Available Online at http://www.recentscientific.com International Journal of CODEN: IJRSFP (USA) Recent Scientific

International Journal of Recent Scientific Research Research Vol. 11, Issue, 03 (B), pp. 37776-37782, March, 2020 ISSN: 0976-3031 DOI: 10.24327/IJRSR Research Article

SPIROMETRY AS AN OBJECTIVE TOOL IN THE ASSESSMENT OF NASAL PATENCY

Dr Gangadhara Somayaji1, Dr Akhila Shetty2 and Dr Rajeshwary A3

1Professor, Department of ENT, Yenepoya Medical College, Mangalore 2Consultant ENT Surgeon, Mumbai 3Professor and Head, Department of ENT, KSHEMA, Mangalore

DOI: http://dx.doi.org/10.24327/ijrsr.2020.1103.5177

ARTICLE INFO ABSTRACT

Article History: Introduction: Spirometry can be used as an objective tool in the measurement of nasal patency. It can act as a simple screening tool in selecting the patients for surgical correction of deviated nasal Received 13th December, 2019 septum Received in revised form 11th Material and Methods: This prospective study was done in a span of 18 months in patients coming January, 2020 to ENT OPD of a tertiary care centre Accepted 8th February, 2020 Method of collection of data: All patients coming to ENT OPD with history of unilateral/bilateral Published online 28th March, 2020 nasal obstruction and who are undergoing a surgical procedure for the same were included in the

study. Key Words: Sample size was taken as 100. Spirometry, Nasal Patency, Nasal Parameters measured were Forced expiratory volume (FEV1 and FEV3), Forced inspiratory nasal Obstruction. flow volume (FINFV) and Maximum breathing capacity (MVV) Parameters measured were checked pre-operatively and post-operatively at 2 weeks & 3 months. Results: Of the 100 patients, 41 cases underwent Septoplasty alone, 17 cases underwent FESS, 22 cases underwent Septoplasty with FESS and 20 cases underwent other surgeries. Statistically, for all the parameters there was highly significant change seen for both the nostrils when compared pre-operatively & post-operatively. Conclusion: Spirometry is a useful tool for the objective assessment of nasal airway patency which can be retained as a record. Spirometry is also a useful screening tool in selecting the suitability of patients for nasal surgery. The procedure is easy to perform, non-invasive and comfortable for the patient.

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studies have shown that these methods do not always correlate INTRODUCTION [3] with the patient's reported subjective improvement. Moreover, The nose is the first structure in the airway. Nasal obstruction is the size of the equipment, cost, training required are the a common symptom affecting 9.5 - 15% of the general disadvantages with rhinomanometry. Nasal spirometry has population. Nasal septal deviation is one of the most frequent . [1,2] been used effectively to monitor the nasal cycle and thereby causes of nasal obstruction Septoplasty is the conventional nasal airway. The procedure done using spirometry is non- surgery for correcting the deviated nasal septum and improving invasive, simple, easy to perform and comfortable to the the airway. However, the functional benefits of this procedure patient. In our study, we have tried spirometry as a tool to have often been questioned. Objective measures to quantify and assess the nasal patency. establish the success of surgery for nasal obstruction have been a challenge.[3] Questionnaires are always subjective and may Many techniques have been designed to assess the nasal airflow not give the accurate picture. Hence there is a need for an and resistance. It started with a Glatzel mirror which used to be objective tool which may help to establish the efficacy of held under the nostrils and the resulting area of condensed different procedures and can also be used as a screening tool in breath measured. Rhinometry was first employed by Courtade selecting the patients for the surgical procedure. This will also (1903) and is being used now with modifications. [4] help in the proper documentation of the results. The two most Uddstromer (1940) used a face–mask divided into commonly used methods for objective measurement of nasal compartments so that spirometric measurements pertaining to [5] airway are rhinomanometry and acoustic rhinometry. Most both nose and mouth could be made.

*Corresponding author: Dr Gangadhara Somayaji Professor, Department of ENT, Yenepoya Medical College, Mangalore Dr Gangadhara Somayaji, Dr Akhila Shetty and Dr Rajeshwary A., Spirometry as an Objective Tool in the Assessment of Nasal Patency

MATERIALS AND METHODS

This is a Prospective study done in a span of 18 months in patients coming to ENT OPD, of a tertiary care hospital. All patients above 12 years of age, coming to the ENT OPD with history of unilateral/bilateral nasal obstruction and who are undergoing a surgical procedure for the same were taken as the sample. Cases with medical contraindications and those under 12 years of age were excluded. Cases with acute infection were given appropriate treatment for adequate duration before taking up for the procedure. Clearance from the institutional ethical committee was obtained. After taking a detailed history, a detailed general physical and ENT examination was done on all Figure 2 Spirometer mouthpiece with endotracheal tube. Spirometer the patients. All patients underwent routine preoperative mouthpiece with light body condensation silicone prosthetic material. investigations. Following this the patients were counselled for Parameters Measured were this study. A written informed consent was taken. Topical and systemic decongestants and antihistamines were stopped for 1 1. Forced expiratory volume (FEV1 and FEV3) week prior to the procedure. A course of antibiotics is given for 2. Forced inspiratory nasal flow volume(FINFV) 5 days prior to surgery for patients presenting with upper 3. Maximum breathing capacity (MVV) respiratory tract infection. Sample size was taken as 100. Parameters measured were checked pre-operatively and post-

operatively at 2 weeks & 3months. MATERIALS FEV was measured by instructing the patient to first inspire Spirometry apparatus- RMS Helios 401 and Modified maximally then expire as forcefully & rapidly as possible and Endotracheal tube. finally the patient should again inspire maximally into the Objective assessment of nasal patency was done using endotracheal tube. The patient should inspire completely. The Spirometry apparatus in the pulmonary medicine department. inhalation should be rapid but not forced. There should be only Endotracheal tube was used to check the patency in each nostril a brief pause at maximal inspiration; a prolonged pause (4-6 of appropriate size (adults-8 & children-6) alternatively. The sec) may decrease flow during the subsequent expiration. The mouthpiece of the spirometer and the endotracheal tube were manoeuver is displayed on a computer monitor screen & connected by using an air-tight seal light body condensation analyzes the signal from the spirometer, then calculates & silicone prosthetic material. displays the FEV1 and FEV3 i.e. at 1 sec and 3 sec respectively and the FINFV. When the parameters are being measured in one nostril, the opposite nostril was blocked. The procedure was similarly done for the opposite nostril and also for all the parameters. Graph obtained is a Flow-Volume curve – The FVC graphs the flow generated during an FVC maneuver against volume change. FVC maneuver is performed by inspiring fully & then exhaling as rapidly as possible. To complete the loop, the patient inspires as rapidly as possible from the maximal expiratory level back to maximal inspiration. Volume is plotted on the horizontal X-axis, & flow is plotted on the vertical Y-axis. Expiratory flow is plotted upward. Expired volume is usually plotted from left to right. FEV, as well as PEF & FINFV, can be directly calculated from the F-V loop.

Figure 1 Nasal Spirometry being performed

Figure 3 Flow-Volume Curve

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MVV is the volume of air exhaled in a specific interval during Table 1 Procedures performed rapid, forced breathing. The manoeuvre should last at least 12 Frequency Percent seconds. It is recorded in litres per minute. MVV is measured FESS 17 17.0 by having the patient breathe deeply & rapidly for a 12-15 SEPT 41 41.0 seconds interval. SEPT+FESS 22 22.0 SEPT+FESS+PIT 5 5.0 The graph obtained is shown below SEPT+PIT 6 6.0 SEPT+SMD 5 5.0 SEPTRH 4 4.0 Total 100 100.0

Improvement: At Post-op 2weeks- Results are shown in table no.2 and 3

Table 2: 2 weeks right side

Improved No Change Detoriated FEV 1 75.0% 2.0% 23.0% FEV 3 72.0% 1.0% 27.0% FINFV 65.0% 1.0% 34.0% MVV 62.0% 7.0% 31.0%

Table 3: 2 weeks left side

Improved No Change Detoriated FEV 1 65.0% 3.0% 32.0% FEV 3 66.0% 2.0% 32.0% FINFV 65.0% 3.0% 32.0%

MVV 57.0% 17.0% 26.0% Figure 4 Maximum Voluntary Ventilation Curve

Observations At Post-op 3months –Results are shown in table 4 and 5.

This is a prospective study which was conducted in the Table 4: 3 months right side Department of Otorhinolaryngology of a tertiary care centre in patients who came to the OPD with complaints of nasal Improved No Change Detoriated obstruction and underwent appropriate procedure for the same. FEV 1 75.0% 1.0% 24.0% FEV 3 68.0% 4.0% 28.0% FINFV 71.0% 2.0% 27.0% MVV 68.0% 0.0% 32.0%

Table 5: 3 months left side

Improved No Change Detoriated FEV 1 68.0% 0.0% 32.0% FEV 3 70.0% 0.0% 30.0% FINFV 68.0% 2.0% 30.0% MVV 72.0% 2.0% 26.0%

Significance of the parameters: Was done by ANOVA F test FEV1 – There was highly significant change seen for both the nostrils when compared pre-operatively & post-operatively. According to the Pair wise comparison done by BONFERRONI TEST. In Left Nostril –It’s highly significant

Pre-op to Post-op 3 months and between post-op 2weeks to Figure 4 Age distribution post-op 3months.

Out Out of 100 patients,41casesunderwent Septoplastyalone,17 In Right nostril – It’s highly significant Pre-op to Post-op 2 Casesunderwent FESS, 22 casesunderwent Septoplasty with weeks & Post-op 3 months and significant between post-op FESS, 5 casesunderwent 2weeks to post-op 3months. (Figure no.1) Septoplasty+FESS+PIT,6 casesunderwent Septoplasty with PIT, 5 casesunderwent with PIT,5casesunderwent Septoplasty with SMD & 4 patients underwent Septorhinoplasty. For Statistical purpose, septoplasty with other procedures like FESS, turbinoplasty and septorhinoplasty were categorized as other surgeries amounting to 20 cases. (Table no.1)

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Figure 1 Showing changes in FEV 1

FEV3- There was highly significant change seen for both the nostrils when compared pre- operatively & post-operatively Figure 4 Showing changes in MVV

Pair wise comparison-In Left Nostril - It’s highly significant Significance of the parameters according to the surgery: Was Pre-op to Post-op 3 months and between post-op 2weeks to done by KRUSKAL WALLIS test. post-op 3months. FEV1- In Left nostril –There is a highly significant change for In Right nostril – It’s highly significant Pre-op to Post-op 2 all the surgeries Pre-op to Post –op 2week and Post-op weeks & Post-op 3 months.(Figure no.2) 3months.In Right nostril - There is a highly significant change for all the surgeries Pre-op to Post – op 2week & significant change between pre-op to Post-op 3months.

FEV3- In Left nostril –There is a highly significant change for all the surgeries Pre-op to Post –op 2week and Post-op 3months & significant change between post-op 2weeks to post-op 3months.In Right nostril - There is a highly significant change for all the surgeries Pre-op to Post – op 2week.

FINV- In Left nostril –There is a highly significant change for all the surgeries Pre-op to Post –op 2week and Post-op 3months & significant change between post-op 2weeks to post-op

3months.In Right nostril - There is a highly significant change Figure 2 Showing changes in FEV 3 for all the surgeries Pre-op to Post – op 2week.

FINFV- There was highly significant change seen for both the MVV- In Left nostril –There is a highly significant change for nostril when compared pre-operatively & post-operatively all the surgeries Pre-op to Post –op 2week and Post-op Pair wise comparison-In Left Nostril - It’s highly significant 3months.In Right nostril –There is a highly significant change Pre-op to Post-op 3 months and between post-op 2weeks to for all the surgeries Pre-op to Post – op 2week and Post-op post-op 3months.In Right nostril – It’s highly significant Pre-op 3months.(Figure no.5) to Post-op 2 weeks & Post-op 3 months and between post-op 2weeks to post-op 3months.(Figure no.3)

FINFV

0.7842 0.7789

0.6407 0.5689 0.5955 0.4757

PRE-OP At 2nd week At 3 months PRE-OP At 2nd week At 3 months

LEFT RIGHT

Figure 3 Showing changes in FINFV

MVV- There was highly significant change seen for both the nostril when compared pre- operatively & post-operatively. In Left Nostril - It’s significant Pre-op to Post-op 3 months and highly significant between post-op 2weeks to post-op 3 months. In Right nostril – It’s significant Pre-op to Post-op 2 weeks & highly significant between pre-op to Post-op 3 months.(Figure no.4)

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DISCUSSION

Nasal obstruction is one of the most common complaints presenting to ENT surgeons and could be secondary to a variety of causes. It’s affecting around 9.5 - 15% of the general population. [2] Nasal septal deviation is one of its most frequent causes. Other causative conditions are Inferior turbinate hypertrophy, nasal tumours and nasal polyps.[3]

A Study by Moore M & Eccles R has classified nasal patency as physiological and anatomical nasal patency. Physiological nasal patency is unstable as it is related to factors such as the nasal cycle & also external environment. Anatomical nasal patency is stable, decongestion of the nose can stabilise anatomical nasal patency & measurements of patency is done in this state. Currently there are no standard reference values for nasal function. Factors such as age, height, sex, weight and race influence the anatomical nasal patency. Because of the great variation associated with nasal cycle, normal [6] physiological nasal patency is also difficult to define.

Figure 5 Comparisons as per KRUSKAL WALLIS test Subjective assessment of improvement in the nasal airway can always be done using questionnaires after the surgical Multiple comparisons: This was done between different procedures on the nose. surgeries for all the parameters in both the nostrils by MANN WHITNEY test: The ability of the clinician to differentiate between the contribution of mucosal and structural factors in producing In Left nostril-FEV1- On comparing Septoplasty+FESS with airflow asymmetry and hence symptoms of nasal blockage can Other surgeries was found to be significant for pre-op to post- be difficult without objective measurement.[7] An objective tool op 2 weeks.FEV3- On comparing FESS with Other surgeries is required for the documentation and to establish the efficacy was found to be significant for pre-op to post-op 2 weeks & of different procedures. highly significant on comparing FESS with Septoplasty& FESS with Other surgeries and also when Septoplasty +FESS was Objective measures to quantify and establish the success of compared with Other surgeries for pre- op to post-op 3months. surgery for nasal obstruction have been a challenge. Several Also significant change was found when FESS was compared methods have been proposed; the two most common are with other surgeries for post-op 2 weeks to post-op 3months. rhinomanometry and acoustic rhinometry. Rhinomanometry measures nasal flow resistance during breathing. Acoustic FINFV- On comparing FESS with Septoplasty and FESS with rhinometry measures nasal permeability and quantifies the Other surgeries was found to be highly significant for pre-op to cross-sectional area of the nostrils up to the nasopharynx, as post-op 2 weeks & highly significant on comparing FESS with well as the nasal cavity volume between any two chosen cross- SEPT & FESS with Other surgeries for pre-op to post-op sections. Most studies have shown that these methods do not 3months. correlate with the patient's reported subjective improvement. A MVV- On comparing FESS with Septoplasty was found to be few studies have shown, however, that septoplasty is generally highly significant and FESS with Other surgeries was effective for treating nasal obstruction and those most patient [3] significant for pre-op to post-op 2 weeks. show improvements in nasal symptoms. Other methods to assess the nasal patency are by peak nasal inspiratory flow, In Right nostril-FEV1- On comparing FESS with Septoplasty it nasalance, spirometry and laser Doppler velocimetry. was found to be significant and FESS with Other surgeries was found to be highly significant for pre-op to post-op 2 weeks. Hanif et al first described the use of nasal spirometry as an Also significant on comparing FESS with Septoplasty and objective measure of the nasal partitioning of airflow in 2001. highly significant on comparing FESS with Other surgeries for The spirometry has the potential to overcome many of the pre-op to post-op 3 months. disadvantages of the more conventional objective measurements of the nasal passages such as rhinomanometry. It FEV3- On comparing FESS with Septoplasty and FESS with is a small, portable, hand-held machine that is easyto use, both Other surgeries was found to be highly significant for pre-op to by the investigator and subject, after only minimal training. The post-op 2 weeks. For pre-op to post-op 3 months on comparing spirometer measures volume of air, and has been adapted to FESS with other surgeries was found to be significant. FINFV- measure airflow through the nasal passages via a nosepiece. On comparing FESS with Septoplasty and FESS with Other Measuring each nasal passage separately allows recoding of the surgeries was found to be highly significant and FESS with distribution or nasal partitioning of airflow. Few studies have Septoplasty +FESS was found to significant for pre-op to post- reported that nasal spirometry is accurate, reliable and op 2 weeks. MVV- FESS compared with Septoplasty, reproducible. It has been shown that nasal partitioning of Septoplasty+FESS and other surgeries were highly significant airflow as measured by spirometry was directly comparable for pre-op to post-op 2weeks. For pre-op to post-op 3months with the results as measured by the rhinomanometer.[8] FESS when compared with other surgeries was found to significant. 37780 | P a g e Dr Gangadhara Somayaji, Dr Akhila Shetty and Dr Rajeshwary A., Spirometry as an Objective Tool in the Assessment of Nasal Patency

Smita K. Nagle & Rajendra S. Kelkar in March 2007 stated that deviated nasal septum, crusting, synechiae formation and nasal patency can be measured with the help of Spirometer in recurrent sinonasal polyposis. order to evaluate patient’s complaints and confirming the pathology leading to nasal obstruction. They measured the In another study by Moore M & Eccles, they reviewed the ventilation in the form of maximum breathing capacity as a efficacy of surgical management of the deviated septum as a parameter to assess the functional average patency of nasal treatment for chronic nasal obstruction. Functional benefit of passage. The only limitation is that it only can be done only in septal surgeries was done by any evidence of a change in an institution[5]In our study MVV was one of the parameters patency of the nasal airway, as assessed by objective methods that was used and it showed significant improvement when such as rhinomanometry, acoustic rhinometry and peak nasal compared preoperative to postoperative results for both the inspiratory flow. They reviewed seven studies to assess the nostril. efficacy of septoplasty where rhinomanometry was used to measure nasal patency, six studies where acoustic In Cuddihy PJ & Eccles R study, the usefulness of nasal rhinomanometry was used, here there was statistically spirometry in studying nasal airflow was demonstrated. Nasal significant increase from pre-op to post-op.[11] spirometry was used to measure the effect of acute rhinitis associated with upper respiratory tract infection (URTI) on the In a similar study,Fyrmpas G, Kyrmizakis D, Vital V changes in nasal airflow that occur with postural change.They &Constantinidis J showed the role of bilateral simultaneous concluded that nasal spirometry is useful in studying nasal nasal spirometry (BSNS) in the preoperative selection of airflow partitioning in health and disease.[7] patients for septoplasty. In this study a modification of the nasal spirometry was used where bilateral simultaneous nasal Roblin DG & Eccles R, in their study used a portable nasal spirometry measurement was done. The results were BSNS spirometry to determine the normal range of nasal partitioning correlated well with rhinomanometry. They concluded that ratio in 100 healthy subjects. They came to a conclusion that BSNS is a simple, quick, non-invasive and reproducible nasal spirometry may prove useful in assessing patients technique, which is easy to interpret and requires minimal complaining of nasal obstruction and also assessing the degree training. This test offers valuable information along with of nasal septal deviation. They also emphasized the point that clinical assessment of the nasal airway in the preoperative the presence of a deviated septum does not necessarily relate to assessment of candidates for septoplasty.[12] symptoms or pathology. This study showed that men were more likely to have a deviated septum than women. They In another study by Cuddihy PJ & Eccles R, nasal spirometry concluded that spirometry is a useful test for nasal respiratory was used as an objective measure of nasal deviation and also to function and provides objective assessment of nasal airway know the effectiveness of septal surgery. Nasal spirometry was patency, which can be retained as record, the method is easy to performed preoperatively and postoperatively at the first visit. handle and sensitive, the method is clinically applicable and Subjective assessment of nasal airway was also done using the recordable.[9] visual analogue score.[7,8]They concluded that spirometry is a useful screening tool in selecting the suitability of patients for In Hooper RC study, individuals with and without nasal septal surgery. In our study the parameters showed significant symptoms underwent forced inspiratory nasal flow–volume changes for the septal surgeries in both the nostrils. Hence, (FINFV) curve measurements. Definitions of normal and nasal surgery has improved the nasal airway therefore showing abnormal were established, Normal curves were defined as improved objective measures in the nasal patency. those from participants who had no nasal symptoms and a peak inspiratory nasal flow greater than 2.5 L/s. Abnormal curves The procedures done using spirometer are sensitive, easy to were defined as those from participants who had 1 or more perform and comfortable to the patient. Spirometry is a useful nasal symptoms, a peak inspiratory nasal flow lower than 2.5 tool for the assessment of nasal respiratory function and L/s, and normal oral inspiratory flow. He concluded that Forced provides an objective assessment of nasal airway patency inspiratory nasal flow–volume curves are a potentially useful which can be retained as a record. The procedure is simple to clinical tool to evaluate the nasal airway for obstruction. It is perform and also comfortable to the patient. Another advantage easy to perform and well- tolerated.[10]In our study nasal flow is the spirometer is portable and a non–invasive procedure. volume curve was used to calculate the FEV1 & 3 (forced The disadvantage being, as the subject breaths in, the nasal expiratory volume at 1 sec and 3 sec) and also the FINFV apparatus flattens and faster the air flow inward the more the (forced inspiratory nasal flow volume). All the parameters were alar cartilage and upper lateral cartilage are drawn inwards, easy to perform and also showed a significant change when increasing nasal resistance. Breathing outward through nose the compared pre-operative results to post-operative results. All the opposite will happen causing a decrease in nasal resistance and parameters showed a significant change when compared from also another common error that can occur is the air leak around pre- operative to post-operative 2weeks and 3 months. Hence, the nostril while expiring. nasal surgery had improved the airway when assessed objectively and also patients had improvement in their CONCLUSION symptoms.The improvement was seen more significant at post- This prospective study of “Spirometry as an objective tool for op 3 months as compared to post-op 2 weeks due to reasons the assessment of nasal patency” was conducted in the such as postoperative oedema and crusting at post- Department of Otorhinolaryngology of a tertiary care centre. operative2weeks. At post-op 3 months patients had better We draw the following conclusions from this study : improvement in the nasal airway as nasal cavity is completely healed. The causes of deterioration in the objective measurements at post-op 3 months were due to persistent 37781 | P a g e International Journal of Recent Scientific Research Vol. 11, Issue, 03 (B), pp. 37776-37782, March, 2020

1. Spirometry is a useful tool for the objective 4. Foxen EH, Preston TD, Lack JA. The assessment of assessment of nasal airway patency which can be nasal air-flow: a review of past and present methods. J retained as a record. Laryngol Otol. 1971; 85(8):811-25. 2. Spirometry is also a useful screening tool in selecting 5. Nagle SK and Kelkar RS. Spirometry as an objective the suitability of patients for nasal surgery. tool for nasal patency. Ind J Otolaryngol Head Neck 3. The procedure is easy to perform, non-invasive and Surg.2006;59(1): 41-2 comfortable for the patient. 6. Moore M, Eccles. Normal nasal patency: Problems in obtaining standard reference values for the surgeon. J References Laryngol Otol. 2012; 126: 563-69.

1. Gleeson M, Browning GG, Burton MJ, ClarkeR, Hibbert 7. Cuddihy PJ, Eccles R. Use of nasal spirometry for J, Jones NS , Lund VJ, assessment of unilateral nasal obstruction associated with editors. Scott-Brown's otorhinolaryngology, head and neck changes in posture in healthy subjects and subjects with surgery. 7th ed.London: Hodder Arnold. 2008 p: 1315- upper respiratory tract infection. Clin. Otolaryngol 43, 1356-77, 1386-90, 1439-44, 1549 -57. .2003; 28(2): 108-11. 8. Cuddihy PJ, Eccles R. The use of nasal spirometry as an 2. Akerlund A, Millqvist E, Oberg D, Bende M. Prevalence objective measure of septal deviation and the of upper and lower airway symptoms: the Skovde effectiveness of septal surgery. Clin. Otolaryngol. 2003; population-based study. Acta Otolaryngol. 2006; 28(4): 325-30. 126:483-88. 9. Roblin DG, Eccles R. Normal range for nasal 3. Velasco LC, Arima LM, Tiago RSL. Assessment of partitioning of airflow determined by nasal spirometry in symptom improvement following nasal septoplasty with 100 healthy subjects. Am J Rhinol. 2003; 17: 179–83. or without turbinectomy. Braz. J. Otorhinolaryngol. 10. Hooper RC. Forced inspiratory nasal flow volume 2011; 77 (5):577-83. curves: A simple test of nasal airflow. Mayo clin proc. 2001; 76: 990-94. 11. Moore M, Eccles. Normal nasal patency: problems in obtaining standard reference values for the surgeon. J Laryngol Otol. 2012; 126: 563-69. 12. Fyrmpas G, Kyrmizakis D, Vital V, Constantinidis J. The value of bilateral simultaneous nasal spirometry in the assessment of patients undergoing septoplasty. Rhinol. 2011; 49: 297-303.

How to cite this article:

Dr Gangadhara Somayaji, Dr Akhila Shetty and Dr Rajeshwary A.2020, Spirometry as an Objective Tool in the Assessment of Nasal Patency. Int J Recent Sci Res. 11(03), pp. 37776-37782. DOI: http://dx.doi.org/10.24327/ijrsr.2020.1103.5177

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