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The actual cross-sectional areas of the cast model nasal cavity were determined hy computed tomography and compared with the corresponding areas measured hy AR. To assess how nasal ohstruction affects the AR resulls, we placed small wax spheres of different diameters at specific sites in the model. The nasal valve and the choana were indicated by significant dips on the AR area-distance curve.
The actual cross-sectional areas of the cast model nasal cavity were determined hy computed tomography and compared with the corresponding areas measured hy AR. To assess how nasal ohstruction affects the AR resulls, we placed small wax spheres of different diameters at specific sites in the model. The nasal valve and the choana were indicated by significant dips on the AR area-distance curve.
The actual cross-sectional areas of the cast model nasal cavity were determined hy computed tomography and compared with the corresponding areas measured hy AR. To assess how nasal ohstruction affects the AR resulls, we placed small wax spheres of different diameters at specific sites in the model. The nasal valve and the choana were indicated by significant dips on the AR area-distance curve.
Aimah of Oliihgy. Rhiniilgy & Uii-yngologv 1 l4[!2):94Q-957.
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Acoustic Rhinometry: Accuracy and Ability to Detect Changes in Passage Area at Different Locations in the Nasal Cavity Ozcan Cakmak. MD: Erkan Tarhan, MD; Mehmet Coskun. MD; Mehmet Cankurtaran, PhD; Hu.seyin Qelik, PhD Objectives: To evaluate the accuracy of acoustic rhinometry (AR) measurements, and to assess how well AR detects obstructions of various sizes at specific sites in the nasal cavity, we created a cast model from an adult cadaver nasal cavity. Methods: The actual cross-sectional areas ofthe cast model nasal passage were determined hy computed tomography and compared with the corresponding areas measured hy AR. To assess how nasal ohstruction affects the AR resulls. we placed small wax spheres of different diameters at specific sites in the model (nasal valve, head ofthe inferior turbinate. head ofthe middle turhinate. middle ofthe middle turhinate. choana. and nasopharynx). Results: The AR-derived cross-sectional areas in the first 6.5 cm of the cast model nasal cavity were very close to the corresponding areas calculated from computed tomographie sections perpendieular to the presumed acoustic axis. How- ever. AR overestimated the passage areas at locations posterior to the 6.5-cm point. Acoustic rhinometry gave an accu- rate indication of the passage area of the nasal valve and its distance from the nostril. The nasal valve and the choana were indicated by significant dips on the AR area-distance curve, whereas the curve was smooth throughout the region that included the head of the inferior turbinate. the head of the middle turhinate. the middle of the middle turbinate. and the nasopharynx. In other words. AR did not discretely identify these latter sites. Acoustic rhinometry detected the dilTerent-si/.ed inserts (obstructions) more accurately at the nasal valve than at sites posterior to this location. Conclusions: The results of the study show that AR is a valuable method tor assessing the anterior nasal cavity. This technique is sensitive for detecting changes in passage area at the nasal valve region: however, the sensitivity is lower at sites posterior to this. The findings suggest that when there is substantial narrowing of the nasal valve. AR will not identify an obstruction at any location posterior to the nasal valve. In such situations. AR measurements heyond the ahnormal nasal valve may easily lead to misinterpretation ofthe patient's nasal anatomy or condition. Key Words: acoustic rhinometry. cast model, computed tomography, curved acoustic axis, nasal cavity. INTRODUCTION For more thati a century, rhinologists have been searchitig for a reliable way to evaluate the nasal air- way in a wide range of patients. In 1989. Hilberg et al' introduced acoustic rbinometry (AR) as an ob- jective method for examining the nasal cavity. This technique is based on the principle that a sound pulse propagating in the nasal cavity is reflected by local changes in acoustic itnpedance. Acoustic rhinometry is a quick, painless, noninvasive method that can be usedtoestimatc the dimensions of nasal obstrnctions. evaluate nasal cavity geometry, monitor nasal disor- ders, and assess surgery results and response to tnedi- cal treatment. Because of these advantages, AR has been widely accepted in a short period of time. How- ever, lack of standardization is one ofthe tnain prob- lems with this tnethod, and the role of AR in the clinic is currently being evaluated.- In order to correctly interpret AR results, it is es- sential to know how certain anatomic structures in the nasal cavity are reflected on the AR area-distance curve, and thus be able to identify their locations on this curve. However, inconsisteticy in the literature has caused confusion. Different terms have been used to denote the same anatomic structute in the nose, and different names have been proposed for corre- sponding cross-sectional areas on AR curves.-^"* It should also be noted that AR actually tneasiires cross- sectional area as a function of distance (from the nos- tril into the nose) along an estimated acoustic axis that passes through the center of the curved nasal airway, as opposed to a straight litie parallel to the floor of the nose. ' "' -Thi s curved course of the na- sal cavity complicates the interpretation of AR data. From the Dcparlnienls of Otorhinoliirynuology {Cakmak. Taihan) and Radiolojiy (Coskun). Baskenl t.lnivcrsity Faculty of Medicine, and ihe Department of Physics iCankiirtaran. ^'olikl. Hiteettepc University Faculty of Enginecting. Ankara. Turkey. This work was partially supported by the BaskL'ni University Research huiid (proiect KA()4/(W). Correspondenfe: Ozcaii Cakmak, MD, Baskent Universilesi Hastancsi, Kulak Burun Bogaz Anabilim Dali, Baheelievler, 06490, Ankara. Tiiikev. 949 950 Cakmak et al. Acoustic Rhinometrx Fig 1. Three-dimensional image of luminai impression of cadaver nasal cavity reconstructed by computed to- mography. Dotted tine represents estimated acoustic axis, and raises questions about the validity of compari- sons between nasal cavity dimensions obtained by AR and those derived from cotnputed tomography (CT) or magtietic resonance imaging. Most published studies have not considered this curved shape of the nasal cavity and acoustic pathway, and this neglect could lead to misinterpretation of AR results.'''-'^ Moreover, recent experimental and theoretical stud- ies of pipe models simulating nasal passage anatomy bave detnonstrated that certain factors inherent to the physics and algorithms used in AR litnit the accuracy of this method, and lead to systematic measurement errors.''"-" Nevertheless, the results of these pipe model studies still need to be confirmed with AR mea- surements of more realistic nasal cavity models.-' Finally, the literature contains very little information about the accuracy and sensitivity of AR measure- ments at different locations within the nasal cav- ity.'-----^Thus. there is also a need to examine how changes in the dimensions of different parts of the nasal cavity influetice the accuracy of AR measure- ments. The aims of this study were to evaluate the accu- racy of AR tneasuretiients and to assess how well this tnethod detects obstructions of various sizes at specific sites in the nasal cavity. To carry out the in- vestigations, we used a cast model of an adult ca- daver nasal cavity. We measured the actual cross- sectional areas of the cast model using CT and then compared these with AR-derived areas. Then we placed small wax spheres of different diameters at specific locations within the cast model. These sites corresponded to the nasal valve, the head of the in- ferior turbinate. the head of the middle turbinate, the middle of the tniddle turbinate. the choana. and the nasopharynx. We reviewed the previously proposed definitions for these anatomic structures in the nose. and attetnpted to identify their locations on the AR area-distance curve. The acoustic properties of our cast model are not identical to those of a vital nasal Fig 2. Cast model of cadaver nasal cavity. Sites at which spherical wax inserts were placed arc shown: 1 nostril: 2 nasal valve: 3 head of inferior turbinate: 4 head of middle turbinate: 5 middle of middle lurbinate: 6 choana; 7 nasopharynx. Dotted line represents estimated acoustic axis, cavity, but investigation with this type of nasal pas- sage model can provide useful information about the value of AR in the clinical setting. ' "-' MATERIALS AND METHODS A cast tnodel of a human cadaver nasal cavity was tnade as follows. A luminai impression was prepared by injecting the right nasal passage of an adult ca- daver with silicotie (RTV-.'iO. Rhone-Poulenc. Saint Fons. France). The tnaterial was allowed to set and was then removed from the nose by dissection. This luminai impression (Fig I) was then used to cast a nasal cavity model (Fig 2). The walls of the cast na- sal passage model were prepared from plaster mate- rial. The posterior portion of the cast model passage- way beyond the choana was rasped to enlarge the contracted cadaver nasopharyngeal cavity to normal adult dimensions. To prevent acoustic leakage and random user-related errors, we tnolded the plaster material anterior to the cast model nostril to form a cylindrical guide, thus ensuring that the nosepiece of the acoustic rhinometer fit tightly to the model (Fig 2). Cakmak et al. Ac<>ti.';!ic Rhliumietrv 951 First., to evaluate the accuracy of AR measurements at specific locations in the nasal cavity (see details below), we initially compared CT-derived and AR- derived area-distance curves for the cast model with no insert in place. In addition to examining for dif- ferences between these curves, we looked for changes within each curve (ie, wbether the area measuretnents with either method distinguished the sites of interest in the study). The distance from the nostril (at 0.0 cm) to each of the designated sites inside the pas- sage model (Xo) was measured along the estimated acoustic axis (Fig 2). The distances recorded for the sites of tbe nasal valve, head of the inferior turbi- nate, head of the middle turbinate, middle of the mid- dle turbinate, choana, and nasopharynx were 2.0,2.8, 4.0. 5.8, 8.8, and 10.0 cm, respectively. These were all in excellent agreement with the corresponding dis- tances detemiined from CT of the luminal impres- sion. Second, to assess AR detection of simulated nasal disorders, we inserted wax spheres of various diam- eters at specific locations in the cast model. The 7 sites of sphere placement chosen were based on pre- vious definitions'-*"^ of the locations of important nasal cavity structures: the nostril and the 6 sites of interest inside the passage listed above. A set of 5 spherical inserts (diameters 0.3, 0.5.0.7,0.9. and 1.1 cm) was tested at each of these sites of interest in the tnodel. For each set of AR measurements, the inserts were placed in sequence (from smallest to largest) at each designated site. To assess whether AR was able to detect sitnulated nasal disorders at the 7 locations, we placed the 5 different inserts otie by one at each site and recorded the AR area-distance curve for each insert size (ie, a set of 5 AR area-distance curves per site). If there was a measurable difference within the set of areas recorded for any particular site, this was considered successful detection of the insert at that location. A ttansient-signal acoustic rhinometer (Ecco Vi- sion, Hood Instruments. Petnbroke. Massachusetts) was used to perform the acoustic measurements. The processed bandwidth for this rhinometer ranged from 100 Hz to 10 kHz, and a lO-kH/. low-pass filter was used to reduce the errors associated with cross modes in the actual nasal cavity. The same nosepiecc was used to obtain all measurements presented in this ar- ticle. All AR measurements were repeated at least 5 titnes to ensure that the results were reproducible. Data collected from the examinations were analyzed with Origin software (version 7.0, Microcal Software Itic. Northampton. Massachusetts). Actual cross-sectional areas for the first 8.8 cm of tbe cast model nasal passage (ie, from nostril to cho- ana) were determined from a CT scan ofthe luminal impression ofthe cadaver nasal passage. The CT ex- aminations were performed with a multislice scan- ner (Somatom Sensation 16. Siemens. Erlangen, Ger- many) with tube voltage of 120 kV and current of 240 mA. The window width was 4,000 Hounsfield units, and the window level was centeted at 600 Hounsfield units. Axial CT slices parallel to the long axis of the luminal impression of the cadaver nasal cavity were obtained with 0.75-mtn coilimation, 2- mm slice thickness, and 5-mm table feet, and these images were reconstructed with l-tnm intervals by means of a soft tissue algorithm. Frotn the recon- structed axial slices, a 3-dimensional (3-D) shaded surface display image ofthe luminal impression was obtained (Fig 1). As described in previous studies,' " ' - the concep- tualized acoustic axis for the AR determinations fol- lows an estimated line that passes through the center ofthe nasal passage, and AR-derived distances from the nostril to sites along this line would be the same irrespective of passageway shape. To determine tbe cross-sectional areas perpendicular to the estimated acoustic axis, we divided the acoustic pathway of the luminal impression of the cadaver nasal passage into 2 segments and drew each manually in a 3-D reconstructed image (Fig 1). The first segment was in the anterior nasal cavity and fortned a quarter-cir- cle; it extended from the center of the nostril open- ing and ended at the head of the inferior turbinate. The second segment ofthe acoustic axis was drawn as a straight line parallel to the long axis ofthe infe- rior turbinate: it extended from the end point of the first axis segtnent to the choana. The length of each segment of the acoustic axis was measured on CT, and 30 slices perpendicular to the acoustic axis were obtaitied for each segtnent (ie, 60 cross-sectional ar- eas recorded for the first 8.8 cm of the model nasal pas.sage). A plot ofthe slice area versus the distance along the estimated acoustic axis yielded the CT-de- rived area-distance curve. RESULTS Figure 3 shows a graphic comparison of the ac- tual cross-sectional areas of the cast model (deter- mined from CT ofthe luminal impression) and the corresponding AR-derived cross-sectional areas. The AR data were in good agreement with the CT data through the first 6.5 cm of the cast model passage. For the nasal valve (the narrowest part of the nasal passage), the AR and CT evaluations yielded altnost identical data for cross-sectional area (passage area: 1.08 cm-) and location relative to the nostril (2.0 cm). The results indicate that in cases in which the pas- sage area of the nasal valve is in the normal adult range. AR measurements ofthe anterior nasal cavity 952 Cakmak el a!. Aiou.stic Rhiniimefr < 2 CT Area oAR Arou 3 4 5 6 7 Distance (cm) 10 II 12 Fig 3. Comparison of eross-sectional areas of east nasal eavity model derived from aeoustie rhinometry (AR: open eireles) and aetual eross-sectional areas caleuiated from eoniputed tomography (CT) ol' luminal impression (seanning done perpendicular to aeoustie axis; solid circles). Numbers 1 to 6 on vctiical dotted lines represent actual sites of nostril, nasal valve, head of inferior turhinate. head of middle turbinate. middle of middle turhinate. and ehoana, respectively. are preci.se. In contrast, at distances farther than 7.0 cm inside the nostril, the AR-derived cross-sectional areas were overestimated as compared to those ob- tained from CT. The degree of this area overestima- tion iticreased with distance, and was extremely high (about 70%) at the location of the choana (8.8 cm). Careful inspection of Fig 3 reveals that the AR- derived area-distance curve was fairly smooth through the part of the nasal passage that includes the head ofthe inferior turbinate (site 3 in Fig 3), the head of the middle turbinate (site 4). and the middle of the middle turbinate (site 5). In other words. AR did not distinctly identify any of these structures. For the head ofthe inferior turbinate, the same held true on the CT-derived curve. At the location ofthe head of the middle turbinate, there was a small but measur- able dip in the CT curve, and a very slight decrease in the slope of the AR curve. At the location of the middle of the middle turbinate, slight decrea.ses in slope were noted on both curves. On both the CT and AR curves, the choana (site 6 in Fig 3) was re- flected as deep minima; however, as noted. AR over- estimated the cross-sectional area at the choana by about 70%. These findings suggest that even when the nasal valve passage area is in the normal adult range, AR only discretely identified the locations of the nasal valve and the choana. Figure 4 illustrates the set of AR-derived area-dis- tance curves that correspond to the cast model with an unobsttucted nostril and with spherical insetts of 4 different diameters (d) placed in the nostril. The AR-measured cross-sectional area at the site of the 4 5 6 7 Distance (cm) Fig 4. Aeoustie rhinometry area-distance curves for cast tnodel with no insert (ohslruction) and with in.serts of diameter d placed at entrance of nostril. Different sym- hols refer to data sets ohiained with inserts of different diameier. nostril decreased from 0.9 to 0.4 cm- as the diameter ofthe insert increased from 0.3 to 0.9 cm. These re- sults confinn that the first tninimum on the AR area- distance curve (site I in Fig 3) corresponds to the junction between the end of the nosepiece of the acoustic rhinotneter and the nostril. In the next sets of experiments, we examined the cast tnodel with spherical wax inserts of diatneter d placed at specific distances (Xo) from the nostril. As noted, this simulated a di.sorder at different sites with- in the nasal passage. Figure 5 shows sets of AR area- distance curves for the cast model with inserts lo- cated at Xo of 2,0 (nasal valve), 2.8 (head of inferior turbinate), 4.0 (head of tniddle turbinate). 5.8 (middle of middle turbinate). S,S (choana). and 10.0 cm (na- sopharynx). Each set contains 6 curves: one corre- sponding to no insert and one for each ofthe 5 insert sizes. One feature comtnon to all ofthe data sets pre- sented in Fig 5 is that regardless of insert location, the AR-measured cross-sectional areas anterior to the obstruction were similar and almost completely in- dependent of the size of the obstruction. The results suggest that in a cast model, regardless ofthe degree of obstruction, AR yields similar cross-sectional ar- eas from the nostril to approximately 1.0 cm before the obstruction. The data also show that beyond a large obstruction in the nasal passage, AR underesti- mates cross-sectional area. The degree of area under- estimation depends on both the diameter and the lo- cation ofthe insert. The same group of graphs (Fig 5) reveals that AR was more sensitive in detecting diffetent-sizcd spher- ical inserts placed at the nasal valve than in detect- ing inserts at tnore posterior sites. The AR area-dis- tance curve obtained with the 0.3 cm diameter insert r P 3 E < 2 Cakmak el ai Acoiislic Rhinometry 5 953 WJi houl iiisen o d = 0.3 cm -A- d - 0.5 cm zi d = 0-7 cm d- 0. 9 cm - o - d 1.1 cm 0 1 2 3 4 5 6 7 X Distance (cm) I (I 11 12 -1 0 I 2 3 4 5 () 7 Distance (cm) 10 I I 12 6 7 a 9 I d 11 12 4 - B 0 1 2 1 4 5 6 7 8 9 10 I I 12 0 1 2 3 4 5 6 7 8 9 1 0 Distance (cm) 12 Distance (cm) 4 S 6 Distance (cm) Fig 5. Acoustic rhinometry area-distance curves for cast model with no insert (obstruction) and with inserts of diameter d placed inside casi model at A) nasal valve. B) head of inlerior turbinate, C) head of middle turbinate. D) middle of middle lurbinate. E) ehoana. and F) nasopharynx. Different symbols refer lo daia seis ohiained wiih inserisof differeni diameier. Xo distance from nostril. placed at the nasal valve of the model was almost identical to that for the tnodel without an insert (Fig 5A). This is because the effective cross-sectional area of this particular insert was very small (0.07 cm-) and therefore did not significantly reduce pa.s.sage area at this location. However, when inserts of 0.5 cm diameter or larger were placed in the nasal valve, the AR-derived area of the nasal valve decreased sub- 954 Cakmak et al. Acoustic Rhinomelty ^ " 3 -Withoui insert -With insert (ll 0.7 tml a! (hi; nusal valve -Case I -Case II -ACase III 2 3 4 .S 6 7 S Distance (cm) 111 II 12 Fig 6. Acoustic rhinometry area-distance curves obtained for cast model with no insert, with inserl at nasal valve. and with combinations of 2 (case I and case II) and 3 (case III) simullaneous obstructions. Case I I insert placed at nasal valve and another at head of middle tur- binate; Case II I insert placed at nasal valve and an- other at choana: Case III inserts placed at nasal valve, head of middle turbinate. and choana, Dianielers of inserts placed at nasiil valve, head of middle turbinate, and eho- ana were 0.7, 0,9, and 0.9 eni, respectively. stantially. and the passage area values beyond the insert were consistently underestimated (Fig 5A). When inserts were placed in locations posterior to the nasal valve, the sensitivity of AR in detecting changes in passage area decreased. Whereas AR de- tected the 0.5 cm diameter insert at the head of the inferior turbinate, the smallest inserts that could be detected at the head of the middle turbinate. the mid- dle of the middle turbinate. and the choana were the 0,7 cm. 0.9 cm. and 0.9 cm sizes, respectively (Fig 5B-E). However, even when the largest insert (1.1 cm diameter) was placed in the nasopharynx, there was no appreciable change in cross-sectional area measured by AR (Fig 5F). In other words, it appears that a disorder in the nasal valve region is likely to be detected by AR and will have a major influence on the results of an AR examination. However, dis- orders beyond the nasal valve are not likely to be detected by AR. We also recorded AR measurements for the cast model with 2 or 3 inserts simultaneously placed at selected sites in the nasal pas.sage. In case I. an in- sert was placed at the nasal valve and another was placed at the head of the middle turbinate. In case 11. an insett was placed at the nasal valve and another was placed at the choana. In case III. inserts were placed at the nasal valve, the head of the middle tur- binate, and the choana. The diameters of the inserts placed at the nasal valve, head of the middle turbi- nate, and choana were 0.7 cm. 0.9 cm. and 0.9 cm. respectively. Figure 6 shows the AR area-distance curves for these 3 cases, for the cast model without an insert, and for the cast model with a 0.7 cm di- ameter insert placed at the nasal valve. In all 3 cases the insert (obstruction) at the nasal valve was suc- cessfully detected by AR. However, when there was aninsertat this site, the second insert (cases ! and II) or the second and third inserts (case III) at more pos- terior sites were not identifiable on the AR area-dis- tance curve. In summary, the findings from this part of the study indicate that when the nasal valve re- gion is significantly narrowed. AR will not detect disorders at sites beyond this region. DISCUSSION None of the research done to date has established how well AR-measured cross-sectional areas corre- late with actual areas in certain regions of the nasal cavity. Use of different terminology for a given ana- tomic structure in the nose causes confusion when one is locating its site on an AR area-distance curve. The rhinology literature has introduced various names for key anatomic sites in the nose. For example, the term "ostium intemum" has been proposed as a coun- terpart to "ostium externum" for denoting the nostril or naris. Previously, Huizing^ discussed the nasal no- menclature that should be abandoned and replaced by anatomically, linguistically, and surgically cor- rect terms. He suggested using the term "nasal valve area" for the narrowest region of the breathing path- way instead of "isthmus nasi" or "ostium internum." Kasperbauer and Kern^"^ considered the head of the inferior turbinate to be a component of the nasal valve area. Acoustic rhinometric examination of the ante- rior nasal cavity of normal human subjects has shown 2 notches (or dips) on the AR area-distance curve that indicate sites of very small cross-sectional area. Lenders and Pirsig"^ described the first such low point on the AR curve as the "l-notch" (I = isthmus) and noted that this corresponded to the functional isth- mus nasi (nasal valve). They identified the second low point as the "C-notch" (C = concha) and noted that this corresponded to the head of the inferior con- cha. Lenders and Pirsig found that in AR of control subjects, the I-notch consistently indicated the over- all smallest cross-sectional area. In contrast, they ob- served that in patients with turbinate hypertrophy (due to allergic or vasomotor rhinitis), the overall small- est cross-sectional area was the C-notch. In line with this observation, they referred to the 2-notch section of an AR curve in which the lowest notch corresponds to the isthmus nasi as a "climbing-W" and to the op- posite situation (lowest notch denoting the head of the inferior turbinate) as a "descending-W," The same authors rept)rted that for patients with turbinate hyper- trophy, the AR trace changes from a descending-W (characteristic of rhinitis and turbinate hypertrophy) Cakmak et al. Acoustic Rhinometry 955 before decongestion to a climbing-W (more charac- teristic of nortnal subjects) after decongestion. Ac- cording to Lenders and Pirsig, these 2 AR curves were identical at the isthmus nasi, reflecting the absence of nasal mucosa in this anatomic location. They noted that the 2 AR curves separated at a point correspond- ing to the anterior inferior turbinate because of the presence of congested nasal mucosa starting at this site. In AR of 21 patients with septal deviation, Grymer et al-* identified the narrowest part of the nose as the isthmus nasi and noted that this structure was located slightly more posteriorly than the anatotnic ostium internum. According to these authors, the isthmus nasi had the overall stnallest cross-sectional area be- fore decongestion and the ostium internum had the overall smalle.st cross-sectional area after deconges- tion. Inalaterstudy of healthy subjects with no gross nasal disorders, Grymer et al-^ noted that the lowest point on the AR curve (site of smallest cross-sectional area) was the head of the inferior turbinate before decongestion and that the lowest point shifted to the site reflecting the isthmus nasi after decongestion. Hatnilton et ai'' reported that the first low point (minitnum) on the AR curve always corresponded to the same distance from the start ofthe acoustic path- way and also noted that its location was not affected by acoustic leakage through the gap between the nosepiece and the nose. They attributed the first min- imum to the junction between the nosepiece and the nostril, as opposed to correlating it with nasal anat- omy alone. Tomkinson and Eccles'" also interpreted the first low point, or tninimum (MI), as the junction of the nosepiece with the nasal aperture, since they found that its location on the AR curve depended on nosepiece length. These authors concluded that the first minimum on an AR curve did not reflect an anatomic entity {and should be strictly interpreted as corresponding to the end of the nosepiece) and that the second tninitnum (M2) represented the nasal valve area. The same article noted that the inferior turbinate might contribute to the magnitude of the second minimum. The results from the present study of variations on a cast tnodel ofthe nasal cavity confirm the inter- pretations in 2 previous reports'^"*: the first minimum on the AR area-distance curve corresponds to the junction between the end of the nosepiece and the cast model nostril, and the second corresponds to the nasal valve. A similar interpretation may apply to the actual nasal cavity, although the acoustic prop- erties of the cast model are not identical to those of a vital nasal cavity, and the geometry ofthe actual nasal cavity is somewhat tnore complicated than the model we investigated. However, Hilberg et aP-^ argued that the complex geometry ofthe actual nasal cavity does not significantly affect AR measurements. In addition, our present study showed that anatom- ic structures posterior to the cast model nasal valve (ie, the head of the inferior turbinate, the head of the middle turbinate, the middle of the middle turbinate, and the nasopharynx) were not distinguishable on the AR curve. Possible explanations for this result tnay be the limited spatial resolution of AR and the fact that AR is not able to reflect sharp changes in cross-sectional area throughout the course ofthe nasal passage.-" Furthermore, previous model studies''^"'^-' demonstrated that the accuracy of AR measurements diminished at locations beyond a significant constric- tion at the nasal valve. These findings suggest that disorders that narrow the anterior nasal passage, such as septal deviations, polyps, tumors, webs, strictures, or the nasal valve of a pediatric patient, tnay signif- icantly affect the AR measurements when equipment intended for adults is used.'"^ '^-' Therefore, for pa- tients with such conditions, the value of AR for eval- uating the entire nasal cavity is limited. In a clinical study that involved magnetic reso- nance imaging, Corey et al^ described valleys (or dips) on the AR curve that represented reductions in cross-sectional area at specific distances from the in- terface, each corresponding to defined anatomic struc- tures in the nose. The authors suggested that the first, second, and third valleys (with respective cross-sec- tional areas CS A1, CSA2. and CS A3) on the AR curve represented the nasal valve, the anterior end of the inferior turbinate, and the anterior end ofthe middle turbinate. respectively. However, in that study, the magnetic resonance images were taken perpendicular to the floor ofthe nose. Later, Corey et al^*' compared AR with rigid endoscopy for assessing landmarks in the nasal cavity. In the examinations, they touched the tip ofthe endoscope to a landmark and then mea- sured the distance from the endoscope tip to the mark- ing. With this method, they found that CSA2 and CSA3 corresponded to the anterior portions of the inferior and middle turbinates. respectively, Corey et al-f" suggested that AR gives a good indication for cross-sectional areas CSA2 and CSA3, but does not clearly delineate the anatomic correlate of CSAI (the nasal valve). However, in the original study that de- scribed the AR technique, Hilberg et al' emphasized that the major probletn with comparing AR findings to those from imaging techniques is that it is difficult to obtain data exactly in the same plane. Later, using a plastic nose model produced by stereolithographic techniques from a 3-D tnagnetic resonance imaging scan, Djupesland and Rotnes" found good agreement between the nasal cavity volumes detertnined from 956 Cakmak et al. Acoustic Rhinometrv AR-derived dimensions and magnetic resonance im- aging when the magnetic resonance cross sections were obtained perpendicular to the presumed course ot the sound pathway. More recently, Cakmak et al'^ showed that when AR data for the nasal valve region are to be compared with calculations based on any imaging technique, the imaging cross sections must be taken perpendicular to the curved acoustic axis. They found a significant correlation between AR data and data from CT images obtained perpendicular to the curved acoustic pathway; however, there was no correlation between AR data and data from CT imag- ing done perpendicular to the nasal floor. Our present findings confirm the results of previous studies"' - that emphasize the importance of the curved acoustic axis: that is. distances on AR curves correspond ac- curately to distances within the nasal passage as mea- sured along the estimated acoustic pathway. Our re- sults also .show that it is not appropriate to make crit- ical statements about the validity of AR on the basis of CT or magnetic resonance imaging data from dif- ferent imaging axes. Previous studies not taking into account the curved shape of the nasal cavity could lead to misinterpretation of AR data. Various imaging methods have been used to test the accuracy of AR in clinical trials with healthy hu- man subjects. These have revealed significant corre- lations between the cross-sectional areas obtained by imaging techniques and the cross-sectional areas ob- tained by AR, with particularly high agreement in the anterior nasal cavity.''-'-''^-^-^ However, with the exception of studies by Terheyden et a!-^ and Cakmak et al,'^ in all previous investigations of living sub- jects the CT and magnetic resonance images were taken perpendicular to the floor of the nose.''-'^'^ Moreover, some investigations used the distances from the anterior nasal spine, whereas others used the tip of the nose as the reference point.^'-^''^ Clearly, it is difficult to make definitive .statements about the validity of AR on the basis of data trom different im- aging techniques, different imaging axes, and poten- tially different sites in the nasal passage due to differ- ent reference points. Similar to studies in which imaging methods have been used in healthy human subjects, model studies have shown that AR is valuable for measuring nasal valve passage area if this area is within the normal adult range.'''^' However, pipe model studies have shown that certain factors inherent to the physics and algorithms used in AR limit the accuracy of this meth- od and lead to systematic measurement errors.'*'"-" These studies suggest that the accuracy of AR mea- surements diminished at locations beyond a signifi- cant constriction at the nasal valve, and also at regions posterior to a paranasal sinus ostium, depending on the ostium size and/or the sinus volume. When the passage area of the nasal valve was small. AR-derived cross-sectional areas beyond the constriction were consistently underestimated and the corresponding area-distance curves showed pronounced oscillations. Previous model studies also demonstrated that para- nasal sinuses led to area overestimation and oscilla- tion of the AR curve posterior to the sinus ostium when the ostium was relatively large. 11 i'^-1-7-29 ^j-gg underestimation or overestimation. as well as oscilla- tions of the AR curve (the physical reasons for which have been discussed'*^-'), may easily lead to misin- terpretation of a patient's nasal anatomy or condition. To avoid such misinterpretations, AR should be per- formed in combination with other methods such as anterior rhinoscopy and endoscopy. Acoustic rhinometry has been widely used in clin- ical trials, but very little is known about how changes in the anatomy of the nasal cavity affect the accuracy of AR measurements. Several authors have investi- gated the sensitivity of AR in realistic nose models and in the living human nasal cavity by placing inserts at various sites in the nasal passage.'-^ Hilberg et al' placed 0.3 cm spheres at different locations in a cast model and found that AR was able to positively identify the presence or absence of these objects. Sim- ilarly, Lenders et al--' in.serted small pieces of wax (volumes, O.I to 0.6 cm-^) at different locations in cast models. They found that a wax piece 0.3 cm-^ in volume placed in the middle meatus was detected by AR, but observed no changes in the AR curve when the same insert was placed in the posterior nasal cavity. Fisher et al-- placed 0.3, 0.3, and 0.7 cm di- ameter spheres into either the middle meatus or the nasal valve of living subjects to assess how well AR would detect these objects. The smallest spheres (0.3 cm diameter) were detected in only a minority of case.s. those 0.5 cm in diameter were detected in most cases, and those 0.7 cm in diameter were identified in the large majority of cases. Although detection rates were similar for both locations, the authors observed greater changes in area and volume for the 0.3 and 0.3 cm spheres placed in the middle meatus than for tho.se placed in the nasal valve.^^ However, in the present study we observed the opposite: AR was more sensitive in detecting different-sized spherical inserts in the nasal valve than in detecting them at all loca- tions posterior to the nasal valve. CONCLUSIONS The results of the present study show that when the passage area of the nasal valve is within the nor- mal adult range, AR measures cross-sectional areas in the anterior nasal cavity with high precision, where- as cross-sectional areas at posterior locations are Cakmak et ai. Acoustic Rhinometrv 957 overestimated. The first minimum on the AR area- distance curve represents the junction between the end ofthe nosepiece and the nostril, and the second one corresponds to the nasal valve. Acoustic rhinom- etry accurately measures both the passage area and the location of the nasal valve. The nasal valve and choana are identified by pronounced dips on the AR curve, whereas the head ofthe inferior turbinate, the head ofthe middle turbinate. the middle ofthe tniddle turbinate, and the tiasopharynx are not distinguish- able on the curve. The reasons for this lack are the limited spatial resolution of AR and the inability of AR to reproduce sharp changes in cross-sectional area throughout the course ofthe nasal passage. The results also .show that AR is sensitive in detecting changes in passage area at the nasal valve, but that its sensitivity is much lower at posterior sites. When the nasal valve region is significantly narrowed, AR does not detect obstructions at sites beyond this re- gion. 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