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B-ENT, 2010, 6, 3-11
Introduction
Rhinomanometry and acoustic
rhinometry are the two most
popular techniques for the objec-
tive assessment of nasal patency1.
However, a lack of consensus
about the methods for assessing
nasal patency, the poor corre -
lation between the objective
measures of nasal patency and
patients’ complaints, and, finally,
accepted standards mean that the
importance of objective meas-
ures for nasal patency in the
clinic is a subject of heated
debate. Some authors consider
these measures to be worthless,2-4
while others see them as being
useful,5complementary, or even
important in the evaluation of
nasal obstruction.6-14
Many believe that these tech-
niques are mainly appropriate for
research,15, 16 while others think
they are the best way of deter-
mining nasal obstruction objec-
tively, using them in their clinical
practice1for monitoring nasal
congestion and evaluating the
subsequent treatment.13
Rhinomanometry and acoustic
rhinometry seem to be more
established in the field of clinical
research, including the study of
nasal physiology, for the objective
evaluation of surgical techniques
and medical treatment, or for
assessing response to various
allergens or mediators of inflam-
mation.1, 7
The purpose of this paper is to
consider:
– the relationship, often de -
scribed as poor, between the
sensation of nasal obstruction
and nasal dyspermeability;
– the evaluation of nasal patency
in clinical practice, which is
often only assessed on the basis
of patient history and the clini-
cal examination;
– the difficulty of establishing
normative values for objective
measures and their variability.
Evaluating nasal patency
Evaluation is difficult because of
the physiological regulation of
nasal patency, which depends on
both the nasal valve (the elastic
properties of the fibro-cartilagi-
nous skeleton, muscle tone,
changes in pressure) and the
turbinate valve (the mucosa, the
nasal cycle, and various stimuli
such as heat, psychological fac-
tors, endocrine factors...).6, 17
The subjective sensation of
nasal obstruction is multifactorial
and so an evaluation with objec-
tive measures that considers only
the values for volume, surface or
flow cannot be expected to pro-
duce a perfect correlation.
A detailed history, physical
examination and nasal endoscopy
are still considered to the best
ways of evaluating nasal obstruc-
tion.15, 18
Nevertheless, these methods
remain subjective and quantifica-
tion is difficult.
A semi-quantitative subjective
assessment is possible and this
approach is considered useful for
assessing the severity of nasal
congestion and its evolution under
treatment.13
Nasal patency can be assessed
objectively with three tests:
Rhinomanometry and acoustic rhinometry in rhinoplasty
S. Tombu*, J. Daele**, P. Lefebvre*
* Department of ENT-HNS, CHU Sart Tilman, Liège; ** Department of ENT-HNS, Hôpital de la Citadelle, Liège
Key-words. Rhinomanometry; acoustic rhinometry; rhinoseptoplasty
Abstract. Acoustic rhinometry (AR) and rhinomanometry (RMM) study two different parameters of nasal ventilation:
respiratory function and the anatomy of nasal cavities. This article looks at their usefulness, in particular in the surgical
field. We list the normal values for these tests. Nasal obstruction is a symptom of multifactorial origin. Nasal patency is
only one factor influencing the sensation of nasal ventilation. Despite the range of divergent opinions in both the litera-
ture and among rhinological clinicians, the objective assessment of nasal patency in functional rhinoplasty or septorhino-
plasty seems to be advisable. The roles of AR and RMM still have to be established.
4S. Tombu et al.
–
active rhinomanometry (RMM),
which quantifies flow, pressure
and nasal resistance;
–
acoustic rhinometry (AR), which
evaluates the cross-sectional
areas, mostly anterior, and the
volumes of the nasal cavities;
– PNIF (Peak Nasal Inspiratory
Flow), or the measure of the
inspiratory flow during a maxi-
mal inhalation. This measure is
considered to be reliable, repro-
ducible, less expensive, fast and
easy to perform.13, 14 The draw-
backs relate to the simultaneous
evaluation of both nasal cavi-
ties, the medial attraction of the
wing of the nose, causing a pos-
sible change in the nasal valves,
the indispensable cooperation
of the patient and the possible
limitation of the flow resulting
from pulmonary disorders.18
The sensitivity of this examina-
tion in the evaluation of nasal
patency seems to identical to
that of AR and RMM. As with
AR and RMM, the correlation
between the values for PNIF
and the subjective sensation of
nasal obstruction is contro -
versial.13, 14, 18-20
Rhinomanometry assesses nasal
airflow, whereas acoustic rhi -
nometry assesses geometry. The
first technique provides a dynamic
and functional evaluation, the
second one a static, geometrical
and anatomical evaluation. The
two tests are often seen as comple-
mentary.1, 3, 7, 9, 13, 21
Both tests suffer from measure-
ment variability which is operator-
dependent, but they are repro-
ducible (5 to 10% reproducibility
for AR; 8 to 15% et for RMM).21, 22
They are considered similar in
terms of sensitivity.3
It seems that the severity of
nasal obstruction assessed subjec-
tively (Visual Analogue Scale) is
more closely correlated with
NAR, (Nasal Airway Resistance)
measured by RMM than with
MCA (Minimum Cross-Sectional
Area) assessed by AR.13, 23, 24
AR is more specific and more
sensitive than RMM for the diag-
nosis of structural abnormalities
in patients complaining of nasal
obstruction, while RMM is more
sensitive and specific in patients
with functional nasal obstruction
(rhinitis).18, 25
Both techniques are sensitive to
the cross-sectional dimensions of
the nasal lumen and modifications
of the lumen,7, 10, 21, 23, 26, 27 particular-
ly RMM, since resistance to air-
flow is exponentially related to
lumen cross-sectional areas.21
A recent study of a large series
of 7283 patients complaining of
nasal obstruction demonstrated a
significant difference in mean
values for total inspiratory nasal
resistance assessed by active ante-
rior RMM between patients with
septal deviation and control indi-
viduals with normal anatomy.28
Rhinomanometry
Rhinomanometry was first
described by Courtade in 1903.
Active rhinometry (anterior and
posterior) was introduced subse-
quently.
This technique allowed for a
better understanding of the physi-
ology of nasal ventilation.6, 17
Until now, hundreds of studies
have been published in which rhi-
nomanometry is used as a tech-
nique for assessing nasal patency3.
The methodology has been exten-
sively described.6
To minimise the variability of
the results, the International
Committee for the Standardisation
of Rhinomanometry proposed a
guideline in 198129 based on 42
years of experience and 10,000
tests.
An update was conducted in
198430and in 2000,16including, in
particular, recommendations for
provocation tests.
A more recent consensus in
2005 reassessed the use of rhino-
manometry and acoustic rhinome-
try, with a particular emphasis on
a standardised nasal decongestion
technique.31
Active anterior rhinomanome-
try is used most frequently and it
has been described as simple, fast,
well tolerated and feasible in all
patients, especially in children. Its
disadvantages are the risk of dis-
tortion of the nasal vestibule and
the impossibility of using it when
there is nasal perforation or com-
plete obstruction. In addition, the
use of rhinomanometry is difficult
in anxious patients who cannot
control the stability of their respi-
ration.6, 18 It takes more time to
complete this test than the AR.18
Active posterior rhinomanome-
try is more respectful of physio-
logical conditions (bilateral venti-
lation) and it reduces the risk of
the deformation of nasal struc-
tures. However, it is not feasible
for every patient,6mainly due to
nauseous reflexes induced by the
intra-oral positioning of the captor
in the region of the velum.
Some believe that RMM can
identify the site of obstruction at
the level of the anterior nasal
valve or turbinate valve and
therefore differentiate between
mucosal pathology and skeletal
deformation.6Others believe that
active anterior RMM cannot accu-
rately assess the resistance of a
specific area or identify the loca-
tion of the nasal obstruction.7, 18
The reproducibility of the
method, which is a subject of
Rhinomanometry and acoustic rhinometry in rhinoplasty 5
controversy , its low correlation
with the subjective sensation,
the lack of uniformity of results,
the variability between author
sequences and between the exami -
nation manoeuvres (anterior/pos-
terior/active/passive) explain why
the RMM is not used routinely in
the clinic.3, 17
Some people, however, are
more positive about the method,
seeing it as useful or necessary, or
even important for the evaluation
of preoperative or allergic nasal
obstruction.5, 6, 10, 1
2
Acoustic rhinometry
Hilberg introduced acoustic rhi-
nometry in 1989.32
The technique reliably e
valu-
ates the dimensions of the first
five centimetres of the nasal
cavities by recording the re
flec-
tion of an acoustic wave.3, 18, 21, 33
The parameters measured are
the volume of the nasal cavity
and the area of the cross-section
in a specific location. The mini-
mum cross-sectional area (MCA)
is the most common parameter
used.
In a normal nose, the MCA is
located at the level of the nasal
valve or at the head of the infe -
rior turbinate. After deconges-
tion, the MCA is found more
anteriorly.34, 35
AR is described as accurate
(accuracy 5-10%), reproducible
(5-10%), reliable, non-invasive,
quick, easy and requiring minimal
patient cooperation.3, 18, 21, 22, 36, 37
AR can identify the exact site
of obstruction in the nose, but
the level of inaccuracy in the
posterior part of the nasal cavity
and beyond a marked narrowing18
is high. AR is considered easier
to perform than rhinomanome-
try.3
AR has been used to under-
stand the anatomy and physiolo-
gy of the nasal cavity, in particu-
lar by confirming that the region
of the nasal valve is the narrow-
est area in the nasal cavity.3
Since the first publication about
clinical application in 1989,35AR
has been used in various fields of
rhinology: to evaluate nasal
obstruction, nasal permeability
before and after provocation tests38
or the efficacy of surgical35, 39 or
medical treatment.3, 40
Guidelines about the method
and recommendations for its use
have been described.3, 36, 38, 41, 42
These guidelines are considered
by the authors to be preliminary
and they are subject to change
with time depending on techno-
logical developments or new
knowledge.
AR provides valuable informa-
tion about the anatomy of the
nasal cavity. However, that infor-
mation is not adequate in itself to
establish a diagnosis of nasal
obstruction.43 The data must be
combined with the history and the
clinical examination.
For some authors, AR is
mandatory in the diagnosis and
study of the effects of treatment
on nasal obstruction, despite the
relatively weak relation between
the subjective and objective
evaluation . AR is not only a tool
for “article writers”.3
The discrepancies in the results
published in the literature and the
cost limit its use in clinical prac-
tice.
Normative values
The establishment of a level dis-
tinguishing between healthy indi-
viduals and patients is not possi-
ble because of individual and
ethnic variations44 and because
the sensation of nasal obstruction
does not depend on the size of the
nasal cavity only.3
Rhinomanometry
Formulating results is beset with
difficulties because of the non-
linear relationship between the
flow variations and pressure
variations measured resulting from
the variability of the ventilatory
regime (linear, turbulent or, more
often, mixed).
It is therefore impossible to
assign a single numerical value for
the precise assessment of the com-
plaints of a given patient.6
The mean normal values for
nasal resistance vary little from
one author to another: for binasal
resistance equal to or less than
3 or 3.5 cm H²O/l.sec. for a flow
rate of 0.5 /.sec; the majority of
normal values are between 1 and
2 cm H²O/l.sec.,60.23 Pa/cm³/sec
(0.15 – 0.39),45 0.24 Pa/cm³/sec
(0.12-0.52),10 0.31 Pa/cm³/sec
(0.13-0.84).46
However, large individual vari-
ations have been observed in all
studies.
For some, binasal resistance
greater than 0.25 Pa/cm³/s indi-
cates nasal obstruction.21
In children, nasal resistance
values rise with younger patient
age.
Unilateral nasal values vary
considerably depending on the
vasomotor cycle. In adults, they
can reach +/- 37.5 cm H²O/l/sec
during the peak of the vasomotor
cycle.6
A few studies have compared
rhinomanometry values of healthy
and pathological subjects.
Overall, there is a significant dif-
ference between the mean values
for total nasal resistance between
healthy subjects and subjects with
6S. Tombu et al.
nasal pathologies. However, indi-
vidually, patients with nasal dis-
ease may have resistance values
within the normative range.10
In French standards, unilateral
or bilateral resistance are con -
sidered to be pathological when
they exceed values of 6 cmH20/l/s
and 3 cm H20/l/s respectively and,
after decongestion, 4 cm H2O/l/s
uninasally and 2 cm H20/l/s
binasally.47
Acoustic rhinometry
Since AR was introduced in 1989,
several articles have examined the
normative values (Table 1).36, 37, 48-50
Although there are currently no
established standards and al though
there are large inter-individual and
ethnic variations, it is accepted by
some authors that, when MCA is
less than 0.5 cm², the sensation of
nasal obstruction is reported as
severe.3
Otherwise, interpretation and
obtaining curves depend very
much on the experience and
practice of each practitioner.46
Studies exploring the correlation
between AR values and the sensa-
tion of nasal obstruction show that
values vary significantly between
patients who complain and those
who do not.35Patients who are not
satisfied after septal surgery have
significantly lower MCAs than
those who are.35 An MCA of
0.50 cm², a cross-sectional area at
the pyriform aperture of 0.70cm²,
and a clear effect of decongestion
on the MCA (more than 0.20 cm²)
are the best variables for distin-
guishing between normal noses
and blocked noses.21, 40
The reference values can vary
more or less depending on the
homogeneity of the selected
patients.36Normality is defined
by the subjective sensation of
normal breathing, with or without
rhinoscopic evaluation in homo-
geneous groups in terms of race,
weight, height and age.44 The
establishment of local standards
would therefore seemto be use-
ful.
In a patient complaining of
nasal obstruction, an MCA of less
than 0.35 cm² indicates, for some
authors, that the narrowing may
play a role in the patient’s subjec-
tive complaints.36
Nasal obstruction and dysper-
meability are not synonymous
Nasal obstruction is a symptom, a
subjective sensation of discomfort
with the flow of air to the nasal
cavities resulting from different
Table 1
Acoustic rhinometry: normal values
Authors Year Population MCA
non-decongested
MCA
decongested
NV
non-decongested
NV
decongested
Hilberg O36 2000 1756 0.60 cm² +/- 0.18 (SD)
Median 0.517 cm²
5 percentile 0.360 cm²
2.5 percentile 0.320 cm
(non-decongested ?)
Larsson C37 2001 102
(51 M, 51F)
98 children
(7.1-16.9 years)
Men: 0.65 +/-0.2 cm²
Women: 0.51 +/-0.12 cm²
Children: 0.52+/-0.14 cm²
Strasszek SP48 2007 146 adults
(127 M, 19 F)
53 children
(9-11 years)
caucasians
Adults: 0.61 cm²
(0.58-0.64)
Children:0.33 cm²
(0.31-0.35)
Adults: 0.73 cm²
(0.70-0.77)
Children: 0.36 cm²
(0.35-0.38)
NV (2-5 cm)
Adults: 3.73 cm³
(3.56-3.91)
Children: 2.48 cm³
(2.34-2.62)
NV(2-5 cm)
Adults: 5.28 cm³
(5.07-5.49)
Children: 3.71 cm³
(3.58-3.84)
Trindade IE49
2007 30 adults
(14 M, 16 F)
(18-30 years)
V1: 1.68+/-0.32
V2: 3.98+/-1.21
V3: 17.67+/-3.57
V1 = 10-32 mm
V2 = 33-64 mm
V3 = 70-120 mm
V1: 1.82+/-0.30
V2: 5.53+/-1.03
V3: 22.72+/-4.06
Gomes A50 2008 30 adults
(14 M, 16 F)
(18-30 years)
0.54 +/-0.13 cm²
(CSA1)
0.56 +/-0.13 cm³
(CSA1)
Rhinomanometry and acoustic rhinometry in rhinoplasty 7
neurophysiological mechanisms
which are not fully elucidated.13, 51.
Several factors are involved:
mucosal (vasomotor cycle, pres-
ence of secretions), structural,
nervous receptors (pressure, tem-
perature, pain) and psychological
factors.1, 3, 4, 7, 13, 14, 40, 43, 52, 53
Quantification in clinical prac-
tice remains difficult. One possi-
bility is a self-report evaluation
(Visual Analogue Scale)13, 54 with
complementary rhinoscopic
examination.
The dimensions of the nasal
cavities depend on mucosal and
anatomical factors. The results of
evaluation, both in the clinic and
rhinomanometry or acoustic rhi-
nometry, cannot be strictly corre-
lated with patient complaints,
which include psychological
depen dence. The fact that nasal
patency is not affected in some
patients complaining of nasal
obstruction or, conversely, that
nasal patency is drastically reduced
in other patients without obstruc-
tive complaints is a familiar phe-
nomenon in clinical practice.10, 13, 17
A sensation of nasal obstruc-
tion does not always mean that
there is an obstruction that can be
identified objectively. The indi-
vidual and subjective assessment
of nasal ventilation, which has
been clearly demonstrated, calls
for objective methods for an
objective evaluation of nasal
patency.8
For example, atrophy of the
sensory nerve endings in mucosal
atrophy or somatised anxiety
may result in the over-estimation
of the severity of nasal obstruc-
tion.25 Since the introduction of
the objective technical assess-
ment of nasal patency, many
conflicting articles have been
published about the relationship
between the values obtained and
patient complaints. Many studies
show no significant correlation
between the values for AR or
RMM and the severity of patient
complaints.2, 6, 8, 10, 25, 27, 37, 52, 55
Several explanations have
been given: the considerable
individual variation in, and eth-
nic values for, nasal resistance or
minimum area,7, 9 the subjective
nature of ventilatory discom-
fort,25the complexity of the sub-
jective sensation of nasal
obstruction (dependent on ther-
mal , algesic and chemical recep-
tors)27 and the difficulty of mak-
ing an objective assessment of
the ventilatory disorder with a
single numerical value.6The sen-
sation of nasal obstruction
depends on receptors located in
the nasopharynx, the area around
the inferior turbinate, whereas
nasal resistance is primarily
determined by the anterior por-
tion of the nasal cavity.52
The different evaluation
methods look at various aspects
of nasal ventilation and so they
must instead be viewed as com-
plementary rather than contradic-
tory.11
Several studies indicate a
certain degree of correlation
between subjective evaluation
and the objective assessment of
nasal obstruction.1, 7, 8, 9, 12-14, 21, 35, 37, 54
Correlation has been found
when patients evaluate unilateral
permeability7, 8, 21 or in cases of
severe obstruction,8as well as
when the complaints result mainly
from the obstructive swelling of
the mucosa, for example during
rhinitis or during provocation tests
with histamine, or after nasal
decongestion or the application of
topical steroids,1, 9, 13, 37 before and
after turbinectomy, or in the con-
text of allergic rhinitis or chronic
rhinosinusitis.54
With chronic nasal complaints
or nocturnal ventilatory disor-
ders, there is a small but signifi-
cant correlation between the sub-
jective sensation of nasal obstruc-
tion and volume measurements,
surfaces and flow assessed
respectively with AR and the
Peak Nasal Inspiratory Flow.14
Discrepancies between subjec-
tive sensation and objective
measures of nasal patency are a
given. Despite this, many studies
perform objective assessments of
nasal patency to quantify and
compare the results.
Functional exploration of nasal
patency and rhinoseptoplasty
In Belgium, the objectivisation of
nasal dyspermeability is required
for the reimbursement of a func-
tional rhinoplasty or rhinosepto-
plasty by the Social Security
System.
An accurate, objective assess-
ment of nasal dyspermeability
may also be requested as part of a
forensic examination.
Putting aside legal and finan-
cial considerations, an objective
assessment of nasal obstruction
can be particularly useful for
evaluating permeability before
and after surgery and for evalu -
ating the functional impact of
surgical procedures on nasal
patency. In clinical practice,
there is a belief that that a
good, or even the best, indication
for the objectivisation of nasal
obstruction is to evaluate surgical
results1, 17, 56 or to predict the
expected benefit when an addi-
tional functional treatment is
added to the rhinoplasty.39, 57, 58
Others believe that the corre -
lation between the subjective
sensation of nasal patency and
the values obtained from rhino-
8S. Tombu et al.
manomety and acoustic rhinome-
try values is too weak.4, 55
Patients with high resistance
values or low values for the cross-
sectional area are more likely to
be satisfied after surgery.19
In clinical practice, we also see
that patients are more satisfied
with their surgery when the com-
plaints are consistent with the
clinical assessment and objective
measures.
Some authors see rhinoma -
nometry as a integral part of the
assessment of nasal patency in
patients complaining of nasal
congestion before rhino(septo) -
plasty,12 in particular for assessing
nasal valve function,58 which is a
potential cause of nasal obstruc-
tion.59
Acoustic rhinometry may be of
particular interest in assessing
pre- and postoperative patients
with complex nasal deformities,
as in cleft palate.43, 60
In nasal valve surgery, as with
turbinate surgery,61 obstruction is
most often assessed clinically.56
Rhinoplasty is a well-known
cause of nasal valve insufficien-
cy.4, 18 Ten percent of aesthetic
rhinoplasties are reported to be
associated with a reduction of
nasal patency.39 The most fre-
quent causes of alterations in
nasal ventilation by surgery are:
the resection of the cartilaginous
dorsum with the disinsertion of
septo-triangular sutures, over-
radical alar cartilage resection
and lateral osteotomies.43, 59
Studies with acoustic rhinome-
try made it possible to document
and objectify these clinical
findings .26, 39, 43, 62 It should be
noted that a significant reduction
in MCA as observed with AR
does not necessarily result in
impairment of subjective nasal
breathing.39, 43
What do Belgian rhinologists
think?
A questionnaire was sent to
the members of the Belgian
Rhinology Society.
Sixteen responses were ob -
tained, corresponding to an annual
total of 1356 rhinoseptoplasties,
15% of which were performed for
aesthetic reasons, 45% for func-
tional reasons, and 40% for mixed
indications. Most procedures were
therefore functional rhinosepto-
plasty (85%).
The assessment of nasal ob -
struc tion is essentially anam-
nestic and clinical (Table 2).
Discrepancies relate mainly to
opinions about rhinomanometry
and acoustic rhinometry.
There is far from being a con-
sensus about the use of these tests,
either with respect to indications
or normative values.
As far as rhinomanometry is
concerned, some clinicians look
only at the symmetry of the
curves, others make their assess-
ments on the basis of flow values,
and others on the basis of nasal
resistance values , which vary
from one practitioner to another.
Turning to acoustic rhinometry,
some practitioners assess the
symmetry of the curves, others
use MCA values, and still others
work with NV values, which also
vary from one practitioner to
another.
Even though consensus about
normative values is often consid-
ered unrealistic, rhinologists are
demanding better information and
training about ‘good practice’ with
these objective techniques, which
continue to depend on individual
practice.
This finding is not surprising
given the lack of consensus
about the assessment of nasal
obstruction.
Conclusion
Rhinoplasty (and rhinoseptoplas-
ty) can have adverse or beneficial
consequences on nasal ventilation.
The objective assessment of
nasal patency with acoustic rhi-
nometry or rhinomanometry
before functional or mixed rhi-
noseptoplasty is a conventional
procedure in Belgium as part of an
application for reimbursement by
the National Health Care system.
Its usefulness in the evaluation of
nasal obstruction is highly contro-
versial. Nasal obstruction is a
highly subjective symptom and
burdened with psychological fac-
tors. Its assessment is based on
subjective anamnestic and clinical
data.15, 56
The objective assessment tech-
niques are often used in the field
Table 2
Evaluation of nasal obstruction (0: not important to 5: very important)
Rhinomanometry and acoustic rhinometry in rhinoplasty 9
of clinical research, but their place
in clinical practice remains con-
troversial and poorly established.16
Despite the conflicting results
about the relationship between the
subjective and objective evalua-
tion of nasal obstruction, several
authors recommend the use of
rhinomanometry and/or acoustic
rhinometry in the pre-operative
evalu ation of septorhinoplasties.12,
39, 56, 58, 59, 60, 62
Objective assessments seem,
independently of any psychologi-
cal factors, to be necessary, in par-
ticular in the area of rhino(septo) -
plasty to avoid over-treatment (the
nasal complaints may be indica-
tive of psychosomatic disorders and
serve as pretexts for un founded
complaints) and to im prove
patients’ understanding of their
respiration and therefore patient
satisfaction after treatment.
For purely aesthetic rhinoplas-
ty, the assessment of nasal patency
may not seem useful. However,
we must remain cautious about the
functional impact of certain surgi-
cal procedures.
Putting aside any legal or finan-
cial considerations, the place of
rhinomanometry and acoustic rhi-
nometry in rhinoplasty or in the
rhinology clinic remains to be
established. The use of these tests
is too dependent on individual
practice.
This work may serve to trigger
a shared and constructive debate
in our Belgian ENT association
about the use in our daily practice
of rhinomanometry, acoustic rhi-
nometry and PNIF. In particular, a
consensus should be established
about standards.
A joint approach could result in
the establishment of courses and
training for the standardisation of
practice and the more efficient use
of these techniques.
References
1. Schumaker MJ. Nasal Congestion and
Airway Obstruction: the validity of
available objective and subjective
measures. Curr Allergy Asthma Rep.
2002;2(3):245-251.
2. Kim CS, Moon BK, Jung DH,
Min YG. Correlation between nasal
obstruction symptoms and objective
parameters of acoustic rhinometry
and rhinometry. Auris Nasus Larynx.
1998;25(1):45-48.
3. Hilberg O. Objective measurement of
nasal airway dimensions using
acoustic rhinometry: methodological
and clinical aspects. Allergy. 2002;
57(Suppl 70):5-39.
4. Andre RF, D’Souza AR, Kunst HP,
Vuyk. Sub-alar batten grafts as treat-
ment for nasal valve incompetence;
description of technique and function-
al evaluation. Rhinology. 2006;44(2):
118-122.
5. Schumacher MJ. Rhinomanometry.
J Allergy Clin Immunol. 1989;83(4):
711-718.
6. Mélon J, Daele J. Functional and
endoscopic studies in rhinology [in
French]. Acta otorhinolaryngol Belg.
1979;33(5):631-870.
7. Roithmann R, Cole P, Chapnik J,
Barreto SM, Szalai JP, Zamel N.
Acoustic rhinometry,rhinomanome-
try, and the sensation of nasal paten-
cy: a correlation study. J Otolaryngol.
1994;23(6):454-458.
8. Sipilä J, Suonpää J, Silvoniemi
P,Laippala P. Correlations between
subjective sensation of nasal patency
and rhinomanometry in both uni -
lateral and total nasal resistance. ORL
J Otorhinolaryngol Relat Spec. 1995;
57(5):260-263.
9. Numminen J, Ahtinen M, Huhtala H,
Rautiainen M. Comparison of rhino-
metric measurements methods in
intranasal pathology. Rhinology.
2003;41(2):65-68.
10.
Suzina AH, Hamzah M, Samsudin AR.
Objective assessment of nasal resistance
in patients with nasal disease. J Laryn -
gol Otol. 2003; 117(8): 609-613.
11. Lam DJ, James KT, Weaver EM.
Comparison of anatomic, physiologi-
cal, and subjectives measures of the
nasal airway. Am J Rhinol. 2006;
20(5):463-470.
12. Oeken J, Kiefer MC. About the func-
tional aspect of septorhinoplasty [in
German]. Mund Kiefer Gesichtschir.
2006;10(2):82-88.
13. Van Spronsen E, Ingels KJ,
Jansen AH, Graamans K, Fokkens WJ.
Evidence-based recommendations
regarding the differential diagnosis
and assessment of nasal congestion:
using the new GRADE system.
Allergy. 2008;63(7):820-833.
14. Kjaergaard T, Cvancarova M,
Steinsvag SK. Does nasal obstruction
mean that the nose is obstructed?
Laryngoscope. 2008;118(8):1476-
1481.
15. Fraser L, Kelly G. An evidence-base
approach to the management of
the adult with nasal obstruction.
Clin Otolaryngol. 2009;34(2):151-
155.
16. Malm L, Gerth van Wijk R, Bachert
C. Guidelines for nasal provocations
with aspects on nasal patency, airflow,
and airflow resistance. International
Committee on Objective Assessment
of the Nasal Airways, International
Rhinologic Society.Rhinology. 2000;
38(1):1-6.
17. Lund VJ. Objective assessment of
nasal obstruction. Otolaryngol Clin
North Am. 1989;22(2):279-290.
18. Chandra RK, Patadia MO, Raviv J.
Diagnostic of nasal airway obstruc-
tion. Otolaryngol Clin North Am.
2009;42(2):207-225.
19. Starling-Schwanz R, Peake HL,
Salome CM, Toelle BG, Marks GB,
Lean ML, Rimmer SJ. Repeatability
of peak nasal inspiratory flow meas-
urements and utility for assessing the
severity of rhinitis. Allergy. 2005;
60(6):795-800.
20. Bermüller C, Kirsche H, Rettinger G,
Riechelmann H. Diagnostic accuracy
of peak nasal inspiratory flow and
rhinomanometry in functional rhi-
nosurgery. Laryngoscope. 2008;118
(4):605-610.
21. Cole P. Acoustic rhinometry and
rhinomanometry . Rhinol Suppl. 2000;
16:29-34.
22. Silkoff PE, Chakravorty S, Chapnik J,
Cole P, Zamel N. Reproducibility
of acoustic rhinometry and rhino-
manometry in normal subjects. Am
J Rhinol. 1999;13(2):131-135.
23. Szücs E, Clement PA. Acoustic rhi-
nometry and rhinomanometry in the
evaluation of nasal patency of patients
with nasal septal deviation. Am
J Rhinol. 1998;12(5):345-352.
10 S. Tombu et al.
24. Strunski V, Stramandinoli E.
Exploration physique et fonctionnelle
des fosses nasales. Encycl Méd Chir
Oto-rhinolaryngologie. Elsevier SAS,
Paris, 2003;20-420-A-10:6p.
25. Passali D, Mezzedimi C, Passali GC,
Niti D, Bellussi L. The role of rhino-
manometry, acoustic rhinometry, and
mucociliary transport time in the
assessment of nasal patency. Ear Nose
Throat J. 2000;79(5):397-400.
26. Roithmann R, Chapnik J, Zamel N,
Barreto SM, Cole P. Acoustic rhino-
metric assessment of the nasal valve.
Am J Rhinol. 1997;11(5):379-385.
27. Tomkinson A, Eccles R. Comparison
of the relative abilities of acoustic rhi-
nometry, rhinomanometry and the
visual analogue scale in detecting
change in the nasal cavity in a healthy
adult population. Am J Rhinol.
1996;10(3):161-165.
28. Canakcioglu S. Nasal patency by
rhinomanometry in patients with
sensation of nasal obstruction. Am J
Rhinol Allergy. 2009;23(3):300-302.
29. Kern EB. Committee report on
standardization of rhinomanometry.
Rhinology. 1981;19(4):231-236.
30. Clement PA. Committee report on
standardization of rhinomanometry.
Rhinology. 1984;22(3):151-155.
31. Clement PA, Gordts F, Standardisa -
tion Committee on Objective Assess -
ment of the Nasal Airway, IRS, and
ERS. Consensus report on acoustic
rhinometry and rhinomanometry.
Rhinology. 2005;43(3):169-179.
32. Hilberg O, Jackson AC, Swift DL,
Pedersen OF. Acoustic rhinometry:
evaluation of nasal cavity geometry
by acoustic reflection. J Appl Physiol.
1989;66(1):295-303.
33. Min YG, Jang YJ. Measurements
of cross-sectional area of the nasal
cavity by acoustic rhinometry and CT
scanning. Laryngoscope. 1995;105(7
Pt 1):757-759.
34. Grymer LF, Hilberg O, Pedersen OF,
Rasmussen TR. Acoustic rhinometry:
values from adults with subjective
normal nasal patency. Rhinology.
1991;29(1):35-47.
35. Grymer LF, Hildberg O, Elbrond O,
Pedersen OF. Acoustic rhinometry:
evaluation of the nasal cavity with
septal deviations, before and after
septoplasty. Laryngoscope. 1989;99
(11):1180-1187.
36. Hilberg O. Pedersen OF. Acoustic rhi-
nometry: recommendations for tech-
nical specifications and standard
operating procedures. Rhinol Suppl.
2000;16:3-17.
37. Larsson C, Millqvist E, Bende M.
Relationship between subjective nasal
stuffiness and nasal patency mesuared
by acoustic rhinometry. Am J Rhinol.
2001;15(6):403-405.
38. Parvez L, Erasala G, Noronha A.
Novel techniques, standardization to
enhance reliability of acoustic rhi-
nometry measurements. Rhinol Suppl.
2000;16:18-28.
39. Grymer LF. Reduction rhinoplasty
and nasal patency: change in the
cross-sectional area of the nose evalu-
ated by acoustic rhinometry. Laryn -
goscope. 1995;105(4 Pt 1):429-431.
40. Grymer LF, Hilberg O, Pedersen OF.
Prediction of nasal obstruction based
on clinical examination and acoustic
rhinometry. Rhinology. 1997;35(2):
53-57.
41. Djupesland PG, Lyholm B. Technical
abilities and limitations of acoustic
rhinometry optimised for infants.
Rhinology. 1998;36(3):104-113.
42. Tomkinson A, Eccles R. Errors arising
in cross-sectional area estimation by
acoustic rhinometry produced by
breathing during measurement.
Rhinology. 1995;33(3):138-140.
43. Grymer LF. Clinical applications of
acoustic rhinometry. Rhinol Suppl.
2000;16:35-43.
44. Morgan NJ, MacGregor FB,
Birchall MA, Lund VJ, Sittampalam
Y. Racial difference in nasal fossa
dimensions determined by acoustic
rhinometry. Rhinology. 1995;33(4):
224-228.
45. Morris S, Jawad MS, Eccles R.
Relationships between vital capacity,
height, and nasal airway resistance in
asymptomatic volunteers. Rhinology.
1992;30(4):259-264.
46. Shelton DM, Eiser NM. Evaluation of
active and posterior rhinomanometry
in normal subjects. Clin Otolaryngol
Allied Sci. 1992;17(2):178-182.
47. Coffinet L, Bodino C, Brugel-Ribere,
Marie B, Grignon Y, Coste A,
Jankowski R. Explorations physiques
et fonctionnelles des fosses nasales.
Encycl Méd Chir Oto-rhino-laryn -
gologie. Elsevier SAS, Paris. 2003;
20-280-A-10:14p.
48. Straszek SP, Schlünssen V,
Sigsgaard T, Pedersen OF. Reference
values for acoustic rhinometry in
decongested school children and
adults: the most sensitive measure-
ment for change in nasal patency.
Rhinology. 2007;45(1):36-39.
49. Trindade IE,Gomes Ade O, Sampaio-
Teixeira AC, Trindade SH. Adult
nasal volumes assessed by acoustic
rhinometry. Braz J Otorhinolaryngol.
2007;73(1):32-39.
50. Gomes Ade O, Sampaio-Teixeira AC,
Trindade SH, Trindade IE. Nasal
cavity geometry of healthy adults
assessed using acoustic rhinometry.
Braz J Otorhinolaryngol. 2008;74
(5):746-754.
51. Klossek JM, Dufour X, Desmons-
Grohler C, Fontanel JP. Physiologie
de la muqueuse respiratoire nasale
et troubles fonctionnels. Encycl
Méd Chir. Oto-Rhino-Laryngologie.
Elsevier SAS, Paris,.2000;20-290-A-
10:10p.
52. Jones AS, Willatt DJ, Durham LM.
Nasal airflow: resistance and sensa-
tion. J Laryngol Otol. 1989;103
(10):909-911.
53. Eccles R. The effects of oral adminis-
tration of (-)-menthol on nasal resis -
tance to airflow and nasal sensation of
airflow in subjects suffering from
nasal congestion associated with com-
mon cold. J Pharm Pharmacol. 1990;
42(9):652-654.
54. Mora F, Cassano M, Mora R,
Gallina AM, Ciprandi G. V.A.S. in
the follow-up of turbinectomy.
Rhinology. 2009;47(4):450-453.
55. Reber M, Rham F, Monnier Ph.
The role of acoustic rhinometry in
the pre- and postoperative evaluation
of surgery for nasal obstruction.
Rhinology. 1998;36(4):184-187.
56. Spielmann PM, White PS,
Hussain SS. Surgical techniques for
the treatment of nasal valve collapse:
a systematic review. Laryngoscope.
2009;119(7):1281-1290.
57. Piccini A, Biagini C, Sensini I. Nasal
dimorphism and respiratory dysfunc-
tion. Preoperative selection of patients
and follow-up using computerized
rhinomanometry [in Italian]. Acta
Otorhinolaryngol Ital. 1991;11(2):
143-149.
58. Ricci EP, Palonta F, Preti G, Vione N,
Nazionale G, Albera R, Staffieri A,
Rhinomanometry and acoustic rhinometry in rhinoplasty 11
Cortesina G, Cavalot AL. Role of
nasal valve in the surgically corrected
nasal respiratory obstruction: evalua-
tion through rhinomanometry. Am
J Rhinol. 2001;15(5):307-310.
59. Constantian MB, Clardy RB. The rel-
ative importance of septal and nasal
valvular surgery in correcting airway
obstruction in primary and secondary
rhinoplasty. Plast Reconstr Surg.
1996;98(1):38-54.
60. Trindade IE, Bertier CE, Sampaio-
Teixeira AC. Objective assessment of
internal nasal dimensions and speech
resonance in individuals with repaired
unilateral cleft lip and palate after
rhinoseptoplasty . J Craniofac Surg.
2009;20(2):308-314.
61. Batra PS, Seiden AM, Smith TL.
Surgical management of adult inferior
turbinate hypertrophy: a systematic
review of the evidence. Laryn-
goscope. 2009;119(9):1819-1827.
62. Grymer LF, Gregers-Petersen C,
Baymler Pedersen H. Influence of
lateral osteotomies in the dimensions
of the nasal cavity. Laryngoscope.
1999;109(6):936-938.
Sophie Tombu
Department of ENT-HNS
CHU Sart Tilman
B-4000 Liège
E-mail: sophietombu@skynet.be
