Rhino-CFD! CFD-Analysis of Unclear Nasal Breathing Problems! Dr. med. T. Hildebrandt! Dr.-Ing. Leonid Goubergrits! M.Sc. Jan Osman!!!!!!!!

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1 Rhino-CFD Dr. med. Thomas Hildebrandt Dr.-Ing. Leonid Goubergrits M.Sc. Jan Osman CFD-Analysis of Unclear Nasal Breathing Problems of Corresponding author: Dr. med. T. Hildebrandt Hardturmstrasse 133, CH-8005 Zurich, Switzerland Tel Fax

2 Case History: The patient underwent nasal surgery in June 2013 because of a significant septal deviation. A conventional septoplasty combined with quite radical resection of the inferior turbinates was performed. Immediately after surgery or removal of the septal splinting, the patient started to complain about an unpleasant or impaired nasal breathing which was especially distressing during the night and apparently caused a sleeping disorder. This seemed to be suspicious for an Empty Nose Syndrome. The patient had consultations at several ENT-specialists. One of them was Dr. in Germany. Among other diagnostic measures, in terms of an ENS, he carried out a cotton wool test which was negative. Therefore, he advised against an operation aiming to narrow the nasal cavity through augmentation. In spite of using various methods of treating the symptoms for some months, there was no relief of the discomforting situation of the nasal breathing. Mr. contacted our research group, initiated through internet research, requesting a CFD-analysis of his nasal airstream. On 2014 he came to Zurich for a physical examination and further diagnostic. Findings: The rhinoscopy and nasal endoscopy showed a remaining high septal deviation towards the right side and almost completely resected inferior turbinates. There was no atrophy of the membranes. In contrast, they even appeared thickened and livid. Furthermore, no crusting or pathological secretion was found which may have been the result of the intensive rinsing and moistening of the nasal cavity by the patient. The rhinomanometry revealed a significant obstruction of the right nasal cavity that might be due to the remaining septal deviation. The CAT-scan showed all sinuses well-ventilated pre- and postoperatively.

3 Computational Fluid Dynamics: We carried out the following steps. Technical details can be provided, if needed, by the authors. - The 3D geometry of the nasal cavities was reconstructed from the DICOM-data set acquired by a CAT-scan pre- and about one month post-operatively. - Generation of an unstructured grid. - The definition of the boundary conditions. - Simulation of a steady inspiratory nasal airstream according to quiet nasal breathing. Results: We compared the pre- and post-operative flow field with a reference one of a healthy subject which is, in our opinion, sufficiently representative of a normal flow field, not least because it is in accordance with investigations of healthy subjects in literature. After surgery, the patient s flow field changed tremendously and shows, for several parameters, quite the same pattern as the reference one does. However, due to the remaining septal deviation, there is still a non-physiological obstruction especially on the right side. This corresponds with the post-operative rhinomanometric measurements. Summary: Altogether, the results of our clinical examination and the simulation of the nasal airflow, in conjunction with the negative cotton wool test, performed elsewhere, do not support the presumed diagnosis of an Empty Nose Syndrome. The missing turbinates in the analyzed case have, as in general, a minor influence on the inspiratory flow field. The importance of the turbinates seems rather to exist in order to facilitate condensation of the exhaled water. This assumption is derived from comparative animal physiology, CFD-studies of human noses by various authors and not least our own investigations. In the described case, the resection of the turbinates did not lead to an atrophy of the membranes and a therapy-resistant crusting. Probably, there is sufficient compensation of the diminished condensation. Although there is still a significant septal deviation, the patient does not specify the postoperative complaints as an typical obstruction-problem. Therefore, we doubt that revision-surgery of the septum would be helpful. We also agree with Dr. that there is no clear indication to narrow the nasal cavities.

4 CAT-scan pre-operative

5 CAT-scan post-operative

6

7

8 before treatment reference after treatment pressure, inner wall left side right side Pa

9 before treatment reference after treatment pressure, outer wall left side right side Pa

10 before treatment reference after treatment wall shear stress, inner wall left side right side Pa

11 before treatment reference after treatment wall shear stress, outer wall left side right side Pa

12 before treatment reference after treatment velocity left side right side 0 1 2m/s

13 static pressure loss [Pa] left side right side before treatment after treatment healthy reference (decongested membranes)

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