4-Phase-Rhinomanometry (4PR)--basics and practice 2010.

The last comprehensive publications about the theory and practice of rhinomanometry appeared more than 20 years ago. Since the 1980's, the general progress of sensor techniques, fluid physics and data processing was accompanied by the permanent work of the authors to analyze the errors of rhinomanometry and to create a fundament for a contemporary and practical method that can be used in functional diagnostics of the nasal air stream. In this special document, the objectives and measurement principles, as well as the history of rhinomanometry are described in the first three chapters. It is pointed out, that the key parameters are not only intranasal pressure and flow, but also the factor time. The technical requirements as following from the dynamics of breathing are described. The process of averaging of rhinomanometric data lead to a separate and time-dependent analysis of the changes of pressure and flow and implicated the introduction of the 4 breathing phases (ascending and descending curve part in inspiration and expiration) into rhinomanometry and is therefore called 4-Phase-Rhinomanometry (4PR). Chapter 4 is containing a comprehensive analysis of the practical errors, which may follow neglecting the 4 breathing phases. The in chapter 5 described mathematical-physical concept of 4PR is based on the introduction of the terms "steady" and "unsteady" flow, in addition to the up to now used terms of laminarity and turbulence. After the derivation of the HOFFRICHTER-equation as explaining the loops around the intersection point of the x-axis and y-axis, a clinical classification of the rhinomanometric findings is given and confirmed by physical experiments with "artificial noses". Finally, testing the rhinomanometric method by CFD (Computational Fluid Dynamics), lead to the same conclusions as to the importance of 4 phases of the breathing cycle. The precondition for the worldwide introduction of new parameters into the 4PR is a comprehensive statistical analysis. The disadvantages of the present recommended standard values are described in chapter 6. Following previous studies in 5800 cases, the parameters Vertex Resistance (VR), Effective Resistance (Reff) and their logarithmic transformations have been investigated in 1580 rhinograms of different degrees of obstructions, also including the correlations to a VAS. It could be confirmed, that the parameters VR and Reff after logarithmic transformation, have a significant and high correlation to the sensation of obstruction. The new clinical classification of obstruction and conductance of the nose is proposed in Table 1 for Caucasian noses. Table 1. Clinical classification of obstruction and conductance for Causcasian noses. [see text for table]. Chapter 7 is dedicated to the advantages of 4PR in the functional diagnosis of nasal valve problems. Graphical as well as numerical solutions are available by the fact, that the motions of the nasal entrance as caused by the breathing process are now visible from the shape of the 4PR-curve. Discussing practical aspects in chapter 8, the start point of proposals and discussions are the standard recommendations of the ISOANA and the results of its consensus conference in 2003. In particular the calibration processes, hygiene, the correct attachment of the pressure tube at the nostril ("tape method") and the different measurement procedures (AAR, APR), decongestion and provocation tests are extensively described. Both the final chapters are clinical contributions from mainland China, which are of high importance because of the racial differences in nasal respiratory function. In chapter 9, tests of the assessment of normal nasal airway in adult Chinese by 4PR, rhinomanometry and acoustic rhinometry are presented. This investigation lead to the conclusion that 4PR is an important supplement to classic rhinomanometry and acoustic rhinometry, if the classification of obstruction is adapted to the higher basic resistance of the Chinese population. Chapter 10 is dealing with 4PR and acoustic rhinometry in the functional evaluation of septal deviations and concludes, that both methods are valuable objective instruments for the evaluation of nasal obstruction.

Chemesthetic responses to airborne mineral dusts: boric acid compared to alkaline materials.

OBJECTIVES: (1) To assess the relation between occupationally relevant exposures to dust of boric acid and magnitude of feel in the eye, nose, and throat during activity (pedaling) equal to light industrial work. (2) To compare feel from the dust of boric acid with that of the alkaline dusts calcium oxide and sodium tetraborate pentahydrate (sodium borate). (3) To chart how magnitude of feel changes with time in exposures up to 3/4 h. METHODS: Twelve subjects, six males and six females, participated in duplicate sessions of exposure to 2.5, 5, and 10 mg m(-3) of boric acid, 10 mg m(-3) of sodium borate, 2.5 mg m(-3) of calcium oxide presented as calcium oxide alone or diluted with hydrated calcium sulfate, and 0 mg m(-3) (blank). Exposures occurred in a plastic dome suspended over the head and closed around the neck with rubber dam. Measurements pre- and post-exposure included nasal secretion and nasal resistance. Measurements during exposure included rated magnitude of feel in the eye, nose, and throat, and respiration (Respitrace System). Six concentrations of carbon dioxide ranging from just below detectable to sharply stinging gave subjects references for their ratings. RESULTS: In general, feel increased for periods up to half an hour, then either declined or held at a plateau. Each material had a temporal signature. The nose led with the highest feel, followed by the throat, then the eyes. This hierarchy proved weakest for boric acid; at one level of exposure, magnitude in the throat overtook that in the nose. Accompanying measures implied that change of feel with time occurred neither because of an increase in dilution of the dissolved dusts in newly secreted mucus nor an increase of consequence in nasal resistance. Most likely, sensory adaptation determined the change. Boric acid of 10 mg m(-3) fell slightly and insignificantly below 10 mg m(-3) sodium borate in feel. Boric acid, though, showed a relatively flat dose-response relationship, i.e., a change in level caused little change in feel. CONCLUSIONS: The time-constant for feel from dusts lies on the order of tens of minutes. A flat concentration-response function for boric acid and a notable response from the throat suggests that perceived dryness, not mediated by acidity but perhaps by osmotic pressure, may account for the feel evoked at levels of exposure at or below 10 mg m(-3). More acidic dusts that could actually change nasal pH may trigger sensations differently.

Odor and chemesthesis from exposures to glutaraldehyde vapor.

OBJECTIVES: Assessment of olfactory and chemesthetic sensitivity (feel, sensory irritation) to vapor of glutaraldehyde in young adult females. For chemesthetic sensitivity, assessment included the variable of duration, with focus on whether concentrations initially too low to evoke feel in the eye or upper airway might do so in exposures up to 15 min. METHODS: Experiment 1 probed sensitivity with forced-choice testing of detection over ranges of concentrations appropriate to three endpoints: odor, feel in the eye, and feel in the nose. A subject participated in hours of testing per endpoint to yield enough data to erect a psychometric (concentration-response) function. Exposure in Experiment 1 entailed use of a vapor-delivery system that stimulated sites of interest separately. Exposure in Experiment 2 occurred in the ambient environment of a chamber, with the sites stimulated simultaneously. In that case, subjects rated confidence by the minute that they felt the presence of vapor in the eyes, nose, and throat during exposures of 15 minutes to 35, 50, 75, and 100 ppb, a blank, and an odor control of mild heptane. RESULTS: In Experiment 1, the typical subject achieved 50% detection (threshold) of odor at 0.3 ppb. The typical subject achieved 50% detection of feel in the eye and nose at 390 and 470 ppb, respectively. Psychometric functions for feel showed much sharper dependence on concentration than those for odor. In Experiment 2, confidence in detection of feel migrated progressively away from no-with certainty toward the zone of uncertainty, with bigger change when the exposures contained any glutaraldehyde. The ratings of confidence failed, however, to show distinguish among these concentrations. CONCLUSIONS: Glutaraldehyde has much higher odor potency than previously thought. Its green-apple odor should signal presence of the vapor at levels more than a 100-fold below any that might evoke sensory irritation in brief exposures. Exposures that start decidedly below irritating (100 ppb and below) seem unlikely to turn irritating over time. Although the effects from these concentrations differentiated themselves from those of air and an odor control, they exhibited none of the concentration dependence seen for sensations of feel. They seemed likely driven by the penetrating odor of glutaraldehyde.

Effect of desloratadine therapy on symptom scores and measures of nasal patency in seasonal allergic rhinitis: results of a single-center, placebo-controlled trial.

BACKGROUND: Desloratadine reduces symptoms and maintains nasal airflow in patients with seasonal allergic rhinitis (SAR) during experimental allergen exposure. OBJECTIVE: To compare the effects of desloratadine and placebo on symptom scores, quality of life (QOL), and nasal airway patency in patients with SAR during the allergy season. METHODS: Adults with symptomatic SAR were randomized in a double-blind manner to receive desloratadine, 5 mg, or placebo for 14 days. Patient-rated SAR symptoms were recorded twice daily (morning and evening). On days 1 and 15, SAR symptoms were scored jointly (investigator and patient), nasal airflow was measured using 4-phase rhinomanometry, and QOL and the overall condition of SAR were rated. Overall treatment response was scored on day 15. Adverse events were recorded. RESULTS: At day 15, total symptom (P = .03) and total nasal symptom (P = .02) scores and patient morning-rated individual nasal symptom scores (except nasal stuffiness) (P < or = .04) decreased significantly from baseline with desloratadine vs placebo. Flow in the descending expiratory nasal airflow phase was significantly greater (P = .046) and the percentage increase in total inspiratory nasal airway resistance was less (P = .03) in the desloratadine group vs the placebo group. The overall condition of SAR was less severe (P = .045), the therapeutic response was greater (P = .004), and the nasal symptom domain of the QOL score was significantly better (P = .03) in the desloratadine group. Adverse event rates were similar in both groups. CONCLUSION: Desloratadine treatment for 14 days improved nasal airflow and resistance as well as symptom and QOL scores in patients with symptomatic SAR during the allergy season.

Nasal cytology: a marker of clinically silent inflammation in patients with obstructive sleep apnea and a predictor of noncompliance with nasal CPAP therapy.

STUDY OBJECTIVES: Patients with obstructive sleep apnea treated with nasal continuous positive airway pressure (CPAP) often complain of nasal side effects. We studied patients before and after initiation of nasal CPAP to see how treatment affected nasal function and markers of nasal inflammation. We searched for pretreatment findings that might help to predict noncompliance. METHODS: Nasal symptom scores, nasal flow by anterior rhinomanometry, mediator levels (intercellular adhesion molecule-1, interleukin-6, interleukin-8 and interleukin-13), and nasal scrapes for cytology were obtained at baseline and monthly for up to 3 months of nasal CPAP therapy. Compliance was assessed from the patient's report and by recording hours of usage for up to 19 months of follow-up. RESULTS: Thirty-eight patients with newly diagnosed obstructive sleep apnea were classified as having no rhinitis (42%), allergic rhinitis (37%), or nonallergic rhinitis (21%). There was no significant difference in compliance in patients with and without rhinitis. Compliant and noncompliant patients showed no significant differences in their baseline nasal symptom scores, nasal flow, and mediator levels. Nasal neutrophil counts before treatment were greater in noncompliant than in compliant patients (p = .004) and greater in those discontinuing because of nasal symptoms than in patients who quit for other reasons (p = .05). There was a positive correlation between neutrophil counts and nasal bacterial scores, both before and after treatment with nasal CPAP. CONCLUSIONS: Patients with increased neutrophil counts in the nasal scrape before beginning nasal CPAP are at increased risk of discontinuing therapy. They appear to have subclinical nasal inflammation that cannot be identified from clinical assessment, nasal symptom scores or rhinomanometry.

Sensory and associated reactions to mineral dusts: sodium borate, calcium oxide, and calcium sulfate.

Occupational exposure limits (OELs) for irritant dusts have had no quantifiable bases. This study (1) charted chemosensory feel, denoted chemesthesis here, to dusts of calcium oxide (1 to 5 mg/m(3)), sodium tetraborate pentahydrate [sodium borate] (5 to 40 mg/m(3)), and calcium sulfate (10 to 40 mg/m(3)); (2) examined correlates of the chemesthetic sensations; and (3) sought to illuminate the basis for potency. Twelve screened men exercised against a light load while they breathed air in a dome fed with controlled levels of dust for 20 min. Measured parameters included nasal resistance, nasal secretion, minute ventilation, heart rate, blood oxygenation, mucociliary transport time, and chemesthetic magnitude, calibrated to pungency of carbon dioxide. Subjects registered time-dependent feel from exposures principally in the nose, secondarily in the throat, and hardly in the eyes. Calcium oxide had the greatest potency, followed by sodium borate, with calcium sulfate a distant third. Of the physiological parameters, amount of secretion showed the best association with chemesthetic potency. That measure, as well as mucociliary transport time and minute ventilation, went into calculation of mass of dust dissolved into mucus. The calculations indicated that the two alkaline dusts increased in equal molar amounts with time. At equal molar concentrations, they had, to a first approximation, equal chemesthetic magnitude. On the basis of mass concentration in air or dissolved into mucus, calcium oxide and sodium borate differed in potency by a factor just above five, equal to the difference in their molecular weights. This relationship could inform the setting of OELs for a critical effect of irritation.

Assessment of upper respiratory tract and ocular irritative effects of volatile chemicals in humans.

Accurate assessment of upper respiratory tract and ocular irritation is critical for identifying and remedying problems related to overexposure to volatile chemicals, as well as for establishing parameters of irritation useful for regulatory purposes. This article (a) describes the basic anatomy and physiology of the human upper respiratory tract and ocular mucosae, (b) discusses how airborne chemicals induce irritative sensations, and (c) reviews practical means employed for assessing such phenomena, including psychophysical (e.g., threshold and suprathreshold perceptual measures), physiological (e.g., cardiovascular responses), electrophysiological (e.g., event-related potentials), and imaging (e.g., magnetic resonance imaging) techniques. Although traditionally animal models have been used as the first step in assessing such irritation, they are not addressed here since (a) there are numerous reviews available on this topic and (b) many rodents and rabbits are obligate nose breathers whose nasal passages differ considerably from those of humans, potentially limiting generalization of animal-based data to humans. A major goal of this compendium is to inform the reader of procedures for assessing irritation in humans and to provide information of value in the continued interpretation and development of empirical databases upon which future reasoned regulatory health decisions can be made.

Triamcinolone acetonide and fluticasone propionate aqueous nasal sprays significantly improve nasal airflow in patients with seasonal allergic rhinitis.

Domiciliary measurement of nasal peak inspiratory flow rate (nPIFR) provides a simple, noninvasive, objective assessment of nasal patency and may be useful for determining the effectiveness of therapeutic interventions. This randomized, parallel-group, investigator-blind study compared the effects of triamcinolone acetonide aqueous nasal spray (TAA AQ), 220 microg everyday (n = 19), and fluticasone propionate (FP AQ), 200 microg everyday (n = 20), for 21 days on nasal airflow in patients with seasonal allergic rhinitis (SAR), using domiciliary nPIFR. Patients had a > or = 2-year history of springtime SAR and positive epicutaneous or intradermal test to grass, tree pollen, or outdoor molds. nPIFR was measured three times each morning (before dosing) and at bedtime using an In-Check nPIF meter. All measurements were recorded on diary cards, and the best of the three measurements was used for data analysis. There were no significant demographic differences between treatment groups at baseline. Baseline nPIFR (+/- SE) was 106.5 L/minute (+/- 51.2) and 97.7 L/minute (+/- 45.0) in the TAA AQ and FP AQ groups, respectively (p = 0.5733). Model-based estimation of mean change from baseline with TAA AQ and FP AQ at the end of the study were 21.72 (+/- 6.04) and 16.48 (+/- 5.73), respectively. Both treatment groups showed an approximately 20% improvement in nPIFR versus baseline (p = 0.0002 and p = 0.0069 for TAA AQ and FP AQ, respectively), with no statistical difference between treatments. Weekly mean nPIFR scores indicated progressive improvement in nasal airflow with both treatments. Both TAA AQ and FP AQ were effective for improving nasal airflow as indicated by increases in nPIFR in patients with SAR.

Lavagem nasal como método de avaliação das cavidades nasais / Nasal lavage as a tool to evaluate nasal cavities

A avaliação das cavidades nasais é extremamente importante nos indivíduos portadores de patologias nasais e nos que estão expostos a substâncias potencialmente nocivas presentes no meio ambiente. Como a histologia da mucosa nasal é similar à das vias respiratórias inferiores, uma resposta inflamatória vista no nariz pode ser um sinal de alerta de inflamação na via aérea inferior. A presença de biomarcadores nas cavidades nasais pode ser facilmente detectada através de inúmeras técnicas. Entretanto, é necessário dispormos de um método para avaliação das alterações encontradas nesta região que seja simples e seguro. A lavagem nasal preenche estes critérios e deve ser considerada sempre que se deseje estudar esta região.

Smell impairment.

Preview People born without a sense of smell may not miss it, but those who have enjoyed and lost the sense certainly do. For some reason, however, the problem is often dismissed or not even sought during evaluation. The authors compile from their experience at a nasal dysfunction clinic information pertinent to primary care physicians and suggestions for management. They describe reversible and nonreversible causes of olfactory impairment and provide simplified algorithms to use in patient evaluation.