Evidence-based recommendations regarding the differential diagnosis and assessment of nasal congestion: using the new GRADE system

Peak Nasal Inspiratory Flow (PNIF) for Nasal Breathing Evaluation

Measuring nasal airflow and nasal breathing has been a major goal of rhinology. Many objective methods for measuring nasal airflow or nasal airway resistance or dimensions provide valuable data but are time-consuming and require expensive equipment and trained technicians, thus making these methods less practical for clinical practice. Peak nasal inspiratory flow (PNIF) measurement is fast, unexpensive, noninvasive, and able to provide an objective evaluation of nasal airflow in real-time. Unilateral PNIF measurements allow separated evaluation of each side of the nasal airway and may prove particularly useful when clinical assessment detects significant asymmetry between both nasal cavities.PNIF measurements are most useful for assessing changes in nasal airflow achieved by any form of therapy, including surgical treatment of the nasal airway. These measurements generally correlate with other objective methods for nasal airway evaluation, but not unequivocally with patient-reported evaluation of nasal breathing. Nevertheless, as low PNIF values prevent the sensation of a suitable nasal breathing, PNIF measurement may also prove useful to optimize the decision of how to best address patients with complaints of nasal airway obstruction.

Overview of Nasal Airway and Nasal Breathing Evaluation

Several methods are available for evaluating nasal breathing and nasal airflow, as this evaluation may be made from several different perspectives.Physiologic methods for nasal airway evaluation directly measure nasal airflow or nasal airway resistance, while anatomical methods measure nasal airway dimensions. Subjective methods evaluate nasal breathing through several validated patient-reported scales assessing nasal breathing. Computational fluid dynamics evaluates nasal airflow through the analysis of several physics' variables of the nasal airway.Being familiar to these methods is of utmost importance for the nasal surgeon to be able to understand data provided by the different methods and to be able to choose the combination of evaluation methods that will provide the information most relevant to each clinical situation.

Intranasal trigeminal sensitivity to mechanical stimuli is associated with the perception of nasal patency

PURPOSE

The aim of this prospective study was to examine the characteristics of a clinical test for the assessment of nasal trigeminal sensitivity to mechanical stimuli and its association with the perception of nasal patency.

METHODS

Thirty-two normosmic healthy subjects participated (17 women and 15 men; age = 26 ± 3 years). Precisely defined air puffs were used with a flow rate of 2L/min for mechanical stimulation. They were presented to the nasal vestibule, nasal septum, and inferior turbinate with various stimulus durations. Thresholds were measured by single-staircase stimuli with changes in stimulus duration in steps of 10 ms. Trigeminal suprathreshold intensity was rated by subjects for stimulus durations of 200, 300, 400, and 500 ms. Test-retest reliability was examined by intraclass correlations (ICCs) and Bland-Altman plot with limits of agreement. Pearson's correlations were calculated between self-rated nasal patency and nasal trigeminal sensitivity.

RESULTS

As indicated by trigeminal threshold and suprathreshold intensities, the nasal vestibule is the most sensitive area among the three locations, followed by the nasal septum and the inferior turbinate (p < 0.001). Coefficients of correlations between test and retest were 0.76 for thresholds, and 0.56 suprathreshold intensities (p < 0.001). The Bland-Altman analysis showed a good agreement between test-retest values. In addition, significant positive associations between trigeminal suprathreshold intensities and self-rated nasal obstruction were found at the inferior turbinate (r = 0.4, p < 0.05).

CONCLUSION

Reliable assessment of nasal trigeminal sensitivity for air puffs appears to be possible. Nasal trigeminal suprathreshold sensitivity to mechanical stimuli is associated with the perception of nasal patency at the inferior turbinate. This opens a window into the assessment of the perception of nasal airflow in various clinical purposes, especially for patients with sinonasal diseases.

LEVEL OF EVIDENCE: 3

Management of Mechanical Nasal Obstruction Isolated or Associated to Upper Airway Inflammatory Diseases in Real Life: Use of both Subjective and Objective Criteria

PURPOSE OF REVIEW

Mechanical nasal obstruction (MNO) is a prevalent condition with a high impact on patient's quality-of-life (QoL) and socio-economic burden. The aim of this study was to determine the usefulness of both subjective and objective criteria in the appropriate management of MNO, either alone or associated to upper airway inflammatory diseases such as allergic rhinitis (AR) or chronic rhinosinusitis with nasal polyps (CRSwNP).

RECENT FINDINGS

A long debate persists about the usefulness of subjective and objective methods for making decisions on the management of patients with nasal obstruction. Establishing standards and ranges of symptom scales and questionnaires is essential to measure the success of an intervention and its impact on QoL. To our knowledge this is the first real-life study to describe the management of MNO using both subjective and objective criteria in MNO isolated or associated to upper airway inflammatory diseases (AR or CRSwNP). Medical treatment (intranasal corticosteroids) has a minor but significant improvement in MNO subjective outcomes (NO, NOSE, and CQ7) with no changes in loss of smell and objective outcomes. After surgery, all MNO patients reported a significant improvement in both subjective and objective outcomes, this improvement being higher in CRSwNP. We concluded that in daily clinical practice, the therapeutic recommendation for MNO should be based on both subjective and objective outcomes, nasal corrective surgery being the treatment of choice in MNO, either isolated or associated to upper airway inflammatory diseases, AR or CRSwNP.

Accuracy of peak nasal flow to determine nasal obstruction in patients with allergic rhinitis

Objective

Methods

Results

Conclusions

Airflow Considerations and the Effect of Webster's Triangle in Reduction Rhinoplasty

BACKGROUND

Reduction rhinoplasties, regardless of the methods used (structural or preservation), can cause a reduction in the internal nasal volume, which may lead to breathing problems. In 1977, Webster proposed preserving a little triangle in the beginning of the lower lateral osteotomy line to prevent breathing problem. However, its importance is still controversial.

OBJECTIVES

and methods: This prospective randomized controlled study (level of evidence 1) included 46 patients without nasal breathing problem. High-to-low (Webster's triangle preservation) osteotomy (control group, n = 23) and low-to-low osteotomy (study group, n = 23) were performed. All operations were performed according to the proposed volumetric rhinoplasty steps (examination/measurement, prevention and treatment). Nasal obstruction symptom evaluation (NOSE) test, visual analog scale, acoustic rhinometry, rhinomanometry, peak nasal inspiratory flow (PNIF), and three-dimensional measurements were performed in all patients. Breathing tests were repeated before and 6 months after surgery with and without xylometazoline administration.

RESULTS

No statistically significant difference in NOSE and visual analog scale scores was found between the two groups. Acoustic rhinometry, PNIF, and rhinomanometry findings showed no statistically significant breathing difference between the two groups.

CONCLUSIONS

In reduction rhinoplasties, a decrease in the internal volume may be expected as directly proportional with the reduction amount. The decrease in the internal volume may create nasal breathing problems. To prevent it, nasal airflow should be adjusted according to new anatomy. In this study, we discussed "volumetric rhinoplasty" steps to prevent breathing problems in reduction rhinoplasty. Following these steps, not preserving Webster's triangle (low-to-low osteotomy) has no effect on the nasal airway.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Which Nasal Airway Dimensions Correlate with Nasal Airflow and with Nasal Breathing Sensation?

Background: Rhinoplasty modifies the nasal pyramid, thereby also modifying the nasal airway. Objectives: To correlate the sensation of nasal breathing, as measured by patient-reported outcome measures, and nasal airflow, as assessed by peak nasal inspiratory flow (PNIF), with nasal airway dimensions, as measured on computed tomography (CT) images. Methods: Fifty Caucasian patients were studied through visual analogue scale (VAS), nasal obstruction symptom evaluation (NOSE) and PNIF. Measurements of the nasal airway were made on CT images: minimal distance between septum and inferior and middle turbinates, nasal valve angle, and nasal valve area. Results: There was a significant association between PNIF and nasal valve area, between VAS and the narrower nasal valve angle and between NOSE and minimal distance between septum and middle turbinate of the narrower side. Conclusions: This study suggests that the dimensions of the nasal valve and of the middle nasal airway have a substantial impact on nasal breathing capacity. It also highlights the importance of unilateral nasal airway obstruction to nasal breathing.

Objective measurement and patient-reported evaluation of the nasal airway: Is correlation dependent on symptoms or on nasal airflow?

BACKGROUND

Evidence has shown that the sensation of nasal breathing is related to variations in nasal mucosa temperature produced by airflow. An appropriate nasal airflow is necessary for changing mucosal temperature. Therefore, the correlation between objective measurements of nasal airflow and patient-reported evaluation of nasal breathing should be dependent on the level of nasal airflow.

OBJECTIVES

To find if the correlation between patient-reported assessment of nasal breathing and objective measurement of nasal airflow is dependent on the severity of symptoms of nasal obstruction or on the level of nasal airflow.

METHODS

The airway of 79 patients was evaluated using NOSE score and peak nasal inspiratory flow (PNIF). Three subgroups were created based on NOSE and three subgroups were created based on PNIF level to find if correlation was dependent on nasal symptoms or airflow.

RESULTS

The mean value of PNIF for the 79 patients was 92.6 L/min (SD 28.1 L/min). The mean NOSE score was 48.4 (SD 24.4). The correlation between PNIF and NOSE was statistically significant (P = .03), but with a weak association between the two variables (r = -.248). Evaluation of correlation based on symptoms demonstrated a weak or very weak association in each subgroup (r = -.250, r = -.007, r = -.104). Evaluation of correlation based on nasal airflow demonstrated a very weak association for the subgroups with middle-level and high PNIF values (r = -.190, r = -.014), but a moderate association for the subgroup with low PNIF values (r = -.404).

CONCLUSIONS

This study demonstrated a weak correlation between NOSE scores and PNIF values in patients non-selected according to symptoms of nasal obstruction or to airflow. It demonstrated that patients with symptoms of nasal obstruction have different levels of nasal airflow and that low nasal airflow prevents the sensation of good nasal breathing. Therefore, patients with symptoms of nasal obstruction may require improving nasal airflow to improve nasal breathing sensation.

Open, prospective, multicenter study on postoperative intranasal phototherapy in nasal polyposis

BACKGROUND

The therapeutic effect of ultraviolet (UV) light is generally attributed to its immunosuppressive and immunomodulatory effects. Since chronic inflammation is the major factor in the development of nasal polyposis, we have previously used mixed ultraviolet-visible light (mUV-VIS, Rhinolight®) phototherapy for the treatment of nasal polyps.

AIMS

In the present open, multicenter study, our aim was to delineate whether mUV-VIS applied postoperatively in vivo together with intranasal steroid treatment could reduce the recurrence of nasal polyps.

METHODS

After functional endoscopic sinus surgery, one group of patients received mUV-VIS light together with standard intranasal steroid (mometason furoate 2 × 200 μg) application for a 12-week treatment period, whereas the other patient group obtained only intranasal steroid for the same duration. We recorded nasal endoscopy images and obtained demographical and clinical data, total nasal score (TNS), and nasal obstruction symptom evaluation (NOSE). We performed acoustic rhinometry and measured nasal inspiratory peak flow. Follow-up was 12 months.

RESULTS

We found that the recurrence of nasal polyps was significantly diminished, and based on video-endoscopic measurements, the size and grade of recurrent polyps were significantly smaller in the phototherapy-receiving group. Nasal obstruction values and NOSE were significantly better throughout the follow-up period in the mUV-VIS light-treated group than in the intranasal steroid monotreatment group.

CONCLUSIONS

Rhinophototherapy together with standard nasal steroid application may have a supportive role in the treatment of recurrent bilateral nasal polyps.

Objectification of the nasal patency assessment techniques used in nasal allergen provocation testing

Topical allergen application in nasal provocation testing (NPT) is associated with remarkably rapid changes in nasal patency. Thus, selecting the techniques of assessing the extent of nasal obstruction (as one of the responses to topical allergen application) is an important component of NPT. The study attempted to systematize and evaluate the techniques selected for assessing nasal patency during NPT based on a review of relevant literature. We reviewed the literature on the attempts to standardize the objective techniques for assessing nasal patency and their use in NPT. The best known, well-established technique for assessing nasal patency as part of NPT was rhinomanometry, followed by peak nasal inspiratory flow (PNIF) testing and acoustic rhinometry.

Role of rhinomanometry in the prediction of therapeutic positive airway pressure for obstructive sleep apnea

Background

This study was conducted to evaluate the relationship between nasal resistance in different posture and optimal positive airway pressure (PAP) level. Other potential factors were also assessed for possible influence on PAP pressure.

Methods

Forty- three patients diagnosed with obstructive sleep apnea (OSA) were prospectively recruited in this study. Nasal resistance was assessed by active anterior rhinomanometry in a seated position and then in a supine position at pressures of 75, 150, and 300 pascal. The factors correlating with PAP pressure were analyzed, including nasal resistance and patients’ clinical data.

Results

Univariate analysis revealed that PAP pressure was correlated to nasal resistance in the supine position at 75 and 150 pascal (SupineNR75 and SupineNR150) (P = 0.019 and P = 0.004 in Spearman’s correlation coefficient analysis), but not correlated to nasal resistance in the seated position at different pressures or in the supine position at 300 pascal. The multiple linear regression analysis revealed that both SupineNR150 and body mass index (BMI) significantly predicted PAP pressure (β = 0.308, p = 0.044; β = 0.727, p = 0.006). The final PAP pressure predictive model was:

PAP pressure = 0.29 BMI + 2.65 SupineNR150 + 2.11.

Conclusions

Nasal resistance in the supine position measured at 150 pascal may provide valuable information regarding optimal PAP pressure. Rhinomanometry should be included in the treatment algorithm of OSA patients when PAP therapy is considered.

Immediate effects of a rhino-pharyngeal clearance protocol in nasal obstruction and middle ear condition of children under 3 years of age with upper respiratory infections: A randomized controlled trial

INTRODUCTION AND OBJECTIVES

Children up to 2 years old are at high risk of respiratory infections and nasal irrigation is often prescribed. Yet, to date there is no sufficient knowledge about its immediate effects on the nasopharynx and middle ear. Therefore, this study aimed to analyze the effect of a rhino-pharyngeal clearance intervention protocol on nasal obstruction and middle ear condition in children under 3 years of age with URTI.

MATERIALS AND METHODS

Randomized controlled trial in a day-care centre of Porto, including 44 children randomized to Intervention Group (IG) and Control Group (CG). Nasal auscultation and tympanometry were performed at baseline (M0) as well as after the intervention (M1), which consisted of nasal irrigation (NaCl .9%) followed by a forced nasal inspiration in the IG, and after 30min of normal activities, in the CG.

RESULTS

In M1 there was a lower frequency of children classified as having an obstructed nasal sound in the IG when compared to the CG (IG=33.3%; CG=68.4%; p=0.042). We also observed an improvement of mean peak pressure (PP) in the IG (Left ear: M0=-124daPa; M1=-92daPa; p=0.022. Right ear: M0=-102daPa; M1=-77daPa; p=0.021), which was not observed in the CG (Left ear: M0=-105daPa; M1=-115daPa; p=0.485. Right ear: M0=-105daPa; M1=-131daPa; p=0.105). There were no significant results concerning the compliance of the tympanic membrane.

CONCLUSIONS

The rhino-pharyngeal clearance improved the nasal obstruction and PP of the middle ear of children under 3 years of age with URTI.

Computed Tomography Evaluation of Nasal Bone and Nasal Pyramid in the Turkish Population

OBJECTIVE

To classify shapes of the nasal bones in the Turkish population and comparatively evaluate the sizes of nasal bone and piriform apertures.

METHODS

Two- and three-dimensional paranasal sinus computed tomography images of 363 patients were evaluated. Upper, intermediate, and inferior thickness of bilateral nasal bones and thickness of medial and lateral osteotomy line were measured. The shapes of the nasal bones were classified.

RESULTS

The mean thickness of nasal bone in the study participants was 1.99 ± 0.40 mm, the mean thickness at the level of medial osteotomy line was 1.99 ± 0.40 mm, the mean thickness at the level of lateral osteotomy line was 1.75 ± 0.30 mm, the mean length of nasal bone was 1.75 ± 0.30 mm, maximum width and height of piriform aperture were 23.41 ± 2.68 and 36.76 ± 7.06 mm, respectively. When the patients were classified according to the type of nasal bone, 26.7% had type A, 10.5% had type B, 19.6% had type D, and 15.4% had type E nasal bone.

CONCLUSION

The results of the current study provide information about morphological characteristics of nasal bone and piriform aperture in the Turkish population and would therefore reduce postoperative complications after reconstructive surgery and contribute otolaryngology and anthropology.

Estimation of partitioning of airflow in septal surgery: A prospective study with reference to the NOSE scale

Improper patient selection for septal surgery often has been found to result in therapeutic failure, and there needs to be an objective assessment of nasal obstruction before the surgery and for postoperative follow-up that can be applied in the routine otolaryngology practice. The purpose of this study is to assess the usefulness of a cost-effective device for objective measurement of the nasal airway partitioning in selecting patients for septal surgery and for postoperative outcome evaluation. A hospital-based, prospective, observational study was carried out in a tertiary-care teaching institution involving 74 patients waiting for septal surgery. Each patient was exposed to subjective assessment of nasal obstruction by the Nasal Obstruction Symptom Evaluation (NOSE) scale and objective measurement by Nasal Partitioning Ratio (NPR) using a new device, Nasal Airway Partition Meter (NAPM), once before and twice after surgery. Overall, average NOSE score and NPR values were 66.42 ± 9.42 and 0.57 ± 0.18, respectively, at preoperative assessment (correlation coefficient 0.441). Sixty of the 74 patients had high values for both NPR and NOSE scores (Group 1), but in the remaining 14, NPR values were found to be lower despite high NOSE scores (Group 2). Postsurgery, the NOSE score and NPR values were significantly reduced in Group 1. In contrast, participants in Group 2 showed no alteration in the values of both the parameters after the same operative maneuver. However, 2 patients in Group 1 had NOSE score and NPR values unaltered, while 1 patient in Group 2 had a reduced NOSE score after surgery. Therefore, the validity of the new equipment was calculated to be 96.7% sensitive and 92.9% specific to identify patients who needed to undergo septal surgery for their nasal obstruction. It can be deduced from the present study that NAPM can be a cost-effective device for clinicians to objectively measure nasal airway obstruction and screen patients for septal surgery.

Correlations of nasal responses to leukotriene D4 and histamine nasal provocation with quality of life in allergic rhinitis

Background

The symptoms of allergic rhinitis (AR) greatly affect the quality of life (QoL) in the patients with AR. The correlations of nasal response to leukotriene D4 (LTD4) and histamine nasal provocation with health related QoL in AR are not clear.

Objective

To evaluate the correlations of nasal response to LTD4 and histamine nasal challenge with QoL in AR.

Methods

Patients randomly underwent LTD4 and histamine nasal challenge tests, completed the rhinoconjunctivitis quality of life questionnaire (RQoLQ), and rating the symptom severity score (total symptom score 4, TSS4) in the previous week. The correlations between nasal challenge tests induced nasal responses and QoL in RQoLQ were analyzed.

Results

A total of 25 eligible AR patients enrolled and finished both LTD4 and histamine nasal challenge and completed the questionnaire of RQoLQ. Histamine nasal challenge induced sneezing, increased nasal resistant were correlated with most of the dimensions (general, practical, nasal, eye problems, and quality of sleep, p < 0.05), while LTD4 nasal challenge induced sneeze, increased nasal resistant only correlated with nasal and ocular problems. On the contrary, the severity of the sneeze assessed by TSS4, was not correlated with QoL, while the severity of rhinorrhea, congestion, and nasal pruritus were correlated with nasal and practical problems, and nasal congestion was also correlated with ocular problems (r = 0.60, p = 0.01).

Conclusion

LTD4 and histamine nasal challenge induced nasal responses were correlated with different clinical symptoms severity and QoL, which can be used as a good diagnosis and evaluation methods for the management of AR.

Risk and safety requirements for diagnostic and therapeutic procedures in allergology: World Allergy Organization Statement

One of the major concerns in the practice of allergy is related to the safety of procedures for the diagnosis and treatment of allergic disease. Management (diagnosis and treatment) of hypersensitivity disorders involves often intentional exposure to potentially allergenic substances (during skin testing), deliberate induction in the office of allergic symptoms to offending compounds (provocation tests) or intentional application of potentially dangerous substances (allergy vaccine) to sensitized patients. These situations may be associated with a significant risk of unwanted, excessive or even dangerous reactions, which in many instances cannot be completely avoided. However, adverse reactions can be minimized or even avoided if a physician is fully aware of potential risk and is prepared to appropriately handle the situation. Information on the risk of diagnostic and therapeutic procedures in allergic diseases has been accumulated in the medical literature for decades; however, except for allergen specific immunotherapy, it has never been presented in a systematic fashion. Up to now no single document addressed the risk of the most commonly used medical procedures in the allergy office nor attempted to present general requirements necessary to assure the safety of these procedures. Following review of available literature a group of allergy experts within the World Allergy Organization (WAO), representing various continents and areas of allergy expertise, presents this report on risk associated with diagnostic and therapeutic procedures in allergology and proposes a consensus on safety requirements for performing procedures in allergy offices. Optimal safety measures including appropriate location, type and required time of supervision, availability of safety equipment, access to specialized emergency services, etc. for various procedures have been recommended. This document should be useful for allergists with already established practices and experience as well as to other specialists taking care of patients with allergies.

Evaluation of a nasal surgical questionnaire designed for monitoring surgical outcomes and comparing different techniques

OBJECTIVE

This study evaluated a nasal surgical questionnaire designed for monitoring surgical outcomes and comparing different techniques.

METHODS

Eighty-three healthy volunteers answered the same questionnaire twice with a minimum interval of five weeks. Three visual analogue scale items were used to assess nasal obstruction during the day, at night and during exercise. Respondents rated nasal obstruction severity by marking on a 10 cm line, with scores ranging from 0 to 100 (measured in millimetres). Other nasal symptoms, considered secondary outcomes, were graded using four-point Likert scales.

RESULTS

Mean visual analogue scale scores for nasal obstruction severity experienced during the day, at night and during exercise at initial assessment were 9.99, 12.95 and 11.67, respectively. Thirty-eight per cent of scores indicated no obstruction (scores of 0), 47 per cent indicated mild obstruction (scores 1-30), 13 per cent indicated moderate obstruction (scores 31-70) and 2 per cent indicated severe obstruction (scores 71-100). Males had higher scores than females. The scores for the first and second assessment did not differ, except at night for obstruction in allergic individuals which was considered clinically unimportant.

CONCLUSION

The questionnaire reliably assesses nasal symptoms and may be useful for prospective studies of nasal surgery.

Does Functional Septorhinoplasty Provide Improvement of the Nasal Passage in Validated Patient-Reported Outcome Measures?

OBJECTIVE

The aim of this study was to determine whether functional septorhinoplasty provides improvement of the nasal passage in validated patient-reported outcome measures (PROMs) for adults with an anatomical obstruction of the nasal valve. All patients with an anatomical obstruction of the nasal valve area due to nasal valve pathology and/or septal deviations in this area were included.

METHODS

A systematic PubMed, Embase and Cochrane Library search was performed to identify relevant articles. The articles were critically appraised and ranked according to validity and relevance.

RESULTS

Sixteen articles met our inclusion criteria, and after critical appraisal, 10 were eligible for further analysis. In 9 studies, the Nose Obstruction Symptom Evaluation (NOSE) score improved from 35 to 60 points. In 1 study, the Sino-Nasal Outcome Test (SNOT-22) improved 3.5 points.

CONCLUSION

The results suggest that there is a significant improvement of the validated PROMs after functional septorhinoplasty in the first postoperative year. We recommend that adults with nasal breathing problems due to an anatomical problem of the nasal valve area should consider undergoing functional septorhinoplasty.

Surgery of the external nasal valve: the correlation between subjective and objective measurements

OBJECTIVES/HYPOTHESIS

Minimum cross-sectional area of the nasal passage on CT (CT-MCA) is an objective computerised determination of the minimum cross-sectional area of the nasal passage on CT. CT-MCA was evaluated before and after surgery on the external nasal valve using the 'lateral crus pull-up' procedure (LCPU). The outcomes of CT-MCA were compared with other currently available objective tests for nasal valve patency.

STUDY DESIGN

Prospective cohort study.

METHODS

This study included 34 patients undergoing surgery on the external nasal valve with the use of the LCPU technique. CT-MCA was performed before and after surgery and compared with the subjective perception of nasal passage using the Nasal Obstruction Symptom Evaluation (NOSE) scale and with objective tests such as acoustic rhinometry (A-MCA), rhinomanometry (NAR) and peak nasal inspiratory flow (PNIF).

RESULTS

This study showed a significant correlation between CT-MCA and the NOSE scale, PNIF and NAR. Paired-samples t-tests showed significant improvement after surgery on CT-MCA, PNIF and the NOSE scale. Multiple linear regression analysis showed that PNIF, CT-MCA and NAR were significantly associated with the NOSE scale.

CONCLUSION

CT-MCA and PNIF were both significantly correlated and associated with the patient's subjective perception of nasal passage. The surgical procedure, the 'lateral crus pull-up', showed a significant improvement in the postoperative result both subjectively and objectively.

Allergic Rhinitis in Children: A Randomized Clinical Trial Targeted at Symptoms

Allergic rhinitis (AR) underlies many symptoms and complications which severely affect children's quality of life. This two-arm study aimed at evaluate the efficacy and safety of the medical device Narivent(®) versus topical corticosteroids in the symptomatic management of allergic rhinitis in paediatric patients. A randomized study was conducted. Forty subjects with a diagnosis of allergic rhinitis were randomized to receive one puff of Narivent(®) into each nostril twice daily for 30 days (n = 20) or to receive one puff of topical intranasal corticosteroid into each nostril twice daily for 30 days (n = 20). In both treatment arms, severity of major symptoms related to AR, including nasal congestion, rhinorrhoea, sneezing and nasal itching, was assessed subjectively on a 0-100 mm visual analogue scale. Nasal congestion, rhinorrhoea and sneezing improved significantly after 30 days of treatment with Narivent(®). Similarly, in topical steroids group severity of all subjective symptoms decreased significantly. Narivent(®) appears to be efficacious in treating nasal congestion and other major symptoms in children with AR over a 30-day period, showing comparable results to intranasal corticosteroids therapy but with a better safety profile.

Assessment of nasal obstruction: correlation between subjective and objective techniques

BACKGROUND

Nasal sensation of airflow describes the perception of the passage of air through the nose. Nasal obstruction can be assessed using subjective techniques (symptom scores and visual analogue scales [VAS]) and objective techniques (anterior rhinomanometry [RMN], acoustic rhinometry [AR], and peak nasal inspiratory flow [PNIF]). Few studies have evaluated the correlation between these techniques.

OBJECTIVE

The primary objective of our study was to determine the degree of correlation between subjective and objective techniques to assess nasal obstruction.

MATERIALS AND METHODS

Nasal obstruction was assessed using a symptom score, VAS, RMN, AR (minimal cross-sectional area [MCSA] and volume), and PNIF in 184 volunteer physicians. Spearman's rho was recorded. Correlations were considered weak if r ≤ 0.4, moderate if 0.4 < r < 0.8, and strong if r > 0.8.

RESULTS

Mean (SD) age was 37.1 (6.9) years (range, 25-56 years); 61% were women. We found a strong correlation (r > 0.8; p = 0.001) between the different parameters of RMN and a moderate correlation between symptom score and VAS (r = 0.686; p = 0.001) and between MCSA and RMN (resistance) (r = 0.496; p = 0.001) and PNIF (r = 0.459; p = 0.001). The correlations were weak or non-significant for the remaining comparisons.

CONCLUSION

Nasal obstruction can be assessed using subjective and objective approaches. The correlations between objective techniques were moderate to strong. In addition, between subjective techniques we reported a moderate correlation. Finally, the correlations between the subjective and objective techniques were weak and absent. These findings suggest that each of the techniques assesses different aspects of nasal obstruction, thus making them complementary.

A single-centre, before-after study of the short- and long-term efficacy of Narivent(®) in the treatment of nasal congestion

OBJECTIVE

Nasal congestion is a common symptom in allergic and nonallergic rhinitis, rhinosinusitis and nasal polyposis. The present study evaluated the clinical effectiveness of Narivent(®), an osmotically-acting medical device with anti oedematous and anti-inflammatory effects, in nasal congestion.

METHODS

A single-centre, prospective study with a pre- post design and consecutive patient enrolment was conducted in an Italian otolaryngology department. Patients with persistent nasal congestion were allocated to treatment groups as follows: group 1 (n = 36) treated for 7 days; group 2 (n = 56) treated for 30 days. In each group, patients received two puffs of Narivent(®) into each nostril twice daily. Symptom severity was assessed subjectively on a 0-10 visual analogue scale, and objectively by the presence/absence of signs and symptoms. Differences in subjective and objective severity measures before and after treatment were compared using Wilcoxon's signed rank test.

RESULTS

All symptoms and objective scores improved after treatment with Narivent(®) for 7 or 30 days and no adverse effects were reported by the patients in either group.

CONCLUSION

Narivent(®) appears to be efficacious in treating nasal congestion over a 7- or a 30-day period.

Recommendations for the standardisation of oxytocin nasal administration and guidelines for its reporting in human research

A series of studies have reported on the salubrious effects of oxytocin nasal spray on social cognition and behavior in humans, across physiology (e.g., eye gaze, heart rate variability), social cognition (e.g., attention, memory, and appraisal), and behavior (e.g., trust, generosity). Findings suggest the potential of oxytocin nasal spray as a treatment for various psychopathologies, including autism and schizophrenia. There are, however, increasing reports of variability of response to oxytocin nasal spray between experiments and individuals. In this review, we provide a summary of factors that influence transmucosal nasal drug delivery, deposition, and their impact on bioavailability. These include variations in anatomy and resultant airflow dynamic, vascularisation, status of blood vessels, mode of spray application, gallenic formulation (including presence of uptake enhancers, control release formulation), and amount and method of administration. These key variables are generally poorly described and controlled in scientific reports, in spite of their potential to alter the course of treatment outcome studies. Based on this review, it should be of no surprise that differences emerge across individuals and experiments when nasal drug delivery methods are employed. We present recommendations for researchers to use when developing and administering the spray, and guidelines for reporting on peptide nasal spray studies in humans. We hope that these recommendations assist in establishing a scientific standard that can improve the rigor and subsequent reliability of reported effects of oxytocin nasal spray in humans.

Sino-nasal characteristics in asthmatic patients

OBJECTIVE

The Unified Airways Hypothesis suggests an involvement of the upper airways in asthma. We aimed to evaluate the association between subjective sino-nasal complaints, nasal air flow, and sino-nasal quality of life (QOL) in patients with asthma compared with nonasthmatic subjects.

STUDY DESIGN

Case-control study.

SETTING

A tertiary referral center.

SUBJECTS AND METHODS

Symptoms, quality of life, and nasal airflow were assessed in 91 asthmatics and 95 nonasthmatic controls with Visual Analog Scale (VAS, 0-100), Sino-Nasal Outcome Test (SNOT-20), and Peak Nasal Inspiratory Flow (PNIF), respectively. Asthma and allergy status were assessed by Asthma Control Questionnaire (ACQ) and skin prick test or specific IgE.

RESULTS

Asthmatic patients (men/women, 37/54; mean age, 43.7 years; range, 19-64 years) reported significantly more nasal obstruction (mean VAS, 37 mm; SD = 26, 95% CI, 32-43 vs 9 mm, SD = 11, 95% CI, 7-11, P < .001) and lower sino-nasal quality of life (mean SNOT-20, 1.3; SD = 0.8, 95% CI, 1.1-1.5 vs 0.4, SD = 0.5, 95% CI, 0.3-0.5, P < .001) than controls (men/women, 42/53; mean age, 43.8 years; range, 20-65 years). PNIF was significantly lower in asthmatic patients than controls (mean PNIF, 84 l/min; SD = 24, 95% CI, 79-89 vs 100 l/min SD = 24, 95% CI, 95-105, P < .001).

CONCLUSION

Both allergic and nonallergic asthma were associated with increased sino-nasal symptoms, reduced sino-nasal QOL, and reduced inspiratory nasal air flow compared to controls. This provides further evidence of the clinical importance of the upper airway in the diagnostic and therapeutic management of asthma patients beyond the scope of allergy.

Subjective nasal fullness and objective congestion

How well do subjective descriptions of the sensation of nasal closure or absence of nasal patency agree with objective measures of nasal geometry and airflow? Problems with this concept begin with terminology. "Congestion" has been applied to both the subjective and objective measures. Therefore, the term "fullness" will be used to describe perceptions of nasal mucosal heaviness or blockage that subjects with allergic rhinitis articulate. "Congestion" will refer to the objective measures used to assess patency. Sensations attributed to the nasal mucosa are highly integrated interpretations summed from multiple subsets of nociceptive and other neurons. Activation of sensor systems is required to depolarize afferent neurons. These sensors and other receptor proteins can be modulated by inflammation as part of the neural plasticity that leads to increased sensitivity to nasal stimuli. This plasticity and hyperalgesia may extend from the afferent neuron to spinal cord dorsal horn synapses, and regulatory and analytical regions of the brainstem and cerebrum. Although glandular hypersecretion can deliver obstructing material into the nasal cavities, the dilation of deep venous sinusoids is the strongest factor regulating nasal airspace volumes. There is a long history of attempts to correlate subjective sensations to objective measurements such as airflow resistance (rhinomanometry), nasal wall geometry (acoustic rhinometry), and peak nasal inspiratory flow. The medical evidence supporting each method has been analyzed on the basis of the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. These results provide a starting point for linking the outcomes of pathophysiological processes with a patient's psychometrically calibrated sensation of airflow.

Smoker's nose: structural and functional characteristics

OBJECTIVES/HYPOTHESIS

The effects of smoking on endonasal geometry and airflow remain largely unknown. Our study examined the relationship between smoking status and objective measures of nasal cavity dimensions, nasal congestion, and nasal airflow, using acoustic rhinometry (AR) and peak nasal inspiratory flow (PNIF).

STUDY DESIGN

Cross-sectional study.

METHODS

Included in the study were 2,523 consecutive patients referred for evaluation of chronic nasal or sleep-related complaints. Smoking history was recorded, and AR and PNIF were measured at baseline and after decongestion of the nasal mucosa. Minimal cross-sectional areas (MCA), nasal cavity volumes (NCV), and PNIF, as well as quantified reversible mucosal congestion based on nasal congestion indexes (NCI) were analyzed to reveal possible associations with smoking status. Linear and logistic regressions were applied adjusting for possible confounders.

RESULTS

Smokers exhibited lower values of MCA, NCV, and PNIF than nonsmokers, both at baseline and after decongestion. Further, smokers had a lower decongestive capacity of the nasal mucosa, reflected by lower NCI for AR measures. Cigarette consumption, expressed as either pack-years or cigarettes smoked per day, showed a similar inverse relationship with the rhinometric measures even though a linear dose-response relationship could not be established.

CONCLUSIONS

We have clearly demonstrated that smokers exhibit lower MCA and NCV, achieve lower PNIF values, and have a less-compliant nasal mucosa than nonsmokers. Our results are unique, and provide evidence that smoking has adverse effects on the nasal airway, possibly due to mucosal inflammation. This might have further implications because altered nasal function could compromise the lower airways.

Objective improvement in nasal congestion and nasal hyperreactivity with use of nasal steroids in persistent allergic rhinitis

OBJECTIVE

Our objective was to evaluate the action of topical nasal steroid in nasal congestion and nasal hyper-reactivity in children and adolescents with persistent allergic rhinitis.

METHODS

Twenty atopic children and adolescents (6 to 18 years) with moderate-to-severe persistent allergic rhinitis (PAR) were treated with mometasone furoate (100 microg once a day) for 21 days. At the beginning and end of treatment, the following were recorded: a) nasal symptoms score; b) several parameters of nasal congestion measured by acoustic rhinometry (SRE 2000 Rhinometrics); c) degree of nasal hyper-reactivity to histamine (concentration of histamine necessary to induce at least 100% increase in total nasal resistance during nasal provocation test). Data were compared with those from 20 controls.

RESULTS

Compared to controls, PAR patients had significantly higher score of symptoms, as well as higher degree of nasal hyper-reactivity and lower nasal volumes. After treatment, there was a significant decrease in the mean nasal symptoms score (8.0 versus 3.8; p < 0.001) and in the nasal hyper-reactivity (histamine concentration: 0.72 mg/ml versus 2.60 mg/ml; p < 0.001). Congestion improvement was observed by the increase in all acoustic rhinometry parameters. Among all studied volumes, the volume in the segment between 2 and 5 cm showed the highest mean increase (19.8%).

CONCLUSION

Treatment with topical nasal steroid objectively reduced nasal congestion and nasal histamine hyper-reactivity in children and adolescents with PAR.

Cigarette smoking and self-assessed upper airway health

Habitual smoking represents a chronic insult to the airway. However, the effects of smoking on upper airway health remains poorly described. Our objective was to examine the relationship between cigarette smoking and self-assessed upper airway health and evaluate dose-response relationships between exposure and complaints in a sample of 2,523 patients. Eligible subjects were adults referred to ENT specialist for evaluation of chronic nasal or sleep-related complaints. Thirteen specific symptoms and conditions, mainly related to the upper airway, were graded based on visual analog scales (VAS). Smokers, representing 33% of the sample, were more likely to report severe upper airway complaints compared to non-smokers (odds ratio 1.31-2.08) and exhibited significantly higher visual analog scale scores than non-smokers for 9 out of 13 outcome variables (p < 0.001-0.007). Further, significant associations were found between cigarette consumption and severity of complaints (p < 0.001-0.01), heavy smokers generally being more likely to exhibit high VAS scores than light smokers. In several cases smoking status and self-reported asthma/allergy had similar impact on subjective outcomes. Cigarette smoking was clearly associated with impaired upper airway health and seemed to be an important determinant in subjects seeking medical attention due to chronic nasal or sleep-related complaints. Both threshold and dose-response like relationships were evident between cigarette consumption and the outcome measures.

Diagnostic strategies in nasal congestion

Nasal congestion is a major symptom of upper respiratory tract disorders, and its characterization an important part of the diagnosis of these illnesses. Patient history and assessment of nasal symptoms are essential components of diagnosis, providing an initial evaluation that may be adequate to rule out serious conditions. However, current congestion medications are not always fully effective. Thus, if symptoms do not respond adequately to therapy, or symptoms suggestive of more serious conditions are present, specialized assessments may be needed. Various techniques are available for diagnosing patients, including those used chiefly by primary care clinicians and those requiring the expertise of otolaryngologists, allergists, and other specialists. Endoscopy remains a mainstay for evaluating nasal blockage and its causes, while modalities such as peak nasal inspiratory flow and acoustic rhinometry are evolving to provide easy-to-use, noninvasive procedures that are sensitive enough to measure small but clinically important abnormalities and therapeutic changes. Several imaging modalities are available to the specialist for severe or unusual cases, as are specialized diagnostic procedures that measure adjunctive features of congestion, such as impaired mucociliary function.