Perfect Physiology of the Nose - Airflow Properties
What does nasal hyperventilation mean?
Normally, there are 3 turbinates in each cavity in our nose and the air entering the nose is rotated by contacting these turbinates, moistened, purified and heated. Especially inferior turbinates are responsible for most of the nasal functions. When we take in air at normal speed, the air entering into the nose rotates by hitting the turbinates thanks to the round and sausage-shaped structure of the inferior turbinates. Since the mucus layer on the turbinate is warmer than normal, the particles in the air entering the nose, microorganisms, allergens are caught by this mucus layer and almost a very high rate of air filtration is provided. When the cross-sectional area of the aerodrome in the nose is increased for various reasons, the flow turns linear when we take air from the nose and therefore the amount of air taken from the nose increases. This condition is called nasal hyperventilation. The structures in the nose contribute to the air taken from the nose to encounter a certain resistance and to slow down the air, moisturize, purify, heat and pressurize it. Nasal hperventilation may occur in nasal septum perforations, as in patients with turbinate resection.
In the video above, it is seen that the air entering through the nose spreads around the turbinates, expands, and reunites as a single beam towards the back of the nose. In this way, the air heated, purified, humidified and pressurized in the nose moves towards the lower respiratory tract.
Why are turbinates important?
When the air we take from the nose is transmitted to the lungs, it must be warm, clean, moist and at a certain amount of pressure. Turbinates have a dense network of blood vessels and are very hot structures. Especially the lower turbinates are responsible for most of the nasal functions. The mucosa covering the turbinate has a ciliated structure and constantly moves the mucus layer to which the air particles adhere backwards. Mostly, this mucus layer drips back from our nasal passage to our throat and goes to our stomach, and in this way, external air particles, bacteria, viruses are kept by adhering to the mucus, but when turbinates are swollen in our nose, which has such a complex and systematic treatment, heating and humidification mechanism, sometimes our nose is blocked. It causes mouth-open sleep and a decrease in quality of life. Current publications emphasize that turbinates should be considered as an organ and should only be scaled down to a limited extent.
Regarding the photos I have shared above and below, I would like to add the following: 4 photos are the visible visual, the upper two are the intra-nasal photos of the patient who had an exaggerated nasal concha resection and radiofrequency procedure in another clinic and revealed an abnormal air cross-sectional area in the nose. The two photographs below are the photographs of the patient whose inferior turbinates have been reduced by radiofrequency in a limited amount of nasal meat on the right and left. The reason I put 4 photos is to allow you to compare the top and bottom photos at the same time. Tomography sections belong to the patient who has undergone this abnormal nasal concha reduction procedure, and as you can see there, there is a volume increase in the nose, which is much more than normal.
What is empty nose syndrome?
Empty nose syndrome is the abnormal reduction of the tissues in the nose and the appearance of abnormal large air volume in the nose. In this case, complaints such as severe impairment of nasal functions, drying in the nose, intense discharge in the nasal passage, changes in the sense of airing, structural changes in the nasal mucosa over time, smell problems and sometimes painful stimuli in the nose or a feeling of suffocation occur. Irreversible tissue loss occurs in patients whose turbinates are completely removed from the root and completely removed. In empty nose syndrome, the treatment of which has not been found definitively, the amount of remaining nasal concha and how large the air volume in the nose determine the complaints of the patients. In the patient I shared with you above, there are some inferior turbinates on both sides and the patient complains of air hunger, especially while breathing. The next stage of nasal hyperventilation can be considered as empty nose syndrome, and patients with empty nose syndrome may experience atrophic rhinitis, changes in the nasal mucosa, odor loss, lung infections, and a decrease in oxygen absorption.
Turbinates should be considered organs and minimal traumatic procedures should be performed!
No structure in the nose is unnecessary and non-functional. It may be appropriate to reduce a limited amount of turbinate volume, especially in patients whose turbinates are swollen and therefore have nasal congestion; However, with the patient's request, surgical removal of the nasal meat and permanent removal of the nasal concha is not a correct approach. When patients with swelling of the turbinate put pressure on their doctors for turbinate resection during the procedure, it may cause a health problem that negatively affects their lifelong life.
Sensation of being unable to breathe complaints may occur in patients with nasal hyperventilation!
Here I want to give you information about a diagnosis confusion. Especially in patients whose turbinates are abnormally reduced (as in the patient with 4 pictures that I shared here), there is air flow in the nose faster than normal. For this reason, many patients may say that when they breathe through the nose, as if there are patients with a blocked nose, there is a feeling that there is not enough air entering or a sufficient amount of oxygen, and there may be differences in diagnosis and approach among physicians. For example, the inferior turbinate on the left of this patient seems quite small, and unfortunately, the patient has been recommended to increase the intranasal volume with nasal valve surgery if there is repeated turbinate resections or air hunger in different clinics. In particular, the patient who had more complaints on the left side, where the inferior turbinate was quite small, was recommended to narrow the nose by preparing a cotton ball with regular saline and eye pomade with antibiotics. If the patient describes a decrease in the complaints when the intranasal narrows, modified Young's surgery or various implant placement procedures (alloderm, cartilage or fascia placement ...) can be planned accordingly. Unfortunately, there are clinics that recommend and apply inferior turbinate radiofrequency repeatedly in patients with nasal hyperventilation due to sensation of being unable to breathe. After these procedures, almost the entire volume of turbinates may disappear and empty nose syndrome may occur.
What are the differences between nasal hypoventilation and hyperventilation?
In patients with turbinates larger than normal (especially in patients with recurrent upper respiratory infections with allergic rhinitis), complaints such as difficulty in breathing through the nose and breathing through the mouth, sleeping with an open mouth may occur due to increased nasal air resistance. In fact, this situation arises due to the insufficient amount of air entering the nose, ie evil eye hypoventilation; However, as an opposite situation, when the turbinates are oversized, when air is taken from the nose, rapid or excessive air enters the abnormal nose. Since the turbinates remaining in the nose in this way cannot have the capacity to humidify, heat or purify the large amount of air, dry, cold, particulate and compressed air is delivered to the lungs. In this case, oxygen absorption in the air in the lungs is adversely affected. If you pay attention to the quadruple photos, you can see a very dense, solid secretion in the form of drops under the inferior turbinate in the right nostril. In fact, this is due to the drying effect of the air entering the nose intensely, and the intranasal secretions to dry, darken and become sticky. One of the biggest differences between nasal hypoventilation and hyperventilation is drying in the nose, darkening of the secretion and the complaint of protection in the nasal cavity. Drying of the nasal passages is evident in patients who usually enter hyperventilation and excessive amount of air. Unfortunately, in both cases, due to insufficient air taken from the nose; With a wrong diagnosis, turbinates can be shrunk repeatedly and the patient's complaints are increasing gradually in this case. As a rough suggestion to the patients, I ask whether there is a decrease in their complaints when they use nasal strip Breathe Right, if the patient describes an increase in his complaints when he uses nasal bands; There is probably nasal hyperventilation and complaints increase as the amount of air entering increases when the nasal wings are enlarged. In this case, it is not correct to perform an intranasal airway expansion procedure on the patient.
In nasal hyperventilation, procedures to reduce the intranasal air volume can be performed!
The patient, whom I shared here on the upper part of the quadruple photos and presented to you the tomography sections at the same time, had complaints such as drying, obstruction, sensation of being unable to breathe and very sticky secretion, especially on the left side. It was learned that this patient's complaints gradually increased when he used a nasal patch before, and if the patient was given regular saline water and if necessary, when the antibiotic eye pomade and cotton ball were placed in the nose, his complaints decreased; Implant placement procedures have been planned to narrow the airway in the nose with the modified Young's surgery or to narrow the airway that appears wide in the nose. There is no technology to recreate or produce turbinates in the world, so it is essential to make the smallest possible anatomical changes, the smallest tissue reduction and tissue-respectful procedures....
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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul
Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52
Appointment Phone: +90 212 561 00 52
Mobile phone: +90 533 6550199
Mobile phone: +90 533 6550199
Fax: +90 212 542 74 47