of motor activity in the orofacial region. Int J Mol Sci. 2017;18:2051.
15. Liu T, Gao Y-J, Ji R.Emerging role of toll-like recep­tors in the control of pain and itch. Neurosci Bull. 2012;28:131–44.
16. Shinoda M, Hayashi Y, Kubo A, Iwata K.Pathophysiological mechanisms of persistent oro­facial pain. J Oral Sci. 2020;62:131–5.
17. Durham PL. Diverse physiological roles of calci­tonin gene-related peptide in migraine pathology: modulation of neuronal-glial-immune cells to pro-
212
https://t.me/medicina_free
J. Bartley
mote peripheral and central sensitization. Curr Pain Headache Rep. 2016;20:48.
18. Jay GW, Barkin RL.Primary headache disorders: part I- migraine and the trigeminal autonomic cephalal­gias. Dis Mon. 2017;63:308–38.
19. Welch K.Contemporary concepts of migraine patho­genesis. Neurology. 2003;61(8 Suppl 4):S2–8.
20. Jones N.Midfacial pain segment pain: implications for rhinitis and sinusitis. Curr Allergy Asthma Rep. 2004;4:187–92.
21. Fumal A, Schoenen J.Tension-type headache: current research and clinical management. Lancet Neurol. 2008;7:70–83.
22. Cupini LM, Sarchielli P, Calabresi P. Medication overuse headache: neurobiological, behavioural and therapeutic aspects. Pain. 2010;150:222–4.
23. Silberstein S.Headaches due to nasal and paranasal sinus disease. Neurol Clin. 2004;22:1–19.
24. Jones N.Sinus headaches: avoiding over- and mis­diagnosis. Expert Rev Neurother. 2009;9:439–44.
25. Eross E, Dodick D, Eross M.The sinus, allergy and migraine study (SAMS). Headache. 2007;47:213–24.
26. Aaseth K, Grande RB, Kvaerner K, Lundqvist C, Russell MB. Chronic rhinosinusitis gives a nine­fold increased risk of chronic headache. The Akershus study of chronic headache. Cephalalgia. 2010;30:152–60.
27. Naranch K, Park Y, Repka-Ramirez M, Velarde A, Clauw D, Baraniuk J.A tender sinus does not always mean rhinosinusitis. Otolaryngol Head Neck Surg. 2002;127:387–97.
28. Friedman A, Batra P, Fakhri S, Citardi M, Lanza D. Isolated sphenoid sinus disease: etiology and management. Otolaryngol Head Neck Surg. 2005;133:544–50.
29. Fadda GL, D'Eramo A, Grosso A, Galizia A, Cavallo G. Isolated sphenoid sinus inammatory dis­ease- a report of 14 cases. Iran J Otorhinolaryngol. 2020;32:101–7.
30. Clerico DM. An experimental study of pain upon stimulation of the nasal and sinus cavities. Am J Otolaryngol. 2014;35:300–4.
31. Moretz W, Kountakis S.Subjective headache before and after sinus surgery. Am J Rhinol. 2006;20:305–7.
32. Phillips J, Vowler S, Salam M.Endoscopic sinus sur­gery for ‘sinus headache’. Rhinology. 2007;45:14–9.
33. Soler Z, Mace J, Smith T. Symptom based presenta­tion of chronic rhinosinusitis and symptom-specic outcomes after endoscopic sinus surgery. Am J Rhinol. 2008;22:287–301.
34. Tarabichi M. Characteristics of sinus related pain. Otolaryngol Head Neck Surg. 2000;122:842–7.
35. Chester A, Antisdel J, Sindwani R. Symptom­specic outcomes of endoscopic sinus surgery: a systematic review. Otolaryngol Head Neck Surg. 2009;140:633–9.
36. Ayoub J, Cohendy R, Dauzat M, Targhetta R, De la Coussaye J, Bourgeois J, etal. Non-invasive quanti­cation of diaphragm kinetics using M-mode sonogra­phy. Can J Anaesth. 1997;44:739–44.
37. Cappo B, Holmes D.The utility of prolonged respi­ratory exhalation for reducing physiological and psy­chological arousal in non-threatening and threatening situations. J Psychosom Res. 1984;28:265–73.
38. Noble DJ, Hochman S.Hypothesis: pulmonary affer­ent activity patterns during slow, deep breathing contribute to the neural induction of physiological relaxation. Front Physiol. 2019;10:1176.
39. Carlson C.Psychological considerations for chronic orofacial pain. Oral Maxillofac Surg Clin North Am. 2008;20:185–95.
40. Levine H, Setzen M, Cady R, Dodick D, Curtis P, Schreiber C, et al. An otolaryngology, neurology, allergy and primary care consensus on diagnosis and treatment of sinus headache. Otolaryngol Head Neck Surg. 2006;134:516–23.
41. Abu-Bakra M, Jones N.The prevalence of nasal con­tact points in a population with facial pain and a con­trol population. J Laryngol Otol. 2001;115:629–32.
42. Peric A, Rasic D, Grgurevic U.Surgical treatment of rhinogenic contact point headache: an experience from a tertiary care hospital. Int Arch Otorhinolaryngol. 2016;20:166–71.
43. Schonsted-Madsen U, Stocksted P, Christensen P, Koch-Hnedriksen N. Chronic headache related to nasal obstruction. J Laryngol Otol. 1986;100:165–70.
44. Sacco S, Ricci S, Carolei A.Tension-type headache and systemic medical disorders. Curr Pain Headache Rep. 2011;15:438–43.
45. Cho SJ, Song TJ, Chu MK.Sleep and tension-type headache. Curr Neurol Neurosci Rep. 2019;19:44.
46. Koh H, Robinson P.Occlusal adjustment for treating and preventing temporomandibular joint disorders. J Oral Rehabil. 2004;31:287–92.
47. Fouda AAH.No evidence on the effectiveness of oral splints for the management of temporomandibular joint dysfunction pain in both short and long-term fol­low- up systematic reviews and meta-analysis studies. J Korean Assoc Oral Maxillofac Surg. 2020;46:87–98.
48. Suvinen T, Reade P, Kemppainen P, Kononen M, Dworkin S.Review of aetiological concepts of tem­poromandibular pain disorders: towards a biosocial model for integration of physical disorder factors with psychological and psychosocial illness factors. Eur J Pain. 2005;9:613–33.
49. Nitzan D.The process of lubrication impairment and its involvement in temporomandibular joint disc dis­placement: a theoretical concept. J Oral Maxillofac Surg. 2001;59:36–45.
50. Bartley J.Breathing and temporomandibular joint dis­ease. J Bodyw Mov Ther. 2011;15:291–7.
51. Aggarwal V, Tickle M, Javidi H, Peters S.Reviewing the evidence: can cognitive behavioral therapy improve outcomes for patients with chronic orofacial pain? J Orofac Pain. 2010;24:163–71.
52. Aggarwal VR, Fu Y, Main CJ, Wu J. The effective­ness of self-management interventions in adults with chronic orofacial pain: a systematic review, meta-analysis and meta-regression. Eur J Pain. 2019;23:849–65.
18 Sinus Pain
https://t.me/medicina_free
213
53. Hadjivassiliou M, Sanders D, Grünewald R, Woodroofe N, Boscolo S, Aeschlimann D. Gluten sensitivity: from gut to brain. Lancet Neurol. 2010;9:318–30.
54. Egger J, Carter CM, Wilson J, Turner MW, Soothill J. Is migraine food allergy? A double-blind con­trolled trial of oligoantigenic diet treatment. Lancet. 1983;2:865–9.
55. Lin B, Wang Y, Zhang P, Yuan Y, Zhang Y, Chen G.Gut microbiota regulates neuropathic pain: poten­tial mechanisms and therapeutic strategy. J Headache Pain. 2020;21:103.
56. Wasan A, Fernandez E, Jamison R, Bhattacharyya N. Association of anxiety and depression with reported disease severity in patients undergoing eval­uation for chronic rhinosinusitis. Ann Otol Rhinol Laryngol. 2007;116:491–7.
57. Gildir S, Tuzun EH, Eroglu G, Eker L. A random­ized trial of trigger point dry needling versus sham needling for chronic tension-type headache. Medicine (Baltimore). 2019;98:e14520.
58. Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, et al. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016;4:CD007587.
59. Simons DG, Travell JG, Simons LS. Travell & Simons Myofascial pain and dysfunction: the trigger point manual (3rd edition). Philadelphia: Williams and Wilkins; 2018.
60. Gerwin R. A review of myofascial pain and bro­myalgia – factors that promote their persistence. Acupunct Med. 2005;23(3):121–34.
Computational Fluid Dynamics
https://t.me/medicina_free
oftheNasal Cavity
RalphMösges
19
Core Messages
• Computational uid dynamics (CFD) is a mature technology used widely in engineering to solve and analyze problems that involve uid ows.
• Computational uid dynamics has been used to demonstrate physiologic and pathologic conditions of nasal ow and to support preop­erative planning and control of postsurgical outcomes.
• Using high-denition three-dimensional imaging CFD may offer a chance to study the effects of medication on the tissues lining the surface of the nasal cavity.
• CFD may help to design devices for optimal nasal delivery of medications such as nasal spray applicators.
• CFD may become a universal tool not only for research and pharmaceutical development but also for advanced patient care in rhinology.
The nose is not a tube, nor can it be regarded as two pipelines transporting air to the lung.
The nose has multiple functions, enabling the
exchange of gas between the circulating blood and the environment, humidication, warming and cleaning of the air, and last but not least it
R. Mösges (*) Institute of Medical Statistics, Informatics and Epidemiology, University Hospital of Cologne, Köln, Germany e-mail: ralph@moesges.de
supports the sense of smell as an alarm function but also to nd the ideal mate.
The nasal cavity is optimized for all these tasks and only surgical hybris can lead to the assumption that one could easily ameliorate its structure. It is this “Plummer’s mentality” that has transformed human beings with slightly obstructed noses into “nasal wrecks” suffering from the empty nose syndrome.
For a long time, otorhinolaryngologists have tried to measure nasal ow under conditions of obstruction, in order to surgically remove what is deemed to be the obstacle to normal nasal breath­ing. But even in cases where the pre−/post- comparison of nasal ow, measured under dened conditions demonstrated signicant improvements, patients were sometimes unhappy with the outcome. Septoplasty and turbinectomy are typical interventions with a high rate of “non­responders” to therapy, at least in the long run. The difference between objective nasal patency and the subjective feeling of obstruction has been very well described in excellent reviews [1]. One of the reasons for this discrepancy may be that we measure nasal ow in our tests at pressures that are by far higher (150Pa or 200Pa) than those produced in a normal breathing cycle under rest­ing conditions. However, the test equipment we use these days (and have been using over the last 20years) does not allow for reliable, reproduc­ible measurements at pressures as low as those occurring in real life. Therefore, especially in
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 Ö. Ö. Celebi, T. M. Önerci (eds.), Nasal Physiology and Pathophysiology of Nasal Disorders,
https://doi.org/10.1007/978-3-031-12386-3_19
215
216
https://t.me/medicina_free
R. Mösges
cases of obstructed anatomy, other methods may be more adequate to calculate nasal ow and the exchange of warmth and humidity at the border­line, the supercial tissue which is the mucous membrane lining the wall of the nasal cavity.
Physics has developed a tool for this task. It is called computational uid dynamics (CFD), a mature technology used widely in engineering to solve and analyze problems that involve uid ows [2]. The mathematical predictions of CFD can also be applied to the nasal airow. For numerical simu­lation of the nasal airow, patients have to undergo computed tomography (CT) or magnetic resonance imaging (MRI) scans of the head [3].
Many of the rst ow simulation studies focused on nasal airow biophysics [46]. CFD has already been used for the ow analysis of pathological cases [716] and has been proposed as a tool to predict actual surgical outcomes using virtual nasal surgery models [1721]. A new eld of application, for which CFD has been success­fully used, is the three-dimensional visualization of the distribution and the consecutive effects of intranasally applied medications such as nasal steroids or decongestive nasal sprays [2224].
It is the objective of this review, on the one hand, to present a summary of current applica­tions of CFD in rhinology (demonstration of physiologic and pathophysiologic ow distribu­tions in the nose, preoperative planning, and postsurgical assessment of rhinosurgery out­comes); on the other hand, we want to demon­strate that CFD is a powerful tool for the three-dimensional presentation of drug action on the nasal mucous membranes.
19.1 Current Applications
ofComputational Fluid Dynamics
19.1.1 Demonstration ofPhysiologic
andPathologic Flow Distributions intheNose
An adequate example of the three-dimensional visualization of physiologic ow in the nasal cav­ity is found in the paper published by Ishikawa
and colleagues in 2006. They investigated the dif­ferences between nasal inspiration and expiration on the basis of computed tomography. They found that during inspiration, nasal ow in the middle meatus was considerably more pro­nounced and turbulent than during expiration [4]. Tan and coworkers observed a similar ow pat­tern in their clinical trial. During inspiration, tur­bulence occurred primarily in the anterior part and on the oor of the nasal cavity. In contrast, no turbulence occurred during expiration. They measured the maximum nasal ow around the plane of the palatine velum during both inspira­tory and expiratory phases [5]. Wen and col­leagues also investigated the physiologic ow in the nose. They were able to demonstrate that the high velocities in the constrictive nasal valve area region and the high ow appeared close to the septum walls [6].
Moreover, pathophysiologic aberrations in the nasal cavity like septal deviations [7, 10, 14, 15], turbinate hypertrophy [8, 11, 12], nasal bone fracture [9], septal perforation [13], deviation of the external nose [16], and their consequences can be visualized by means of CFD technology.
Sun and colleagues compared, for example, patients with nasal septum deviations with others without anatomical irregularities. They came to the conclusion that ow simulation allows to visualize the differences in nasal ow origination from abnormal anatomy [15]. The Chinese scien­tist Liu demonstrated the inuence of different forms of septum deviation on nasal ow charac­teristics [14]. His compatriot Guo proved that unilateral infraturbinal hypertrophy also changed the normal anatomy and inuenced the aerody­namics of the nasal cavity. According to his work, these changes have a substantial effect on the important functions of the nose-like humidica­tion, warming of the inhaled air, and the sense of smell [11].
Bailie and coworkers validated in a clinical trial in ve patients that ow simulations based upon computed tomography can help to analyze the function of the lower and middle turbinate regarding warm up and cool down of inhaled air. Moreover, this ow model may explain that shear stress created by the ow around the turbinates in
19 Computational Fluid Dynamics oftheNasal Cavity
https://t.me/medicina_free
217
Kiesselbach’s area may induce nasal bleeding [25]. This clinical trial supported ndings pub­lished by Pless and colleagues in 2004. They came to the conclusion that both the lower and the middle turbinates are primarily responsible for heat recovery during expiration and that areas of the highest decrease in temperature are charac­terized by turbulent airow [26]. Sommer and his working group attributed utmost importance to the middle turbinate for climatization and humid­ication of inhaled air [27].
Ishikawa and colleagues gave primary atten­tion to olfaction in their publication. In their three-dimensional ow model, they were able to demonstrate that inspiratory airow is widely distributed in the olfactory region than exhaled air. In contrast, snifng ow had the widest dis­tribution in the olfactory region, although no increase in nasal ow was noticed in the ow model. They drew the conclusion that recircula­tion ow strongly promotes olfactory function in the nose [28].
hypertrophic turbinate [18], septoplasty, and par­tial lateral turbinectomy [19].
Another application of CFD technology is the clinical picture of sleep apnea syndrome. Sung and Xu conducted ow simulations in 2006 that resulted in a better understanding of the patho­physiology of obstructive sleep apnea syndrome in adults as well as in children [29, 30]. Bimaxillary surgery with maxillomandibular advancement to widen the post-glossal space is one standardized procedure in the treatment of obstructive sleep apnea syndrome [31]. In a clini­cal trial in two patients with sleep apnea syn­drome conducted by Yu and coworkers, nasal airow before and after surgical intervention (maxillomandibular advancement) was calcu­lated on the basis of computed tomography slices. CFD demonstrated a postoperative widening of the upper airways with balanced volume ows and pressure patterns. The postsurgical clinical picture of the patient (reduced inspirative energy and better ventilation) conrmed the prognostic value of CFD [32].
19.1.2 Preoperative Planning andPostsurgical Outcome Assessment inRhinosurgery
Another stronghold of CFD is the eld of preop­erative planning and postsurgical outcome assessment in rhinosurgery. As early as 2000, Bockholt and colleagues investigated the poten­tial benet of nasal ow simulations in the eld of rhinosurgery. They came to the conclusion that by setting up a three-dimensional model of the nasal cavity based upon CT slices, planning of a surgical intervention may be optimized and the outcome may be improved for the patient [17]. In their clinical trial, Xiong and colleagues assessed the use of CFD for preoperative planning and postsurgical outcome control. By visualization of nasal airow before and after a virtual endo­scopic intervention, they could simulate patients’ outcome [21].
Other research groups conrmed the applica­bility of CFD to visualize the postsurgical out­come of various rhinosurgical interventions such as rapid maxillary expansion [18], surgery of a
19.1.3 Recently Developed Applications ofComputational Fluid Dynamics
A new application of CFD is the visualization of drug effects on the nasal mucosa in three­dimensional ow simulations. Garlapati and his working group investigated in their clinical trial the effects of the application of nasal sprays on the mucosa. Based upon magnetic resonance imaging, they could demonstrate that intranasal application of medication is most effective when the patient actively inspires during the applica­tion. Surprisingly, the posture of the head had no signicant inuence on the distribution of the inhaled aerosol [24]. Frank and colleagues com­plemented this observation with the nding that the posture of the head only inuences the distri­bution of the nasal sprays in the case of absent or minimal inspiratory airow [23]. Chen and col­leagues also investigated the effects of nasal sprays using CFD technology. With the nasal ow
218
https://t.me/medicina_free
R. Mösges
model of their patient, they could show that the distribution of nasally applied drugs with a parti­cle diameter of 10μm was signicantly improved after functional endoscopic sinus surgery (FESS), resulting in a moderate nasal ow [22]. Frank and coworkers agree to this observation saying that surgical correction of nasal anatomic deformities (e.g., nasal septum deviation) could improve drug delivery on the nasal mucosa [23].
The application of CFD technology is not only limited to the visualization of drug effects in healthy [24] subjects or patients that underwent surgery [22, 23]. It can also be used to study changes of the mucous membranes in patients treated for symptoms of allergic rhinitis. In two clinical trials, we have studied the anti- obstructive effects of antiallergic medications on the swell­ing status in a patient suffering from seasonal allergic rhinitis. This example is used to describe the methodology applied in CFD.
19.2 Methodology
19.2.1 Imaging andGrid Generation
19.2.1.1 Using Computed
Tomography
The computational grid is generated based on a surface denition by a computer tomographic scan of the human nasal cavity which results in about 300 cuts 1mm apart or less, a resolution of 512×512 pixels or higher per cut, and 2 bytes per pixel for the density resolution.
To allow a better interface detection, blurring must be reduced by sharpening the image, by applying a 3 × 3 ×3 convolution matrix lter, which emphasizes the voxel differences depend­ing on the 3 × 3 × 3 neighborhood around the center voxel. This supports the manual segmenta­tion of the nasal cavity by an experienced ENT specialist, who examines each slice of the three­dimensional image and identies the region of interest (ROI) with a digital pen tablet. The image is then further preprocessed. A seeded region growing algorithm [33] is used to identify the previously detected ROI by placing seed points inside the uid volume of the nasal cavity and
recursively descending in the neighborhood of them. The identication is based on a lower and an upper threshold depending on the assignment method of the ENT specialist. Based on this seg­mentation, the Marching Cubes algorithm [34] is used to extract the surface of the nasal cavity yielding a three-dimensional triangle representa­tion. This algorithm is based on the intensity detection along voxel edges and denes vertices along these lines by a bilinear interpolation between the intensities at the corners of the vox­els. A set of triangles is dened for such a vertex conguration, which is looked up in a congura­tion table, containing 256 possible combinations. In a post-processing step, the surface is smoothed using a windowed sinc function [35], removing high-frequency noise in Fourier space by apply­ing a transfer function. In a nal step, the surface is split into multiple parts. The nostrils and the throat are separated from the rest of the nasal cav­ity and are smoothed with a Laplace lter until convergence. This lter performs a relaxation of the mesh and iteratively moves all vertices into one plane. This step allows the proper application of the boundary conditions in the ow simula­tion. Based on this model, an automatic Cartesian grid generator creates the computational mesh. A minimal bounding cube is initially placed around the surface. This cube is then continuously split into eight smaller cubes until a user-dened level of renement is reached. During the splitting pro­cess, cells outside the uid domain are removed.
Using a marching cube algorithm for triangu­lation of the scanning data, an unstructured sur­face with 200,000 nodes and 420,000 triangles can be obtained. For an exact match of the experi­mental ow conditions, pipes for in- and outow are added. Via the grid generation tool, a struc­tured grid of 450,000 nodes in 34 blocks (Fig. 19.2) is generated which has a nested O-topology and additional blocks underneath the turbinates. To ensure a divergence-free solution, the blocks match at their interfaces.
19.2.1.2 Using MRI
T2-weighted MRI is used to visualize detailed internal structures and restricted body functions. It provides a three-dimensional image of the
19 Computational Fluid Dynamics oftheNasal Cavity
https://t.me/medicina_free
219
nasal cavity, the sinuses, and the pharynx and allows the assessment of the nasal mucosa mem­brane swelling. To perform a uid mechanical analysis of the ow in the human nasal cavity, the surface of the region of interest, i.e., the volume of the nasal cavity, is extracted from MRI data and processed in multiple steps [36]. Since MRI measures the uid characteristics of different tissues, the distinction between bone and air is generally difcult because they contain no or only a small amount of uid and give a similar MRI signal, i.e., these areas appear black.
To extract a suitable model of the nasal cavity from MRI data, the rst step is segmentation. This is performed manually by an experienced radiologist on a graphic tablet. During the next step, the segmented volume is converted into a triangular mesh surface by a Marching Cubes algorithm. The surface then is smoothed and used for generating a volumetric grid again. This can be done by dividing a large starting cube contain­ing the entire surface into eight smaller ones with the same size each. The small cubes now lying outside of the surface are omitted, while the cubes inside are further divided. The procedure nishes with the so-called Cartesian lattice of approximately 4.1 million cells. For more com­plex calculations including analysis of humidi­cation, the lattice may have 25 million cells or more.
To simulate nasal airow, the Navier–Stokes equations, which describe the motion of uid substances, must be solved for every cell. Therefore, several boundary conditions are required. The applied “no-slip” condition denes the velocity at the walls of the nasal cav­ity as zero. At the nostrils, a constant inow is set, which causes a stationary ow eld to develop after a sufcient number of simulated time steps. Therefore, the assumption of a quasi­steady ow is needed. The local velocity and pressure are obtained for every cell of the simu­lated lattice. Since the inow is set as a xed input for all four ow simulations, the total ow is identical. The computational uid dynamics model used implements a Lattice–Boltzmann method. It was validated experimentally by an articial nose model.
19.2.2 Method ofSolution
To simulate the ow eld, the three-dimensional Navier–Stokes equations are solved. An explicit ve-step Runge–Kutta method of second-order accuracy is used for time integration. The fol­lowing boundary conditions are imposed. A no­slip isothermal wall condition is assumed and the pressure gradient normal to the wall is set to zero. At the inow section, a parabolic velocity prole is prescribed with the mean velocity determined from an assumed isentropic expan­sion from a stagnation state to the local static pressure that is computed from the interior pres­sure distribution using a vanishing pressure gra­dient in the streamwise direction. At the outow plane, the static pressure level is prescribed and a nonreecting boundary condition of Poinsot and Lele is applied [37].
The simulation was carried out using a Lattice­Boltzmann method and was performed on grids containing about 20 × 106 cells. As for the imposed boundary conditions, a no-slip wall con­dition proposed by Bouzidi etal. [38] was used. A volume ux of 125ml/s was prescribed at the inow boundaries with a von Neumann condition for the velocity. The density was extrapolated in surface normal direction by applying a Dirichlet condition. The outow boundary condition was based on the formulation by Finck etal. [39] and imposed a constant pressure and extrapolated the velocities. The Reynolds number based on the mean hydraulic diameter of the nostrils and a vol­ume ux of 125ml/s were calculated for all nasal cavity geometries to guarantee an equal volume ux in all cases (Fig.19.1).
19.2.3 Virtual Reality-Based
Visualization ofFlow Simulation Results
Visualization is a fundamental ingredient for gaining insights into the simulation results.
In particular, visualization is indispensable to the understanding of complex, dynamic pro­cesses observed in computational uid dynam­ics, whose scientic and technical analyses