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Aimah of Oliihgy. Rhiniil«gy & 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
—o—AR 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
-A—Case 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.
Acknowledgments; We thank Dr Ulkeiii Cilasun and Dr Aktaii Cclik from Baskenl University Faculty of Dentistry for Lhcir help in
preparing the cast model used in the sludy.
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