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20 Physiology andPathophysiology ofNasal Breathing
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Flow right [ml/s]
Flow
800
600
400
200
0
18 : 00 20 : 00 22 : 00 0: 00 2 : 00 4: 00 6: 00 8: 00 10: 00 12: 00 14: 00 16: 00
Heart rate (HR) [1/min] Breathing rate (BR) [1/min] Nasal minute volume (NMV) [L/min]
HF
AF
120
100
80
60
40
18 : 00 20 : 00 22 : 00 0: 00 2 : 00
Moderate
physical stress
classical type with
incomplete resting phases
4: 00 6: 00 8: 00 14: 00 16: 00
No physical stress (sleep)
classical type with
complete resting phases
Fig. 20.19 Graphical illustration of the result of a longterm rhinometric examination of a healthy subject with
non-obstructed nasal breathing and the simultaneous
physical activity from a study protocol. (a) During moderate physical stress (blue background), during sleep (green
background), during moderately increased physical stress
(yellow background), and during heavy physical stress
Flow left [ml/s]
Moderate
increasing
physical stress
classical type with
incomplete resting phases
and increasing flow on both sides
subject during very heavy physical stress (intensive red
background). Upper Part of the gure: X-axis: time;
Y-axis: Nasal airow velocity at maximal inspiration in
mL/s for the right (red) and left (blue) nasal side. Lower
Part of the gure: X-axis: time; Y-axis: Heart rate (HR)
orange, breathing rate (AR): violet, nasal respiratory minute volume in mL/s (NMV): green
12: 0010: 00
Heavy physical stress
(light red background). (b) Measuring results of the same
in-Concert-Type
Flow
800
600
400
200
0
: 00 8 : 00 10 : 00 12
NMV
AF
30
20
10
0
: 00 8 : 00 10 : 00 12
Very heavy physical stress
complete mouth breathing
20.6 Conclusions
• In functional rhinosurgery, reducing pathological breathing resistance by expanding the
• The long-term results after functional rhinosurgery are not satisfactory. Frequently
reported postoperative complaints are insufciently improved nasal breathing and dry
mucous membranes up to symptoms of an
empty nose syndrome. One reason for this is
the insufcient consideration of the physiological importance of structures that are
essential for the respiratory function in the
nose.
• In recent years, our understanding of the relationship between efcient breathing and the
very complex structure of the nose has
increased signicantly. The transfer of this
knowledge into rhinosurgical practice is not
sufcient. More satisfactory long-term results
should be achieved in functional rhinosurgery
through a greater inclusion of physiological
aspects.
nasal ow channel is an essential part. This
almost always involves straightening the septum in conjunction with reducing the size of
the turbinates.
• When the breathing resistance is sufciently
normalized, oral bypass breathing is eliminated and the respiratory function of the nose
is reactivated.
• However, the patient is only symptom-free
after surgery if the structures in the nose that
are essential for its respiratory function have
been preserved or reconstructed.
• If there is a physiological septal deviation, a
septoplasty with turbinate reduction is not
indicated as the physiological slit-shaped
nasal ow channel will be broadened too
much. Therefore, before a septoplasty, it
should be determined whether the existing
deviation is causing the pathological skeletal
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A. G. Beule et al.
resistance or whether it is a physiological
deviation. In the latter case, the real reason for
the patient’s discomfort should be identied
(e.g. narrowing of the isthmus with pathological valve collapse, sagging nose, etc.) and
corrected.
• Correction of the septum is required in the
event of pathological deviations. However, the
septum should not be fully straightened. It
should be placed in the middle between the
asymmetrical lateral nasal walls so that the
cavum is approximately the same size on both
sides. This is an important requirement for an
undisturbed nasal cycle and thereby for the
respiratory function.
• The slit-shaped cavum should be sufciently
wide on both sides of the nose so that the
inhaled air can ow unhindered for the working phase after decongestion. For the resting
phase, the nose should not be too wide so that
it can be closed by swelling. Both are prerequisites for an undisturbed nasal cycle.
• With their shape and size, the turbinates contribute signicantly to the narrowing of the
cavum to a slit-shaped ow channel. With
their cavernous bodies and the respiratory
mucosa, the turbinates are important structures for the respiratory function of the nose.
For these reasons, the turbinates should be
preserved as much as possible.
• In cases in which the turbinates are enlarged
for compensatory reasons (e.g. to narrow a
cavum that is too wide on the concave side
of the deviation), septoplasty should not be
routinely combined with surgical reduction
of the turbinate size. In these cases, it is
important to distinguish between turbinate
enlargement due to swelling or hyperplasia
by also performing an examination after
decongestion.
• When treating the compensatory swelling of
turbinates, resections are seldom necessary,
since the turbinates can adapt with the extent
of their swelling in shape and size to the available space.
• In pre-pubertal septal deviations, it is often
observed that the turbinate has grown far
medially in the area of the concave deviated
septum. In these cases, a lateral positioning of
the lower turbinate in the region of septal
deviation is indicated in order to create a symmetrical slit-shaped channel.
• The reconstruction of the inow area requires
special attention. With drooping noses, the
alar cartilage should be rotated and xed up to
a normal nasolabial angle. This restores an
even distribution of the airow over the entire
cross section in the turbinate region. From a
functional point of view, no overcorrection
should be made.
– If the valve angle is too small or too large
(tension and saddle noses), the height of
the septum in the cartilaginous nose should
be normalized. Therewith, the nozzle effect
of the nasal vestibulum also normalizes.
– During the operation of crooked noses, the
diffusers in both nasal sides should be
reconstructed as symmetrically as possible,
because that is an important prerequisite
for regulating turbulence during the nasal
cycle.
– If possible, the head of the lower turbinate
should not be reduced because of its function in regulating turbulence. If necessary,
a lateral positioning is often sufcient.
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Function oftheTurbinates:
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Nasal Cycle
AchimG.Beule andRainerK.Weber
21
Core Messages
• Spontaneous changes in nasal airway resistance
in the two separate nasal passages due to congestion and decongestion of nasal venous sinuses are
called the nasal cycle. One respiratory function of
the nose is to sufciently condition the respirated
air which goes along with the nasal cycle.
• It is important to consider the nasal cycle and
other physiologic changes in the congestion of
the nasal mucosa when making a clinical
assessment of a patient complaining of nasal
obstruction. The indication faor surgery
should be based on clinical history, on examination by anterior rhinoscopy and nasal endoscopy, and by considering these physiologic
variations in addition to measurements of
nasal airway patency. Long-term rhinoowmetry offers a new possibility for investigating
nasal patency for up to 72h.
A. G. Beule
Department of Otorhinolaryngology, University
Hospital Münster, Münster, Germany
Department of Otolaryngology, Head and Neck
Surgery, University Medicine Greifswald,
Greifswald, Germany
e-mail: achimgeorg.beule@ukmuenster.de
R. K. Weber (*)
Department of Otolaryngology, Municipal Hospital
Karlsruhe, Karlsruhe, Germany
Sinus Academy, Karlsruhe, Germany
e-mail: rainerweber@rainerweber.de
21.1 Denition ofNasal Cycle
The respiratory function of the nose is to sufciently condition the respirated air, which is
maintained by supplying the mucosa with thermal energy and uid for humidication. This is
supplied by blood circulation and in coherence
with the nasal cycle [1]. The erectile tissue
enables the turbinates to cyclically congest and
decongest. We distinguish between three different patterns of congestion and decongestion
during the nasal cycle: During the classical
nasal cycle, one side of the nose is in its working
phase conditioning the air, with an unimpeded
air passage and increased turbulence. At the
same time, the contralateral side is in its resting
phase, saving energy and moisture by high airway resistance and low turbulence [2]. This type
of nasal cycle is the physiologic ideal, enabling
the resting side to regain the full mucosal potential to clean and humidify the air during the next
cycle. In cases of increased physical activity or
decreased respiratory function of the nose, a
decongestion on both sides can be observed,
called the in- concert- type or parallel type [3]. If
the erectile tissue is severely malfunctioning,
e.g. after excessive resection or due to atypical
central nervous impulses to the erectile tissue,
the congestion on both sides is irregular.
Congestion and decongestion are no longer
responsive to the physical or respiratory activity
of the subject and the duration of a congestive
© 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_21
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A. G. Beule and R. K. Weber
phase is less than 30min. to correctly attribute
this term. Some authors suggest the use of the
term acyclic; however, this fourth type I up to
now is rarely used in the literature. To understand the possible inuencing factors resulting
in one of these three types, the regulation of the
nose needs to be remembered:
The airow through the nose is regulated by
the activity of the erectile venous tissue of the
nasal mucosa [4]. The nasal epithelium has a very
complex vascular nature with a submucosal
plexus of venous sinuses lining the nasal mucosa.
These venous sinuses from erectile tissue are
well developed in the anterior part of the nasal
septum and the inferior turbinate [5]. These submucosal cushions of the venous sinuses expand
and shrink depending on the degree of congestion, hence altering the calibre of the nasal passages and inuencing the nasal airow.
An enlargement of this tissue leads to a reduc-
tion of the nasal lumen and increases the ow
resistance. The cyclic congestion and decongestion of the nasal mucosa is called nasal cycle [4]
and is observed in about 80% of the people [6, 7],
and only about 20–40% seem to show a classical
type [3, 6, 8, 9]. As the nasal cycle had already
been described by Kayser in 1895 [9], the nasal
cycle was investigated using several techniques,
including rhinoscopy [9, 10], acoustic rhinometry [2, 11–20], rhinomanometry [21–26], rhinoresistometry [2], radiologic tomographic imaging
[27], computed tomography [28], or magnetic
resonance imaging [29–32].
Rhinomanometry reveals an opposite swelling
behaviour of both nasal sides, while the total
resistance of the two nasal sides, the nasal passage, and the respiratory work remain relatively
constant [8, 25, 26, 33, 34].
Magnetic resonance imaging could show that
even the ethmoid mucosa is involved in the
nasal cycle, however, only to a lower degree
[30]. Also the tubal function changes with the
nasal passage resistance in a homolaterally concordant way [35].
By means of radiologic tomographic proce-
dures, Masing [27] could show that in cases of
nasal obstruction or non-existing nasal breathing,
the classic nasal cycle can no longer be observed
but paradox or irregular turbinate movements
occur, which conrms the observations made by
others [3, 23, 25, 26]. In the anterior and posterior parts of the nose, the changes were comparable so that the hydraulic diameter of the whole
nose seemed to be equally maintained. In cases
of signicant septal deviation, in-concert or no
nasal cycle could be found. In only two of six
cases, a unilateral turbinate movement was
observed on the obstructed side. The nasal cycle
stopped with the beginning of acute rhinitis [27]
and may be abolished by use of topical decongestants [36].
Rhinoresistometry and acoustic rhinometry
could reveal the changes of the nasal turbulence
occurring in the context of the nasal cycle [2].
During the resting phase, a laminar airow was
observed. During the working phase (decongested side), turbulences were also found with
low speed. The increasing turbulence was caused
by an increased cross-section surface of the anterior nasal area. Hereby, the turbinates and the
mucosa of the nasal septum are decongested.
Long-term rhinoowmetry is a complementary tool in addition to established rhinological
diagnostics. The nasal ow can be investigated
up to 72h. Therefore, it appears to be an ideal
tool to measure the cyclic alterations of the nasal
cycle [1]. Technical details have been published
for commercially independent reports on its
function [37]. Long-term rhinoowmetry is especially helpful if nasal obstruction is reported during nighttime or in specic environment to
objectify these complaints [38].
Keerl etal. [39] were the rst to realize visualization by means of nasal endoscopy and
dynamic description with timelapse video. In
analogy to the clinical and rhinomanometric
observations that the total resistance of both
nasal sides is almost constant [8, 20, 33, 40], the
congestive procedures on one side occur nearly
parallel to the decongestive procedures of the
contralateral side (Fig. 21.1a–e). Most of the
time, continuous swelling patterns are found
with congestion of one side and decongestion of
the contralateral side. These swelling changes
are relatively rapid with 15min in our analysis
for a cyclic duration of 5h.
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a
b
c
247
d
Fig. 21.1 (a–e) Swelling of inferior turbinate according
to the nasal cycle in a healthy young man (parallel endoscopy using a 0° endoscope): (a) Decongested mucosa on
the right and congested mucosa on the left side at the
beginning. (b) Change of swelling. (c) Maximal congestion on the right and maximal decongested mucosa on the
left side. (d) Reciprocal change of swelling. (e) Same situation at the end of the nasal cycle as at the beginning
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e
Fig. 21.1 (continued)
A. G. Beule and R. K. Weber
With the endoscopic description in timelapse
video, the extent of the congesting process could
be evaluated precisely. The process of congestion
and decongestion occurs relatively rapidly so that
the turbinates remain most of the time in a kind of
plateau phase of submaximal to maximal congestion or decongestion. Based on our clinical evaluations in healthy subjects, most of the nasal cycle
changes occur within 5min. The size of the turbinates varies between very small and very large
with complete obstruction of the nasal cavity in
the visible area. During the course of the cycle,
complete decongestion of both turbinates never
occurred. For a short phase, a similar middle congestion status of both turbinates can be found.
The diagnosis of hyperplastic turbinates is
often made in the clinical routine, but with the
background of the mentioned results, it must be
reconsidered. Hyperplasia means rst the
enlargement of tissue by cellular multiplication.
During the nasal cycle, the healthy turbinate continuously changes from a low to a high degree of
congestion. Internal and external factors additionally inuence the extent of the swelling situation. As the physiology of a normal turbinate
allows each size from minimal to maximal, there
is no reference for the diagnosis of hyperplasia or
hypertrophy or for denition of a standard normal size at one given time point. Even if one side
of the nose is completely obstructed because of
the maximally congested inferior turbinate, the
other decongested side allows a sufcient nasal
air passage based on the physiologic nasal cycle
due to the relatively unchanged total nasal resistance of the nose. Only the bilateral massive
swelling of the inferior turbinates seems to be
unphysiological [39, 41]. It seems to be appropriate demanding to limit the use of the term of
hyperplasia only for enlarged turbinates with
atypical changes of the surface (e.g. polypous,
mulberry-like changes) and to speak about congested turbinates in all other cases.
Besides the congesting and decongesting processes, regular changes of the secretory production could be observed endoscopically [3, 41,
42]. The congesting turbinate seemed to become
increasingly humid so that maximally congested
situation led to small droplets. Reason is the activation of the parasympathic nervous system.
During the decongesting phase, the mucosa dries
more and more, partly with resulting small dry
layers. In this context, the dehydrating effect of
nasal breathing accompanies the sympathomimetic and reduced parasympathic tonus.
However, in cases of rhinitis, the interaction of
secretory function and nasal cycle has been
shown to be affected as well [3].
21.2 Types ofNasal Cycles
Three types of nasal cycles are described [1]: the
classical reciprocal type, the in-concert type
(simultaneous reduction and increasing of the
nasal passage on both sides), and the irregular
type. Recently, the term acyclic nose has been
introduced [3, 6].
In addition, Kern [43] describes three types of
non-cycle noses: there is no uctuation of the
nasal passage, the uctuation is moderate only on
one side, and the uctuation does not change
from one side to the other.
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249
The cyclic duration is very variable with an
interval of about 1–6h [4, 8, 10, 39, 41] but use
of rhinoowmetry has demonstrated that cyclic
duration may take up to 11h [36, 38, 44].
More recent quantitative studies using numerical parameters seem to show that true periodicity
and reciprocity of nasal airow exist only in
21–39% of the population, reciprocity being the
truly reciprocal changes in airow between right
and left passages and periodicity being the regularity of changes in airow occurring with time in
each nasal passage. Otherwise, these studies used
measurement periods no longer than 8h. So the
timeperiod of examination may be too short to
discover the nasal cycle as was outlined by
Grützenmacher.
To characterize the nasal cycle apart from its
type, duration of the working or resting phase, as
well as the magnitude of maximal nasal ow,
called amplitude, is currently evaluated [38].
These parameters may also be expressed as ratio
of both nasal sides, as calibration and normalization of the measurement used are still challenging. Recently, a more similar distribution of nasal
cycle measured by rhinoowmetry has been
reported after septoplasty in comparison to a preoperative measurement [45].
Also in children, a nasal cycle can be revealed
[16, 46–48]. For children up to the age of 6, it
amounts to a mean of 1h and 20min and is not
inuenced by physical activity. Even infections
do not signicantly inuence the nasal cycle. As
studies with a longer observation time are still
not available (possibly due to ethical consideration), these ndings may be controversially
discussed.
Even if the distribution of the nasal cycle types
changes, a uctuation of the nasal passage is found
in laryngectomized patients (25% classical type,
40% irregular type, 35% in-concert type) [14].
According to Ingels etal. [49], no correlation
is found between the ciliary beating rate (CBR)
of the nasal epithelia and the rhinomanometrically measured passage of the nasal cavity. The
CBR of different cells in the same biopsies was
clearly different.
In contrast to this, Doyle and van Cauwenberge
[50] could detect a higher mucociliary clearance
rate with increased nasal passage by means of the
saccharin test. Also Soane etal. [51] found a signicant acceleration of the mucociliary clearance
on the free side in comparison to the obstructed
nasal side with a factor of 2.5:1 using the gamma
scintigraphy.
21.2.1 Pearls
• Spontaneous changes in nasal airway resistance due to congestion and decongestion of
nasal venous sinuses are called nasal cycle.
• Three types of nasal cycles are described with
a duration of about 1–11h.
• Consider the nasal cycle and other physiologic
changes in the congestion of the nasal mucosa
when making a clinical assessment of a patient
complaining of nasal obstruction.
• Long-term rhinoowmetry offers a new possibility for investigating nasal patency for up
to 72h.
21.3 Origin, Function,
andRegulation oftheNasal
Cycle
Finally, the origin and the function of the nasal
cycle are still under scientic discussion: As rst
suggested by Mlynski [52] and subsequently
rened [38, 44, 53], the decongested side is in the
working phase of the nose [1]. The respirated air
passes through the decongested nasal side; the air
is conditioned, i.e. warmed up, moistured, and
cleaned. The congested side is in its resting
phase.
The regulation of the nasal cycle is probably
performed by the central sympathomimetic tonus
[4, 5, 54–58]. This tonus is controlled by two
centres in the brain stem. They are connected and
dominate the tonus via right and left cervical
sympathomimetic nerve bres nally asymmetrically. Consequently, medical conditions affecting
this central nervous function of pace making may
be detected via the nasal cycle [54, 55].
Changes in the nasal patency that are related
to positional changes may be explained by two
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A. G. Beule and R. K. Weber
different mechanisms: an increased central
venous pressure when changing from a standing
to a lying position and a reectory change of the
nasal vasomotoric tonus when a lateral lying
position is taken. The increase of the venous
pressure causes an increased lling of the nasal
venous sinusoids and an increase in the nasal
resistance. The passive hydrostatic effect adds to
each asymmetry in the context of the nasal cycle.
The side with the highest degree of congestion
generally has the highest increase of swelling and
is completely obstructed [59]. Lying down leads
to a temporary disturbance of the nasal cycle with
congestion of the mucosa and increased ow
resistance. This effect is especially pronounced
in the bottom nasal side and mediated via thoracic receptors [60, 61] or those in the area of the
axilla [62]. The amplitudes of the changes in the
resistance in the nasal cycle are higher in supine
and lateral position [59, 61, 63, 64].
The reciprocal changes of the nasal patency
when taking a lateral lying position are induced
by the pressure in the area of the shoulder girdle,
the lateral thorax, and the hip that are the most
sensitive regions. During local anaesthesia in the
area of the skin, surface of the axilla cannot suppress this reectory reaction; this is possible by
an intercostal neural blockade [64]. This leads to
the effect that the upper side of the nose is mainly
open for nasal passage. An explanation may be
that this avoids closure of the inferior side of the
nose when lying on the ground so that nasal
breathing is still possible.
The diagnosis of nasal obstruction and the
nasal patency have to bear in mind the physiologic nasal cycle as well as changes of the nasal
respiratory resistance in dependence of the surrounding conditions (temperature, probably
humidity, irritating substances) [53, 65], the
physical activity, body position [61, 66], or pharmacological inuences [36, 67, 68].
Physical activity leads to a reduced nasal
resistance [28, 38, 44, 66, 69]. According to some
studies, the nasal resistance mostly increases
with cold temperatures [65, 70]. Schlegel [71]
reports about the main decrease of the resistance
with cold temperatures and an increase with
warmth. The change of the humidity from 20% to
more than 90% has no inuence on the nasal
patency [70].
The nasal cycle may inuence the nasal
allergy provocation test [72–74]. Gotlib etal. [73,
75] found that the determination of the bilateral
reduction of the cross-section surface in the area
of the inferior turbinates is more sensitive than
the determination of the one of the more reactive
side. However, the risk of a spontaneous unilateral total increase of the nasal resistance must be
considered.
There is some evidence that the nasal cycle is
associated with ultradian rhythms of the cerebral
hemispheres which affect cognitive function of
the brain [57, 76–78]. This includes atypical
ndings during psychiatric conditions including
hallucinations [77, 79]. Alternating dominance
of cerebral hemispheric activity can be demonstrated in humans by EEG, and relative changes
in electro-cortical activity seem to have a direct
correlation with the nasal cycle [79–81]. These
studies found a greater EEG activity on the side
contralateral to the decongested side of the nose;
a signicant improvement in spatial and verbal
cognitive function performed by the contralateral (in females) and ipsilateral (in males) cerebral hemisphere occurred in unilateral forced
nasal breathing [57, 76]. This may explain why
some patients with nasal obstruction nd this
more than just a simple annoyance and may
develop medical indication to normalize the
nasal cycle using rhinosurgery. The nasal
obstruction may have effects on the ability to
work during daytime [5].
Patients with upper respiratory tract infections
become far more apparent with a signicant
increase in the amplitude of the changes than
healthy people [82].
As physical activity decreases signicantly
during sleep, long-term rhinoowmetry enables
to detect a more regular or classical type of nasal
cycle during night. Currently, it is discussed
whether this is an indicator of increased individual resistance or respiratory malfunctioning of
the nose and possible indication for surgical
correction.
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