Objetivo: Estimar a prevalência de sintomas de apneia obstrutiva do sono (AOS), obstrução nasal (ON) e enurese em crianças com fissura labiopalatina unilateral, não sindrômicas. Local de execução: Unidade de Estudos do Sono do Laboratório de Fisiologia - HRAC/USP. Método: Estudo prospectivo transversal com a participação de 174 sujeitos que atenderam aos critérios de inclusão, de 6 a 12 anos de idade (média de 10,0 ± 1,8 anos, 58,62% do sexo masculino). A prevalência de sintomas de AOS e de ON foi estimada pela análise dos escores obtidos pelos instrumentos: Escala de Distúrbios do Sono em Crianças (EDSC); Índice de Congestão Nasal (CQ-5) e Escala Visual Analógica (EVA). A enurese foi considerada como presente quando relatada incontinência urinária intermitente durante o sono (no mínimo 1 episódio/mês, nos últimos 3 meses). Para caracterizar a enurese como monossintomática ou polissintomática, sintomas de disfunção do trato urinário inferior (DTUI) foram investigados pelo instrumento Dysfunctional Voiding Scoring System (DVSS), em Português. Foram colhidos dados sociodemográficos, antecedentes e comorbidades, índice de massa corpórea (IMC) e razão circunferência abdominal/altura (CA/A). Foram analisadas medidas de posição e dispersão, frequências percentuais e absolutas e razão de prevalências. Diferenças entre subgrupos foram analisadas a um nível de significância de 5%. Resultados: Escore EDSC positivo para AOS foi observado em 60 (34,48%) crianças da amostra; escore CQ-5 positivo para ON em 45 (25,86%), escore DVSS positivo para DTUI em 30 (17,24%) e 29 (16,67%) crianças apresentaram enurese. Ronco habitual foi observado em 75,00% no subgrupo AOS e sensação de nariz obstruído habitual em 75,56% no subgrupo ON. Não foram constatadas diferenças significativas quanto a sexo, raça, IMC e razão CA/A. A ocorrência de enurese foi maior aos 6 e 7 anos, com queda gradativa aos 8 anos e ausência aos 12 anos. Houve predomínio de enurese primária (65,52%), infrequente (68,96%) e polissintomática (72,41%). Comparativamente aos dados da literatura, as razões de prevalências de AOS, do sintoma nariz obstruído e de enurese foram até 6,75 vezes (IC 95% 5,3 - 8,7), 2,14 vezes (IC 95% 1,8 - 2,5) e 3,33 vezes (IC 95% 2,3 - 4,7) maiores, respectivamente. Foi identificada associação entre sintomas de AOS e ON (p=0,0001), com correlação positiva e moderada entre os escores médios do EDSC e do CQ-5 (0,545). Não se verificou maior prevalência de enurese nas crianças com sintomas de AOS. Conclusão: As crianças com FLPUNS tem alta prevalência de obstrução nasal e enurese e estão sob risco para apneia obstrutiva do sono / Objectives: To estimate the prevalence ratios of nasal obstruction (NO) symptoms, OSA-related symptoms and enuresis in Brazilian nonsyndromic children with repaired unilateral cleft lip and palate (UCLP/NS). Setting: Sleep Studies Unit, Laboratory of Physiology, HRAC/USP. Methods: 174 children with repaired UCLP/NS, meeting inclusion criteria, participated in this prospective, cross-sectional study (aged 6-12 y, 58.62% boys). Validated questionnaires were used to predict OSA and subjective NO, Sleep Disturbance Scale for Children (SDSC), Congestion Quantifier Five Item (CQ-5) and Visual Analog Scale (VAS), respectively. Enuresis was defined as intermittent incontinence of urine during sleeping (with a minimum of one episode per month and at least for 3 months). In order to identify non-monosymptomatic enuresis, lower urinary tract dysfunction was assessed by a validated questionnaire, the Dysfunctional Voiding Scoring System (DVSS). Sociodemographic data, medical history, comorbidities, body mass index (BMI) and waist-to-height ratio (WHR) were analyzed. Measures of central tendency and dispersion, absolute and relative frequencies and prevalence ratios were analyzed. Subgroups were compared at 5% significance level. Results: Positive screening for OSAS-related symptoms was seen in 60 (34.48%) children and subjective NO in 45 (25.86%). Enuresis was seen in 29 (16.67%) children and positive DVSS score in 30 (17.24%). Habitual snoring was seen in 75.00% of the children with OSA-related symptoms and sensation of nasal obstruction in 75.56% of the children with positive CQ-5 score. No differences were observed for gender, race, BMI and WHR. The occurrence of enuresis was higher at 6/7 y of age, with a gradual decline at 8 years and absence at 12 y. There was a predominance of primary (65.52%), infrequent (68.96%) and non-monosymptomatic (72.41%) enuresis. Compared to literature data, prevalence ratios of OSA-related symptoms, NO and enuresis were, respectively, 6.75 (95% CI 5.3 - 8.7), 2.14 (95% CI 1.8 - 2.5) and 3.33 (95% CI 2.3 - 4.7) times higher. Association was identified between symptoms of OSA and ON (p=0.0001), with a positive and moderate correlation between the average scores of the EDSC and CQ-5 (0.545). Prevalence of enuresis was not higher in children with symptoms of OSA. Conclusion: Nonsyndromic children with cleft lip and palate have a high prevalence of symptoms of nasal obstruction and enuresis, and are at risk for obstructive sleep apnea

Objetivos: Determinar e comparar os valores de nasalância em amostras de fala na presença e ausência da turbulência nasal (TN) e da hipernasalidade. Métodos: Foram analisadas um total de 288 amostras de fala com fonemas de alta e baixa pressão, sendo que, 110 foram excluídas por apresentarem articulação compensatória (AC) ou disfonia. Cinco (5) juízes avaliaram as 178 amostras (110 + 20%) para indicar a presença e ausência da TN e da hipernasalidade. Resultados: As palavras e frases contendo fonemas líquidos (baixa pressão) foram julgados, por todos os juízes, com ausência de TN, e não foi encontrada diferença significante entre as amostras analisadas (lalá, lalá olhou a lua, e frases LO). No caso das 5 amostras com fonemas de alta pressão (papai, bebê, papai pediu pipoca, o bebê babou, frases PO) observou-se que somente nas frases PO a diferença foi estatisticamente significante (p=0,02) para o fator hipernasalidade. Conclusão: Comparando os valores de nasalância na presença e ausência da TN podemos concluir que a nasalância apresentou-se elevada em todas as palavras e frases contendo fonemas orais de alta pressão, porém a diferenças encontradas não foram estatisticamente significantes. Comparando os valores de nasalância na presença e ausência da hipernasalidade notamos que os valores apresentaram-se elevados nas palavras e frases contendo fonemas orais sonoros de alta pressão e nas frases LO. / Objective:The objective of this study was to determine and to compare nasalance scores at the presence and absence of nasal turbulence (NT) and hypernasality. Methods: Nasometric scores and audio recordings were obtained simultaneously from 30 participants with operated unilateral cleft lip and palate during production of speech samples with low and high pressure phonemes. From a sample of 288 recording, 110 were excluded when rated with presence of compensatory articulation (CA) or dysphonia by a group of 5 judges and the remaining 110 sample were classified according to the presence or absence of NT and hypernasality and their mean nasalance scores were calculated. Results: Intra-rater agreement between the judges ranged from regular to perfect and inter-rater agreement ranged from moderate to substancial. The words and phrases with low pressure phonemes (lalá, lalá olhou a lua e low pressure phrases) were rated by all judges with absence of NT. All nasalance scores for low pressure phonemes were found to be suggestive of the presence of hypernasality for the samples rated as hypernasal. There was no significant difference between the nasalance scores for all low pressure samples analysed (lalá, lalá olhou a lua and other low pressure phrases). The nasalance scores for high pressure phonemes (papai, bebê, papai pediu pipoca, o bebê babou, phrases high pressure) were found to be suggestive of the presence of hypernasality for the samples rated as hypernasal and also when the samples were rated with presence of NT. There was significant difference between the nasalance scores only for the high pressure phrases (p=0,02). Conclusion: While statistically significant higher nasalance scores were found only for the longer speech sample of high pressure phrases, elevated nasalance scores were observed for all samples rated with presence hypernasality or presence of NT suggesting the importance, during clinical practice, of carefully interpreting nasalance scores at the presence of turbulence.

Objetivo: Analisar as áreas seccionais, distâncias e volumes de segmentos específicos da cavidade nasal de crianças com fissura de lábio e palato unilateral, comparativamente a crianças sem fissura, por rinometria acústica. Modelo: Estudo prospectivo. Local de Execução: Laboratório de Fisiologia, HRAC-USP. Participantes: Trinta e nove crianças com fissura transforame unilateral e 34 crianças sem fissura, de ambos os sexos, com idade de 6 a 9 anos. Intervenções/Variáveis: Foram avaliadas as áreas seccionais correspondentes ao 2º, 3º e 4º entalhes do rinograma (AST1, AST2 e AST3), suas respectivas distâncias (d1, d2, d3) e os volumes nos segmentos correspondentes a 1-3,2cm (V1), 3,3-6,4cm (V2) e 7-12cm (V3), relativamente à narina, antes e após a aplicação tópica de vasoconstritor nasal (VC), utilizando um Rinômetro Acústico Eccovision-Hood Laboratories. Resultados: No lado fissurado (LF) as médias (±DP) de AST1, AST2, AST3 (em cm2), d1, d2 e d3 (em cm) e V1, V2 e V3 (em cm3) foram: 0,17±0,12, 0,29±0,20, 0,40±0,28, 2,02±0,40, 3,74±0,51, 5,50±0,44, 0,54±0,30, 1,22±0,86 e 4,52±3,37, respectivamente. No lado não-fissurado (LNF) as médias corresponderam a 0,33±0,11, 0,65±0,28, 0,90±0,43, 1,69±0,48, 3,67±0,53, 5,60±0,70, 1,04±0,37, 2,57±1,20, 8,77±4,85, respectivamente. As médias de AST e V em LF foram estatisticamente menores e a média de d1 foi maior que as observadas em LNF e no grupo controle, antes e após o uso do VC (p<0,05). A vasoconstrição provocou aumento dos valores de AST e V em ambos os grupos. Conclusão: Os resultados obtidos mostram significativo comprometimento da permeabilidade nasal em crianças com fissura labiopalatina unilateral. / Objective: To evaluate cross-sectional areas, distances and volumes of specific segments of the nasal cavity of children with unilateral cleft lip and palate, compared to children without cleft, by acoustic rhinometry. Design: Prospective analysis. Setting: Laboratory of Physiology, HRAC-USP. Participants: Thirty-nine children with unilateral cleft lip and palate and 34 controls without cleft, of both genders, aged 6 to 9 years. Interventions/Variables: Cross-sectional areas measured at the 2nd, 3rd and 4th notches in the rhinogram (CSA1, CSA2 and CSA3), their distances from the nostril (d1, d2 and d3) and volumes measured at 1-3.2cm (V1), 3.3-6.4cm (V2) and 7-12cm (V3) from the nostril were evaluated by means of an Eccovision Acoustic Rhinometer-Hood Laboratories, before and after nasal decongestion. Results: At the cleft side (CS), the mean values (±SD) of CSA1, CSA2, CSA3 (in cm2), d1, d2 and d3 (in cm) and V1, V2 e V3 (in cm3) were: 0.17±0.12, 0.29±0.20, 0.40±0.28, 2.02±0.40, 3.74±0.51, 5.50±0.44, 0.54±0.30, 1.22±0.86 and 4.52±3.37, respectively. At the non-cleft side (NCS) mean values corresponded to 0.33±0.11, 0.65±0.28, 0.90±0.43, 1.69±0.48, 3.67±0.53, 5.60±0.70, 1.04±0.37, 2.57±1.20, and 8.77±4.85, respectively. CSA and V means at CS were significantly lower and d1 mean was higher than NCS and control means, before and after decongestion (p<0.05). Increased CSA and V mean values were seen after decongestion in both groups. Conclusion: The results show a significant impairment of nasal patency in children with unilateral cleft lip and palate.

Objetivo: Determinar as áreas seccionais e os volumes de segmentos específicos da cavidade nasal, incluindo a nasofaringe, de indivíduos sem evidências de obstrução nasal, e os mesmos volumes na produção da fala, com vistas ao estabelecimento de valores de referência. Modelo: Análise prospectiva. Local de Execução: Laboratório de Fisiologia, HRAC-USP. Participantes: 30 voluntários caucasianos, com idade entre 18 e 30 anos, sendo 14 homens e 16 mulheres. Intervenções/Variáveis: Foram avaliadas, por rinometria acústica, áreas de secção transversa nos segmentos correspondentes à válvula nasal (AST1), região anterior da concha nasal inferior (AST2) e região posterior da concha nasal inferior (AST3) e volumes, nos segmentos correspondentes à região da válvula nasal (V1), dos cornetos (V2) e da nasofaringe (V3). As medidas foram feitas antes e após a descongestão nasal, no repouso (suspensão voluntária da respiração) e durante a atividade velofaríngea (produção contínua e silenciosa do fonema /f/). Resultados: Os valores médios (±DP) das áreas (em cm2) e volumes (em cm3) obtidos no repouso, foram: AST1=0,54±0,13, AST2=0,98±0,31, AST3=1,42±0,44, V1=1,68±0,32, V2=3,98±1,12 e V3=18,93±3,51. Após a DN os valores foram significantemente maiores (p<0,05). Na fala, os volumes foram os seguintes: V1=1,80±0,22; V2=4,22±1,20; V3=15,32±5,40. O valor de V3 na fala foi significantemente menor que o observado na ausência de atividade velofaríngea (p<0,05). Conclusão: A comparação das áreas seccionais e dos volumes obtidos com os relatados na literatura validam seu uso como valores de referência, assim como o emprego da rinometria acústica como método de avaliação objetiva da geometria nasal e da atividade velofaríngea na fala. / Objective: To determine cross-sectional areas and volumes of specific segments of the nasal cavity, including the nasopharyngeal region, of individuals without evidences of nasal obstruction, and the same volumes during speech, with the purpose of establishing reference values. Model: Prospective analysis. Setting: Laboratory of Physiology, HRAC-USP. Participants: 30 caucasians volunteers, aged between 18 and 30 years (14 males and 16 females). Intervention/Variables: Cross-sectional areas corresponding to the nasal valve (CSA1), anterior edge of the inferior turbinate (CSA2) and posterior edge of the inferior turbinate (CSA3), and volumes corresponding to the nasal valve (V1), turbinate (V2) and nasopharyngeal regions (V3) were evaluated. Measurements were performed by acoustic rhinometry before and after nasal decongestion, at rest (voluntary interruption of respiration) and during velopharyngeal activity (silent continuous production of the sound /f/). Results: Mean values (±SD) of areas (in cm2) and volumes (in cm3) were the following: CSA1=0,54±0,13, CSA2=0,98±0,31, CSA3=1,42±0,44, V1=1,68±0,32, V2=3,98±1,12 and V3=18,93±3,51. After decongestion, the values were significantly larger (p<0,05). During speech, volumes were the following: V1=1,80±0,22; V2=4,22±1,20; V3=15,32±5,40. Nasopharyngeal volume (V3) measured during speech was significantly smaller than at rest (p<0,05). Conclusion: The comparison of the nasal cross-sectional areas and volumes obtained with those reported in the literature validate their use as reference values and the use of acoustic rhinometry to assess nasal geometry and velopharyngeal activity during speech.

Neste estudo avaliou-se a eficácia da radiografia panorâmica na detecção de desvio do septo nasal. Para tanto, utilizou-se como padrão ouro o exame clínico e imagens tomográficas da face. A amostra foi composta por imagens radiográficas panorâmicas e por imagens de tomografia computadorizada da face de 70 indivíduos. Dentre os indivíduos que compuseram o estudo, 30 eram pacientes que seriam submetidos a tratamento odontológico e possuíam radiografias panorâmicas nas quais foram observadas imagens compatíveis com desvio do septo nasal. Estes pacientes foram avaliados por um otorrinolaringologista e submetidos, segundo o critério da justificação, ao exame de tomografia computadorizada da face. Os outros 40 indivíduos foram selecionados a partir de imagens panorâmicas dos prontuários de pacientes disponíveis no arquivo da Clínica de Estomatologia da FOB-USP e que também haviam realizado tomografia computadorizada da face para elaboração de diagnóstico e plano de tratamento odontológico. Os resultados mostraram que a radiografia panorâmica, segundo a metodologia adotada, foi eficaz na detecção do desvio do septo nasal, com 100% de Especificidade. Além disso, este exame permite a confirmação da ausência deste desvio na maioria dos casos, com 86% de Sensibilidade. / OBJECTIVE: Discern the efficacy of panoramic radiography on nasal septum deviation. Gold standard computerized tomography along with clinical examination was used for comparison. MATERIAL AND METHODS: Sample was composed of 70 subjects from Stomatology files of FOB-USP. Nasal septum deviation was assessed using the panoramic radiographies. Then, computerized tomography was analyzed and the results confronted. RESULTS: Images of nasal septum deviation were observed and confirmed in both exams on 100% of the subjects. However, in those cases with no deviation observed with the panoramic radiographies, its presence was confirmed in 86% after computerized tomography. CONCLUSION: Panoramic radiography was trustable for confirmation of nasal septum presence, with 100% of Specificity. Further, this exam allows the confirmation of the absence of this deviation in the majority of cases, with 86% of Sensibility.

O objetivo neste trabalho foi de analisar a geometria nasal, a nasofaringe e a orofaringe, em crianças respiradoras orais com indicação de cirurgia desobstrutiva das vias aéreas superiores, e verificar a existência de uma possível influência direta da respiração na determinação do tipo facial. Foram avaliadas 657 crianças e, dentre elas, foram selecionadas 75, que se submeteram a avaliação otorrinolaringológica por meio de exames clínico, de radiografia cavum e/ou nasofibroscopia, e com as quais ficaram evidenciadas as obstruções das vias aéreas superiores com indicação cirúrgica. Ao final 41 crianças (21 do gênero masculino e 20 do feminino), entre 6,16 e 14,66 anos de idade, brasileiras, leucodermas, sem história de tratamento ortodôntico ou otorrinolaringológico cirúrgico (remoção de tonsilas faringeanas, palatinas, ou estruturas internas da cavidade nasal), aceitaram participar do estudo. Foram obtidas telerradiografias em norma lateral para a determinação do tipo facial e realizado o exame de rinometria acústica para a obtenção da área transversal mínima da cavidade nasal. A análise estatística dos dados (ANOVA, Razão de Verossimilhanças, análises de variâncias com medidas repetidas com dois fatores, comparações múltiplas de Bonferroni, teste Kruskal- Wallis; com nível de significância de 5%) e a interpretação dos resultados obtidos não mostraram diferença estatisticamente significativa na área total em MCA1 e MCA2 entre os tipos faciais (p > 0,05). Além disso, a obstrução das tonsilas faringeanas e palatinas avaliadas separadamente ou combinadas não variou estatisticamente segundo os tipos faciais (p = 0,582 para tonsila faringeana e p = 0,733 para tonsila palatina; e p = 0,925 quando combinadas). Conclui-se que, no presente estudo, não foi encontrada evidência de que a obstrução das vias aéreas superiores tenha influência determinante na definição do tipo facial. / The objective of this paper was to analyze the nasal geometry, the nasopharynx and the oropharynx in oral breathing children with indication for surgery clearence upper airway, in order to verify the existence of a possible direct influence of breathing in the determination of the facial type. A group of 657 children was evaluated and, among them, 75 were selected for otorhinolaryngologic evaluation through clinical exams, cavum radiography and/or nasal endoscopy , when the obstruction of the upper airway with surgical indication has been confirmed. From this subgroup, 41 children agreed to participate in the study (21 males: 20 females), with ages between 6,16 and 14,66 years, brazilians, whites, with no history of orthodontic treatment nor otorhinolaryngologic surgery (removal of the pharyngeal or palatine tonsils or internal structures of the nasal cavity). Radiographs were taken in lateral norm for the determination of the facial type and the acoustic rhinometry exam was performed for the determination of the nasal minimal transversal area. The statistical analyses of the data were made with the variance analysis (ANOVA), likelihood ratio test, analyses of variance with measures repeated with two factors, Bonferroni multiple comparisons, and Kruskal-Wallis test. The significance level was chosen as 0.05. No statistically significant difference was detected in the total area in MCA1 and MCA2 between the facial types. Besides that, the obstruction of the pharyngeal or palatine tonsils, taken separately or in combination, did not vary statistically according to the facial pattern (p = 0.582 for pharyngeal tonsil; p = 0.733 for palatine tonsil; and p = 0.925 when combined). Therefore, in the present study, no evidence has been found that the obstruction of the superior airway has determinant influence in the determination of the facial type.

Les cellules épithéliales nasales humaines (CENH) sont des acteurs importants de la physiopathologie de la polypose naso-sinusienne (PNS), le plus souvent la PNS est primitive (étiologie inconnue), plus rarement, elle est secondaire à la mucoviscidose (PNS CF) ou la dyskinésie ciliaire primitive (PNS DCP). L'objectif de cette thèse est d'identifier des protéines différentiellement exprimées dans les PNS primitives et secondaires par approche protéomique puis de les caractériser par des techniques classiques. Dans cette étude, nous avons utilisé des cultures primaires (interface air/liquide) de CENH, dérivant de déchet per-opératoire (PNS) ou de brossages (muqueuse saine). Le marquage iTRAQ suivie d'une analyse par nano-LC-MALDI-TOF-TOF à en particulier montré : 1) une augmentation de six marqueurs du stress du réticulum endoplasmique (RE) dans la PNS primitive et la PNS CF, 2) une altération du métabolisme du glucose dans la PNS CF (sous-expression de 6 protéines dont la pyruvate kinase, enzyme clef de la glycolyse) et 3) une sous expression de 12 protéines des filaments acto-myosines dans la PNS DCP (dont 3 tropomyosines). Nous avons caractérisé le stress du RE dans la PNS primitive, montrant qu'il est induit par le biais d'une sensibilité des CENH à un stress oxydatif probablement d'origine mitochondrial et qu'il participe activement à l'inflammation (sécrétion d'IL-8 et de LTB4). Ces observations nous permettent de proposer que, dans la PNS primitive, il existe un cercle vicieux entre stress du RE, stress oxydatif et inflammation et que la sensibilité au stress oxydatif observée apparaît comme une nouvelle cible thérapeutique dans le traitement de la PNS. / Human nasal epithelial cells (HNEC) play an important role in nasal polyposis(NP). NP have generally an unknown etiology, less frequently, NP is secondary to cystic fibrosis (CF NP) or primary ciliary dyskinesia (PCD NP). The aim of this thesis is to identify differentially expressed proteins in NP, CF NP and PCD NP using proteomic approach then to characterize them by classical methodes. In this study, we used primary culture (air/liquid)of HNEC derived from NP patients (surgery waste) or healthy patients (brushing). The iTRAQ labeling folowing by nano-LC-MALDI-TOF-TOF analysis shown in particular :1)an increased expression of six endoplasmic reticulum (ER) stress markers in NP and CF NP, 2)an alteration of glucose metabolism (decreased expression of six proteins with in particular the pyruvate kinase, glycolysis key enzyme) and 3)an decreased expression of 12 acto-myosin filament proteins (in particular three tropomyosins). We caracterized the ER stress in NP showing that ER stress is activated by an oxydative stress susceptibility of NP HNEC probably of mitochondrial origin and that it directly participate to inflammation (IL-8 and LTB4 secretions). Altogether, our results underline a vicious circle that exists between oxidative stress, ER stress and inflammation.The oxydative stress susceptibility observed in NP may represent new therapeutic target in such a pathology.

PURPOSE:To assess if intensity-modulated radiotherapy (IMRT) can possibly lead to improved local control and lower incidence of vision impairment/blindness in comparison to non-IMRT techniques when treating sinonasal malignancies / what is the most optimal dose constraints for the optic pathway / and the impact of different IMRT strategies on optic pathway sparing in this setting.METHODS AND MATERIALS:A literature search in the PubMed databases was conducted in July, 2012.RESULTS:Clinical studies on IMRT and 2D/3D (2 dimensional/3 dimensional) RT for sinonasal malignancies suggest improved local control and lower incidence of severe vision impairment with IMRT in comparison to non-IMRT techniques. As observed in the non-IMRT studies, blindness due to disease progression may occur despite a lack of severe toxicity possibly due to the difficulty of controlling locally very advanced disease with a dose less than or equal to] 70Gy. Concurrent chemotherapy's influence on the the risk of severe optic toxicity after radiotherapy is unclear. A maximum dose of less than or equal to] 54Gy with conventional fractionation to the optic pathway may decrease the risk of blindness. Increased magnitude of intensity modulation through increasing the number of segments, beams, and using a combination of coplanar and non-coplanar arrangements may help increase dose conformality and optic pathway sparing when IMRT is used.CONCLUSION:IMRT optimized with appropriate strategies may be the treatment of choice for the most optimal local control and optic pathway sparing when treating sinonasal malignancy.

Nasal high flow (NHF) cannulae are used to deliver heated and humidified air to patients at steady flows ranging from 5-50 l/min. Knowledge of the airflow characteristics within the nasal cavity with NHF and during natural breathing is essential to understand the treatment's efficacy. In this thesis, the distribution and velocity of the airflow in the human nasal cavity have been mapped during natural and NHF assisted breathing with planar- and stereo-PIV in both steady and oscillatory flow conditions. Anatomically accurate transparent silicone models of the human nasal cavity were constructed using CT scan data and rapid prototyping. Breathing flowrates and waveforms were measured in vivo and dimensionally scaled by Reynolds and Womersley number matching to reproduce physiological conditions in vitro. Velocities of 2.8 and 3.8 m/s occurred in the nasal valve during natural breathing at peak expiration and inspiration, respectively; however on expiration the maximum velocity of 4.2 m/s occurred in the nasopharynx. Velocity magnitudes differed appreciably between the left and right sides of the nasal cavity, which were asymmetric. NHF modifies nasal cavity flow patterns significantly, altering the proportion of inspiration and expiration through each passageway and producing jets with in vivo velocities up to 20.8 m/s for 40 l/min cannula flow. The main flow stream passed through the middle airway and along the septal wall during both natural inspiration and expiration, whereas NHF inspired and expired flows remained high through the nasal cavity. Strong recirculating features are created above and below the cannula jet. Results are presented that suggest the quasi-steady flow assumption is invalid in the nasal cavity during both natural and NHF assisted breathing. The importance of using a three-component measurement technique when investigating nasal flows has been highlighted. Cannula flow has been found to continuously flush the nasopharyngeal dead space, which may enhance carbon dioxide removal and increase oxygen fraction. Close agreement was found between numerical and experimental results performed in identical conditions and geometries.

Nasal continuous positive airway pressure (CPAP) is reportedly superior to mechanical ventilation in the neonatal population by reducing bronchopulmonary dysplasia (BPD). The neonate is vulnerable to injury secondary to immature physiological systems and skin structures and the current CPAP devices place constant pressure on nares, nasal septum and forehead, increasing injury risk. Through the framework of comparative effectiveness research an examination of nasal interfaces currently used during neonatal CPAP was conducted in an effort to provide scientifically supported recommendations and improve clinical outcomes. The primary aim of this study was to determine differences in the frequency, severity and specific types of nasal injuries described when comparing different nasal CPAP interfaces (prongs/mask/rotation) used in the treatment of neonatal respiratory distress syndrome (RDS). A secondary aim of the study was to identify risk factors that may be associated with skin breakdown during nasal CPAP administration. A three group prospective randomized experimental design was used to study78 neonates <1500 grams receiving nasal CPAP using the same delivery system. The subjects were randomized into three groups: 1) continuous nasal prong group, 2) continuous nasal mask group, or 3) alternating mask/prongs group. Serial data collection included: demographic, biophysical measures and the Neonatal Skin Condition Scale (NSCS). This study demonstrated a significant difference in the frequency and severity of skin injury when utilizing a method of rotating mask and prong nasal interfaces during neonatal CPAP therapy; a useful clinical recommendation. Specific nursing care implications related to study findings include; choosing a device for best fit for infant (face shape and infant size); positioning of the CPAP device; developmental position of the infant; and focused skin assessment with rapid intervention. Standardized care including skin barriers, clinical expertise of nursing and respiratory therapy, and skin care management are strategies that warrant additional research.