Acoustic rhinometry and its uses in rhinology and diagnosis of nasal obstruction

Facial Plast Surg Clin N Am 12 (2004) 397 – 405

Acoustic rhinometry and its uses in rhinology and diagnosis of nasal obstruction Devyani Lal, MS, DipNBE, Jacquelynne P. Corey, MD, FACS* Section of Otolaryngology – Head and Neck Surgery, University of Chicago, 5841 South Maryland Avenue, MC 1035, Chicago, IL 60610, USA

Nasal obstruction is a common concern for rhinologic surgeons. Nasal obstruction can be treated easily by medical, surgical, or combined approaches. However, treatment without adequate assessment of both medical and anatomic causes of blockage will often result in failure. Testing for nasal obstruction should be convenient, reliable, repeatable, and able to make an objective measure of nasal blockage to aid surgical planning. A test for nasal airway obstruction should also be able to document the effect of surgical intervention on the nose on nasal airflow, volume, and physiology. Acoustic rhinometry is one such tool that can help assess the degree and type of nasal obstruction. Acoustic rhinometry is a noninvasive, rapid, convenient, and reliable means of studying the nasal cavity. It is easy for the subject to undergo and for the operator to administer. It causes minimal discomfort to the patient and requires only minimal patient cooperation. The procedure requires no sedation or anesthesia and can be performed in the office on adults and children. It can also be performed under general anesthesia or during normal sleep to give a measure of nasal functioning in its natural state.

Anatomy of the nasal cavity The nasal cavity is framed laterally by rigid bony walls. It is divided in half by a septum. These bound-

* Corresponding author. E-mail address: [email protected] (J.P. Corey).

aries form the structural or fixed components of the nasal passage. Distortions in the bony and cartilaginous anatomy or bony hypertrophy of the turbinates form the ‘‘irreversible’’ component of nasal obstruction. These are potentially amenable to surgical treatment. Lesions such as polyps, tumors, and foreign bodies can also cause nasal obstruction. The nose is lined by a highly vascular mucosa. The turbinates in particular are composed of cavernous tissue that can rapidly swell up or shrink in response to autonomic stimuli. The mucosa congests because of physiologic stimuli such as the nasal cycle, posture, and temperature [1 – 4]. Pathologic conditions such as allergy, infection, vasomotor rhinitis, rhinitis medicamentosa, hormones, and drugs can also induce nasal congestion [2]. Mucosal factors constitute the ‘‘functional’’ or ‘‘reversible’’ component of nasal obstruction.

Acoustic rhinometry Nasal endoscopy, nasal peak flows, anterior and posterior rhinomanometry, rhinostereometry, and acoustic rhinometry have been used for clinical study of the nasal airway. Acoustic rhinometry is a technique first described by Hilberg et al [5] in 1989. It can be used complementarily with the other tests to judge different aspects of nasal anatomy and function. The validity of acoustic rhinometry has been well established in the literature. Previous studies by the senior author (JPC) and others have correlated the findings of acoustic rhinometry with those of CT scans [6,7], MRI [6,8], and nasal endoscopy [9].

1064-7406/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.fsc.2004.04.002

398

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405

Principles Acoustic rhinometry is based on the principle of analyzing changes in the reflected wave when an incident sound wave passes into the nasal cavity. Variations in the size and contour of the nasal airway cause distortions in the reflected sound wave. The time at which these reflected changes occur gives an estimate of the distance in the nasal cavity that causes the distortion, and the magnitude of distortions is a measure of the change in cross-sectional area. Equipment A trigger module generates an acoustic pulse that is conducted to the nasal cavity by means of a hollow plastic tube. The nasal end of this tube is fitted with a nosepiece to sit against the anterior nares. The nosepiece is contoured and available in different sizes. The sound wave passes through this tube and enters the nasal cavity. The acoustic wave is reflected back from the nasal cavity. An analog-to-digital converter converts these waves into digital impulses that feed into a computer. The computer uses these data to generate an area – distance graph using mathematical algorithms. These graphs can be read on-screen or printed. Acoustic rhinometry thus provides the investigator with a topographic map of the nasal passage. Technique The test is performed in a quiet room. The subject is seated comfortably and allowed to relax for a few minutes before testing. The equipment is first calibrated using a test acoustic impulse. The tester stands in front of the subject or sits beside him. The subject is asked to hold his head steady by fixing his gaze and to hold his breath. The tester aligns the nasal tube in the same axis as the nose. The nosepiece is held against the nostril on the side to be tested first. An acoustic pulse is generated for about 10 seconds and stopped as soon as a satisfactory curve displays on the computer screen. It is important that there be no subject or tester motion at this stage of the test, to avoid fallacious results. The nosepiece should be held against the anterior nares to ensure a seal without causing any distortion of the anatomy. This seal can be facilitated by use of a jelly on the outer edge of the nosepiece. The procedure is repeated on the other side. Next, a nasal decongestant is sprayed into both sides of the nose, and the test is repeated after 10 minutes. Acoustic rhinometry following nasal decongestion affords the clinician a means to quantify both the

structural and mucosal components of nasal congestion [10,11]. By decongesting the nasal mucosa with a topical spray, the clinician eliminates or minimizes the reversible mucosal component. When the test is then repeated, it gives a measure of the structural or irreversible causes of nasal obstruction. The amount of mucosal decongestion also gives an estimate of whether the mucosa is normal or diseased.

The area– distance graph The computer generates a curve that shows distance in centimeters on the x-axis and cross-sectional area in square centimeters on the y-axis. The position of the anterior nares is at 0 cm. Only the first 6 cm of the distance are used in interpretation, because the test loses accuracy in the posterior areas of the nasal cavity [11]. Fig. 1 shows a typical graph. The graph shows three ‘‘valleys’’ or ‘‘notches.’’ These are the areas of constriction in the cross-section of the nasal cavity. They are labeled ‘‘cross-sectional areas 1, 2, and 3’’ (CSA 1, CSA 2, and CSA 3) and may also be referred to as minimal cross-sectional areas (mCSA). Though protocols and interpretation have become more standardized, there are differences in terminology between the United States and Europe. In the United States, the narrowest areas in the nasal cavity are referred to as ‘‘valleys,’’ or minimal cross-sectional areas 1, 2, and 3. In the European literature, this area is described as a ‘‘rising W’’ or an ‘‘I-notch’’ (Isthmus-notch) [11].

Correlation with nasal anatomy CSA 1 corresponds to the area of the nasal valve. CSA 2 correlates with the location of the anterior head of the inferior or middle turbinate. The exact location of CSA 2 should be correlated with the physical examination. Fig. 2 demonstrates the ‘‘normal’’ variations in the location of CSA 2. CSA 3 corresponds to the location of the midposterior end of the middle turbinate. The cross-sectional area of the nasal cavity increases posteriorly toward the nasopharynx [9]. The acoustic rhinometry graph is read to measure cross-sectional area as a function of the distance from the anterior nares. The areas at CSA 1, CSA 2, and CSA 3 are measured. The total volume from 0 cm to 6 cm of the curve is estimated from these areas. This data is then compared with normative data for age, sex, and race. Various authors have published normative measurements of the nasal cavity of adult

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405

399

Fig. 1. A sample acoustic rhinometry graph. Cross-sectional area (CSA) 1 is thought to represent the anterior end of the inferior turbinate and nasal valve area. CSA 2 is usually identified at approximately 4 cm and corresponds to the anterior half of the inferior turbinate and the anterior end of the middle turbinate. CSA 3 is usually identified at approximately 6 cm and corresponds to the middle portion of the middle turbinate. The negative values are created by the acoustic rhinometry probe. (From: Mamikoglu B, Houser SM, Corey JP. An interpretation method for objective assessment of nasal congestion with acoustic rhinometry. Laryngoscope 2002;112(5):927; with permission.)

males and females of different racial and ethnic groups [11].

Interpretation and analysis: the ‘‘congestion factor’’ The ‘‘congestion factor’’ gives an estimate of the nonstructural component of nasal obstruction. Mucosal factors such as allergy, infection, and vasomotor

rhinitis should be addressed by medical means before surgery is attempted. The patient can be counseled with regard to the benefit of surgery, taking into account the congestion factor. The senior author has previously published a method for assessing nasal congestion with acoustic rhinometry [10]. The baseline values at CSA 1, CSA 2, and CSA 3 are noted. Usually these are identified at distances of 2 cm, 4 cm, and 6 cm, respectively. The nose is then decongested with

Fig. 2. Variations in the location of CSA 2. (A) The inferior and middle turbinate are directly overlying in the vertical plane (most common). (B) The bulk of the inferior turbinate is anterior to the middle turbinate. (C) The bulk of the inferior turbinate is posterior to the middle turbinate.

400

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405

0.05% topical oxymetazoline spray. Acoustic rhinometry is repeated after 10 minutes. The same data (CSAs and volume) are noted. The ‘‘congestion factor’’ is calculated as follows: Congestion factor ¼ ðdecongested CSA 2 value baseline CSA 2 valueÞ =baseline CSA 2 value The CSA 2 value of the side that shows the largest difference in the decongested state is used. The congestion factor is categorized as normal, mild, moderate, severe, or markedly severe by comparing it with a grading scale. This scale uses normative values from previously published data [12]. Table 1 contains the normative values obtained from adults in the United States [12]. The severity of blockage is calculated by comparison. A difference of greater than two standard deviations from normal values of CSA 2 in the baseline and decongested state is abnormal [10].

Limitations of acoustic rhinometry The accuracy of acoustic rhinometry decreases as the distance from the anterior nares increases [11]. There may be variation in measurements performed by different operators, or by the same operator in different sessions. A good nasal seal is necessary. Many authors have described techniques to ensure that the subject’s head and the probe are held stable during testing to reduce movement between the subject and the operator [13,14]. The test environment should be quiet [11,13,15], and testing should preferably be performed in controlled temperature and humidity conditions to limit those factors’ confounding effects [14]. Decongestion of the nose can also lead to confusing artifacts [16]. New data suggest that the body surface area of an individual may influence the minimal cross-sectional area of the nose [17]. While measurements with acoustic rhinometry correlate well with other objective measures such as nasal peak flows, video-endoscopy, anterior and posterior rhinomanometry, CT scan, and MRI, the technique correlates poorly with symptom scoring done by the patients themselves [18,19].

Applications of acoustic rhinometry Acoustic rhinometry has been widely used in rhinology to study the normal and diseased nasal passage. Acoustic rhinometry can characterize and

localize deviations of the nasal septum. It can also identify the relative location of valve stenosis, septal deviation, tumors, and turbinate hypertrophy. Acoustic rhinometry is now considered an effective method for comparing the preoperative and postoperative status of patients undergoing surgeries such as turbinate reduction and septoplasty [7,20 – 22]. The impact of procedures such as medial maxillectomy and lateral rhinotomy can also be assessed using acoustic rhinometry [23]. Acoustic rhinometry is increasingly applied in the diagnosis of diverse nasal conditions such as congenital choanal atresia [24]. Obstructive sleep apnea is another condition in whose treatment acoustic rhinometry has an emerging role. Houser et al [25] have demonstrated that acoustic rhinometry can detect statistically significant differences in nasal mucosal congestion in patients with mild sleep apnea compared with controls. Virkkula et al [26] studied the effect of supine position on nasal obstruction and sleep apnea in snorers, employing acoustic rhinometry, polysomnography, and anterior rhinomanometry. They found that nasal volume in the supine position at a distance of 2 cm to 4 cm from the nares was significant and inversely correlated with the apnea-hypopnea index and oxygen desaturation index. Improved nasal patency with the use of external nasal dilators for snoring and sleep apnea has been well documented by investigators [27,28]. Nasal congestion caused by exposure to various environmental agents such as airborne irritants, dust, solvents, poor air ventilation, and chemical irritants can be documented by acoustic rhinometry [29 – 31]. Human and animal studies have used acoustic rhinometry to study the nasal cycle [32 – 34]. Acoustic rhinometry can document the effect of pharmacological agents such as decongestants, steroids, and leukotriene modifiers in improving nasal patency [35,36]. Nasal reactions to provocation testing in nonallergic and allergic rhinitis can be documented [37,38]. Subjects and laboratory models of rhinitis and nasal reaction in diseases such as asthma may also be studied by means of acoustic rhinometry [39 – 41].

Acoustic rhinometry and the facial plastic surgeon Rhinoplasty is one of the commonest procedures undertaken by facial plastic surgeons. The facial plastic surgeon also often deals with treating nasal obstruction. Concerns about the effect of cosmetic nasal surgery on the patency and the physiology of the nose are therefore relevant to the practice of facial plastics.

CSA 1

Before decongestion Mean (cm2) SD (cm2) Distance (cm)a After decongestion Mean (cm2) SD (cm2) Distance (cm)a

CSA 2

CSA 3

Asian

Black

White

Asian

Black

White

Asian

Black

White

0.53 0.10 0.59 – 1.66

0.67 0.10 1.04 – 1.86

0.52 0.12 0.57 – 1.45

0.87 0.22 0.96 – 3.15

0.94 0.23 1.16 – 2.96

0.83 0.24 0.94 – 2.88

1.35 0.35 1.74 – 4.83

1.41 0.42 1.55 – 4.86

1.31 0.42 1.49 – 4.62

0.61 0.12 0.65 – 1.99

0.81 0.11 1.27 – 2.03

0.64 0.12 0.91 – 1.73

1.47 0.36 1.65 – 5.61

1.64 0.32 2.19 – 4.58

1.51 0.36 1.95 – 4.51

1.99 0.47 2.49 – 6.17

2.20 0.43 3.12 – 6.49

2.08 0.60 2.39 – 6.28

Abbreviation: SD, standard deviation. a Measured from 0 cm – 7 cm. Modified from: Corey JP, Gungor A, Nelson R, Liu X, Fredberg J. Normative standards for nasal cross-sectional areas by race as measured by acoustic rhinometry. Otolaryngol Head Neck Surg 1998;119(4):389 – 93.

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405

Table 1 Mean CSAs, standard deviations and distance (minimum – maximum)

401

402

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405

The nasal valve The nasal valve is the narrowest area of the nose. It is bounded laterally by the caudal part of the upper lateral cartilage. The medial boundary is formed by the nasal septum. The rim of the piriform aperture usually forms the ventral boundary. While the cartilaginous septal wall of the valve is rigid, the alar cartilage can flare or collapse. The anterior head of the inferior turbinate contributes to a ‘‘physiologic’’ nasal valve. Though structurally the inferior turbinate lies a few millimeters posterior to the anatomical nasal valve, it forms a functional valve because it contains erectile tissue. Engorgement and vasoconstriction of this cavernous tissue can decrease or increase the patency of the nasal valve area. The anterior part of the nose has the greatest effect on the nose’s resistance [42]. Any variations in the patency of this part can have a major impact on nasal airflow. A minimal narrowing of the nasal valve can produce uncomfortable stuffiness. Assessment of the nasal valve area is thus of paramount concern to the rhinologic surgeon. Acoustic rhinometry is a validated tool for assessing the nasal valve area [43,44]: its measures of this area are both accurate and reproducible. CSA 1 usually lies about 2 cm from the anterior nares and corresponds to the structural nasal valve. CSA 2, which usually lies about 4 cm to 5 cm posterior to the anterior nares, denotes the area of the ‘‘physiologic’’ nasal valve. Decongestion will increase the area at CSA 2. By virtue of being minimally invasive, acoustic rhinometry can be used to study the nasal valve area in its natural state. Alar collapse produced by negative pressure, as in deep inspiration, can also be documented [45]. Acoustic rhinometry is used to assess the nasal valve area before and after surgical intervention. Roithmann et al [46] made measurements with acoustic rhinometry in 79 normal subjects and 26 patients who had undergone rhinoplasty. In the postrhinoplasty group, they found a single case of nasal valve constriction that persisted after nasal decongestion. The use of an external nasal dilator relieved the obstruction. They concluded that acoustic rhinometry was a useful, objective means to determine the structural and mucovascular components of the nasal valve area in normal and postrhinoplasty subjects. Schlosser et al [47] performed acoustic rhinometry on six fresh cadavers and repeated the test after placing spreader grafts, flaring suture, and spreader graft and flaring suture together. They also followed up 30 patients who underwent surgery to the nasal valve area. They found acoustic rhinometry a useful

tool for documenting the increase in the cross-sectional area of the wall before and after the operative intervention in both cadavers and patients. Reduction rhinoplasty Grymer [48] studied 37 patients who underwent reduction rhinoplasty for cosmetic reasons. Patients who had undergone septorhinoplasty or other functional operations were excluded from the study. Hump removal and lateral and transverse osteotomies had been performed in all cases. Tip plasty had been performed in 26 cases, either by cartilage splitting technique (17 patients) or by delivery of the alar cartilage (nine patients). Acoustic rhinometry was performed preoperatively and 6 months after rhinoplasty. Baseline and postdecongestion studies were made with acoustic rhinometry in both instances. Grymer found that the cross-sectional areas of the nose decrease critically after reduction rhinoplasty, especially in the anterior segments. The minimal cross-sectional area at the nasal valve decreased by 22% to 25% both totally and unilaterally (P < 0.000). The cross-sectional areas at the piriform aperture decreased by 11% to 13% (P = 0.02). Grymer concluded that it is advisable to perform acoustic rhinometry in all patients undergoing aesthetic nose surgery, both to prevent further decrease of nasal patency in patients at risk and to document the changes conferred by surgery. Osteotomies Grymer et al [49] also performed controlled lateral osteotomies in 16 cadaveric noses. Eight of these osteotomies were low (below the inferior turbinate) and eight were high (above the inferior turbinate). Medial osteotomies were performed in all 16 noses. The dimensions of the nasal cavity were measured by acoustic rhinometry both before and after the osteotomies. The minimal cross-sectional area and the cross-sectional area at the piriform aperture were calculated. The investigators found no significant difference in the reduction of cross-sectional area between the group that underwent high lateral osteotomy and the group that underwent low osteotomy. However, in both groups the minimal cross-sectional area was reduced by 12% (P < 0.001). The crosssectional area at the piriform aperture was reduced by 15% after osteotomy (P = 0.000). The investigators concluded that medial and lateral osteotomies decrease the anterior dimensions of the nose, and this effect does not depend on the placement of the lateral osteotomy. The decrease is probably

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405

caused by the detachment of the bony vault from the surrounding structures. Cleft palate, cleft lip, and cleft nose Kunkel et al [50] studied 34 adult patients with complete unilateral cleft lip and palate and 15 controls with normal subjective nasal patency. Acoustic rhinometry was performed in each nostril, before and after decongestion. Minimal cross-sectional area, nasal volume, and the congestion factor were calculated for both sides in both groups. The investigators detected pathologic obstruction on the cleft side in 75% and contralateral obstruction in 15% of the cleft patients (P < 0.001). The nasal valve area of the cleft side had significantly lower cross-sectional area compared with the contralateral side (P < 0.001). The total nasal volume was 35% lower on the cleft side (P < 0.001). Higher decongestion was achieved on the cleft side, indicating reversible mucosal hypertrophy. Kunkel et al concluded that acoustic rhinometry is a powerful tool for acquiring topographic information about the airway. In the cleft nose, acoustic rhinometry documented the classical ‘‘W’’ airway pattern. The investigators recommended using acoustic rhinometry in the preoperative and postoperative evaluations of cleft nose. Maxillofacial applications Acoustic rhinometry has been employed along with sonography by Wriedt et al [51] to study surgically assisted rapid palatal expansion of the maxilla. Evaluations were performed before and after the procedure. The investigators were able to monitor the success of their procedure satisfactorily using these noninvasive means. Erbe et al [52] have used acoustic rhinometry to study nasal airway changes after Le Fort I impaction and advancement. They followed 20 patients prospectively to assess anatomic and functional changes in the nose. They performed anterior rhinomanometry, acoustic rhinometry, and clinical inspection before surgery and 3 months postoperatively. They documented an increase in the cross-sectional area at the nasal isthmus using acoustic rhinometry.

Summary The most common clinical and practical use of acoustic rhinometry for the rhinologic surgeon is in the assessment of ‘‘mixed’’ blockage. Mixed block-

403

Box 1. Practical uses of acoustic rhinometry  Documentation of nasal alar collapse  Preoperative planning for reduction

rhinoplasty  Documentation of the positive effect

of septoplasty on nasal airway obstruction  Documentation of reversible mucosal components of nasal airway obstruction that may be present concurrently with structural obstruction  Documentation of nasal airway obstruction in cleft nose, lip, and palate

age is composed of reversible components (mucosal congestion, nasal valve collapse) and irreversible structural problems. The topographical location (depth) of obstruction in the nasal cavity can be assessed with acoustic rhinometry. Acoustic rhinometry can also document and compare the status of the nasal cavity before and after surgery. As a research tool, it can help the rhinologic surgeon assess the effect of surgical maneuvers (eg, placement of osteotomy) on nasal patency and physiology. Box 1 summarizes the practical uses of acoustic rhinometry.

References [1] Moinuddin R, Mamikoglu B, Barkatullah S, Corey JP. Detection of the nasal cycle. Am J Rhinol 2001;15(1): 35 – 9. [2] Corey JP, Houser SM, Ng BA. Nasal congestion: a review of its etiology, evaluation and treatment. Ear Nose Throat J 2000;79(9):690 – 702. [3] Hasegawa M. Nasal cycle and postural variations in nasal resistance. Ann Otol 1982;91:112 – 4. [4] Lundqvist GR, Pedersen OF, Hilberg O, Nielsen B. Nasal reaction to changes in whole body temperature. Acta Otolaryngol (Stockh) 1993;113:783 – 8. [5] Hilberg O, Jackson AC, Swift DL, Pederson OF. Acoustic rhinometry: evaluation of nasal cavity geometry by acoustic reflection. J Appl Physiol 1989; 66(1):295 – 303. [6] Hilberg O. Objective measurement of nasal airway dimensions using acoustic rhinometry: methodological and clinical aspects. Allergy 2002;57(Suppl 70):5 – 39. [7] Mamikoglu B, Houser S, Akbar I, Ng B, Corey JP. Acoustic rhinometry and computed tomography scans for the diagnosis of nasal septal deviation, with clini-

404

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405 cal correlation. Otolaryngol Head Neck Surg 2000; 123(1 Pt 1):61 – 8. Corey JP, Gungor A, Nelson R, Fredberg J, Lai V. A comparison of the nasal cross-sectional areas and volumes obtained with acoustic rhinometry and magnetic resonance imaging. Otolaryngol Head Neck Surg 1997;117(4):349 – 54. Corey JP, Nalbone VP, Ng BA. Anatomic correlates of acoustic rhinometry as measured by rigid nasal endoscopy. Otolaryngol Head Neck Surg 1999; 121(5):572 – 6. Mamikoglu B, Houser SM, Corey JP. An interpretation method for objective assessment of nasal congestion with acoustic rhinometry. Laryngoscope 2002;112(5): 926 – 9. Hilberg O, Pedersen OF. Acoustic rhinometry: recommendations for technical specifications and standard operating procedures. Rhinol Suppl 2000;16:3 – 17. Corey JP, Gungor A, Nelson R, Liu X, Fredberg J. Normative standards for nasal cross-sectional areas by race as measured by acoustic rhinometry. Otolaryngol Head Neck Surg 1998;119(4):389 – 93. Parvez L, Erasala G, Noronha A. Novel techniques, standardization tools to enhance reliability of acoustic rhinometry measurements. Rhinol Suppl 2000;16: 18 – 28. Wilson AM, Fowler SJ, Martin SW, White PS, Gardiner Q, Lipworth BJ. Evaluation of the importance of head and probe stabilisation in acoustic rhinometry. Rhinology 2001;39(2):93 – 7. Corey JP, Gungor A, Nelson RH, Velde T. The effects of environmental noise on acoustic rhinometry. Am J Rhinol 1996;10:247 – 9. Tomkinson A, Eccles R. Acoustic rhinometry: an explanation of some common artefacts associated with nasal decongestion. Clin Otolaryngol 1998;23(1):20 – 6. Jurlina M, Mladina R, Dawidowsky K, Ivankovic D, Bumber Z, Subaric M. Correlation between the minimal cross-sectional area of the nasal cavity and body surface area: preliminary results in normal patients. Am J Rhinol 2002;16(4):209 – 13. Tomkinson A, Eccles R. Comparison of the relative abilities of acoustic rhinometry, rhinomanometry and the visual analog scale in detecting change in the nasal cavity in a healthy adult population. Am J Rhinol 1996; 10:161 – 5. Larsson C, Millqvist E, Bende M. Relationship between subjective nasal stuffiness and nasal patency measured by acoustic rhinometry. Am J Rhinol 2001; 15(6):403 – 5. Grymer LF, Hilberg O, Elbrond O, Pederson OF. Acoustic rhinometry: evaluation of the nasal cavity with septal deviations, before and after septoplasty. Laryngoscope 1989;99(11):1180 – 7. Lenders H, Persig W. Diagnostic value of acoustic rhinometry: patients with allergic and vasomotor rhinitis compared with normal controls. Rhinology 1990; 28(1):5 – 16. Kemker B, Liu X, Gungor A, Moinuddin R, Corey JP.

[23]

[24]

[25]

[26]

[27]

[28]

[29]

[30]

[31]

[32]

[33]

[34]

[35]

[36]

Effect of nasal surgery on the nasal cavity as determined by acoustic rhinometry. Otolaryngol Head Neck Surg 1999;121(5):567 – 71. Lueg EA, Irish JC, Roth Y, Brown DH, Witterick IJ, Chapnick JS, et al. An objective analysis of the impact of lateral rhinotomy and medial maxillectomy on nasal airway function. Laryngoscope 1998;108(9): 1320 – 4. Djupesland P, Kaastad E, Franzen G. Acoustic rhinometry in the evaluation of congenital choanal malformations. Int J Pediatr Otorhinolaryngol 1997; 41(3):319 – 37. Houser SM, Mamikoglu B, Aquino BF, Moinuddin R, Corey JP. Acoustic rhinometry findings in patients with mild sleep apnea. Otolaryngol Head Neck Surg 2002;126(5):475 – 80. Virkkula P, Maasilta P, Hytonen M, Salmi T, Malmberg H. Nasal obstruction and sleep-disordered breathing: the effect of supine body position on nasal measurements in snorers. Acta Otolaryngol 2003; 123(5):648 – 54. Ng BA, Mamikoglu B, Ahmed MS, Corey JP. The effect of external nasal dilators as measured by acoustic rhinometry. Ear Nose Throat J 1998;77(10):840 – 4. Gosepath J, Amedee RG, Romantshuck S, Mann WJ. Breathe right strips and the respiratory disturbance index in sleep related breathing disorders. Am J Rhinol 1999;13(5):385 – 9. Walinder R, Norback D, Wieslander G, Smedje G, Erwall C, Venge P. Acoustic rhinometry in epidemiological studies—nasal reactions in Swedish schools. Rhinol Suppl 2000;16:59 – 64. Klimek L, Hundorf I, Delank KW, Hormann K. Assessment of rhinological parameters for evaluating the effects of airborne irritants to the nasal epithelium. Int Arch Occup Environ Health 2002;75:291 – 7. Norback D, Wieslander G. Biomarkers and chemosensory irritations. Int Arch Occup Environ Health 2002;75(5):298 – 304. Baczek M, Hassmann E, Alifer M, Iwaszko-Krawczuk W. Acoustic rhinometry assessment of the nasal cycle in neonates. Acta Otolaryngol 2001;121(2):301 – 4. Lang C, Grutzenmacher S, Mlynski B, Plontke S, Mlynski G. Investigating the nasal cycle using endoscopy, rhinostereometry, and acoustic rhinometry. Laryngoscope 2003;113(2):284 – 9. Koss MC, Yu Y, Hey JA, McLeod RL. Measurement of nasal patency in anesthetized and conscious dogs. J Appl Physiol 2002;92(2):617 – 21. Taverner D, Danz C, Economos D. The effects of oral pseudoephedrine on nasal patency in the common cold: a double blind single-dose placebo-controlled trial. Clin Otolaryngol 1999;24(1):47 – 51. Giger R, Pasche P, Cheseaux C, Cantini L, Rossetti A, Landis BN, et al. Comparison of once-versus twicedaily use of beclomethasone dipropionate aqueous nasal spray in the treatment of allergic and non allergic chronic rhinosinusitis. Eur Arch Otorhinolaryngol 2003;260(3):135 – 40.

D. Lal, J.P. Corey / Facial Plast Surg Clin N Am 12 (2004) 397–405 [37] Baraniuk JN, Ali M, Naranch K. Hypertonic nasal provocation and acoustic rhinometry. Clin Exp Allergy 2002;32(4):543 – 50. [38] Marquez F, Sastre J, Hernandez G, Cenjor C, SanchezHernandez JM, Sanchez J, et al. Nasal hyperreactivity to methacholine measured by acoustic rhinometry in asymptomatic allergic and nonallergic rhinitis. Am J Rhinol 2000;14:251 – 6. [39] Corey JP, Kemker BJ, Nelson R, Gungor A. Evaluation of the nasal cavity by acoustic rhinometry in normal and allergic subjects. Otolaryngol Head Neck Surg 1997;117(1):22 – 8. [40] Lai VWS, Corey JP. The use of acoustic rhinometry to quantitatively assess changes after intranasal allergen challenge. Am J Rhinol 1994;8:171 – 3. [41] Casadevall J, Ventura PJ, Mullol J, Picado C. Intranasal challenge with aspirin in the diagnosis of aspirin intolerant asthma: evaluation of nasal response by acoustic rhinometry. Thorax 2000;55(11):921 – 4. [42] Hirschberg A, Roithmann R, Parikh S, Miljeteig H, Cole P. The airflow resistance profile of healthy nasal cavities. Rhinology 1995;33:10 – 3. [43] Cole P. Acoustic rhinometry and rhinomanometry. Rhinol Suppl 2000;16:29 – 34. [44] Cakmak O, Coskun M, Celik H, Buyuklu F, Ozluoglu LN. Value of acoustic rhinometry for measuring nasal valve area. Laryngoscope 2003;113(2):295 – 302.

405

[45] Brugel-Ribere L, Fodil R, Coste A, Larger C, Isabey D, Harf A, et al. Segmental analysis of nasal cavity compliance by acoustic rhinometry. J Appl Physiol 2002; 93:304 – 10. [46] Roithmann R, Chapnik J, Zamel N, Barreto SM, Cole P. Acoustic rhinometry assessment of the nasal valve. Am J Rhinol 1997;11(5):379 – 85. [47] Schlosser RJ, Park SS. Surgery for the dysfunctional nasal valve: cadaveric analysis and clinical outcomes. Arch Facial Plast Surg 1999;1(2):105 – 10. [48] Grymer LF. Reduction rhinoplasty and nasal patency: change in the cross-sectional area of the nose evaluated by acoustic rhinometry. Laryngoscope 1995; 105(4 Pt 1):429 – 31. [49] Grymer LF, Gregers-Petersen C, Baymler Pedersen H. Influence of lateral osteotomies in the dimensions of the nasal cavity. Laryngoscope 1999;109(6):936 – 8. [50] Kunkel M, Wahlmann U, Wagner W. Acoustic airway profiles in unilateral cleft palate patients. Cleft Palate Craniofac J 1999;36(5):434 – 40. [51] Wriedt S, Kunkel M, Zentner A, Wahlmann UW. Surgically assisted rapid palatal expansion. J Orofac Orthop 2001;62(2):107 – 15. [52] Erbe M, Lehotay M, Gode U, Wigand ME, Neukam FW. Nasal airway changes after Le Fort I-impaction and advancement: anatomical and functional findings. Int J Oral Maxillofac Surg 2001;30(2):123 – 9.