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18.8 Causes Removed
fromtheOrofacial 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 signicant 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 inammatory causes are usually relatively obvious.
Many patients may have symptoms reecting 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

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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 forenger [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 reects 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 signicant
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 forenger [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 deciency. Vegetarians
and the elderly can have undiagnosed vitamin
B12 deciencies. 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 signicantly changed
• There is signicant 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, difculty 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

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often have a signicant vitamin D deciency.
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-inammatory 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 classication Committee of the
International Headache Society. The international
classication 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, etal. 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 inammation. 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 inammatory 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-specic
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. Symptomspecic 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, etal. Non-invasive quantication 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
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oftheNasal Cavity
RalphMösges
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-denition 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, humidication, 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
dened conditions demonstrated signicant
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 (150Pa or 200Pa) 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
20years) 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

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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 supercial 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 airow. For numerical simulation of the nasal airow, 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 airow biophysics [4–6]. CFD
has already been used for the ow analysis of
pathological cases [7–16] and has been proposed
as a tool to predict actual surgical outcomes using
virtual nasal surgery models [17–21]. 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 [22–24].
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
ofComputational Fluid
Dynamics
19.1.1 Demonstration ofPhysiologic
andPathologic Flow
Distributions intheNose
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 inuence 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 inuenced the aerodynamics of the nasal cavity. According to his work,
these changes have a substantial effect on the
important functions of the nose-like humidication, 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

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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 airow [26]. Sommer and his
working group attributed utmost importance to
the middle turbinate for climatization and humidication 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 airow is widely
distributed in the olfactory region than exhaled
air. In contrast, snifng 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
airow 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) conrmed the prognostic
value of CFD [32].
19.1.2 Preoperative Planning
andPostsurgical Outcome
Assessment inRhinosurgery
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 benet 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 airow before and after a virtual endoscopic intervention, they could simulate patients’
outcome [21].
Other research groups conrmed 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
ofComputational 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
signicant inuence on the distribution of the
inhaled aerosol [24]. Frank and colleagues complemented this observation with the nding that
the posture of the head only inuences the distribution of the nasal sprays in the case of absent or
minimal inspiratory airow [23]. Chen and colleagues also investigated the effects of nasal
sprays using CFD technology. With the nasal ow

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model of their patient, they could show that the
distribution of nasally applied drugs with a particle diameter of 10μm was signicantly 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 andGrid Generation
19.2.1.1 Using Computed
Tomography
The computational grid is generated based on a
surface denition by a computer tomographic
scan of the human nasal cavity which results in
about 300 cuts 1mm 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 identies 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 identication 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 denes vertices
along these lines by a bilinear interpolation
between the intensities at the corners of the voxels. A set of triangles is dened for such a vertex
conguration, which is looked up in a conguration 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-dened level
of renement 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 outow
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 oftheNasal Cavity
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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 difcult 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 humidication, the lattice may have 25 million cells or
more.
To simulate nasal airow, 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
denes the velocity at the walls of the nasal cavity as zero. At the nostrils, a constant inow is
set, which causes a stationary ow eld to
develop after a sufcient 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 inow 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
articial nose model.
19.2.2 Method ofSolution
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 inow section, a parabolic velocity
prole 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 outow
plane, the static pressure level is prescribed and
a nonreecting 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 etal. [38] was used.
A volume ux of 125ml/s was prescribed at the
inow boundaries with a von Neumann condition
for the velocity. The density was extrapolated in
surface normal direction by applying a Dirichlet
condition. The outow boundary condition was
based on the formulation by Finck etal. [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 125ml/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 ofFlow
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 scientic and technical analyses
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