Background: Empty nose syndrome (ENS) remains highly controversial, with aggressive inferior turbinate reduction (ITR) or mucociliary dysfunction frequently implicated. However, the appropriate degree of ITR is highly debatable. Methods:We applied individual computed tomography (CT)-based computational fluid dynamics (CFD) to 5 patients receiving relatively aggressive ITR but with no ENS symptoms, and compared them to 27 symptomatic ENS patients who all had histories of aggressive ITRs, and 42 healthy controls. Patients' surgical outcomes were confirmed with 22-item Sino-Nasal Outcome Test (SNOT-22) (ITR: 6.40 ± 4.56; ENS: 58.2 ± 15.9; healthy: 13.2 ± 14.9), Nasal Obstruction Symptom Evaluation (NOSE) scores (ITR: 4.00 ± 2.24; ENS: 69.4 ± 17.1; healthy: 11.9 ± 12.9), and Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) (ࣙ11 for ENS). Results:Both aggressive ITR without ENS symptoms and symptomatic ENS patients had significantly lower nasal resistance (ITR: 0.059 ± 0.020 Pa·s/mL; ENS: 0.052 ± 0.015 Pa·s/mL; healthy: 0.070 ± 0.021 Pa·s/mL) and higher crosssectional areas surrounding the inferior turbinate (ITR: 0.94 ± 0.21 cm 2 ; ENS: 1.19 ± 1.05 cm 2 ; healthy: 0.42 ± 0.22 cm 2 ) than healthy controls. The lack of significant differences among patient groups indicated similar degrees of surgeries between ITR with and without ENS symptom cohorts. However, symptomatic ENS patients have paradoxical significantly less airflow in the inferior meatus (ITR: 47.7% ± 23.6%; ENS: 25.8% ± 17.6%; healthy: 36.5 ± 15.9%; both p < 0.01), but higher airflow around the middle meatus (ITR: 49.7% ± 22.6%; ENS: 66.5% ± 18.3%; healthy: 49.9% ± 15.1%, p < 0.0001) than aggressive ITR without symptoms and controls. Aggressive ITR patients have increased inferior meatus airflow as expected (p < 0.05). This imbalanced airflow produced less inferior wall-shear-stress distribution among symptomatic ENS patients only (ITR: 42.45% ± 11.4%; ENS: 32.2% ± 12.6%; healthy: 49.7% ± 9.9%). ENS patients (n = 12) also had impaired nasal trigeminal function, as measured by menthol lateralization detection thresholds (ITR: 15.2 ± 1.2; ENS: 10.3 ± 3.9; healthy: 13.8 ± 3.09, both p < 0.0001). Surprisingly, aggressive ITR patients without ENS symptoms have be er menthol lateralization detection thresholds (LDTs) than healthy controls. Conclusion:Although turbinate tissue loss is linked with ENS, the degree of ITR that might distinguish postoperative patient satisfaction in their nasal breathing vs development of ENS symptoms is unclear. Our results suggest that a combination of distorted nasal aerodynamics and loss of mucosal sensory function may potentially lead to ENS symptomology. C 2019 ARS-AAOA, LLC.

Background Empty nose syndrome ENS is a controversial upper airway disorder most commonly associated with tissue loss from the inferior turbinates The inferior meatus augmentation procedure IMAP has been shown to effectively reduce ENS symptoms in a durable manner but the precise mechanisms that may govern this symptomatic improvement remain unknown Methods Five patients with ENS who underwent bilateral IMAP via submucosal costal cartilage implant were assessed Pre-implant and months post-implant computed tomography CT imaging for each ENS patient was analyzed in a blinded fashion using computational fluid dynamics CFD modeling to investigate intrapatient changes in airflow parameters Results Following surgery ENS patients have significantly improved symptoms as indexed by Empty Nose Syndrome -Item Questionnaire ENS Q scoring pre-implant ± mean ± standard deviation confidence interval CI to post-implant ± CI to Cohen's d = p = Using CFD a significant shi in nasal airflow patterns was observed where airflow deviates away from the middle meatus upon hitting the implant pre-implant ± CI to post-implant ± CI to d = p < toward the inferior meatus pre-implant ± CI to post-implant ± CI to d = p < No significant changes were found in nasal resistance pre-implant ± CI to Pa*s/mL post-implant ± CI toPa*s/mL In addition the improvement of ENS Q scoring significantly correlated with percent reduction in aberrant airflow through the middle meatus R = p = Conclusion This study supports our prior working hypothesis that disordered vectors of nasal airflow congregate in the middle meatus contribute to ENS symptoms not nasal resistance Moreover these data illuminate a paradoxical but consistent restoration of nasal airflow to the inferior meatus following the replacement of turbinate tissue volume in the inferior meatus via IMAP surgery potentially due to the Coandȃ effect © 2020 ARS-AAOA, LLC.

Background: Empty nose syndrome (ENS) remains a controversial disease primarily associated with inferior turbinate tissue loss. Co on placement into the inferior meatus o en alleviates ENS symptoms within minutes, but the physiologic explanation for this phenomenon is unknown. Computational fluid dynamics (CFD) was employed to evaluate the mechanisms of altered nasal airflow conferred by co on testing. Methods:Six ENS patients (12 sides) with pre-existing sinus computed tomography (CT) imaging were enrolled a er marked symptomatic improvement (decrease in score on the Empty Nose Syndrome 6-Item Questionnaire [ENS6Q] of >7 points) with office-based co on testing. The fashioned co on plug was labeled in situ with iohexol contrast spray, and sinus CT was immediately obtained to detect co on contouring in the inferior meatus. CT imaging from pre-and post-co on placement was analyzed using comparative CFD techniques. Results:A er co on placement, significant symptomatic improvement and reduced ENS6Q scores (16.8 ± 4.1 to 3.1 ± 2.4; p < 0.001) were recorded. Using CFD, co on placement produced an expected 21% increase in upper airway resistance (p < 0.05). However, a significant shi in the nasal airflow distribution was also detected, with a transition of airflow vectors away from a middle meatus jetstream (−41%; p < 0.002). Conclusion:Objective CFD assessment confirmed that the co on test not only increases nasal resistance, but also restores airflow distribution to the inferior meatus in symptomatic ENS patients. These results highlight the potential efficacy of co on test in ENS patients and further bolster the utility of this tool in identifying appropriate candidates for the inferior meatus augmentation procedure. C 2020 ARS-AAOA, LLC.

Objectives/Hypothesis: About 260,000 septoplasties are performed annually in the US to address nasal septal deviation (NSD). Yet, we do not consistently understand what aspects of NSD result in symptoms.Study Design: Blinded cohort study. Methods: Two fellowship-trained surgeons blindly reviewed computerized tomography (CTs) of 10 confirmed NSD patients mixed with 36 healthy controls. All patients were correctly identified, however, 24/36 controls were falsely identified by both surgeons as patients (33.3% specificity), which were grouped as asymptomatic NSD (aNSD), while the remaining controls as non-NSD (healthy). Acoustic rhinometry, rhinomanometry, individual CT-based computational fluid dynamics and nasal sensory testing were applied to address the puzzling questions of why these aNSD had no symptoms and, more fundamentally, what caused symptoms in sNSD patients.Results: aNSD reported no nasal symptoms -

The inability to open the collapsible Eustachian tube (ET) leads to the development of chronic Otitis Media (OM). Although mucosal inflammation during OM leads to increased mucin gene expression and elevated adhesion forces within the ET lumen, it is not known how changes in mucosal adhesion alter the biomechanical mechanisms of ET function. In this study, we developed a novel multi-scale finite element model of ET function in adults that utilizes adhesion spring elements to simulate changes in mucosal adhesion. Models were created for six adult subjects and dynamic patterns in muscle contraction were used to simulate the wave-like opening of the ET that occurs during swallowing. Results indicate that ET opening is highly sensitive to the level of mucosal adhesion and that exceeding a critical value of adhesion leads to rapid ET dysfunction. Parameter variation studies and sensitivity analysis indicate that increased mucosal adhesion alters the relative importance of several tissue biomechanical properties. For example, increases in mucosal adhesion reduced the sensitivity of ET function to tensor veli palatini muscle forces but did not alter the insensitivity of ET function to levator veli palatini muscle forces. Interestingly, although changes in cartilage stiffness did not significantly influence ET opening under low adhesion conditions, ET opening was highly sensitive to changes in cartilage stiffness under high adhesion conditions. Therefore, our multi-scale computational models indicate that changes in mucosal adhesion as would occur during inflammatory OM alter the biomechanical mechanisms of ET function.