Accepted Article
Received Date : 13-Jan-2014 Revised Date : 23-Mar-2014 Accepted Date : 06-Apr-2014 Article type
: Original Manuscript
E-mail id: [email protected] Surgery of the External Nasal Valve: The Correlation between Subjective and Objective Measurements
Dirk. J. Menger (1), Karin M.A. Swart (1), Gilbert J. Nolst Trenité (2), Christos Georgalas (3), Wilko Grolman (1)
(1) Department of Otorhinolaryngology / Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery. University Medical Center, Utrecht, The Netherlands. (2) Bergman Clinics, Den Haag, The Netherlands. (3) Department of Otorhinolaryngology. Academic Medical Center, Amsterdam, The Netherlands.
Correspondence: D.J. Menger Department of Otorhinolaryngology / Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery. Heidelberglaan 100 3584 CX, Utrecht This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/coa.12243 This article is protected by copyright. All rights reserved.
Accepted Article
The Netherlands [email protected]
ABSTRACT
OBJECTIVES/HYPOTHESIS: CT-MCA is an objective computerized determination of the minimum cross-sectional area of the nasal passage on CT. CT-MCA was evaluated before and after surgery of 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 of 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; 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 significantly improvement after surgery of 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
This article is protected by copyright. All rights reserved.
Accepted Article
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 of the postoperative result both subjectively and objectively.
INTRODUCTION Nasal passage, or the ability to breathe through the nose, is a subjective feeling in which multiple factors contribute. These factors include the anatomical architecture of the nose, mucosal features, the requirements of the respiratory system or the force of inspiration, the quality and temperature of the inhaled air, and psychological factors. Today, there is still no consensus regarding the value of objective measurements in the evaluation of nasal patency. Both rhinomanometry (a dynamic test that calculates nasal airway resistance: NAR) and acoustic rhinometry (a static test that calculates a minimal cross sectional area: A-MCA) correlate poorly with the individual subjective sensation of breathing (1). This correlation seems to be stronger when each nostril is evaluated individually and in the presence of breathing complaints. However, results are conflicting and knowledge about the role of these techniques in current medical practice is limited [1]. In the quest for an objective, quantifiable test that correlates with the subjective complaints of the patient we developed and described an objective computerized determination of the minimum cross-sectional area of the nasal passage on CT (CTMCA) [2]. This software allowed determination of the cross-sectional area on any oblique plane intersecting with the nasal passage on CT. Results of CT-MCA showed that the plane of the minimal cross-sectional area often was tilted with respect to the coronal plane (2). This finding demonstrated that methods that determine the cross-sectional area only on coronal slices, are not able to calculate
This article is protected by copyright. All rights reserved.
Accepted Article
the true minimum cross-sectional area of the nasal cavity [2-5]. The effect of nasal valve surgery on CT-MCA was prospectively evaluated by comparing pre- and postoperative outcomes in patients who presented with external nasal valve insufficiency and who underwent a specific surgical procedure, the “lateral crus pullup” (LCPU) [6]. The aim of this study was to evaluate CT-MCA in relation with other objective measurements. CT-MCA was compared with the Nasal Obstruction Symptom Evaluation (NOSE) scale. The validated NOSE scale measures the subjective complaints of nasal breathing in order to allow us to capture the true patient experience [7]. The results of CT-MCA were compared with other objective tests A-MCA, NAR and Peak Nasal Inspiratory Flow (PNIF).
MATERIALS AND METHODS This study included 34 patients undergoing surgery of the external nasal valve with the use of the LCPU technique between November 2006 and February 2011 in the Academic Medical Center, University of Amsterdam, Netherlands. No patients were excluded
Patient selection and surgical technique: All patients had a history of impaired nasal breathing and progression of symptoms during forced inspiration due to collapse of the vestibular side wall. This alar insufficiency was the result of a narrow external valve area due to medially displaced- or weak lateral crura of the lower lateral cartilages. There was an indication for external nasal valve surgery in all patients. The surgical method used was the “lateral crus pull-up technique, a method for collapse of the external nasal valve” [6]. This is an endonasal technique, performed in general anesthesia, in which
This article is protected by copyright. All rights reserved.
Accepted Article
the lateral crus was rotated upward and affixed to the piriform aperture with the use of a sub-mucosal permanent Gore-tex 3/0 spanning suture (Figure 1).
Ethical Considerations From all of the participants a written informed consent was obtained according to the Declaration of Helsinki.
Subjective score and objective measurements: Before and three months after surgery all patients were evaluated for subjective symptoms and objective measurements, unilateral for each nostril. Each nostril was scored for subjective symptoms in nasal obstruction with the validated NOSE scale (Appendix 1) [7]. In line with the recommendations, the NOSE score was scaled from 0 to 100 by multiplying the raw score by 5. Higher scores indicate more severe nasal obstruction. Within 30 minutes and without decongestion of the nasal mucosa, all patients underwent the following objective tests; CT-MCA, A-MCA, NAR and PNIF. The CT images for this study were acquired with Philips CT scanners, a standard sinus protocol with a pitch of 0.875, at 120 kV and 50 mAs. The software that automatically calculates CT-MCA was performed for each nasal passage as described in the original paper [2]. In summary, this process was performed by an initial estimate of the location of the CT-MCA by selecting a location in one of three orthogonal CT-views (Figure 2). The three orthogonal views were interlinked so that selecting a point in one view automatically made the other two orthogonal views run through the same selected point. (deleted technical details about CT-MCA). The calculated CT-MCA and the orientation of the planes were recorded. (deleted technical details about CT-MCA).
This article is protected by copyright. All rights reserved.
Accepted Article
The A-MCA was measured in the standard procedure for each individual nostril using an A1 acoustic rhinometer (GM instruments Ltd, Kilwinning, Scotland, UK). NAR was measured using the active anterior method, for each nostril separately, with the NR6-2 rhinomanometer from GM instruments (GM instruments Ltd, Kilwinning, Scotland, UK). PNIF was measured for each nostril individually by securely and water-tight-closing the contra-lateral side with foam tape, without changing the anatomy of the tested nostril. Each nostril was tested three times; the highest peak flow was recorded. All measurements were performed with the same PNIF-instrument using the in-check nasal, a portable hand-held inspiratory flow meter (Clement Clarke Int Ltd, Harlow, UK).
Statistical analysis: All analyses were conducted using IBM SPSS Statistics (version 20) for Windows. For all tests, p-values
Received Date : 13-Jan-2014 Revised Date : 23-Mar-2014 Accepted Date : 06-Apr-2014 Article type
: Original Manuscript
E-mail id: [email protected] Surgery of the External Nasal Valve: The Correlation between Subjective and Objective Measurements
Dirk. J. Menger (1), Karin M.A. Swart (1), Gilbert J. Nolst Trenité (2), Christos Georgalas (3), Wilko Grolman (1)
(1) Department of Otorhinolaryngology / Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery. University Medical Center, Utrecht, The Netherlands. (2) Bergman Clinics, Den Haag, The Netherlands. (3) Department of Otorhinolaryngology. Academic Medical Center, Amsterdam, The Netherlands.
Correspondence: D.J. Menger Department of Otorhinolaryngology / Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery. Heidelberglaan 100 3584 CX, Utrecht This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/coa.12243 This article is protected by copyright. All rights reserved.
Accepted Article
The Netherlands [email protected]
ABSTRACT
OBJECTIVES/HYPOTHESIS: CT-MCA is an objective computerized determination of the minimum cross-sectional area of the nasal passage on CT. CT-MCA was evaluated before and after surgery of 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 of 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; 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 significantly improvement after surgery of 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
This article is protected by copyright. All rights reserved.
Accepted Article
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 of the postoperative result both subjectively and objectively.
INTRODUCTION Nasal passage, or the ability to breathe through the nose, is a subjective feeling in which multiple factors contribute. These factors include the anatomical architecture of the nose, mucosal features, the requirements of the respiratory system or the force of inspiration, the quality and temperature of the inhaled air, and psychological factors. Today, there is still no consensus regarding the value of objective measurements in the evaluation of nasal patency. Both rhinomanometry (a dynamic test that calculates nasal airway resistance: NAR) and acoustic rhinometry (a static test that calculates a minimal cross sectional area: A-MCA) correlate poorly with the individual subjective sensation of breathing (1). This correlation seems to be stronger when each nostril is evaluated individually and in the presence of breathing complaints. However, results are conflicting and knowledge about the role of these techniques in current medical practice is limited [1]. In the quest for an objective, quantifiable test that correlates with the subjective complaints of the patient we developed and described an objective computerized determination of the minimum cross-sectional area of the nasal passage on CT (CTMCA) [2]. This software allowed determination of the cross-sectional area on any oblique plane intersecting with the nasal passage on CT. Results of CT-MCA showed that the plane of the minimal cross-sectional area often was tilted with respect to the coronal plane (2). This finding demonstrated that methods that determine the cross-sectional area only on coronal slices, are not able to calculate
This article is protected by copyright. All rights reserved.
Accepted Article
the true minimum cross-sectional area of the nasal cavity [2-5]. The effect of nasal valve surgery on CT-MCA was prospectively evaluated by comparing pre- and postoperative outcomes in patients who presented with external nasal valve insufficiency and who underwent a specific surgical procedure, the “lateral crus pullup” (LCPU) [6]. The aim of this study was to evaluate CT-MCA in relation with other objective measurements. CT-MCA was compared with the Nasal Obstruction Symptom Evaluation (NOSE) scale. The validated NOSE scale measures the subjective complaints of nasal breathing in order to allow us to capture the true patient experience [7]. The results of CT-MCA were compared with other objective tests A-MCA, NAR and Peak Nasal Inspiratory Flow (PNIF).
MATERIALS AND METHODS This study included 34 patients undergoing surgery of the external nasal valve with the use of the LCPU technique between November 2006 and February 2011 in the Academic Medical Center, University of Amsterdam, Netherlands. No patients were excluded
Patient selection and surgical technique: All patients had a history of impaired nasal breathing and progression of symptoms during forced inspiration due to collapse of the vestibular side wall. This alar insufficiency was the result of a narrow external valve area due to medially displaced- or weak lateral crura of the lower lateral cartilages. There was an indication for external nasal valve surgery in all patients. The surgical method used was the “lateral crus pull-up technique, a method for collapse of the external nasal valve” [6]. This is an endonasal technique, performed in general anesthesia, in which
This article is protected by copyright. All rights reserved.
Accepted Article
the lateral crus was rotated upward and affixed to the piriform aperture with the use of a sub-mucosal permanent Gore-tex 3/0 spanning suture (Figure 1).
Ethical Considerations From all of the participants a written informed consent was obtained according to the Declaration of Helsinki.
Subjective score and objective measurements: Before and three months after surgery all patients were evaluated for subjective symptoms and objective measurements, unilateral for each nostril. Each nostril was scored for subjective symptoms in nasal obstruction with the validated NOSE scale (Appendix 1) [7]. In line with the recommendations, the NOSE score was scaled from 0 to 100 by multiplying the raw score by 5. Higher scores indicate more severe nasal obstruction. Within 30 minutes and without decongestion of the nasal mucosa, all patients underwent the following objective tests; CT-MCA, A-MCA, NAR and PNIF. The CT images for this study were acquired with Philips CT scanners, a standard sinus protocol with a pitch of 0.875, at 120 kV and 50 mAs. The software that automatically calculates CT-MCA was performed for each nasal passage as described in the original paper [2]. In summary, this process was performed by an initial estimate of the location of the CT-MCA by selecting a location in one of three orthogonal CT-views (Figure 2). The three orthogonal views were interlinked so that selecting a point in one view automatically made the other two orthogonal views run through the same selected point. (deleted technical details about CT-MCA). The calculated CT-MCA and the orientation of the planes were recorded. (deleted technical details about CT-MCA).
This article is protected by copyright. All rights reserved.
Accepted Article
The A-MCA was measured in the standard procedure for each individual nostril using an A1 acoustic rhinometer (GM instruments Ltd, Kilwinning, Scotland, UK). NAR was measured using the active anterior method, for each nostril separately, with the NR6-2 rhinomanometer from GM instruments (GM instruments Ltd, Kilwinning, Scotland, UK). PNIF was measured for each nostril individually by securely and water-tight-closing the contra-lateral side with foam tape, without changing the anatomy of the tested nostril. Each nostril was tested three times; the highest peak flow was recorded. All measurements were performed with the same PNIF-instrument using the in-check nasal, a portable hand-held inspiratory flow meter (Clement Clarke Int Ltd, Harlow, UK).
Statistical analysis: All analyses were conducted using IBM SPSS Statistics (version 20) for Windows. For all tests, p-values
