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.

Rhinomanometry for preoperative and postoperative assessment of nasal obstruction.

In this retrospective study we used active, anterior mask rhinomanometric methods to measure nasal resistance before and after surgery for nasal obstruction. The study group comprised 60 patients with nasal obstruction who had 63 preoperative and postoperative rhinomanograms and the control group contained 14 asymptomatic patients who underwent rhinomanometric studies before transnasal, transsphenoidal pituitary surgery. Before surgery the study group had significantly higher total and combined unilateral nasal resistances than either the control group before surgery (p less than 0.05 and p less than 0.01, respectively) or the study group after surgery (p less than 0.0001 for both comparisons). Surgery normalized the nasal resistances of the study group in relation to the control group. A total nasal resistance greater than 1 cm H2O/L/sec or a unilateral resistance greater than 3.5 cm H2O/L/sec suggests clinically significant nasal obstruction. Airway narrowing and obstructive symptoms correlated with airway resistance in the preoperative patient, but symptoms did not correlate well with postoperative resistance.

Normal nasal resistance.

Eighty normal adults without nasal symptoms were studied to determine normal nasal resistance values and the variation of nasal resistance in normal adults. A microprocessor-based system for collection and analysis of transnasal pressure and flow was used to obtain nasal resistance values. Unilateral and total transnasal pressure and flow values were determined before and after decongestion of the nose with 1% phenylephrine spray. The distribution of the 80 resistance values was found to be skewed to the right. Log transformation of the resistance values was the best method to normalize their distribution. The mean and variation of normal nasal resistance are reported at flows of 0.1 and 0.2 L/sec, at pressures of 0.5 and 1 cm H2O, and at radii of 1, 2, and 3 on the pressure-flow curve.

Spiral saphenous vein graft for replacement of internal jugular vein: a series of case reports.

Bilateral radical neck dissection with internal jugular vein extirpation, be it simultaneous or staged, results in severe cephalic venous hypertension. Symptoms remit with time, however, acutely contribute to the morbidity of the procedure. Internal jugular vein replacement using autogenous saphenous vein that is fashioned into a spiral conduit has been used in three patients undergoing bilateral or second side radical neck dissection. The technique entails construction of a large vein conduit by wrapping saphenous vein around a chest tube in a spiral fashion. Patients treated had objective relief of the acute venous hypertension based on cephalic venous pressure measurements. The three patients undergoing the spiral vein grafting were notable for the lack of any expected symptoms derived from venous hypertension, and postoperative venograms demonstrate graft patency at one to two weeks.

Prosthetic closure of nasal septal perforations.

One hundred seventy-one patients had closure of symptomatic nasal septal perforations by insertion of a Silastic nasal septal prosthesis between June 1972 and August 1981. Follow-up revealed that successful closure of the defect was accomplished in 73% of cases, with reduction in crusting and epistaxis and improvement in nasal respiration in many cases. Prefabricated prostheses have been effective in treating smaller perforations. The treatment of four patients with unusually large septal perforations by custom-carved prostheses sized using computerized axial tomographic scanning is described.

Adenocarcinoma and adenoma of the middle ear.

Primary middle ear glandular tumors of the adenocarcinoma and adenoma types are rare. The terminology used in describing them is quite varied. Some investigators presume that a distinct recognizable group of these tumors are benign, but because of the rarity of the lesions, such conclusions have been difficult to verify. We review the literature of these lesions and report 11 additional cases. The course was documented in 25 cases in the literature; 20 of these were reported to be benign over periods of follow-up from 1 month to 10 years, and 5 were fatal. Among our patients, 5 had a benign course, 3 died of causes related to the tumor, and 3 had persistence of their lesion and substantial consequent morbidity. We emphasize the slow growth and elusive nature of these lesions. Histologic evidence of mitoses, roentgenologic evidence of bony destruction, and cranial nerve involvement were factors consistent with a poor prognosis. The origin of these tumors may vary. A similarity to paragangliomas is noted. The ultimate course of these tumors cannot always be predicted from the histologic appearance. Early surgical removal appears to be the most successful therapy. Three of the 4 types of glandular tumors of the external ear canal described by Wetli, et al, can be found in the middle ear: adenoma, adenocarcinoma, and adenoid cystic carcinoma. In addition, several other types of glandular lesions can occur in the middle ear--the "choristomas," mucoepidermoid carcinomas, and what we believe to be a variant of paragangliomas. The adenoid cystic tumors are well described in the literature and will not be discussed here. We reviewed cases of the adenoma and adenocarcinoma types, some of which bore a resemblance to the paragangliomas.