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G. H. Mlynski et al.
(septal deviation). This cannot be proven by
ARM.Taking into account the limitations of ARM
(see Sect. 27.2.1.1) and the physiologic laws of
uid dynamics (see Sect. 20.2.1), a slit- like conguration of the internal ostium indicated by the
small valve angle with a sufcient cross- sectional
area has to be suspected as aetiology of nasal
obstruction in this setting (see Sect. 27.2.1.1).
Moreover, the pathologically increased turbu-
lence on the left > right causes mucosal dryness,
including sicca syndrome, and contributes to
nasal obstruction.
Rhinosurgical Planning
Septoplasty to correct the stenosis will not lead to
satisfactory results. While resistance on the left
would get better, it would not be normalized.
Simultaneously, the slightly increased nasal
obstruction on the right would get worse.
Consequently, septoplasty needs to be combined
with a nasal valve repair on both nasal sides. A
turbinate reduction is not necessary, as conguration after decongestion is normal.
Rhinosurgery
Septoplasty and valve repair on both nasal sides
without surgery of the turbinates.
One year postoperatively, the patient was
re-assessed:
• Complaints: No nasal obstruction, no sicca
syndrome.
• Outer Nose: Normal.
• Endonasal ndings: Septum in the midline.
Sufciently wide nasal valve angle on both
sides. Inferior turbinates after decongestion normally congured. Mucosa normal (no dryness).
• Postoperative rhinometric ndings: cf.
Fig.27.15b.
• Analysis of postoperative rhinometric ndings
RRM: The preoperatively increased resistance on
the right has normalized. On the left slightly
too low. Besides, the pathological turbulence
is normalized on the right and clearly improved
on the left.
ARM: The septum is within the midline in Cottle
areas 2 and 3 and accordingly, both nasal cavi-
ties are sufciently wide. MCA1 indicating
the dimensions of the internal ostium is
enlarged on both sides in comparison to
preoperatively.
27.3.2.4 Example 4: Severe Nasal
Obstruction onBoth Sides
DuetoaTension Nose
Patient: female, 32years of age
• History: No trauma recalled.
• Complaints: Severe nasal obstruction on both
sides since many years.
• Outer Nose: overprojected nasal tip with a
high bony and cartilaginous dorsum, an
oblique nasal labial angle and the nasal pyramid is narrow and resembles a high, narrow,
pointed gothic arch, positive U-phenomenon.
• Endonasal ndings: Typical tension nose with
slit-like internal ostium on both sides and to a
lesser extent also external ostium on both
sides. Septum within the midline. Turbinate
on both sides congested, after decongestion
normally congured inferior turbinates.
Normal mucosa.
• Rhinometric ndings: cf. Fig.27.16a.
• Analysis of preoperative rhinometric ndings:
Extent ofObstruction
RRM resistance: Before and after decongestion,
severe obstruction on both sides.
Cause oftheObstruction onBoth Sides
RRM: Based on the increase of width by decon-
gestion from a hydraulic diameter of 1.8 to
3.3mm on the right and from 2.2 to 3.5mm on
the left indicate severe swelling and severe
skeletal stenosis on both sides. Complete turbulence at 81 mL/s on the right and at
122mL/s on the left as well as the increase of
resistance by NVC of more than 100% contribute to the severe nasal obstruction.
ARM: The most pronounced stenosis on both
sides is localized in the internal ostium
(MCA1). But also the external ostia (MCA0)
contributes to the increased resistance due to
its small dimensions.
ab
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Fig. 27.16 Pre- (a) and 1 year postoperative (b) rhinoresistometric measurements for clinical example 4
355
Assessment
The strong swelling on both nasal sides should be
claried by more rened diagnostic testing for
allergic and non-allergic rhinitis [54]. The severe
obstruction after decongestion is caused on both
sides by a stenosis of the internal more than the
Surgery
Septorhinoplasty to relax and deproject the nose.
No stabilization of the lateral nasal wall, no turbinate surgery.
One year postoperatively, the patient was
re-assessed:
external ostium. In addition, the narrow internal
ostium on both sides leads by the Bernoulli phenomenon to a pathological NVC and by a narrow
diffuser entrance to severe pathological turbulence (see Sects. 20.4 and 20.5). Thus, the resistance is further increased.
• Complaints: No nasal obstruction.
• Outer Nose: Normal. In comparison to preoperatively, deprojected nose, physiologic nasal
pyramid.
• Endonasal ndings: Septum in the midline.
Sufciently wide nasal valve angle on both
Rhinosurgical Planning
Correction of the internal and external ostium on
both sides is possible by decreasing the height
of the septum and reducing overprojection, as
well as reducing and reconguring the bony
pyramid. This will result in extension and
rounding of both ostia on both nasal sides.
Due to this change, Bernoulli phenomenon
will be greatly reduced and the entrance of the
nasal diffuser will be enlarged. Accordingly,
normalization of the nasal valve and of turbulence behaviour has to be expected. Reduction
of turbinates is not required, as conguration
after decongestion is normal.
sides, rounded in comparison to preoperatively. Inferior turbinates after decongestion
normally congured. Mucosa normal.
• Rhinometric ndings: cf. Fig.27.16b.
• Analysis of postoperative rhinometric ndings:
RRM: The preoperatively increased resistance on
both nasal sides is normalized. Besides, the
pathological turbulence behaviour is nearly
normal on the right and completely physiologic on the left. Pathological NVC has been
corrected on both sides; only a physiologic
one persists on the left.
ARM: The septum is still within the midline.
The entrance areas of both nasal cavities
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G. H. Mlynski et al.
are significantly increased in width, as
indicated by MCA0 and MCA1 after
decongestion.
27.3.2.5 Example 5: Severe Nasal
Obstruction onBoth Sides
DuetoBroad Columella
Patient: male, 40years of age
• History: No trauma recalled. Patient is referred
for septoplasty and turbinate surgery.
• Complaints: Severe nasal obstruction on both
sides since childhood.
• Outer Nose: broad columella, small external
ostia on both sides, otherwise normal.
• Endonasal ndings: Slight septal deviation to
the right in Cottle areas 2 and 3, no stenosis of
endonasal airow channel within the cavum.
Normal mucosa.
• Measurement ndings: cf. Fig.27.17a.
• Preoperative analysis of the ndings.
Extent ofObstruction
RRM resistance: Before and after decongestion,
severe obstruction on both sides.
Cause oftheObstruction onBoth Sides
RRM: Based on the increase of width by decon-
gestion from a hydraulic diameter of 2.8 to
3.1mm on the right and from 2.5 to 3.5mm on
the left indicate both, severe swelling and
severe skeletal stenosis on both nasal sides.
On both nasal sides, increase of resistance by
NVC of more than 100% contributes to the
severe nasal obstruction. Turbulence behaviour is physiologic on both sides.
ARM: The most pronounced stenosis on both
sides is localized in the external ostium
(MCA0).
Assessment
The aetiology of congestion on both nasal sides
should be claried by more rened diagnostic
testing for allergic and non-allergic rhinitis [54].
Septal deviation is regarded as physiologic,
because no impact on uid dynamic parameter of
nasal airow is detectable [54, 55]. The severe
obstruction after decongestion is caused on both
sides by a stenosis of the external ostia. In addition, the Bernoulli phenomenon at the ostium
externum contributes to nasal resistance by NVC.
Rhinosurgical Planning
Correction of the external ostium on both sides
by addressing the pathological broad columella
will decrease the skeletal, permanent resistance
as well as the dynamic increase in nasal resistance caused by pathological NVC.Stiffening of
Fig. 27.17 Pre- (a) and 1 year postoperative (b) rhinoresistometric measurements for clinical example 5
ab
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357
the lateral nasal valve is not indicated, as enlargement of the nasal airow channel in this segment
will reduce the effect of the Bernoulli phenomenon. Reduction of turbinates is not required, as
conguration after decongestion is normal.
Surgery
Columella narrowing.
One year postoperatively, the patient was
re-assessed:
• Complaints: No nasal obstruction.
• Outer Nose: Normal. In comparison to preop-
eratively normal width of the Columella.
• Endonasal ndings: Septum in the midline.
Inferior turbinates after decongestion normally congured. Mucosa normal.
• Postoperative rhinometric ndings: cf.
Fig.27.17b.
• Analysis of postoperative rhinometric ndings:
RRM: The preoperatively increased resistance on
both nasal sides is nearly normalized. Besides,
the pathological NVC has been successfully
corrected on both sides. The turbulence behaviour remains physiologic.
ARM: The septum is still within the midline. The
ostium externum (MCA0) is clearly enlarged
compared to preoperatively.
27.3.2.6 Example 6: Subjective Nasal
Obstruction Without Evident
Aetiology
Patient: male, 46years of age
• History: No trauma recalled. Multiple prior
consultations of different rhinologists because
of “insufcient nasal breathing”. Concurring
assessments after clinical and rhinomanometric
examination. RRM (cf. Fig.27.18): right side:
no obstruction, left side: very slight obstruc-
Fig. 27.18 Pre- (a) and 1 year postoperative (b) rhinoresistometric measurements for clinical example 6
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G. H. Mlynski et al.
tion. Hence, no pathological endonasal nding
as evident aetiology of the nasal obstruction.
Therefore, no indication for functional rhinosurgery. However, the patient complains believably on disability by obstruction of his nasal
breathing. Consultation of a psychologist: no
evidence on aggravation. Decision for a RRM
re-examination (Fig.27.18).
Clinical re-examination
• Complaints: Nasal obstruction on both sides,
during several years increasing.
• Outer nose: Normal.
• Endonasal ndings: Septum in the midline.
Inferior turbinates after decongestion normally congured. Normal mucosa.
• Rhinometric measurement ndings: cf.
Fig.27.18a.
• Preoperative analysis of the rhinometric
ndings:
Extent ofObstruction
RRM resistance: Before decongestion slight
obstruction on the right. After decongestion on
the right no and on the left side slight nasal
obstruction.
Cause oftheObstruction
RRM: The increase of width by decongestion on
the right from a hydraulic diameter of 4.9 to
5.4mm objectives a slight congestion, but no
skeletal stenosis. The increase of the hydraulic
diameter on the left from 3.5 to 4.9 mm by
decongestion indicates a severe congestion
and a very slight skeletal stenosis. NVC and
turbulence are physiologic.
ARM: The physiologic stenoses on both sides
seem sufciently wide.
Assessment
The congestion on the left is interpreted as resting phase of the nasal cycle. The subjective nasal
obstruction claimed by the patient cannot be sufciently explained by clinical examination and
rhinometric objective diagnostics.
This discrepancy between subjective com-
plaints and objective assessment is the indication
to employ LRM [54, 56].
LRM (cf. Fig.27.9a, lower graph): During
the whole measurement, a classical type of a
nasal cycle persists. But nasal airflow, indicated by nasal minute volume, is very low
with flow values during the day of about 5L/
min and increasing during physical activity, as
indicated by increased heart rate, only up
to10 L/min (e.g. 21:00, 11:00, 14:15 and
18:15). This indicates a permanent mouthbypass breathing.
Assessment Together withResults
oftheLRM Examination
The constant mouth-bypass breathing objectively
conrmed the subjective complaint of nasal
obstruction by the patient. The key message is
that “this respiratory function is insufcient for
this patient”.
Rhinosurgical Planning
The aim is a limited enlargement if the isthmus
region on the left > right using functional (wedgeshaped) spreader grafts [17]. Reduction of turbinates is not required, as conguration after
decongestion is normal.
Surgery
Septorhinoplasty with functional spreader grafts
to enlarge the internal ostium. No turbinate
surgery.
One year postoperatively, the patient was
re-assessed:
• Complaints: No nasal obstruction.
• External Nose: Normal.
• Endonasal ndings: Septum in the midline.
Sufciently wide nasal inow area on both
sides. Inferior turbinates after decongestion
normally congured. Mucosa normal.
• Rhinometric ndings: cf. Fig.27.18b.
Analysis ofPostoperative Rhinometric
Findings
RRM: The preoperatively only slightly increased
resistance on the left nasal side is decreased
and normalized. Also on the right side the
resistance is slightly increased, and NVC and
turbulence behaviour are normal.
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ARM: The nasal inow area is slightly wider on both
nasal sides in comparison to preoperatively.
LRM: Classical type of nasal cycle with signi-
cantly increased nasal minute volume in comparison to preoperatively. During physical
activity [56], in concert type with sufcient
and more pronounced increase of NMV (e.g.
at 19:00, 7:45, 10:00, 10:45 12:45, and 16:45).
27.4 Conclusions
• RMM does not allow a sufcient differentiation of nasal obstruction causes. It only provides the rhinosurgeon with insufcient
information with regard to the appropriate
diagnosis and surgical approach. Despite
RMM being world widely currently available,
it has not yet been implemented in routine preoperative diagnostics. However, preoperative
mismanagement may contribute to an unsatisfying surgical result.
• Therefore, RMM has been rened further to
RRM.With this method, not only the extent of
nasal obstruction can be objectied but it also
allows a differentiation of the four possible
causes of nasal obstruction:
– Mucosal swelling
– Skeletal stenosis
– Inspiratory collapse of the nasal valve
– Pathologically increased degree of
turbulence
• With ARM the localization of the decisive
narrowings which cause obstruction, the identication of narrowings as cause of a NVC and
causes for pathological turbulences in the
nose, such as
– Strong increase of diameter in the nasal dif-
fuser (opening angle).
– Narrow diffuser entrance may be diagnosed.
• LRM allows objectication of the following:
– Changes in ow due to physiological swell-
ing, separately in both sides of the nose,
depending on physical stress.
– The nasal cycle as an important precondi-
tion for the nasal respiratory function and
its disturbances.
– Pathological swelling under a patient’s
daily living conditions within the course of
24h.
A combination of these methods allows a preoperative objectication of the aetiology of a
patient’s complaints due to nasal obstruction.
With this, also the measurement-relevant precondition for a postoperative quality management as
a fundament for an evidence-based therapy, similar to developments in other specialities such as
otology/neurotology or phonosurgery, is given.
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Testing ofTransport
https://t.me/medicina_free
andMeasurement ofCiliary
Activity
MarkJorissen andMartineJaspers
28
Core Messages
• The mucociliary transport (MCT) can be studied by recording MCT as well as by measuring ciliary activity, but none of these tests are
reliable for the diagnosis of inherited
abnormalities.
• Most people with PCD have unusually low
levels of nasal NO, but a low nNO measurement is nondiagnostic for PCD. Sequential
monolayer–suspension cell culture with dedifferentiation and redifferentiation of the ciliated epithelium is the most reliable screening
test for the diagnosis of PCD.
28.1 Introduction
Ciliary activity causes the transport of mucus in
the airways, which is an essential defense mechanism of the respiratory tract. Inhaled particles,
bacteria, and viruses are trapped in the mucus
layer that covers the airways and are transported
by the beat of the cilia to the nasopharynx, where
they are either swallowed or coughed up. Inborn
disorders of the mucociliary transport are due to
ciliary dysfunction as in primary ciliary dyskine-
M. Jorissen (*) · M. Jaspers
ENT Department, University Hospitals Leuven,
Leuven, Belgium
e-mail: mark.jorissen@uzleuven.be;
martine.jaspers@med.kuleuven.be
sia (PCD) or to increased viscosity of the respiratory secretions as in cystic brosis (CF). Also
frequently mucociliary transport is impaired
because of inammation, infection, and exposure
to ciliotoxic agents.
Mucociliary transport (MCT) can be studied
by recording MCT invivo, as well as by measuring ciliary activity in vitro. Methods based on
nasal ciliary motility for the diagnosis of primary
ciliary dyskinesia (PCD) are often hampered by
the presence of acquired abnormalities [secondary ciliary dyskinesia (SCD)].
Mucociliary clearance can be evaluated by using
the saccharine and/or the
test as well as by measuring ciliary activity and is
important in the diagnosis of primary ciliary
dyskinesia.
99m
Tc-albumin colloid
28.2 Testing ofTransport
28.2.1 Testing ofTransport InVivo
The mucociliary transport rate can be measured
invivo either by using the saccharine test [1, 2] or
by using the radioisotope technique [3]. If with
one of these methods active mucociliary transport can be demonstrated, it is accepted that the
diagnosis of PCD is excluded. An abnormal
result can certainly not be considered as proof for
the disease. It implicates only that further investigation is needed.
© 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_28
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M. Jorissen and M. Jaspers
28.2.1.1 Saccharine Test
With the saccharine test, a particle of saccharine
(most frequently dipped in a blue color, such as
indigo blue powder) is placed on the inferior turbinate and the time elapsed before the patient
taste the saccharine is measured. Patients are
instructed to swallow at least once per minute.
The appearance in the pharynx can be veried by
the blue color in the pharynx. With this technique
the mean normal mucociliary transport time
(MTT) is about 10min. MTT up to 30min is still
considered normal. If this takes more than
30min, the test is considered abnormal. For this
test cooperation of the individual is needed, since
he/she has to report the sweet taste. Also snifng,
sneezing, and blowing the nose are prohibited
since these may affect the position of the particles. This limits the use of the test in children.
The saccharine has to be placed on the respiratory (ciliated) epithelium. Otherwise no transport
will be found.
Most frequently a color (methylene blue,
indigo blue, charcoal, etc.) is added to the test, as
a visual control. Repeated examination will allow
one to verify the transport of the particle and to
compare the appearance of the color in the pharynx with the perception of the sweet taste.
When combined with nasal endoscopy, the
colored particles can be followed to evaluate the
transport pattern. That technique can also be used
to follow and study the pathways within the
(maxillary) sinuses.
28.2.1.2 Nuclear Testing
Up to now measuring the transport of radiolabeled albumin remains the most reliable method
for measuring mucociliary transport.
When a minute amount of radiolabeled
99m
Tcalbumin colloid particles [3] is placed on the
inferior turbinate or on the nasal septum, the
migration can be followed with a gamma camera.
Normally within 30 min the majority of the
radioactivity must have disappeared from the
nasal cavity. The percentage of radioactivity
remaining in the nasal cavity can be calculated
and in sagittal views the migration of the spot can
be measured. It has been shown that the dose of
radioactivity is low enough that immotility does
not create problems. In contrast to the saccharine
test, this test is not inuenced by snifng. A normal test result is considered an exclusion criterion of PCD.If the particles moved insufciently,
further investigation is needed, because dysmotility could be due to upper airway infections or
PCD.Moreover, in up to 25% of individuals with
SCD and also in controls, no migration of the
tracer is found.
Marthin et al. [4] studied an alternative
method, the pulmonary radioaerosol mucociliary
clearance technique, which has a higher specicity for PCD as secondary dysmotility is much
less prevalent in the lower airways. The
radioactive- labeled
99m
Tc-albumin transportation
test is more reliable than the saccharine test but
requires expensive equipment and can only be
done in specialized centers.
28.2.2 Testing ofTransport InVitro
Bioptic or brushed material can be checked for
the presence of cilia under phase contrast microscopy. Real movements such as displacements and
rotations of cell clusters or cell sheets within the
uid and movement of particles within the uid
lining the cilia are criteria for the presence of
coordinated ciliary activity. Absence of these elements in the presence of ciliary activity is
recorded as “uncoordinated ciliary activity.” It
should always be checked whether cilia are
present.
28.3 Testing ofCiliary Activity
28.3.1 In Vivo
Laser light-scattering spectroscopy provides an
improved, precise, and simple method to study
ciliary activity. The light from a laser beam is
directed at a ciliated surface, and due to the
Doppler effect, the scattered light returning from
the moving cilia has an altered frequency and
phase induced by the movement of the reecting
surfaces of the cilia. The scattered light can be
detected with a photomultiplier tube, and the
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