BACKGROUNDOlfactory dysfunction is an increasingly recognised condition, associated with reduced quality of life and major health outcomes such as neurodegeneration and death. However, translational research in this field is limited by heterogeneity in methodological approach, including definitions of impairment, improvement and appropriate assessment techniques. Accordingly, effective treatments for smell loss are limited. In an effort to encourage high quality and comparable work in this field, among others, we propose the following ideas and recommendations. Whilst the full set of recommendations are outlined in the main document, points include the following: - Patients with suspected olfactory loss should undergo a full examination of the head and neck, including rigid nasal endoscopy with small diameter endoscopes. - Subjective olfactory assessment should not be undertaken in isolation, given its poor reliability. - Psychophysical assessment tools used in clinical and research settings should include reliable and validated tests of odour threshold, and/or one of odour identification or discrimination. - Comprehensive chemosensory assessment should include gustatory screening. - Smell training can be helpful in patients with olfactory loss of several aetiologies.CONCLUSIONSWe hope the current manuscript will encourage clinicians and researchers to adopt a common language, and in so doing, increase the methodological quality, consistency and generalisability of work in this field.
The advent of endoscopic sinus surgery led to a resurgence of interest in the detailed anatomy of the internal nose and paranasal sinuses. However, the official Terminologica Anatomica used by basic anatomists omits many of the structures of surgical importance. This led to numerous clinical anatomy papers and much discussion about the exact names and definitions for the structures of surgical relevance. This European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses was conceived to re-evaluate the anatomical terms in common usage by endoscopic sinus surgeons and to compare this with the official Terminologica Anatomica. The text is a concise summary of all the structures encountered during routine endoscopic surgery in the nasal cavity, paranasal sinuses and at the interface with the orbit and skull base but does not provide a comprehensive text for advanced skull base surgery. It draws on a detailed review of the literature and provides a consensus where several options are available, defining the anatomical structure in simple terms and in English. It is recognised that this is an area of great variation and some indication of the frequency with which these variants are encountered is given in the text and table. All major anatomical points are illustrated, drawing on the expertise of the multi-national and multi-disciplinary contributors to this project.
The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007.The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps and chronic rhinosinusitis with nasal polyps are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed.
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.
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.
Tumours affecting the nose, paranasal sinuses and adjacent skull base are fortunately rare. However, they pose significant problems of management due their late presentation and juxtaposition to important anatomical structures such eye and brain. The increasing application of endonasal endoscopic techniques to their excision offers potentially similar scales of resection but with reduced morbidity. The present document is intended to be a state-of-the art review for any specialist with an interest in this area 1. to update their knowledge of neoplasia affecting the nose, paranasal sinuses and adjacent skull base; 2. to provide an evidence-based review of the diagnostic methods; 3. to provide an evidence-based review of endoscopic techniques in the context of other available treatments; 4. to propose algorithms for the management of the disease; 5. to propose guidance for outcome measurements for research and encourage prospective collection of data. The importance of a multidisciplinary approach, adherence to oncologic principles with intent to cure and need for long-term follow-up is emphasised.
Rhinosinusitis is a significant and increasing health problem which results in a large financial burden on society. This evidence based position paper describes what is known about rhinosinusitis and nasal polyps, offers evidence based recommendations on diagnosis and treatment, and considers how we can make progress with research in this area. Rhinitis and sinusitis usually coexist and are concurrent in most individuals; thus, the correct terminology is now rhinosinusitis. Rhinosinusitis (including nasal polyps) is defined as inflammation of the nose and the paranasal sinuses characterised by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), +/- facial pain/pressure, +/- reduction or loss of smell; and either endoscopic signs of polyps and/or mucopurulent discharge primarily from middle meatus and/or; oedema/mucosal obstruction primarily in middle meatus, and/or CT changes showing mucosal changes within the ostiomeatal complex and/or sinuses. The paper gives different definitions for epidemiology, first line and second line treatment and for research. Furthermore the paper describes the anatomy and (patho)physiology, epidemiology and predisposing factors, inflammatory mechanisms, evidence based diagnosis, medical and surgical treatment in acute and chronic rhinosinusitis and nasal polyposis in adults and children. Evidence based schemes for diagnosis and treatment are given for the first and second line clinicians. Moreover attention is given to complications and socio-economic cost of chronic rhinosinusitis and nasal polyps. Last but not least the relation to the lower airways is discussed.
This document is the result of the work and discussion of the Standardization Committee on Acoustic Rhinometry and presents guidelines for quality control and optimal application of acoustic rhinometry at its present stage. It is suggested that: 1. A well-defined standard nose is used for testing and optimising the equipment (data for a standard nose is given in the paper). 2. Procedures for evaluation of accuracy and repeatability of the measurements in the standard nose are presented, and error limits are defined for the area-distance curve as a whole, for the minimum cross-sectional area and for the volume from 0-5 cm into the nose. 3. Publication of results should include the volume 0-5 cm into the nose (volume from 2-5 cm for mucosal changes) the minimum cross-sectional area or preferably the two first minima and the distances to those areas. 4. The operator should be trained, follow a standard operating procedure and the environmental conditions (temperature and noise) be controlled. 5. Attention should be given to the nosepiece and the coupling between the equipment and the nose to obtain correct position, and sufficient seal without disturbing the anatomy. 6. The manufacturer should give information about the performance of the equipment, calibration procedures and maintenance, hygiene, environmental and safety standards.
We describe the development of a clinical model of nasal congestion using a fixed dose histamine challenge in normals. The objective was to use histamine to induce a similar degree of nasal congestion as a natural common cold (from unpublished data of 250 cold sufferers) and thus establish a rapid screening system for decongestant drug effects. Sixtynine normal subjects were challenged with histamine diphosphate (300 micrograms/nostril) on 2 visits. Thirtytwo subjects were identified showing reproducible baseline values (< 15%CV (coefficient of variation)) and adequate nasal congestion (minimum 20%) without excessive sneezing. Reproducibility was evaluated in them post challenge using acoustic rhinometry and rhinomanometry. Twentythree subjects showed a variation < 25%CV of nasal volume over multiple visits in a 5 month period. The average reduction in nasal volume and airflow 15 minutes post challenge was 32% and 41% respectively. Acoustic rhinometry values were less variable than rhinomanometry values. Negligible differences (< 2%) in histamine response over visits and similar correlation between measured values at first, second and last visits indicate that 2 visits are adequate to evaluate response reproducibility in a selected population. We conclude that it is feasible to develop a robust clinical model of nasal congestion using histamine.
The clinical value of acoustic rhinometry (AR) is its ability to measure the dimensions of the nasal cavity in terms of a curve describing the cross-sectional areas as a function of distance. This curve describes nasal airway patency and gives an impression of the degree of nasal obstruction. The method provides values before and after decongestion which allow to evaluate the cause of the nasal obstruction as mainly skeletal or mucosal. This makes AR a tool for diagnosis and follow-up of treatment in both rhinology and rhinosurgery. Similarly, AR is a reliable method to show the dimensional changes of the nasal cavity before and after a given treatment. In the evaluation of a surgical intervention it is reasonable to use decongested values. Turbinate surgery, septo- and rhinoplasty, orthognatic surgery and paranasal sinus surgery and their influence on the dimensions of the nasal cavity may be reflected by AR. The absolute minimum cross-sectional area, and cross-sectional areas and volumes at fixed distances are the recommended parameters to show dimensional changes after nasal surgery. The predictive value of AR, in relation to nasal obstruction, should have high specificity and sensitivity to be used in a clinical setting. It seems that the single variables do not provide enough information for the diagnosis of obstruction, and it has been stressed that the results should be interpreted together with rhinoscopy and subjective complaints. A statistical model based on questionnaire, rhinoscopic findings and several variables from AR has been proposed to increase the diagnostic specificity and sensitivity of AR.
A cross-sectional study was performed on the relationships between hygienic measurements and nasal investigations in 234 personnel in 12 primary schools in mid-Sweden. Hygienic data included building characteristics, measurements of indoor air pollutants, air change rate, temperature and humidity. Clinical examinations included symptom reports, acoustic rhinometry and nasal lavage, with the determination of biomarker levels for eosinophil cationic protein (ECP), lysozyme, myeloperoxidase (MPO) and albumin. Subjective nasal obstruction was increased in schools with mechanical ventilation (adjusted prevalence OR = 2.0; 95 CI 1.1-3.7) and subjects reporting nasal obstruction had higher levels of dust in the classroom, compared to those not reporting this symptom (p = 0.008 by Mann-Whitney U-test). Congruently, a decreased nasal patency measured by acoustic rhinometric minimum cross-sectional areas (MCA1 and MCA2) was related to the use of mechanical ventilation (p = 0.008 and p = 0.02 respectively, by Mann-Whitney U-test), dust levels (p = 0.03 and p < 0.001 respectively, by Kendall's tau correlation analysis), a lower cleaning frequency of desks (p < 0.001 and p = 0.02 respectively, by Kendall's tau correlation analysis), the use of wet mopping (p < 0.001 and p = 0.04 respectively, by Mann-Whitney U-test) and PVC floor material (p < 0.001 and p = 0.034 respectively, by Mann-Whitney U-test). The cleaning frequency of floors was positively correlated with MCA1 (p = 0.049 by Kendall's tau correlation analysis). In buildings with signs of water damage, flat roof or a concrete slab fundament the personnel had increased ECP, lysozyme or albumin levels in nasal lavage. A reduced nasal patency and an increased inflammatory biomarker response were seen for higher levels of formaldehyde (MCA1, MCA2, VOL1, VOL2, ECP and lysozyme) and nitrogen dioxide (MCA1, VOL2, ECP and lysozyme) in the classrooms. In conclusion, the results indicate that acoustic rhinometry in combination with the determination of nasal lavage biomarkers can be used to study effects on the upper airways of the indoor environment. Actual exposures to indoor air pollutants in Swedish schools can affect the occurrence of subjective nasal obstruction and give clinical signs of reduced nasal patency together with an inflammatory biomarker response in the nasal mucosa.
Acoustic rhinometry measurements are influenced by factors related to subject posture, breathing, inclination and positioning of the wavetube, leaks and distortion at the nostril-nose adapter connection and ambient noise. We present simple techniques to control these errors. Thus, gel on contoured nose adapters, shadow tracing to maintain posture, laser homing for wavetube alignment, are all integrated into a practical scheme that is easy to implement and causes minimum discomfort to subjects. Repeatability improved to below 3% coefficient of variation (CV) in non decongested subjects when trained operators used all the techniques together viz. gel on nose adaptors, shadow tracing, laser homing. In a factorial experiment, repeated measurements were made on subjects over two consecutive days with operator training and standardization tools as variables. An analysis of variance identified the most important factors to be gel on contoured nose adapters, operator training and control of breathing. With gel, the mean CV between readings was 5.8%, measurement time 30.3 seconds. The tools, especially gel and shadow tracing, helped untrained operators achieve performance levels that were more comparable with trained operators. Reproducible curves could be taken rapidly. Thus a significant difference of 31.2 seconds between untrained and trained operators reduced to 12.6 seconds using tools. These techniques significantly improve the reliability, speed and ease of doing repeated acoustic rhinometry measurements and thus the quality of data generated in nasal studies.
Acoustic rhinometry (AR), introduced a decade ago for assessment of the nasal airways of adults, has several attractive features relevant to application in a paediatric population. Its non-invasive nature, simplicity and rapidity are prime assets when examining infants and small children. Valid AR measurements can be obtained in a few seconds and require minimal co-operation. The striking consistency of AR studies of healthy subjects and the agreement with CT-derived and directly measured choanal dimensions are a strong indication of its reliability. Acoustic rhinometry optimised for infants and small children opens new perspectives and possibilities in the assessment of nasal airway dimensions and their relationship to pathological conditions in both the upper and the lower airways. The objective of this paper is to describe the advantages of AR in infants and children, but also point out its limitations and potential sources of error. Practical guidelines as to the measurement procedure and analysis and interpretation of AR-data are outlined.
Allergic rhinitis (AR) is a very common disease in children, often underdiagnosed and with underestimated complications. Its prevalence has increased during the last years, due to changes in environmental factors. The therapeutic strategy will include prevention by identification and eviction of the main allergens, associated to pharmacological therapy. Among antirhinitic drugs, the new generation of non-sedative specific antihistamines represent the main choice. We report our own experience with astemizole, one of these new antihistamines which confirms that astemizole is an effective and safe drug for the management of AR in children.
There are no studies available in the literature on the effects of classical antihistamines on the central nervous system (CNS) in children. Clinical studies indicate that somnolence occurs more often with classical antihistamines than with placebo. There is no difference in inducing somnolence in children between placebo and astemizole or terfenadine, two new antihistamines that have thoroughly been shown to have no sedative effect greater than placebo in adults. A double-blind, cross-over trial investigating the CNS-effects of astemizole and chlorpheniramine in schoolchildren failed to show a negative effect of either of these drugs on performance.
