CC: Physiological Nasal Airflow

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This clinical concept video will focus on physiologic nasal airflow a fundamental topic to understanding most disease processes that impact the nasal airway.

So the modern nose clinic is developing a series of videos and we're going to clump them into different categories. This is called a clinical concept video and the goal is to instruct you and teach you about some important principles that you can apply to understand your particular disease process.

So physiologic airflow, why do you care? Does it really matter?

Will it be important to your life?  It does! It matters, with almost all disease processes that we deal with here at the modern nose clinic.

What you want is a good foundation for your nasal airway, and that starts with, having correct air flow through your nose.

So let's start off with a little bit anatomy first okay. First the anatomy, so this is a basic anatomic chart you might see in your ear nose and throat doctors office.

I'm going to focus in on the nasal piece of it which is this panel of images. I'll try to keep it somewhat simple. It's the front view this is the side view, air enters the front of your nose here, into your nostril, this is called the nasal vestibule. As it moves through the nasal passageway, this is the respiratory portion of the nasal passageway and this region up here is called the olfactory cleft. As a matter of fact, you can see here the olfactory bulb setting several nerves in through the roof of your nasal passageway. On the other side of this structure here, which is called the middle turbinate. If you could go in and behind, you would see that you would have openings to all of your sinuses. Your major sinuses here, then as the air flows back more posterior it flows right across the opening of your eustachian tube here. The eustachian tube moves from up here, let's see where the best picture is, up into your middle ear space and then the air will continue back, and this area is called the nasal pharynx, and then back into the oral pharynx, and then into the hypo-pharynx, then into your airway. So again the front of your nose the nasal vestibule, just like a house so your vestibule, then it moves through this area here where air does a variety of different things, we'll get to, different sinuses flow into it. You smell food along the olfactory cleft right here, and it even ventilates your ear right here until it passages into the back of the nose the back of the throat and down into your airway.

So the next concept I'd like to relay to you because it's really important I kind of refer to it often during our clinic visits is something called Bernoulli's principle. And Bernoulli was a scientist who wrote a book called Hydrodynamica back in 1738, and it's important, it's important that's why airplanes fly. That's why air moves through your nose. It's kind of like a river and, I want to talk about the nose as if it's a river, if you don't mind? So a river will follow the path of least resistance and so too will air flow through your nasal passageway. Let's take a look at our diagram for that. So one common error that occurs with many many ear nose and throat doctors surgeries, and this is probably true for the majority of doctors across the United States.

Is that most ear nose and throat doctors have what I would refer to as a blatant disregard for this structure here. This is referred to as the inferior turbinate this is the middle turbinate and this is the superior turbinate, and why I say that is because it is very common for a general ENT across the United States to dramatically reduce the size of this structure. And there's probably 20 different ways that could occur.

Another common thing that an ear nose and throat doctor will do is to straighten the septum. And in regards to straightening the septum, it's always a bit of an issue because well where the modern nose clinic and we really focus on the nasal airway. We need physiologic airflow. So having a straight septum can be helpful. Having said that, I often joke, do you know who else has a deviated nasal septum? And the answer is everybody! Everybody seems to have a deviated septum. Whenever the septum is perfectly straight you're either genetically blessed, you've never had an active lifestyle, you didn't have a big brother, or you've had surgery.

So it's not nearly as important that you have a deviated septum as it is whether or not you sleep at night with your mouth open. If you sleep at night with your mouth open, there's too much resistance in your nasal airway. And the nasal septum being deviated may be one reason why.

So in summary, to what I just was discussing is a very common combination surgery that a general ENT across the United States will perform at least in 2018, is a septoplasty where you straighten the septum so that it is straight. That makes sense although it's not always crucial and reduction of the inferior turbinate because, as I said earlier there seems to be a blatant disregard for the structure.

But at the conclusion of this video, I hope you feel otherwise about these topics.

So what have we talked about so far? We've talked about Bernoulli's principle. The idea that the nose the nasal airway is like a river and water will flow through following the path of least resistance. We talked about how many ear nose and throat doctors do a surgery to improve nasal airflow. And I'm about to explain.

When you pull these together, why it's a bad idea to do it in that manner. So as we remember fluid will follow the path of least resistance. If this structure is dramatically reduced in size and it's not done in a careful way air will enter that nasal vestibule and flow along the floor of the nasal passageway into the back of the throat, and you're not using 90% of your nasal airway. This is an important 90%, I see patients almost every day who've had this done and they're not really ventilating their nose. They complain that their nose feels stuffy, they may even complain of pain. There's something called an empty nose syndrome and it's a very difficult thing to fix. So it's ideal is if you can avoid that in the first place and that gets to our final topic.

Physiologic airflow, so with physiologic airflow at the Modern Nose Clinic, we want to direct air up along the roof of the nasal passageway so we can ventilate the sinuses. We want to direct air up along the roof of the nasal passageways so that your olfactory cleft where you smell food is maximally utilized. A large percentage of your sense of taste comes from your sense of smell.  We happen to live in the wine country, here for those of you who don't know where the modern nose clinic is. So having a good sense of smell is also important.

Finally, you want the air to be filtered maximally humidified and basically maximally conditioned as it flows through the nasal passageway. Then the air will move across the back, across the opening of your eustachian tube and as you're following this pathway it's a nice sweeping gradual turn, and I often talk about a car driving on a highway, and as you're hitting a large sweeping turn you can maintain your speed of 65 miles an hour without slowing down, but occasionally our highways are littered with tiny sharp turns. We have a place called Terwilliger curves in the Portland area. Air enters the mouth if it enters the mouth and bounces back and forth between the soft palate the hard palate.

The tongue hitting your epiglottis making this vibrate and then this vibrating air will hit your epiglottis also by the time the air hits the airway down here you've lost a lot of momentum.

So it's really important to not be a mouth breather you want to be a nasal breather. It's really important the air does not flow along the floor of the nasal passageway taking all this out of the system. You want to flow up across everything and down the backside and now is going to emphasize that one more time before we conclude this video.

So some of the reasons why I think it's important that you have airflow in this manner. You want air to come in and be dished upward. You want it to hit all the mucosal surfaces around the openings of your sinuses around your ethmoid system so on and so forth. You want to be careful that your surgeon doesn't just resect all of your ethmoid air cells every time because it takes a lot of that mucosal surfaces out of the question. You want the air to interchange so any dust, any antigens, if you have allergies any viruses any infectious particles have the opportunity to stick to the surface. And what's left is the air that has been properly conditioned. You want the air to move up so it could be humidified, it can be warmed and it will be higher quality. And then as it moves down back here there's something that I will refer to in another video where there's a common final pathway of mucus all collecting and moving down here. It serves a function too. So you want the air to move this way and you'll have some resistance when you're done this surgery but yet you'll have the highest quality air moving down the back of your throat in a correct direction. And by the way if your doctor tells you to get your uvula cut out, don't do that!

The uvula is there for a reason it's not just an accident, it's a reason why there is a uvula in every person across the world. It's actually directing the airflow down hopefully behind your epiglottis and down into your airway.

So Bernoulli will be happy to know that at least one ear nose and throat doctor seems to care about what you had to discuss and this is physiologic airflow thank you for your time.

So, first of all, I want to thank any of you who have stuck this video out to the end. At the modern nose clinic we believe the clinical experience should continue beyond the appointment and therefore you can continue to learn some of the topics we discussed during your appointment with these, what we refer to as clinical concept videos.

And I want to conclude by refreshing what we discussed. We discussed the physiologic air flow. We discussed understanding the basics of the nasal anatomy. We discussed Bernoulli's principle in Hydrodynamica in 1978, 1738. I wouldn't read it, but that's the idea. You can google it. Bernoulli's principle, it's b-e-r-o, oh well I don't know how to spell it, you'll probably get it. We talked about the nose as a river and that that air wants to follow a path of least resistance. We talked about some common mistakes, that occur across the country with people doing surgeries that direct airflow along the floor the nasal passageway and why that's not a good idea. And we discussed physiologic airflow and some basics with that.

More content will follow if you think these are of any value please leave a comment and thanks again from the modern nose clinic I'm Dr. Douglas Skarada thank you.