Relationships Among Nasal Obstruction, Daytime Sleepiness, and Quality of Life

An adjoint-based approach for the surgical correction of nasal septal deviations

Deviations of the septal wall are widespread anatomic anomalies of the human nose; they vary significantly in shape and location, and often cause the obstruction of the nasal airways. When severe, septal deviations need to be surgically corrected by ear-nose-throat (ENT) specialists. Septoplasty, however, has a low success rate, owing to the lack of suitable standardized clinical tools for assessing type and severity of obstructions, and for surgery planning. Moreover, the restoration of a perfectly straight septal wall is often impossible and possibly unnecessary. This paper introduces a procedure, based on advanced patient-specific Computational Fluid Dynamics (CFD) simulations, to support ENT surgeons in septoplasty planning. The method hinges upon the theory of adjoint-based optimization, and minimizes a cost function that indirectly accounts for viscous losses. A sensitivity map is computed on the mucosal wall to provide the surgeon with a simple quantification of how much tissue removal at each location would contribute to easing the obstruction. The optimization procedure is applied to three representative nasal anatomies, reconstructed from CT scans of patients affected by complex septal deviations. The computed sensitivity consistently identifies all the anomalies correctly. Virtual surgery, i.e. morphing of the anatomies according to the computed sensitivity, confirms that the characteristics of the nasal airflow improve significantly after small anatomy changes derived from adjoint-based optimization.

Prevalence of nasal obstruction and its impact on quality of life in Saudi Arabia

Purpose/Background

Nasal obstruction is a significant issue influencing the patient's quality of life. Chronic nasal obstruction is frequently associated with other symptoms such as headache, sleep disturbance, and daytime sleepiness. This study aims to investigate the prevalence of nasal obstruction in Saudi Arabia and examine its effect on patients' quality of life.

Methods

This is a cross-sectional study conducted in Saudi Arabia. Data were collected using a self-administered combination of two previously validated questionnaires (the NOSE scale and the WHOQOL-BREF) translated into Arabic. The Mann-Whitney test was used to investigate the association between nasal obstruction prevalence and the participants' QOL.

Results

The study included 1039 participants from different regions of Saudi Arabia. The prevalence of nasal obstruction was 60.3% among the participants. Several factors significantly affected the prevalence of nasal obstruction, including sex, suffering from a chronic disease, having a family member with nasal obstruction, and using medications (P < 0.001 for all factors). A better score was shown in the four domains of the WHOQOL-BREF questionnaire by the participants who had no nasal obstruction: the physical health domain, psychological health, social relationships, and environment (P < 0.001 for all factors).

Conclusions

Quality of life is affected by nasal obstruction. The subjective assessment is essential in evaluating the severity of nasal obstruction disease. It is recommended that healthcare providers use subjective tools combined with objective tools to assess the degree of nasal obstruction severity.

Economic impact analysis of a minimally invasive temperature-controlled radiofrequency device versus nasal surgery for the treatment of nasal airway obstruction in the United States

OBJECTIVE

To determine the economic impact of a minimally invasive temperature-controlled radiofrequency (TCRF) device for treating nasal airway obstruction (NAO).

METHODS

A budget impact model was developed for two scenarios: a reference scenario of functional rhinoplasty surgery with concomitant septoplasty and inferior turbinate reduction (ITR) performed in the hospital outpatient department where TCRF is not an available treatment option and a new scenario consisting of in-office TCRF treatment of the nasal valve and ITR. A payor perspective was adopted with a hypothetical population plan size of one million members. Costs were estimated over a time horizon of 4 years. The eligible population included patients with severe/extreme NAO and nasal valve collapse (NVC) as the primary cause or significant contributor. Data inputs were sourced from targeted literature reviews. Uncertainty within the model structure and input parameters was assessed using one-way sensitivity analysis.

RESULTS

The introduction of a TCRF device resulted in population-level cost savings of $20,015,123 and per-responder average cost savings of $3531 through a 4-year time horizon due to lower procedure costs and complication rates of the device relative to the surgical comparator. Results were robust when varying parameter values in sensitivity analyses, with cost savings being most sensitive to the prevalence of NAO and estimated response rates to functional rhinoplasty and TCRF.

CONCLUSIONS

In patients with severe/extreme NAO, with NVC as the primary or major contributor, introducing TCRF with ITR as a treatment option demonstrates the potential for significant cost savings over functional rhinoplasty with septoplasty and ITR.

The Impact of Sinonasal Symptoms in Relation to Potentially Life-Threatening Comorbidities

OBJECTIVE

While general health may be influenced by sinonasal symptoms, their effects may be overshadowed by comorbid states which may be more serious. To assess the validity of this postulate, we measured the extent to which sinonasal symptoms and concurrent conditions influenced general health.

STUDY DESIGN

Observational outcomes study.

SETTING

Academic medical center, community care sites.

METHODS

Adults with sinonasal symptoms completed the 22-item Sinonasal Outcome Test, along with the Patient-Reported Outcomes Measurement Information System global health short form. Comorbidities were categorized with the Deyo modification of the Charlson comorbidity index. Multivariate regression analyses were utilized to determine the relative impact of sinonasal symptoms and concurrent comorbid conditions on general health.

RESULTS

Data from 219 consecutive patients demonstrated that sinonasal symptoms were associated with significantly diminished general physical (β = -1.431, p < .001), mental (β = -1.000, p < .001), overall (β = -1.026, p < .001), and social health (β = -0.872, p = .003), regardless of the presence of potentially life-threatening comorbid conditions. Comorbid conditions included cardiovascular disease, chronic obstructive pulmonary disease, connective tissue disease, peptic ulcer, diabetes mellitus, and hepatic disease. The effect of sinonasal symptoms was neither subsumed nor overshadowed by the effects of comorbid states. Nasal, ear, sleep, and psychological domain scores were also associated with general physical, mental, and global health while adjusting for the impact of comorbidities.

CONCLUSION

Sinonasal symptoms have a substantial effect on general health which is not subsumed by the presence of potentially life-threatening concurrent comorbidities. These data may help support the importance of funding and resource allocation for conditions causing sinonasal symptoms.

Temperature-controlled radiofrequency device treatment of septal swell bodies for nasal airway obstruction: An open-label, single arm multicenter study

BACKGROUND

Nasal airway obstruction (NAO) is a highly prevalent disorder. Septal swell body (SSB) hypertrophy is an often overlooked contributor to NAO. SSB treatment may relieve symptoms of NAO. The objective of this study was to assess the clinical use of a temperature-controlled radiofrequency (TCRF) device to treat SSBs to improve symptoms in adults with NAO.

METHODS

In this prospective, multicenter, open-label, single arm study, patients with severe or extreme NAO related to SSB hypertrophy received bilateral TCRF treatment in the SSB area. The primary endpoint was improvement in Nasal Obstruction Symptom Evaluation (NOSE) Scale scores from baseline to 3 months postprocedure. A subset of study patients underwent computed tomography (CT) imaging to evaluate posttreatment changes in SSB size.

RESULTS

Mean NOSE Scale scores significantly improved from 73.5 (SD 14.2) at baseline to 27.9 (SD 17.2) at 3 months postprocedure, a reduction of -45.3 (SD 21.4, 95% confidence interval [CI]: -50.4 to -40.1; p < 0.0001); the responder rate was 95.7% (95% CI: 0.88 to 0.99; p < 0.0001). CT evaluation at 3 months showed statistically significant reductions in the SSB with the greatest reduction in the middle thickness (mean change -3.4 [SD 1.8] mL, 95% CI: -4.0 to -2.8; p < 0.0001). Minimal adverse events with any relationship to the device or procedure were reported; none were serious in nature and no septal perforations occurred.

CONCLUSIONS

This study demonstrates that TCRF treatment of SSB hypertrophy is well tolerated and effective at reducing both SSB size and symptoms of NAO at 3 months posttreatment.

Prevalence and Identification of Nasal Airway Obstruction in Patients Presenting to Otolaryngology Clinics: Results From a Large Descriptive Practice Survey

Objective: Determine the prevalence of nasal airway obstruction (NAO) in patients presenting to general otolaryngology clinics using the Nasal Obstruction Symptom Evaluation Scale (NOSE) score as a screening tool. Study Design: The clinic staff at 149 otolaryngology specialty clinics geographically distributed in the United States administered the NOSE Scale assessment to 3533 patients presenting to the clinics over a period of 1 week, regardless of the reason for the visit. All patients completed the NOSE Scale score, and additional data were collected, including the primary reason for the visit. Demographic and patient characteristics were summarized using frequencies and percentages for categorical variables. Results: The overall mean NOSE Scale score for the 3533 patients surveyed was 37.6 (SD 31.5). A total of 37.4% (1320/3533) of surveyed patients, regardless of visit reason, had severe/extreme NAO symptoms. Overall, the most common visit reason category was "Other" (61.2%, 2162/3533), followed by "NAO" (22.6%, 798/3533) and "Sinus" (16.2%, 573/3533). The mean NOSE scores for patients in each of the visit categories were 23.4 (SD 25.9), 64.7 (SD 23.3), and 53.3 (SD 28.1); for "Other," "NAO," and "Sinus," respectively. Among the patients coming in with "NAO" or "Sinus" as a primary complaint, 76.2% (608/798) and 57.2.% (328/573) had severe or extreme NOSE scores. A total of 17.8% (384/2162) of patients coming in for "Other" reasons had NOSE scores indicating severe/extreme NAO symptoms. Conclusions: The findings of this large, descriptive otolaryngology practice survey found a high prevalence of moderate to severe/extreme NAO among patients presenting to otolaryngology practices. Incorporating assessments, such as the NOSE Scale score and other diagnostic practices into the patient intake workflow and assessments, could help identify symptomatic NAO patients that might otherwise be overlooked.

TRPA1/M8 agonists upregulate ciliary beating through the pannexin-1 channel in the human nasal mucosa

BACKGROUND

Nasal breathing is important for maintaining physiological respiration. However, airflow in the nasal cavity has an inherent cooling effect and may suppress ciliary beating, an essential frontline defense in the airway. Nasal airflow is thought to be perceived by thermoreceptors for cool temperatures. We herein investigated the effect of the activation of thermosensitive transient receptor potentials (TRPs) for cool/cold temperatures on ciliary beating to search for a compensatory mechanism.

METHODS

Inferior turbinates were collected from patients with chronic hypertrophic rhinitis. Ex vivo ciliary beat frequency (CBF) and ATP release were measured using a high-speed digital video camera and by luciferin-luciferase assay, respectively. Intracellular Ca²⁺ ([Ca²⁺]_i) imaging of isolated ciliated cells was performed using Fluo-8. The nasal mucosae were also subjected to fluorescence immunohistochemistry and real-time RT-PCR for TRPA1/TRPM8.

RESULTS

CBF was significantly increased by adding either cinnamaldehyde (TRPA1 agonist) or l-menthol (TRPM8 agonist). This increase was inhibited by pannexin-1 blockers, carbenoxolone and probenecid. Cinnamaldehyde and l-menthol also increased the ATP release from the nasal mucosa and [Ca²⁺]_i of isolated ciliated cells. Immunohistochemistry detected TRPA1 and TRPM8 on the epithelial surface including the cilia and in the submucosal nasal glands. Existence of these receptors were confirmed at the transcriptional level by real-time RT-PCR.

CONCLUSIONS

These results indicate the stimulatory effect of the activation of TRPA1/TRPM8 on ciliary beating in the nasal mucosa, which would be advantageous to maintain airway mucosal defense against the fall of temperature under normal nasal breathing. This stimulatory effect is likely to be mediated by pannexin-1.

Differential Recovery Patterns of the Maxilla and Mandible after Eliminating Nasal Obstruction in Growing Rats

Although nasal obstruction (NO) during growth causes maxillofacial growth suppression, it remains unclear whether eliminating the NO affects maxillary and mandibular growth differentially. We aimed to clarify whether eliminating NO can help regain normal maxillofacial growth and to determine the optimal intervention timing. Forty-two 4-week-old male Wistar rats were randomly divided into six groups. Their left nostril was sutured to simulate NO over different durations in the experimental groups; the sutures were later removed to resume nasal breathing. Maxillofacial morphology was assessed using microcomputed tomography. Immunohistochemical changes in hypoxia-inducible factor (HIF)-1α, osteoprotegerin (OPG), and receptor activator of nuclear factor kappa-B ligand (RANKL) of the condylar cartilage were evaluated to reveal the underlying mechanisms of these changes. Maxillary length was significantly lower in rats with NO for ≥5 weeks. In groups with NO for ≥7 weeks, the posterior mandibular length, ramus height, thickness of the hypertrophic cell layer in the condylar cartilage, HIF-1α levels, and RANKL levels were significantly lower and OPG levels and RANKL/OPG were significantly higher than those in the control group. Our findings suggest that eliminating NO is effective in regaining maxillofacial growth. Moreover, the optimal timing of intervention differed between the maxilla and mandible.

Outcomes 12 Months After Temperature-Controlled Radiofrequency Device Treatment of the Nasal Valve for Patients With Nasal Airway Obstruction

Question

Is temperature-controlled radiofrequency device treatment of the nasal valve safe and associated with improvement in symptoms of nasal airway obstruction through 12 months postprocedure?

Findings

At 12-month follow-up of 108 patients treated in a randomized clinical trial with 3-month crossover available to patients in the index sham control arm, patients in the combined active treatment group exhibited a sustained improvement in symptoms over baseline, measured by the Nasal Obstruction Symptom Evaluation Scale.

Meaning

Temperature-controlled radiofrequency device treatment of the nasal valve was associated with a sustained improvement in symptoms of nasal airway obstruction through 12 months.

Importance

Nasal valve collapse is a primary cause of nasal airway obstruction (NAO). Patients with NAO and nasal valve collapse experience a variety of symptoms that lower their quality of life, such as nasal congestion, headache, sleep disturbance, daytime sleepiness, and snoring.

Objective

To determine if active treatment of the nasal valve with a temperature-controlled radiofrequency (TCRF) device, previously demonstrated superior to a sham procedure at 3 months, was safe and associated with sustained improvements in symptoms of NAO through 12 months.

Design, Setting, and Participants

In a prospective, multicenter, single-blinded, randomized clinical trial, patients in 16 centers in the US with index procedures between August and December 2020 were assigned to TCRF device treatment of the nasal valve or a sham control procedure (no RF energy). Patients had a baseline Nasal Obstruction Symptom Evaluation (NOSE) Scale score of 55 or greater with nasal valve collapse as the primary or substantial contributor to NAO. After primary end point evaluation at 3 months, eligible patients in the sham control arm crossed over to active treatment. Data analysis was performed between April and May 2022.

Interventions

Patients were treated bilaterally with the TCRF device at 4 or fewer nonoverlapping areas on the nasal mucosa at the junction of the upper and lower lateral cartilage on the lateral nasal wall.

Main Outcomes and Measures

The primary end point measure was responder rate, defined as 20% or greater reduction in NOSE Scale score or 1 or greater reduction in NOSE Scale clinical severity category.

Results

A total of 108 patients received active treatment (77 as index active treatment, 31 after crossover). The mean (SD) age of patients was 48.5 (12.3) years; 66 (61.1%) were women. The combined group of patients receiving active treatment had a mean baseline NOSE Scale score of 76.3 (95% CI, 73.6-79.1). At 12 months (n = 88), the responder rate was 89.8% (95% CI, 81.7%-94.5%). The NOSE Scale score improved from baseline (mean change, −44.9 [95% CI, −52.1 to −37.7]). No device/procedure-related serious adverse events were reported.

Conclusions and Relevance

In this follow-up of a cohort from a randomized clinical trial, the minimally invasive TCRF device, previously demonstrated to be superior to a sham procedure, was safe and associated with improvement in symptoms of NAO through 12 months postprocedure.

Trial Registration

ClinicalTrials.gov Identifier: NCT04549545

Efficacy and Safety of Lactobacillus reuteri CCFM1040 in Allergic Rhinitis and Asthma: A Randomized, Placebo-Controlled Trial

The coexistence of allergic rhinitis (AR) and asthma reinforces the concept of “one airway, one disease,” which has prompted the exploration for a single intervention to treat both diseases. Lactobacillus reuteri CCFM1040 (CCFM1040) was found to be an inhibitor of the common pathogenesis of AR and asthma in our previous studies. This study presented a randomized, placebo-controlled trial to investigate the clinical effects of CCFM1040 on both diseases. The total symptom score (TSS), the quality of life (QoL), and the modulation in the gut microbiota of patients with AR, the Asthma Control and Test (ACT) of patients with asthma, and the safety of both AR and asthma were measured. In patients with AR, CCFM1040 numerically decreased TSS, Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), 3 nasal scores in TSS (nasal congestion, watery eyes, and rhinorrhea), and sleep and significantly improved (P = 0.014) non-nose/eye symptoms. The ACT score was numerically increased in patients with asthma (from partially controlled to well-controlled). Significant microbial (from class level to genus level) and metabolic differences (P < 0.05) were found in patients with AR. No adverse reactions were observed. No effect on the blood and urine routine indexes. CCFM1040 has a potential benefit on both diseases. Further studies based on these findings will help to optimize the management of AR and asthma.

Effects of Surgical Treatment for Allergic Rhinitis on Sleep and Mental Health in Adolescents

Allergic rhinitis (AR) is a common chronic condition that is usually treated medically. Adolescents form a unique population in which AR-associated symptoms are greater than those in adults or children, and are closely related to sleep and mental disorders. In the current study, a retrospective analysis was performed to illustrate the surgical effects of AR symptoms on sleep and mental disorders in adolescents. In 81 adolescents with AR symptoms refractory to medical management, the severity of the AR symptoms was correlated with that of sleep or mental disorders. As a standard surgical procedure, submucosal bony resection of inferior turbinates with posterior nasal neurectomy was performed and half of the subjects underwent septoplasty due to severe deviation of the nasal septum. The degree of improvement in AR-associated symptoms by surgical treatment was correlated with that of mental disorders in adolescent patients who had sleep and mental disorders preoperatively. Considering the impact of AR symptoms on the quality of life of adolescents, surgical treatment can be a potent option for the treatment of AR refractory to medical management in this population.

Evaluation of the clinical efficacy of nasal surgery in the treatment of obstructive sleep apnoea

STUDY OBJECTIVES

The aim of the study was to evaluate the clinical efficacy of nasal surgery in the treatment of obstructive sleep apnoea (OSA) by comparing the improvement of subjective symptoms and objective metrics before surgery and after 6 months of surgery.

METHODS

Patients with the main complaint of nasal congestion combined with habitual snoring who were hospitalized and treated were selected. Patients underwent subjective symptom tests and objective indicator monitoring both before surgery and 6 months after surgery. Comparisons between groups were performed using the independent samples t-test.

RESULTS

Subjective scale evaluations demonstrated that nasal congestion, daytime sleepiness, snoring, nose-related symptoms, and sleep symptoms in patients with simple snoring or with OSA were improved after nasal surgery. Additionally, vitality was improved in all groups except for the patients with simple snoring and emotional consequence was improved in patients with simple snoring and mild OSA. Objective evaluations indicated the apnoea-hypopnoea index (AHI), the thickness of the soft palate, and the maximum cross-sectional area of the sagittal plane of the soft palate decreased after surgery in patients with mild OSA. The lowest blood oxygen concentration (LSaO₂) and anteroposterior diameter of the soft palate increased after surgery in patients with mild OSA. The arousal index also significantly decreased in patients with mild and moderate OSA. The nasal cavity volumes (NCVs) and the nasal minimal cross-sectional areas (NMCAs) of all groups showed significant differences after surgery.

CONCLUSIONS

Nasal surgery can effectively improve nose and sleep symptoms in patients with simple snoring or with OSA. It can significantly reduce the nasal resistance and increase the ventilation volume.

STATEMENT OF SIGNIFICANCE

Obstructive sleep apnoea (OSA) is becoming a global health problem. OSA is associated with several coexisting conditions, reduced health-related quality of life, and impaired work productivity. This study performed nasal surgery on OSA patients with the main complaint of nasal congestion combined with snoring and patients with simple snoring to compare the improvement of subjective symptoms and objective metrics before and after surgery. We found that: (1) symptoms such as nasal congestion, daytime sleepiness or snoring were improved after nasal surgery; (2) the apnoea-hypopnoea index (AHI) and arousal index decreased after surgery in patients with OSA; (3) the nasal and oropharyngeal cavity volumes increased after surgery. These findings suggest that patients with OSA or with simple snoring could benefit from nasal surgery.

Feasibility of Distraction Osteogenesis Maxillary Expansion (DOME) in patients with persistent nasal obstruction after septoplasty

BACKGROUND

Distraction osteogenesis maxillary expansion (DOME) is an emerging surgical concept for obstructive sleep apnea patients presenting with nasal obstruction, with a high-arched and narrow hard palate. We demonstrate the feasibility of DOME in the treatment of patients with persistent nasal obstruction after primary septoplasty.

METHODS

A total of 32 consecutive patients with persistent nasal obstruction after septoplasty who underwent DOME were enrolled in this study. The efficacy of DOME in treating persistent nasal obstruction in septoplasty failure patients was evaluated by using the validated Nasal Obstruction Symptom Evaluation (NOSE) scale. Pre- and postoperative computed tomography (CT) scans were performed to measure the change of nasal floor width after surgery.

RESULTS

The NOSE score significantly improved from 13.62±4.74 to 5.15±3.50 (p<0.001) after DOME. The postoperative CT scan showed a significant increase of the nasal floor width from 22.4±4.21 to 28.06±4.52 (p<0.01). No patient experienced major complications, such as wound infection, oronasal fistula, sinusitis, loss of incisor teeth, and malunion.

CONCLUSIONS

This study shows that DOME appears to improve persistent nasal obstruction after septoplasty in patients with narrow and high-arched hard palate. This article is protected by copyright. All rights reserved.

Decreased CFTR/PPARγ and increased transglutaminase 2 in nasal polyps

OBJECTIVE

Transglutaminase (TGM)2 and peroxisome proliferator-activated receptor (PPAR)γ are thought to participate in the pathogenesis of nasal polyp formation in cystic fibrosis (CF). We herein investigated expressions of cystic fibrosis transmembrane conductance regulator (CFTR), TGM2, PPARγ and isopeptide bonds, a reaction product of TGM, in non-CF nasal polyps.

METHODS

Nasal polyps and inferior turbinates were collected from chronic rhinosinusitis patients without CF during transnasal endoscopic sinonasal surgery. Expressions of CFTR, TGM2, isopeptide bonds and PPARγ were examined by fluorescence immunohistochemistry and quantitative RT-PCR. Expression of CFTR was also analyzed by Western blot.

RESULTS

Immunohistochemical fluorescence of the nasal polyp was significantly lower for CFTR and PPARγ, and significantly higher for TGM2 and isopeptide bonds than that of the turbinate mucosa. Lower expression of CFTR in the nasal polyp than in the turbinate mucosa was also observed in Western blot. Expression of PPARG mRNA was significantly lower in the nasal polyp than in the turbinate mucosa, whereas expressions of CFTR mRNA or TGM2 mRNA did not differ between the two tissues. Immunohistochemical fluorescence for CFTR showed significant negative correlation with that for TGM2 and isopeptide bonds, and significant positive correlation with that for PPARγ. The fluorescence for TGM2 was positively correlated with that for isopeptide bonds and negatively correlated with that for PPARγ. The fluorescence for isopeptide bonds tended to be negatively correlated with that for PPARγ.

CONCLUSIONS

These results suggest a possible role of the CFTR-TGM2-PPARγ cascade in the pathogenesis of nasal polyp formation in non-CF patients as in CF patients.

Temperature-controlled radiofrequency device treatment of the nasal valve for nasal airway obstruction: A randomized controlled trial

Background

Nasal valve collapse is one of several causes of nasal obstruction. The safety and efficacy of a temperature‐controlled radiofrequency (RF) device for the treatment of the nasal valve for nasal airway obstruction (NAO) has been established in single‐arm studies. The objective of this trial was to compare active device treatment against a sham procedure (control).

Methods

In a prospective, multicenter, single‐blinded, randomized controlled trial (RCT), patients were assigned to bilateral temperature‐controlled RF treatment of the nasal valve (n = 77) or a sham procedure (n = 41), in which no RF energy was transferred to the device/treatment area. The device was applied to the mucosa over the lower lateral cartilage on the lateral nasal wall. The primary endpoint was responder rate at 3 months, defined as a ≥20% reduction in Nasal Obstruction Symptom Evaluation (NOSE)‐scale score or ≥1 reduction in clinical severity category.

Results

At baseline, patients had a mean NOSE‐scale score of 76.7 (95% confidence interval [CI], 73.8 to 79.5) and 78.8 (95% CI, 74.2 to 83.3) (p = 0.424) in the active treatment and sham‐control arms, respectively. At 3 months, the responder rate was significantly higher in the active treatment arm (88.3% [95% CI, 79.2%‐93.7%] vs 42.5% [95% CI, 28.5%‐57.8%]; p < 0.001). The active treatment arm had a significantly greater decrease in NOSE‐scale score (mean, −42.3 [95% CI, −47.6 to −37.1] vs −16.8 [95% CI, −26.3 to −7.2]; p < 0.001). Three adverse events at least possibly related to the device and/or procedure were reported, and all resolved.

Conclusion

This RCT shows temperature‐controlled RF treatment of the nasal valve is safe and effective in reducing symptoms of NAO in short‐term follow‐up.

A 300 IR sublingual tablet is an effective, safe treatment for house dust mite-induced allergic rhinitis: An international, double-blind, placebo-controlled, randomized phase III clinical trial

BACKGROUND

Allergic rhinitis induced by house dust mites (HDMs) is a highly prevalent but often underdiagnosed and undertreated/untreated chronic disease. It often has a negative impact on sleep, work, leisure activities, and health-related quality of life. Allergen immunotherapy is a proven, safe treatment for respiratory allergies.

OBJECTIVE

We sought to assess the efficacy and safety of a 300 index of reactivity (IR) sublingual tablet formulation of Dermatophagoides pteronyssinus:Dermatophagoides farinae 1:1 extract in adolescents (aged ≥12) and adults with moderate to severe HDM-induced allergic rhinitis.

METHODS

In a phase III, international, double-blind, placebo-controlled, randomized clinical trial, participants received approximately 12 months of treatment with placebo or the 300 IR tablet. The primary end point was the average total combined score during 4 weeks at the end of the treatment period.

RESULTS

A total of 1607 participants were randomized, and 1476 (including 555 [37.6%] with concomitant mild controlled asthma at inclusion) comprised the full analysis set. Over the primary evaluation period, the least squares mean average total combined score in the 300 IR group (3.62) was significantly lower (P < .0001) than in the placebo group (4.35), with a relative least squares mean difference of -16.9% (95% CI, -24.0% to -9.2%). All prespecified secondary end points were consistently improved in the 300 IR group, relative to placebo. The 300 IR tablet was generally well tolerated. Treatment-related adverse events (mainly mild or moderate local reactions) were reported for 51.0% of the patients in the 300 IR group and 14.9% in the placebo group.

CONCLUSIONS

The 300 IR sublingual HDM tablet is an effective, safe treatment for HDM-induced allergic rhinitis.

Quality-of-life impact after in-office treatment of nasal valve obstruction with a radiofrequency device: 2-year results from a multicenter, prospective clinical trial

Background

Insufficiency of the nasal valve is increasingly being recognized as a cause of nasal airway obstruction. The condition is associated with many symptoms, including nasal congestion, sleep disturbance, snoring, and an overall decline in quality of life (QoL). An in‐office, minimally invasive radiofrequency treatment of the nasal valve has been associated with improved symptoms of nasal obstruction and patients’ QoL for a 6‐month period in a noncontrolled, prospective, single‐arm study. The purpose of this study was to determine whether the results achieved with radiofrequency treatment at 6 months would be sustained through 24 months.

Methods

Thirty‐nine adult patients from an original cohort of 49 patients with severe to extreme Nasal Obstruction Symptom Evaluation (NOSE) Scale scores and dynamic or static internal nasal valve obstruction as the primary or significant contributor to obstruction were studied. Patients received intranasal bilateral radiofrequency treatment in a clinical study with a follow‐up to 6 months, and were prospectively evaluated at 12, 18, and 24 months at 8 community‐based otolaryngology practices. The patient‐reported NOSE Scale score and 21 QoL questions were assessed.

Results

Clinically significant improvement from baseline in NOSE Scale score change demonstrated at 6 months (mean, 55.9; standard deviation [SD], 23.6; p < 0.0001) was maintained through 24 months (mean, 53.5; SD, 24.6; p < 0.0001). Responders (≥15‐point improvement) consisted of 92.3% of participants at 6 months and 97.2% at 24 months. Responses to the QoL questions also showed improvement in patients’ QoL.

Conclusion

Treatment of the nasal valve with an in‐office, transnasal temperature‐controlled radiofrequency procedure was associated with stable and lasting improvement in symptoms of nasal obstruction and QoL through 24 months in this noncontrolled, single‐arm study.

The Impact of Nasal Obstruction and Functional Septorhinoplasty on Sleep Quality

Importance: Functional septorhinoplasty (FSRP) has been shown to improve both global and disease-specific quality of life (QOL). However, the mechanism by which FSRP improves QOL has not been fully defined. We reasoned that NAO may impact sleep quality and, therefore, studied the relationship using validated patient-reported outcome measures. Objective: To investigate the correlation between NAO and sleep quality using Nasal Obstruction Symptom Evaluation (NOSE) and Functional Outcomes of Sleep Quality (FOSQ-10) questionnaires, and to evaluate the effect of FSRP on NAO and sleep quality. Design, Setting, and Participants: This is a prospective longitudinal study of 125 patients undergoing FSRP for the repair of NAO between November 2017 and April 2019 in a university-based tertiary care medical center. The individuals (mean age = 38 ± 15.6 years, 65 females; 52%) were invited to complete the FOSQ-10 survey preoperatively and at 2, 4, 6, and 12 months postoperatively, and 122 of these patients also completed the NOSE questionnaire. Sixty individuals who reported a history of snoring also completed the Snoring Outcomes Survey (SOS). Twelve of 125 patients had obstructive sleep apnea. Patient demographics, nasal surgery, and medical histories and outcomes were analyzed. Intervention: Functional septorhinoplasty. Main Outcomes and Measures: Comparison of pre- and postoperative sleep and NAO scores to determine the correlation between the severity of NAO and sleep quality and the impact of correction of NAO on sleep quality. Results: A total of 125 patients completed FOSQ-10 questionnaire with a median score of 18.00 (IQR = 15.33-19.66) at baseline. Among these individuals, 122 patients completed the NOSE questionnaire with a median score of 65 (IQR = 45-75). A negative correlation between NOSE and FOSQ-10 scores was found at baseline (r = -0.380, p < 0.001). There was a significant difference in baseline FOSQ-10 scores between individuals with (n = 12, mean FOSQ-10 score = 13.28 ± 3.19) (p < 0.001) and without sleep apnea (n = 100, mean FOSQ-10 score = 17.24 ± 3.21). After FSRP, the NOSE and FOSQ-10 scores improved at each postoperative follow-up time point. The change in FOSQ-10 scores was statistically significant at months 2, 4, and 6 (p < 0.001) but not at month 12 (p = 0.161). The NOSE scores were statistically different from baseline level for each postoperative follow-up visits (p < 0.001-months 2, 4, and 6 and p = 0.031-month 12). The distribution of NOSE scores was not different statistically (p = 0.984). The negative correlation between NOSE and FOSQ-10 mean scores that was demonstrated at baseline increases postoperatively (r = 0.508, p < 0.001). Conclusions and Relevance: FSRP can improve both symptoms of NAO and sleep quality. The increased correlation between NAO and sleep quality after surgery is consistent with the hypothesis that improvement in NAO improves sleep quality and QOL.

The relationship between the Ottawa Valve Collapse Scale (OVCS) and clinical outcomes in septoplasty patients

The Ottawa Valve Collapse scale (OVCS) was developed to classify the severity of nasal valve collapse (NVC) in patients with nasal obstruction. The goal of this study was to determine, in patients who have nasal obstruction due to a septal deviation, whether those with a higher OVCS grade will have a reduced improvement in patient-centered clinical outcomes at one-year following septoplasty with inferior turbinate diathermy compared to those with a normal or lower OVCS grade. This study was a prospective study of 78 patients who completed an assessment using the NOSE questionnaire before and at one-year following the surgical intervention. A repeated-measures ANOVA was used to asses for differences in scores between OVCS groups. There was a significant improvement in NOSE scores one year post-septoplasty (p < 0.01). There was no difference in NOSE score improvement when comparing the grades of the OVCS at one-year (F = 0.09, p = 0.968). Though the OVCS was designed to categorize the severity of NVC preoperatively, there is no evidence that it is helpful in predicting which patients will demonstrate poor results following septoplasty. Future studies are required to further evaluate the OVCS and whether complimentary assessments will improve its clinical utility.

Moderate OSAS and turbinate decongestion: surgical efficacy in improving the quality of life and compliance of CPAP using Epworth score and SNOT-20 score

SUMMARY

Drug-induced sleep endoscopy (DISE) is an important procedure in diagnostic pathway of patients affected by moderate OSAS. However, the Italian National Health System does not provide any compatible Diagnosis-related-group (DRG) code codification for DISE, which makes it impossible to obtain regional reimbursement. In order to overcome this problem, DISE is usually associated with other codified surgical procedures. The aim of our study is to assess the association of turbinate decongestion (TD) and DISE in order to combine in a single operating session diagnostic and therapeutic procedures. The objective of our work is to assess the role of nasal surgery on symptoms of moderate OSA. Recent studies have confirmed that isolated nasal surgery improves quality of life (QOL), but not the apnoea hypopnoea index (AHI) during polygraph registration. We enrolled 30 patients, aged between 29 and 64 years (mean 50.53 ± 9.20), 26 males and 4 females, with a mean BMI of 26.07 ± 2.81 kg/m², who were affected by moderate OSAS. All patients underwent otolaryngologycal pre-operative evaluation, home respiratory polygraph and subjective evaluation through Sino-Nasal-Outcome Test (SNOT-20) and Epworth Sleepiness Scale (ESS). During the same surgery session, they underwent DISE and TD. Patients were re-evaluated six months later using the same questionnaires. We observed a significant improvement (p #x003C; 0.05) in both the mean ESS index (6.03 ± 2.75 vs 4.16 ± 4.63) and total SNOT score (22.53 ± 12.16 vs 13.23 ± 10.82). Significant differences (p #x003C; 0.05) were also identified for partial SNOT questions 1-11 (9.1 ± 5.11 vs 6.13 ± 4.12) and 11-20 (13.36 ± 10.20 vs 7.13 ± 9.644). The results of the present study confirm that TD alone can improve sleepiness, QOL and nasal symptoms. Thus, in absence of a National Health System recognition for DISE, the association of this procedure with TD can be useful for diagnostic and therapeutic management of OSAS, improving CPAP compliance and adherence, reducing sleepiness, ameliorating nasal symptoms and therefore QOL.

In-office treatment of nasal valve obstruction using a novel, bipolar radiofrequency device

Objectives

To assess the safety and effectiveness of in‐office bipolar radiofrequency treatment of nasal valve obstruction

Study Design

Prospective, nonrandomized, multicenter case series

Methods

Adult patients with a Nasal Obstruction Symptom Evaluation scale (NOSE) score ≥60 were selected. Patients were clinically diagnosed with dynamic or static internal nasal valve obstruction as primary or significant contributor to obstruction and were required to have a positive response to nasal mechanical dilators or lateralization maneuvers. Bilateral radio‐frequency treatment was applied intranasally using a novel device, under local anesthesia in a single session. Safety and tolerance were assessed by event reporting, inspection, and Visual Analogue Scale (VAS) for pain. Efficacy was determined using the NOSE score and patient‐reported satisfaction survey at 26 weeks.

Results

Fifty patients were treated. No device or procedure‐related serious adverse events occurred. Soreness, edema, and crusting resolved by 1 month. The mean baseline NOSE score was 79.9 (SD 10.8, range 60–100), and all had severe or extreme obstruction. At 26 weeks, mean NOSE score was 69% lower at 24.7 (P < .0001) with 95% two‐sided confidence intervals 48.5 to 61.1 for decrease. The decrease in NOSE score did not differ significantly between patients who did or did not have prior nasal surgery. Patient satisfaction mean by survey was 8.2 of 10.

Conclusion

In office treatment of internal nasal valve obstruction using a bipolar radiofrequency device is safe and well‐tolerated. Nasal obstruction, as assessed using the NOSE questionnaire at 26 weeks, was markedly improved with high patient satisfaction.

Level of Evidence

2b, prospective cohort

Chronic Nasal Obstruction Causes Daytime Sleepiness and Decreased Quality of Life Even in the Absence of Snoring

Background

There has been a growing awareness that nasal obstruction may impair various daily and social activities. We performed a questionnaire survey in a working population to clarify the contribution made by snoring concomitant with nasal obstruction to daytime sleepiness and quality of life (QOL).

Methods

Seven thousand nine hundred eighty daytime workers were asked to complete questionnaires, 7702 responded, and the data from 3442 subjects were finally analyzed. Nasal obstruction and snoring were graded into three and four categories, respectively. Daytime sleepiness and QOL were assessed by the Epworth Sleepiness Scale (ESS) and the Medical Outcomes Study 36-Item Short-Form Health Survey, respectively.

Results

Subjects with chronic nasal obstruction, even if snoring was absent, reported significantly higher ESS scores and lower QOL scores than control subjects, and the presence of habitual snoring had an additive influence on these changes. The ESS and mental QOL scores adjusted for age, sex, and body mass index showed the same tendency.

Conclusion

Induction of sleep-disordered breathing (SDB) is a possible cause of excessive daytime sleepiness and impaired QOL in subjects with nasal obstruction. A variant of SDB such as silent upper respiratory resistance syndrome may participate in this phenomenon in the absence of snoring.

Airwayplasty: long-term outcome of nasal wall lateralisation

BACKGROUND

There are a variety of surgical techniques which can be used to treat structural nasal obstruction. Airwayplasty is a procedure, combining septoplasty, turbinate surgery, and nasal wall lateralization. The article reports the long-term result of this novel approach.

METHODOLOGY

Patients who have evidence of structural nasal obstruction were offered the option to have airwayplasty under the senior surgeon. Patients were asked to quantify the severity and the impact of their nasal obstruction using the Visual Analogue Scale (VAS) and the validated Sino-Nasal Outcome Test (SNOT-22) pre-operatively and post-operatively.

RESULTS

The mean total SNOT-22 score and VAS score showed a reduction of more than 50% with significant p value at 6 and 12 months post-operatively.

CONCLUSIONS

This novel approach to nasal obstruction can provide good long-term functional results for patients suffering from nasal obstruction.

Age and Unplanned Postoperative Visits Predict Outcome after Septoplasty: A National Swedish Register Study

Objective

To study predictors of symptom relief six months after septoplasty using data from the Swedish National Septoplasty Register.

Participants

This is a retrospective register study of adult patients undergoing septoplasty in Sweden in 2003–2012.

Outcome

Relief of nasal symptoms was analysed in relation to age, gender, size of hospital performing the surgery, addition of turbinoplasty, and unplanned postoperative visits to the hospital due to pain, bleeding, or infection.

Results

In all, 76% of the patients (n = 5,865) rated their symptoms as “almost gone” or “gone” six months after septoplasty. With every 10-year increase in the age of the patients, the OR was 1.19, 95% CI 1.15–1.23, for a better result and 1.54, 95% CI 1.38–1.71, if the septoplasty was performed at a county hospital versus a university hospital. If there was no unplanned postoperative visit due to pain, bleeding, or infection, the OR for a better result was 1.6, 95% CI 1.39–1.85.

Conclusion

In this large national cohort of septoplasties, most of the patients felt that their symptoms had gone or almost gone six months after septoplasty. Higher age, surgery at smaller hospitals, and no unplanned visits to the hospital postoperatively predicted a better outcome.

Relationships between nasal obstruction, observed apnea, and daytime sleepiness

Objective

We administered a questionnaire survey to a working population in an attempt to clarify the relationships between self-reported nasal obstruction, observed apnea during sleep, and daytime sleepiness.

Study Design

A total of 7980 daytime workers were asked to complete questionnaires about nasal obstruction, apnea during sleep, and daytime sleepiness. Of the 7702 responses, the data from 4818 subjects were analyzed. Nasal obstruction and observed apnea were graded into 3 categories. Daytime sleepiness was assessed by the Epworth Sleepiness Scale.

Results

Subjects with chronic nasal obstruction had 5.22 and 2.17 times higher odds for having habitual observed apnea and excessive daytime sleepiness (EDS), respectively, compared with those without nasal obstruction ( P < 0.001). After adjusting for 3 potential confounding factors (age, sex, and body mass index) and the presence of habitual observed apnea, odds ratios for having EDS decreased, but still remained significant.

Conclusion

Nasal obstruction is likely to cause daytime sleepiness, at least in part, by causing sleep-disordered breathing including apnea during sleep.

Electrical Impedance and Expression of Tight Junction Components of the Nasal Turbinate and Polyp

PURPOSE

We investigated the electrical impedance and expression of tight junction components of the turbinate mucosa, nasal polyp, and normal skin.

PROCEDURES

The inferior turbinate and nasal polyp of patients with chronic rhinosinusitis and the postauricular skin of patients with otitis media were examined. Electrical impedance was measured in vivo using a tissue conductance meter. Expressions of claudin-1 and tricellulin were examined by fluorescence immunohistochemistry and quantitative RT-PCR.

RESULTS

Electrical impedance was higher in the skin than in the turbinate and polyp, but did not differ between the turbinate and polyp. Immunoreactivities for claudin-1 and tricellulin were seen in the epithelial/epidermal layer. Expression of claudin-1 was higher in the skin than in the turbinate and polyp. The polyp tended to show higher expression of claudin-1 but showed lower expression of tricellulin than the turbinate. The ratio of claudin-1 to tricellulin was highest in the skin and lowest in the turbinate. The correlation between expressions of the two tight junction components was strongly positive in the skin (r = 0.964) and negative (r = -0.527) in the turbinate and polyp.

CONCLUSIONS

These results suggest that the roles of claudin-1 and tricellulin in barrier function may be complementary, and may thereby maintain a constant level of permeability of the mucosal tissues.

Temporary forced oral breathing affects neonates oxygen consumption, carbon dioxide elimination, diaphragm muscles structure and physiological parameters

OBJECTIVES

We studied adaptation of diaphragm, oxygen consumption and carbon dioxide elimination to forced oral breathing (lasting for only 4 days) following reversible bilateral nasal obstruction performed on day 8 post-natal male rats.

METHODS

Diaphragm myosin heavy chain (MHC) composition, oxygen consumption, carbon dioxide elimination and hormones level were analysed during nasal obstruction period.

RESULTS

Diaphragm muscle showed significant increases in adult isoforms (MHC 1, 2a) in oral breathing group versus control. Reversible nasal obstruction was associated with a decrease of oxygen consumption and carbon dioxide elimination. Nasal obstruction period was associated with reduced growth of the olfactory bulbs and an initial decrease in lung growth. One day after implementing nasal obstruction, basal corticosterone levels had increased (by over 1000). Oral breathing was also associated with a lower level of thyroid hormone.

CONCLUSIONS

We conclude that a 4 day nasal obstruction period in young rats leads to hormonal changes and to Diaphragm myosin heavy chain structural adaptation.

The impact of nasal surgery on sleep quality: a prospective outcomes study

OBJECTIVE

(1) Evaluate the impact of nasal airway surgery on sleep quality using validated outcome measurements, (2) compare the utility of Epworth Sleepiness Scale (ESS) versus Pittsburgh Sleep Quality Index (PSQI) as a reflection of sleep quality, and (3) identify perioperative variables that might correlate with a beneficial effect of nasal surgery on sleep quality.

STUDY DESIGN

Prospective outcome study of patients with symptomatic nasal obstruction undergoing nasal airway surgery.

SETTING

Academic medical center.

METHODS

Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale, ESS, PSQI, and Ease-of-Breathing and Sleep Quality Likert scales preoperatively and 3 months postoperatively. A nonparametric analysis compared pre- and postoperative values, and associations were examined using Spearman correlations.

RESULTS

Sixty-one patients completed the study. Mean NOSE scores decreased significantly from 68.2 preoperatively to 17.5 three months after surgery. Mean ESS scores and PSQI scores improved (P < .0001) over that same interval (7.5 to 5.3 and 7.8 to 4.6, respectively). There was a correlation seen between the degree of change in both NOSE scores and Ease-of-Breathing scores and the change in sleep quality measured using the PSQI or Sleep Quality Likert scores. The PSQI correlated better with Sleep Quality Likert scores than the ESS. Overall, 86.9% of subjects reported subjective improvement in sleep quality postoperatively.

CONCLUSION

In patients undergoing nasal airway surgery there may be a secondary improvement in subjective sleep quality. The degree of change in sleep quality correlates with the severity of nasal obstruction preoperatively and the degree of improvement in obstruction with surgery.

Different expressions of erbB1/2 and tight junction proteins in hypertrophic inferior turbinates and nasal polyps

Both inferior turbinate hypertrophy and nasal polyp formation entail the enlargement of the nasal mucosa caused by rhinosinusitis, but their macro/microscopic and clinical findings differ markedly. This study aimed at investigating differences in the expressions of erbB1/2 and the tight junction proteins, claudin-1 and tricellulin, in the two tissues. Ten inferior turbinates and ten nasal polyps were collected. The expressions of erbB1/2, claudin-1, and tricellulin were examined by fluorescence immunohistochemistry and by quantitative real-time transcription-polymerase chain reaction (qRT-PCR). The eosinophil count and % of nasal gland area in the mucosa were also measured. The fluorescence intensities in the inferior turbinates were higher for erbB1/2 and lower for claudin-1 than those in the nasal polyps. The results of qRT-PCR were consistent with the immunohistochemical findings for erbB1/2. The quantity of tricellulin mRNA was significantly higher in the inferior turbinates than in the nasal polyps. The % of nasal gland area was significantly higher but the eosinophil count was significantly lower in the inferior turbinate than in the nasal polyp. These results suggest that the underlying pathogenesis of hypertrophic inferior turbinates and nasal polyps is likely to differ with respect to regeneration/proliferation and thus the remodeling process.

It takes a mouth to eat and a nose to breathe: abnormal oral respiration affects neonates' oral competence and systemic adaptation

Mammalian, including human, neonates are considered to be obligate nose breathers. When constrained to breathe through their mouth in response to obstructed or closed nasal passages, the effects are pervasive and profound, and sometimes last into adulthood. The present paper briefly surveys neonates' and infants' responses to this atypical mobilisation of the mouth for breathing and focuses on comparisons between human newborns and infants and the neonatal rat model. We present the effects of forced oral breathing on neonatal rats induced by experimental nasal obstruction. We assessed the multilevel consequences on physiological, structural, and behavioural variables, both during and after the obstruction episode. The effects of the compensatory mobilisation of oral resources for breathing are discussed in the light of the adaptive development of oromotor functions.

Expression of epidermal growth factors, erbBs, in the nasal mucosa of patients with chronic hypertrophic rhinitis

PURPOSE

To investigate the expression of erbBs in the nasal mucosa of patients with chronic hypertrophic rhinitis.

PROCEDURES

Inferior turbinates were collected from 12 turbinectomized patients with allergic and nonallergic chronic hypertrophic rhinitis. Differential cell counts in the peripheral blood and allergy tests were conducted before surgery. The expressions of erbB1, 2, 3 and 4 were examined by fluorescence immunohistochemistry and by quantitative real-time transcription polymerase chain reaction (qRT-PCR). Immunohistochemical fluorescence was quantitatively measured using image-analyzing software. Eosinophils infiltrated into the mucosa were counted in sections stained with Hansel solution.

RESULTS

Each of the erbB types 1-4 was expressed in both epithelial cells and nasal gland cells. Immunoreactivity for erbB1 was strong and that for erbB2 and 3 was moderate, while that for erbB4 was faint. These findings were consistent with the results of qRT-PCR. The percentage of peripheral blood eosinophils was significantly correlated with the eosinophil count in the nasal mucosa and with immunoreactivity for erbB1 in the nasal gland.

CONCLUSIONS

These results suggest a possible role of eosinophils in regulating erbB1 and thus in regulating mucosal hypertrophy in chronic hypertrophic rhinitis.

Systematic evaluation of the upper airway in the adult population of São Paulo, Brazil

OBJECTIVES

To study the prevalence of otorhinolaryngologic symptoms and findings of physical examination of the upper airway (UA) of a representative sample of the adult population of São Paulo, Brazil, and the association between these findings.

STUDY DESIGN

Cross-sectional survey.

SETTING

Population sample.

METHODS

A total of 1101 randomly selected volunteers representing the adult population of São Paulo according to sex, age, and socioeconomic class were included in this study. Otorhinolaryngological evaluation included investigation of nasal complaints, physical examination of the UA, and a facial inspection.

RESULTS

A total of 993 volunteers (53.9% women), with a mean age of 41.8 ± 0.89 years, underwent otorhinolaryngologic examination. The most prevalent symptoms were the following: symptoms suggestive of rhinitis (44.9%), snoring (42.8%), mouth breathing (39.3%), and nasal obstruction (33.3%). In physical examination, the most common findings were a web palate (redundant posterior pillar; 62.9%), septum deviation (56.9%), and inferior turbinate hypertrophy (37.7%). Significant associations were found between nasal obstruction and septum deviations, inferior turbinate hypertrophy, high-arched palate, and class II dental occlusion; between symptoms of rhinitis and inferior turbinate hypertrophy; and between snoring and obstructive deviated septum, modified Mallampatti grades III and IV, increased neck circumference, and age greater than or equal to 50 years.

CONCLUSIONS

The prevalence of otorhinolaryngologic symptoms and alterations in physical examination of the UA were high in the adult population of São Paulo, Brazil. The snoring and nasal symptoms were significantly associated with findings from UA physical examination and inspection of the facial skeleton.

Effects of short term forced oral breathing: physiological changes and structural adaptation of diaphragm and orofacial muscles in rats

OBJECTIVE

We studied adaptation of diaphragm and orofacial muscles as well as hormonal responses to forced oral breathing (lasting for only 4 days) following reversible bilateral nasal obstruction performed on day 8 post-natal male rats.

DESIGN

Muscle myosin heavy chain (MHC) composition and hormone levels were analysed during two periods: 1 and 3 days after obstruction (days 9 and 11 post-natal), and following 3 months recovery with nasal breathing (90 days, adult).

RESULTS

Diaphragm muscle showed significant increases in adult isoforms (MHC 1, 2a) in oral breathing group versus control. We observed increases in MHC neonatal and adult type 1 isoforms in muscles involved with oral breathing, masseter superficialis and anterior digastric. No changes were observed in the levator nasolabialis muscle involved with nasal breathing. Reversible nasal obstruction was associated with reduced growth of the olfactory bulbs lasting into adulthood, and an initial decrease in lung growth followed by recovery at 90 days. Adrenal hypertrophy was observed after 1 day of nasal obstruction and lasted into adulthood. The "stress" hormone response was variable, increased (over 1000%) during the obstruction but normal by adulthood. An increase in plasma testosterone was observed during the obstruction, and a decrease in thyroid hormone levels throughout.

CONCLUSIONS

Very short term nasal obstruction, i.e. forced oral breathing, leads to long term hormonal changes and respiratory muscle fibre adaptation.

EDITOR'S CHOICE: objective assessment of the nasal airway in unilateral cleft lip and palate--a long-term study

OBJECTIVE

To objectively evaluate the nasal function in adults operated on for unilateral cleft lip and palate with one-stage or two-stage palate closure.

DESIGN

The population consists of all unilateral cleft lip and palate patients born from 1960 to 1987 and treated at the Cleft Lip and Palate Center, Uppsala University Hospital, Sweden. The patients were treated according to the same protocol except for palate closure, which was performed in one stage until 1977 and in two stages thereafter. Eighty-three patients participated. Mean follow-up time after primary surgery was 32 years. An age-matched control group underwent the same examinations.

MAIN OUTCOME MEASURES

Nasal minimum cross-sectional area (cm(2)) and volume (cm(3)) were assessed (acoustic rhinometry). Airflow resistance (Pa s/cm(3)) (rhinomanometry), peak inspiratory flow (L/min) (peak nasal inspiratory flow), and number of identified odors (Scandinavian Odor Identification Test) were determined.

RESULTS

The cleft side of unilateral cleft lip and palate patients had significantly lower values for all parameters compared with controls (p < .001). No difference was found between one-stage and two-stage procedures in values for the cleft side. However, the nasal area and volume of the noncleft side were significantly larger in patients who underwent one-stage as compared with two-stage procedures (p < .05).

CONCLUSION

The nasal airway of unilateral cleft lip and palate patients demonstrates a wide range of impairments that can be quantified by objective measurements. However, the measurements used did not differentiate between patients operated on with the one-stage and two-stage procedures except for values of the noncleft side.

Effects of short term forced oral breathing in rat pups on weight gain, hydration and stress

Nasal obstruction is a risk factor in sleep-disordered breathing with a negative impact on the quality of life in humans. We investigated hydration changes produced by short term reversible, bilateral, nasal obstruction in young developing rat pups. Physiological parameters of growth (weight gain and gastric content weight) and dehydration were analyzed during two periods; during nasal obstruction at post-natal day 8 (days 9, 11 and 13), plus 7 and 90 days after recovery of nasal breathing (day 15 and adulthood). Body weight gain in oral breathing rat pups was slower compared to controls. Gastric weight was decreased significantly only in oral breathing rat pups on days 9 and 11 while plasma osmolality and vasopressin levels increased (indicators of dehydration). There were no differences between controls and treated rat pups by day 15, or at adulthood. Short term nasal obstruction-induced forced oral breathing, decreased gastric content which had a negative impact on growth and blood glucose concentration in the short term for female rat pups. Plasma corticosterone levels increased during the dehydration but were normal in males by 90 days. This could be a model for blocked nose syndrome in the newborn. Possible long term consequences on development are discussed.

Clinical evaluation of a novel internal nasal dilation stent for the improvement of nasal breathing

OBJECTIVE

This study assessed rhinometric improvement in nasal airflow, perceived comfort, and the utility of nasal dilation devices for individuals with nasal obstruction treated with an external nasal dilator (END) or a novel internal nasal dilation stent (INDS).

STUDY DESIGN

Prospective, randomized, crossover trial.

SUBJECTS

Individuals with symptoms of nasal obstruction.

METHODS

Twenty-three participants underwent rhinometry and a trial with a novel INDS and a validated END. Devices were used in a randomized, crossover fashion. Nasal airflow, maximum use, continuous use, comfort, and challenge with these devices were assessed.

RESULTS

The END and INDS showed greater nasal airflow from baseline, with the INDS being significantly better than the END. The INDS was used significantly more than the END, and demonstrated significantly greater comfort and less associated challenge.

CONCLUSIONS

The novel INDS showed 3.4 times improved nasal airflow from baseline, was used maximally and continuously longer than a validated END, and was judged to be significantly more tolerable.

Effects of Nasal Surgery on Sleep Quality in Obstructive Sleep Apnea Syndrome with Nasal Obstruction

Background

The purpose of this study was to evaluate the effects of nasal surgery on nasal resistance, sleep apnea, and sleep quality in adult male patients with obstructive sleep apnea syndrome (OSAS). A prospective study was performed in OSAS patients who underwent isolated nasal surgery in a tertiary referral center.

Methods

During the 3-year study period, 49 OSAS patients suffering from symptomatic nasal obstruction/impaired nasal breathing underwent the standard polysomnography before and after surgery. Polysomnography along with measures of nasal resistance and daytime sleepiness (the Epworth sleepiness scale [ESS] scores) were reviewed also.

Results

Surgery decreased the nasal resistance (0.55 ± 0.37 Pa/cm3 per second versus 0.17 ± 0.19 Pa/cm3 per second; p < 0.001) and ESS scores (11.7 ± 4.1 versus 3.3 ± 1.3; p < 0.001), without changes in the apnea-hypopnea index (AHI; 44.6 ± 22.5 versus 42.5 ± 22.0). Surgery increased nadir oxygen saturation (76.2 ± 10.9% versus 78.8 ± 8.1%; p < 0.01), shortened apnea–hypopnea duration (averaged/maximum; 33.5 ± 7.3/61.1 ± 46.0 versus 28.8 ± 7.4/47.3 ± 36.1 second; p < 0.05/p < 0.01), and improved sleep quality.

Conclusion

The results suggest that nasal surgery is useful for lowering nasal resistance, ameliorating sleep-disordered breathing, and improving sleep quality and daytime sleepiness in OSAS.