Renato Roithmann

Acoustic rhinometry in the evaluation of nasal obstruction.

Acoustic rhinometry (AR) is a recently developed objective technique for assessment of geometry of the nasal cavity. The technique is based on the analysis of sound waves reflected from the nasal cavities. It measures cross‐sectional areas and nasal volume (NV). To obtain dependable assessments of nasal resistance by rhinomanometry or cross‐sectional area measurements by AR, it is essential that the structural relations of the compliant vestibular region remain undisturbed by the measuring apparatus. The use of nozzles in making these measurements carries a great risk of direct distortion of the nasal valve. We used a nasal adapter that does not invade the nasal cavity and a chin support that stabilizes the head. In 51 healthy nasal cavities, the average minimum cross‐sectional area (MCA) was 0.62 cm2 at 2.35 cm from the nostril and 0.67 cm2 at 2 cm from the nostril, respectively, before and after topical decongestion of the nasal mucosa. The MCA and NV findings in this group were significantly higher than MCA and NV (P<0.001) in people with structural or mucosal abnormalities before mucosal decongestion. After mucosal decongestion, the MCA and NV were significantly higher in healthy nasal cavities than in nasal cavities with structural abnormalities (P<0.001) but were not higher than nasal cavities with mucosal abnormalities (MCA, P = 0.05; NV, P = 0.06). A nozzle was applied in 20 healthy nasal cavities after mucosal decongestion, and a significantly higher MCA was found compared to measurements made with the nasal adapter (P = 0.02). We conclude that the nasal adapter, which does not invade the nasal cavities, avoids the distortion of the nasal valve and gives more accurate results.

Acoustic rhinometric assessment of the nasal valve.

The aims of this study are to assess nasal valve cross-sectional areas in healthy noses and in patients with nasal obstruction after rhinoplasty and to evaluate the effect of an external nasal dilator on both healthy and obstructive nasal valves. Subjects consisted of (i) volunteers with no nasal symptoms, nasal cavities unremarkable to rhinoscopy and normal nasal resistance and (ii) patients referred to our clinic complaining of postrhinoplasty nasal obstruction. All subjects were tested before and after topical decongestion of the nasal mucosa and with an external nasal dilator. In 79 untreated healthy nasal cavities the nasal valve area showed two constrictions: the proximal constriction averaged 0.78 cm2 cross-section and was situated 1.18 cm from the nostril, the distal constriction averaged 0.70 cm2 cross-section at 2.86 cm from the nostril. Mucosal decongestion increased cross-sectional area of the distal constriction significantly (p < 0.0001) but not the proximal. External dilation increased cross-sectional area of both constrictions significantly (p < 0.0001). In 26 post-rhinoplasty obstructed nasal cavities, only a single constriction was detected, averaging 0.34 cm2 cross-section at 2.55 cm from the nostril and 0.4 cm2 at 2.46 cm from the nostril, before and after mucosal decongestion respectively. External dilation increased the minimum cross-sectional area to 0.64 cm2 in these nasal cavities (p < 0.0001). We conclude that the nasal valve area in patients with postrhinoplasty nasal obstruction is significantly smaller than in healthy nasal cavities as shown by acoustic rhinometry. Acoustic rhinometry objectively determines the structural and mucovascular components of the nasal valve area and external dilation is an effective therapeutical approach in the management of nasal valve obstruction.

Role of the External Nasal Dilator in the Management of Nasal Obstruction

The aim of this study is to evaluate the effect of an external nasal dilator in patients with nasal obstruction secondary to mucosal congestion (n = 33) or to septal deviation in the nasal valve area (n = 28). A group of subjects with healthy nasal cavities was tested also (n = 51). Acoustic rhinometric and rhinomanometric nasal measurements were performed with and without the dilator and before and after topical decongestion of the nasal mucosa. A visual analog scale was employed to evaluate the subjective sensation of nasal obstruction. Objective measurements showed that the external dilator increased the minimum cross‐sectional area and decreased the nasal resistance significantly in all three groups (P < 0.01). The effect was more impressive in patients with septal deviation (P < 0.001). Subjective assessments reflected patency in all subjects except those in the mucosal swelling group (P = 0.06). From this study the authors conclude that the external nasal dilator offers an effective, nonsurgical therapeutic approach in the management of septal deviation that obstructs the nasal valve area. Although patients with nasal obstruction secondary to mucosal congestion showed objective improvement with the nasal dilator, these changes were not accompanied by a sensation of enhanced patency.

The Nasal Valve and Current Technology

The principal features and the respiratory role of the nasal valve are surveyed briefly and contributions of current computer-aided techniques of imaging, rhinomanometry, and acoustic rhinometry to an understanding of its structure and function are presented. The nasal valve is a dynamic segment of the anterior nasal airway, where the major portion of nasal resistance is localized and nasal resistance to respiratory airflow approximates half the airflow resistance of the entire respiratory system. This functioning valvular segment of the airway extends several mm beyond its triangular entrance in the compliant vestibule to the hemi-piriform entrance of the rigid cavum. Alar muscles assist in stabilizing the compliant lateral wall of the valve by resisting transmural pressures generated by inspiratory airflow and, by adjustment of alar positioning, these muscles can also direct the inspiratory air stream (e.g., olfactory sniffs). Abundant erectile tissues of both medial and lateral nasal walls are prominent in the valve region, and they play the governing role in regulation of valve lumen and consequent nasal airflow resistance. Pathological mucosal swelling is the commonest cause of obstructive nasal disease, and the narrowed site of the valve is so vulnerable to obstruction that recurring physiological mucovascular swellings frequently impede airflow in the presence of small anterior structural deviations. Assessment of obstructive nasal disease by symptomatology is unreliable, and rhinoscopy has substantial limitations; however, current technology provides minimally invasive, objective, and reliable methods for the study of nasal patency and for the acquisition of useful and dependable clinical information.

Beproducibility of Acoustic Rhinometric Measurements

The purpose of this study is to evaluate the reproducibility of acoustic rhinometric measurements obtained by means of a technique that avoids distortion of the compliant nasal vestibule. Subjects with noses untreated by decongestant were tested every minute for 6 consecutive minutes (576 area-distance curves–A-D curves), every 30 minutes for 6 consecutive hours (672 A-D curves), every day at 9 AM for 5 consecutive days (1200 A-D curves) and every Monday morning for 5 consecutive weeks (1200 A-D curves). The coefficient of variation found for the total minimum cross-sectional area (MCA) and total nasal volume (NV) increased with duration of the time interval between test and retest from 5% to 17% and from 4% to 9%, respectively. Variation of total MCA (combined right and left) and total NV (combined right and left) was smaller than variation of unilateral MCA or NV. Despite the dynamic nature of the nose, a standardized acoustic rhinometric technique can obtain acceptable results from subjects acting as their own controls in nasal physiological research and in clinical assessments.

Endoscopic Drainage of a Superiorly Based Subperiosteal Orbital Abscess

INTRODUCTION Subperiosteal orbital abscess (SPOA) is an uncommon complication of acute sinusitis and is seen most commonly in toddlers and teenagers. Many cases can be successfully treated with intravenous antibiotics,1 but if the patient’s condition does not improve rapidly, or if he or she initially presents with reduced visual acuity, surgical drainage is indicated. In the past, most patients with SPOA have been treated by an external approach via a Lynch-Howarth or transcaruncular incision. Recently, some centers have used transnasal endoscopic approaches to drain the abscess,2 but this technique has been limited to treating those abscesses that are sited medially, directly adjacent to the lamina papyracea. Most centers treating SPOAs located superior to the lamina papyracea do so via an external approach. The purpose of this article is to report our initial experience with treating abscesses that are located above the frontoethmoidal suture line, confined to the superior or superomedial compartments of the orbit (Fig. 1), by using a fully endoscopic transnasal approach. It is important to determine the relationship between the abscess and the anterior ethmoidal artery on computed tomography (CT) scans. A subperiosteal abscess that develops in the superior compartment of the orbit has its origin in most cases from the frontal sinus. Consequently, the abscess is located anterior to the anterior ethmoidal artery, although in some cases it may track posteriorly along the orbital roof. This is important to understand because it determines the transnasal endoscopic route to the abscess. The endoscopic entry into the superior orbital region should be performed anterior to the anterior ethmoidal artery, as described below.

Endoscopic and external dacryocystorhinostomy (DCR): which is better?

Brazilian Journal of otorhinolaryngology 78 (6) novemBer/DecemBer 2012 http://www.bjorl.org.br / e-mail: revista@aborlccf.org.br The traditional approach for patient with epiphora and a blocked naso-lacrimal duct was and external approach Dacryocystorhinostomy (DCR). The technique was popularized by Toti in the early 1900s and has changed little since then. It required an external incision in the medial canthus of the eye for access to the lacrimal sac. Success rates for this procedure have varied widely with report of success as low as the 60% and in the hands of specialized oculoplastic surgeons as high as 95%. In the early 1990’s McDonogh & Meiring published the first accounts of endoscopic endonasal DCRs and this has gained increasing popularity as the endonasal anatomy and endoscopic surgical techniques have improved. The most important development was the understanding of the anatomy of the lacrimal sac in relation to the anatomy of the lateral nasal wall. Early descriptions showed the lacrimal sac to be sited below the axilla of the middle turbinate while more recent research showed that the lacrimal sac is sited about 8 to 10 mm above the axilla. This has had implications for the endoscopic techniques developed to access the lacrimal sac as well as for the results obtained with the endoscopic techniques. Early results with the endoscopic DCR were not as good as the best results obtained by external DCR and this was due to the poor understanding of the endoscopic anatomy of the lacrimal sac. These initial attempts at endoscopic DCR only opened the lower half of the lacrimal sac and therefore did not fully the principles of the external DCR which emphasized the need for full exposure of the sac and therefore full marsupialization of the sac into the lateral nasal wall. Once the anatomy was fully understood endoscopic DCR techniques were adapted and full marsupialization of the lacrimal sac was achieved and the results of this technique has been showed to be as good if not better than those that can be achieved in the best hands with the external technique. The added advantage of the endoscopic DCR technique is that it leave no external scar, does not disrupt the orbicularis oculi muscle which is the main driver of the lacrimal pump and should produce superior results in patients with functional nasolacrimal duct rather than anatomical nasolacrimal duct obstruction. A joint work of the otolaryngologist and the ophthalmologist might be advantageous for the best possible management of the patient with epiphora. Endoscopic and external dacryocystorhinostomy (DCR) which is better? EDITORIAL Braz J Otorhinolaryngol. 2012;78(6):2. .org

A Head and Tube Stabilizing Apparatus for Acoustic Rhinometry Measurements

A new apparatus consisting of a chin rest and forehead support system and an adjustable acoustic tube holder is described. This device provides patient comfort, technical convenience and precise positioning that contribute to reliable measurement. Moderate pressure between forehead and supporting bar incorporated into the apparatus did not induce significant alterations in results.

Anatomical terminology of the internal nose and paranasal sinuses: cross-cultural adaptation to Portuguese

INTRODUCTIONnFunctional endonasal endoscopic surgery is a frequent surgical procedure among otorhinolaryngologists. In 2014, the European Society of Rhinology published the European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses, aiming to unify the terms in the English language. We do not yet have a unified terminology in the Portuguese language.nnnOBJECTIVEnTranscultural adaptation of the anatomical terms of the nose and paranasal cavities of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses to Portuguese.nnnMETHODSnA group of rhinologists from diverse parts of Brazil, all experienced in endoscopic endonasal surgery, was invited to participate in the creation of this position paper on the anatomical terms of the nose and paranasal sinuses in the Portuguese language according to the methodology adapted from that previously described by Rudmik and Smith.nnnRESULTSnThe results of this document were generated based on the agreement of the majority of the participants according to the most popular suggestions among the rhinologists. A cross-cultural adaptation of the sinonasal anatomical terminology was consolidated. We suggest the terms inferior turbinate, nasal septum, (bone/cartilaginous) part of the nasal septum, (middle/inferior) nasal meatus, frontal sinus drainage pathway, frontal recess and uncinate process be standardized.nnnCONCLUSIONnWe have consolidated a Portuguese version of the European Anatomical Terminology of the Internal Nose and Paranasal Sinuses, which will help in the publication of technical announcements, scientific publications and the teaching of the internal anatomical terms of the nose and paranasal sinuses in Brazil.

Surgical Approaches to Sinusitis: Overview of Techniques

In the early 1970s, Professor Walter Messerklinger began his investigations into the anatomy and physiology of the paranasal sinuses and the pathogenesis of sinusitis. He was the first to apply endoscopes routinely in the diagnosis of sinus disease and, subsequently, for the performance of surgical procedures on the paranasal sinuses.