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Characterization of nasal irrigation flow from a squeeze bottle using

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 ORIGINAL ARTICLE
Characterization of nasal irrigation flow from a squeeze bole using
computational fluid dynamics
Kiao Inthavong, PhD1 , Yidan Shang, PhD1 , Eugene Wong, MMed, MS2 and Narinder Singh, MS, FRACS2
Background: Nasal saline irrigation has become standard
of care in various sinonasal conditions, including allergic
and nonallergic rhinitis, chronic rhinosinusitis, and in the
postoperative patient. Evidence regarding the mechanisms
and dynamics of liquid flow through the sinonasal cav-
ity remains limited due to inadequate experimental mod-
els (cadaveric, 3-dimensional [3D] printed, imaging of la-
beled dyes and radioisotopes). We aimed to develop a
computational fluid dynamics (CFD) model of nasal irriga-
tion to demonstrate sinonasal surface coverage, residence
times across the mucosal surfaces, and shearing force of
irrigation.
Methods: A nasal cavity geometry derived from high-
resolution paranasal sinus computed tomography (CT)
scans of a healthy, unoperated, 25-year-old patient was cre-
ated. CFD analysis was performed to assess the distribu-
tion of nasal irrigation from a tapered nozzle bole at a for-
ward head-tilt position of 45 degrees with a 2-second burst
at 35 mL/second.
Results: The model demonstrates nasal irrigation from ip-
silateral to contralateral with precise measures of velocity,
pressure, wall shear stress, and mapping of surface cover-
1 Schoolof Engineering, Royal Melbourne Institute of Technology
(RMIT) University, Melbourne, VIC, Australia; 2 Department of
Otolaryngology, Head and Neck Surgery, Westmead Hospital, Sydney,
NSW, Australia
Correspondence to: Eugene Wong, MMed, MS, Department of
Otolaryngology, Westmead Hospital, Corner Hawkesbury and Mons Road,
Westmead NSW 2145, Australia; e-mail: eugene.hl.wong@gmail.com
Additional supporting information may be found online in the Supporting
Information section at the end of the article.
Funding sources for the study: Garnett-Passe and Rodney Williams
Memorial Foundation Conjoint Grant 2019 (to K.I. and N.S.); Australian
Research Council (Project ID: DP160101953).
Potential conflict of interest: K.I. is a consultant for ENT Technologies and
has received a research grant for part of this current work.
Received: 9 August 2019; Revised: 12 September 2019; Accepted:
16 October 2019
DOI: 10.1002/alr.22476
View this article online at wileyonlinelibrary.com.
age and residence times at specific locations and times. The
nasal cavity experiences almost complete coverage of irri-
gation, while overflow from the nasal cavity facilitates mod-
erate coverage of the ipsilateral maxillary (40%) and an-
terior ethmoid sinuses (30%). Negligible coverage of the
sphenoid and frontal sinuses was noted.
Conclusion: Detailed physical mechanisms of liquid irriga-
tion injected from a commonly used squeeze bole were
shown. Ipsilateral maxillary and ethmoid sinus penetration
are primarily due to overflow rather than direct jet entry,
confirming the recommendation of larger volumes of irri-
gation to “flood” the sinus ostia. 
C 2019 ARS-AAOA, LLC.
Key Words:
nasal airflow dynamics; computational fluid dynamics; com-
puter modeling of airflow; irrigations; CFD
How to Cite this Article:
Inthavong K, Shang Y, Wong E, Singh N. Characteriza-
tion of nasal irrigation flow from a squeeze bole using
computational fluid dynamics. Int Forum Allergy Rhinol.
2019;00:1-12.
S aline irrigation has been recommended in interna-
tional consensus statements for the treatment of vari-
ous sinonasal conditions, including allergic and nonallergic
rhinitis,1 acute and chronic rhinosinusitis (CRS),2, 3 and for
patients undergoing sinonasal surgery, both in the early and
long-term postoperative period.2 It has also been demon-
strated to be beneficial in lavaging the mucosal surface of
inflammatory products and hypersecretory mucin, as well
as delivering topical medications to diseased mucosal tissue.
Although the benefits of nasal irrigation are well
established,4, 5 the mechanisms and dynamics of liquid flow
through the sinonasal cavity remain poorly understood.
In particular, detailed information regarding liquid veloc-
ity, pressure, and volume at various locations and at dif-
ferent time points in the irrigation process is critical to
understanding current mechanisms and developing im-
proved techniques.6
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 1
Inthavong et al.

The creation of accurate models of irrigation flow, with
measurable results, permits the testing of various parame-
ters, including patient factors (head position, squeeze pres-
sure), anatomical factors (presence of septal deviation,
turbinate hypertrophy), surgical factors (extent of sinus
surgery), and device factors (squeeze bottle vs gravity-feed,
nozzle size, angle, position).
Existing experimental evidence has been largely derived
from cadaveric7 or 3-dimensional (3D) printed models, as-
sessed with nasendoscopes.8, 9 Such models are limited by
their capacity to only examine individual sinuses, the re-
liance on subjective human interpretation without precise,
quantifiable data, and the inability of cadaver specimens
to accurately reflect the physiological conditions of the live
patient.9–11
Other attempted models have used contrast-enhancing
dyes or radioisotopes followed by computed tomography
(CT) or scintigraphic imaging, respectively. Such models
have demonstrated data on sinus distribution of liquids
but are only able to assess residual volumes and are unable
to provide real-time information on the how the irrigation
flow interacts with sinonasal anatomy during the irrigation
process.12
To date, limited evidence from such models has shown
that patient head position,7, 13 the extent of surgical ac-
cess, and the type of nasal irrigation device14, 15 have been
demonstrated to affect irrigation penetration, distribution,
and force within various paranasal sinuses. As a result,
the use of nasal irrigation with a squeeze bottle was rec-
ommended in international consensus statements for the
treatment of CRS.16 Cadaveric studies have demonstrated
that only around 2.5% of irrigation fluid is retained in the
nasal cavity or paranasal sinuses, with the highest residual
volume in post–endoscopic sinus surgery (ESS) patients fol-
lowed by non-operated controls and patients with CRS.17
Computational fluid dynamics (CFD) represents a novel,
validated method of modeling air and fluid flows through
the sinonasal tract that is highly accurate, quantifiable, re-
producible, and allows multiple permutations to be rapidly
assessed to determine the ideal combination of parameters.
Despite this, only a few CFD studies of nasal irrigation
have been performed. These include Zhao et al.18 and Craig
et al.,19, 20 who explored squeeze-bottle nasal irrigation and
found the nose-to-ceiling head position was superior to the
nose-to-floor position for irrigation to the sphenoid sinuses;
and Salati,21 who investigated gravity-fed nasal irrigation
(using neti pots) and found that maximum saline distribu-
tion in the nasal cavity was observed in the Mygind head
position.
This study aimed to characterize nasal irrigation by iden-
tifying the critical fluid dynamics mechanisms that dom-
inate the jet stream flowing through a human sinonasal
cavity. It is expected that these key flow behaviors would
persist despite different patients and different parameters.
New, and highly quantitative analysis techniques were de-
veloped for determining sinonasal surface coverage of nasal
irrigation, residence times across the mucosal surfaces, and
shearing force of irrigation. It is expected that the visual
results and quantitative analysis could lead to potential de-
vice modifications to improve both topicalization of medi-
cations and irrigation force for lavage.
Materials and methods
Nasal cavity model
A realistic nasal cavity geometry was reconstructed from
a high-resolution CT scan of a healthy 25-year-old, Asian
female (161 cm height, 53 kg mass, without nasal sep-
tum deviation, turbinate hypertrophy, or sinusitis) at rest-
ing conditions. The CT data was acquired using a (Siemens
Healthineers, Erlangen, Germany) Dual Source CT scanner
with image parameters of 0.39 × 0.39 mm pixel size, 512 ×
512 pixels image dimensions, and 0.5 mm slice thickness.
The nasal cavity and the entire paranasal sinuses includ-
ing the maxillary, ethmoid, frontal, and sphenoid sinuses
were extracted using 3D-Slicer’s segmentation tool by a
computer engineer in conjunction with an ear, nose, and
throat (ENT) surgeon. The geometry of the face was re-
tained, and a hemisphere with a diameter of 200 mm was
attached in front of the face. The soft palate was artifi-
cially “closed” in the computational model by creating a
boundary wall surface. The sinonasal cavity model under-
went mesh independence and mesh quality tests reported in
Zhang et al.22 The final model contained 1.1 million poly-
hexcore cells (equivalent to 4.6 million tetrahedral cells)
with 5 prism layers (first layer height of 0.07 mm, and to-
tal height of prism layer of 0.64 mm) using ANSYS-Fluent
v19.2 meshing. The surrounding hemisphere was set as a
pressure-outlet condition (Fig. 1A), and the entire domain
was initially set as air with zero velocity. The liquid jet was
introduced as a mass flow inlet at the squeeze-bottle nozzle
which had a 5-mm diameter. All other surfaces were set
to a wall boundary condition. Figure 1B shows the nasal
geometry with a squeeze bottle (featuring a tapered noz-
zle) inserted into the left nostril until the nozzle occluded
the nostril opening. The nozzle insertion distance (from the
nozzle tip to the nostril) was 10 mm.
Jet flow stream (volume of fluid modeling)
In general, the practical consensus on administration tech-
nique is a 45-degree forward head tilt, although there is no
evidence-based recommendation for this approach. Salati21
evaluated 4 different head positions for a gravity-fed neti
pot nasal irrigation. These were supine (lying with head
back), 90 degrees (tilting the head sideways at 90 degrees),
head back (head oriented 45 degrees upward from the
ground), and head forward (head inclined downward at
45 degrees to the ground).19 Instructions that accompany
the Flo R
sinus rinse bottle (ENT Technologies, Hawthorn
East, VIC, Australia) suggest the head be angled forward
at 45 degrees (head over sink). In our model, a head tilt
position of 45 degrees forward was used, with the nozzle
jet aligned vertically.

2 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
 CFD of nasal irrigation

A Computational domain B Nasal cavity from left chamber C Coronal slice at x3

35

30
flow rate (mL/sec)

25

20

15

10

0
0.0 0.5
5 1.0 1.5 2.0 2
2.5 3.0
cs)
time (sec
o
D Head tilt of 45 to the horizontal E Jet flow rate profile used as a first case

FIGURE 1. (A) The complete computational domain labeled by the boundary conditions. (B) Lateral view (left chamber side) of the nasal cavity with irrigation
bottle inserted into the left chamber. The paranasal sinuses are colored as: yellow (maxillary sinus), blue (sphenoid sinus), red (ethmoid sinuses), and green
(frontal sinuses). (C) Coronal slice at x3 showing the left chamber only, depicting the poly-hexcore internal computational mesh. (D) Forward head tilt showing
a 45-degree angle and the direction of the liquid jet (denoted by dashed blue arrow), which is vertically aligned, and (E) the jet profile set to a quasi-constant
flow without the effects of ramping up/down durations. Please refer to supplementary video animation demonstrating the nasal irrigation setup.

The nozzle jet diameter was 5 mm based on a commer-
cially available nasal irrigation bottle (FloR
; ENT Tech-
nologies). The liquid jet was introduced into the airway
from zero to a flow rate of 35 mL/second (approximately
1.79 m/second) held for 2 seconds. This gave a total vol-
ume of 70 mL based on preliminary testing of short physical
squeezes of the current 200-mL Flo R
bottle, where less than
one-half the volume was ejected/used. The squeeze dura-
tion represented a rapid squeeze with the hand. The initial
ramp-up and ramp-down times were both set at 0.01 sec-
onds, selected to preclude ramp periods as a physical test
variable. Future experiments will include sinusoidal ramp
profiles of longer duration, which are more likely to accu-
rately reflect physical conditions.
Computational model setup
The Eulerian volume of fluid model was used to track the
interface between the liquid jet and the air described by
the mass, and momentum conservation equations. The im-
plicit body force option was applied to consider the partial
equilibrium of the pressure gradient and the body forces.
The Green-Gauss node-based method was used to calcu-
late gradients at cell centers from face gradients and the
PRESTO! scheme was used for pressure interpolation. The
Second Order scheme was used for discretization of the
momentum and turbulence equations. A second-order im-
plicit scheme was used for the temporal discretization of
the transient term. A variable time step (t), based on a
fixed Courant number of 1, was used.

International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 3
Inthavong et al.

A front (antero-posterior) view

B lateral view of left chamber with 45-deg forward head tilt

FIGURE 2. Jet flow entering the nasal cavity during the early stages of irrigation between t = 0 seconds and t = 0.10 seconds.

Results
A video of key moments of the irrigation simulation can be
found online (Supporting Video 1).
Early stages of nasal irrigation
(t = 0 to t = 0.1 seconds)
The jet flow entering the nasal cavity in the early stages is
shown in Figure 2, with front (anteroposterior) and lateral
views. The images are shown with transparent nasal walls,
and the liquid (water) is colored in blue. The jet immediately
impacts onto the nearby lateral vestibule wall and the nasal
septum (t = 0.012 seconds, t = 0.024 seconds) and quickly
fills the anterior nasal cavity. Due to the head tilt, the initial
jet flow also enters the anterior ethmoid sinus.
Nasal irrigation (t = 0.50 to t = 2.50 seconds)
After the initial jet injection, the left main nasal passage be-
tween the septum wall and turbinates is now covered by the
liquid (Fig. 3). The nasopharynx is partially covered by the
liquid, as the liquid turns and moves into the contralateral
right nasal cavity, under the influence of gravity. The front
view and right chamber views (Fig 3B, C) show the liquid
moving along the floor of the right nasal cavity and exiting
the right nostril after t = 0.5 seconds without ever reaching

4 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019

FIGURE 3. Liquid flow through the nasal cavity at t = 0.50, 1.50, and 2.50 seconds from (A) the left chamber view, (B) front view, and (C) right chamber view.
Please refer to supplementary video animation demonstrating the nasal irrigation modelling.
the right frontal, ethmoid, or sphenoid sinuses. Flow enter-
ing the right maxillary sinus was caused by liquid overflow-
ing from the main passage. At the end of the nasal irrigation
squeeze (t = 2.0 seconds), the injection momentum ceases,
and the liquid decelerates to a rest state and remains in the
nasal cavity as a pool under the influence of gravity.
Water volume fraction and velocity magnitude
contours on coronal slices
Instantaneous contours of water volume fraction (liquid/air
mixture) and velocity are shown in Figure 4, which shows
(in more precise detail) the left main nasal passage filling,
leading to liquid flowing into the maxillary and ethmoid
sinuses. Slice “x4” at the nasopharynx shows the liquid
CFD of nasal irrigation
sloshing as it impinges on the posterior nasopharynx wall.
The liquid returns through the right nasal cavity, where
much of the liquid momentum has dissipated, and remains
along the floor. At the end of the simulation at t = 3.0
seconds, there is still a significant amount of fluid remain-
ing in the left cavity, including the anterior ethmoid and
maxillary sinuses. The velocity contours show regions of
high motion, which would correlate to higher wall shear
stress (WSS). While the left nasal cavity fills with the liq-
uid in its inferior half, the velocity (which represents the
jet flow direction) is primarily in the superior half, sug-
gesting the jet impinges on the superior walls, and set-
tles to the inferior half, filling up the region. In the right
chamber, both velocity and water volume fraction contours
coincide.
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 5
Inthavong et al.

Instantaneous water volume fraction contours

Instantaneous velocity contours

FIGURE 4. Coronal slices taken at locations x1, x2, x3, x4 (depicted in Fig. 1) showing the water volume fraction at (A) t = 1.0 second, (B) t = 2.0 seconds,
and (C) t = 3.0 seconds, and velocity magnitude contours at (D) t = 1.0 second, (E) t = 2.0 seconds, and (F) t = 3.0 seconds. *The maximum velocity magnitude
was 2.9 m/second but the contour legend was capped at 1 m/second to provide clearer visualization.

6 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
 CFD of nasal irrigation

FIGURE 5. Transverse (axial) slices at y1, y2, y3, y4 (depicted in Fig. 1) showing the water volume fraction at (A) t = 1.0 seconds, (B) t = 2.0 seconds, (C) t =
3.0 seconds, and velocity magnitude contours at (E) t = 1.0 second, (F) t = 2.0 seconds, and (G) t = 3.0 seconds. *The maximum velocity magnitude was 2.9
m/second but the contour legend was capped at 1 m/second to provide clearer visualization.

International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 7
Inthavong et al.
Water volume fraction and velocity magnitude
contours on transverse slices
Instantaneous contours of water volume fraction and veloc-
ity are shown in Figure 5, where slices y1 to y4 are in the
superior-inferior direction of the transverse (axial) slices.
The images show the influence of the 45-degree forward
head tilt where the liquid overfill that enters the sinus fills
up the anterior regions of the sinuses (y1, y3, and y4 in
Fig 5A, back), and nasopharynx, whereas there are voids
in their respective posterior regions. Surface coverage in the
right nasal cavity is higher at the lateral nasal wall and less
on the nasal septum. At the end of the simulation, the left
nasal cavity contains residual liquid that is prevented from
exiting by the occluded left nostril (from the nozzle device),
while in the right cavity the liquid continues to exit the right
nostril by gravity. The velocity magnitude contours show
the high jet flow velocities in the superior slices of the left
cavity (slice y2), while the right cavity has higher velocities
in the inferior slice (slice y4).
Mapping the water coverage on nasal surfaces
The 3D nasal cavity walls were projected as 2-dimensional
(2D) unwrapped surfaces (using the technique developed
in earlier work23 ) shown in Figure 6A. The nasal cavity
was separated into a single continuous surface, whereas
the sinuses were separated into individual regions. The wa-
ter volume fraction on each surface was recorded during
the simulation, which showed rapid coverage (eg, t = 0.1
seconds) across the left septum, turbinate, and left ethmoid
walls. At t = 0.3 seconds the left main nasal passage is
primarily covered, and the overflow into the left maxillary
sinus is shown to occur in the anterior region. The na-
sopharynx showed very low coverage, while the soft palate,
which closed the nasal airway, is covered entirely at t = 2.0
seconds. The results at t = 0.5 seconds to t = 3.0 seconds
confirm the spread of liquid travelling along the floor of the
right nasal cavity and inferior turbinate.
Only a small portion of flow enters the sinuses of the right
nasal cavity: the anterior surfaces of the right maxillary
sinus.
Water surface coverage profiles
The water surface coverage for each region as a percent-
age of the region’s total surface area is plotted in Figure 7.
In the left nasal cavity, the main nasal passage walls were
nearly completely covered (>80%, with the left vestibule
= 100%), whereas the ethmoid (40% coverage) and max-
illary sinuses (30%) received the most coverage out of the
sinuses. Negligible amounts (<1%) reached the sphenoid
and frontal sinuses. In the right nasal cavity, the surface
coverage began at approximately t = 0.4 seconds with rel-
atively constant values between t = 0.5 seconds and t =
2.0 seconds. The highest coverage was found in the right
vestibule (up to 100%) due to the liquid exiting the nostril.
Less than 10% surface coverage was found for the right
sinus walls.
8 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
WSS profiles
The averaged surface WSS distribution for each region is
plotted in Figure 8. High WSSs were found at the vestibule
(left and right approximately 5 Pa) and left middle turbinate
(5.5 Pa). The relatively constant region between t = 0.5 sec-
onds and t = 2.0 seconds coincided with the water surface
coverage as well as the jet flow stream profile (Fig. 1D).
The left nasal cavity exhibited consistently higher WSS to
that of the right nasal cavity. Negligible WSS was found in
the sinuses of both cavities (<1.5 Pa).
Discussion
Evaluating the performance of nasal irrigation is challeng-
ing because of the rapid process of dealing with multiphase
mixing of a liquid and air. The computational modeling
provided highly detailed results which revealed the physical
behavior of nasal irrigation that underlies its performance
to distribute to the correct regions. The significant differ-
ence in densities of the 2 phases (liquid and gas/air) involved
means that the liquid phase’s momentum will dominate the
gas (air) phase and that extrapolation of the current results
and behavior to different scenarios (eg, squeezing force,
larger liquid volumes, head angles) can be made with con-
fidence by keeping this notion in mind.
An initial jet of 5 mm was used, and in practice, this
will nearly always lead to impingement on the surrounding
vestibular walls and nasal valve, due to the jet diameter size
relative to the nasal geometry. A thinner jet could lead to di-
rect entry through the nasal valve without initial vestibular
wall impingement. This, however, increases the variability
in patient use/administration because it is significantly in-
fluenced by insertion location and orientation. A thinner
jet also needs to increase its velocity to achieve the same
mass flow rate for a larger diameter jet, leading to sharper
impingement on the vestibular wall. A larger jet diame-
ter can reduce patient variability, improve jet dispersion,
and increase the liquid overfilling the anterior region more
rapidly.
The orientation of the nozzle also influences the initial jet
flow impingement, particularly for the ethmoid sinuses. As
the liquid begins to fill the anterior nasal cavity, the jet ori-
entation influence diminishes. Despite the favorable orien-
tation toward the frontal sinuses, no liquid penetrated this
region, a finding found in previous cadaveric models,14, 24
likely due to the restriction from the narrow and convoluted
frontal recess pathway.
The results show that liquid entry into the maxillary si-
nus relies on overflow from the nasal cavity because it is
positioned almost perpendicularly to the flow. This sup-
ports the results of Grobler et al.,25 who found that the
size of the ostium opening influenced sinus entry. Further-
more, entry into the sphenoid sinuses was not shown in this
study, but based on the principle of mass conservation, a
more considerable amount of liquid with sufficiently high
momentum can overcome the gravitational force and losses
 CFD of nasal irrigation

A Surface unwrapping of nasal cavity and paranasal sinuses

B t = 0.1sec C t = 0.3sec D t = 0.5sec

E t = 1.0sec F t = 2.0sec G t = 3.0sec

FIGURE 6. Nasal cavity surfaces were (A) unwrapped and the instantaneous surface coverage of the water volume fraction is shown at time (B) t = 0.1 seconds,
(C) t = 0.3 seconds, (D) t = 0.5 seconds, (E) t = 1.0 second, (F) t = 2.0 seconds, and (G) t = 3.0 seconds. Please refer to supplementary video demonstrating
full surface coverage mapping animation.

International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 9
Inthavong et al.
A Left main nasal passage walls
C Right main nasal passage walls
FIGURE 7. Water surface coverage as a percentage of the surface area of each region.
into the right nasal cavity, through the choanae. This con-
firms the results from Govindaraju et al.,9 who showed
that irrigation with volumes of 150 and 200 mL led to
better sinus penetration than 100 mL for postoperative
patients irrespective of head position. Craig et al.19 used
CFD to demonstrate that sphenoid sinus penetration is best
achieved through the nose-to-ceiling irrigation position.
In the right nasal chamber, more liquid passed along
the floor and the lateral walls of the nasal cavity. This
is attributed to the centrifugal force produced as the liq-
uid swirls around the posterior nasopharynx performing
a U-turn. This also enhanced entry of fluid into the right
maxillary sinus. The velocity and WSSs were lower than
in the left chamber. This suggests the nasal chamber con-
taining the squeeze bottle experienced the greatest liquid
surface coverage and highest WSS. Furthermore, head tilt
10 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019
B Left paranasal sinus walls
D Right paranasal sinus walls
toward the nasal chamber contralateral to the bottle may
be ineffectual for achieving high WSS but would increase
liquid volume flow.
The results of this study developed quantitative measures
for evaluating nasal irrigation and provided insight into the
mechanisms underlying the physical behavior of the liquid
jet. These included: (1) liquid momentum force competing
against a gravitational force, which relates to head tilt and
its influence; and (2) liquid overflow from the main nasal
passage into the sinuses, which relates to ostia size. As an
example, the 45-degree head tilt orientation was aimed at
improving sphenoid sinus penetration, but despite this, the
ethmoid sinuses experienced 40% surface coverage, while
less than 1% surface coverage was found in the sphenoid
sinuses, suggesting that the liquid volume being injected is
a more sensitive parameter than head tilt orientation.9

A Left main nasal passage walls
C Right main nasal passage walls
FIGURE 8. Average WSS on surfaces of specific regions. WSS = wall shear stress.
This study expands on the CFD literature with several
technological innovations. Visualization of the 3D nasal
cavity is exceptionally challenging due to its highly curved
and overlapping surfaces, and even when a computational
3D software is used to rotate the model to obtain the desired
view, not all surfaces can be viewed adequately. This study
presented the 3D model including all paranasal sinuses into
a 2D representation, a technique that has yet to be used to
incorporate the paranasal sinuses.
A second challenge is quantifying the effectiveness of the
nasal irrigation. We developed a new quantitative analysis
technique for determining sinonasal surface coverage
of nasal irrigation, residence times across the mucosal
surfaces, and shearing force of irrigation. Although it is
CFD of nasal irrigation
B Left paranasal sinus walls
D Right paranasal sinuses walls
expected that the surface coverage method could be
adopted by future computational studies of nasal irriga-
tion, it can be adopted by endoscopic video recordings of
nasal irrigation, where each video frame is image-processed
to pick up the surface coverage over time to obtain similar
plots to Figure 7.
Summary
The physical mechanism of irrigation of a liquid formula-
tion injected into the nasal cavity via a squeeze bottle was
shown. The fluid dynamics governing the liquid jet flow as
it passed through the nasal cavity was described. The key
features found were as follows:
International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019 11
Inthavong et al.

r impingement on the nasal vestibule walls, before filling
the vestibule;
r the jet flow momentum (a combination of velocity and
liquid mass/volume) must overcome gravitational forces
to reach the nasopharynx;
r flow into the ethmoid and maxillary sinuses was more
likely than the frontal and sphenoid because the liquid
jet can fill the adjacent spaces more readily; and
r flow into the sinuses was produced from liquid overflow-
ing from the main nasal passage, rather than direct jet
entry.
To enhance overall jet dispersion, the results suggest that
a larger jet diameter will reduce initial narrow vestibular
wall impingement and enhance the liquid jet dispersion over
a larger area. This leads to a larger liquid volume that
will enhance the liquid overflow into the sinuses while also
overcoming gravitational forces.
It is expected that a larger cohort of computational mod-
els may be undertaken using the existing evaluation method
to investigate the influences of head tilt, liquid volume,
intensity, and duration of flow. Future studies may also
provide insight and characterize the flow of nasal irriga-
tions in order to develop new ideas on device design and
delivery to achieve greater paranasal sinus coverage.
Conclusion
Detailed physical mechanisms of liquid irrigation injected
from a commonly used squeeze bottle were shown. Ipsilat-
eral maxillary and ethmoid sinus penetration are primarily
due to overflow rather than direct jet entry, confirming the
recommendation of larger volumes of irrigation to “flood”
the sinus ostia.
Acknowledgments
We gratefully acknowledge the financial support provided
by Garnett Passe and Rodney Williams Memorial Foun-
dation Conjoint Grant 2019 (Inthavong-Singh) and Aus-
tralian Research Council (Project ID: DP160101953).

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12 International Forum of Allergy & Rhinology, Vol. 00, No. 0, xxxx 2019

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