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This chapter is the first of two chapters demonstrating the wide variety of CFD studies in clinical applications presented from leading researchers in their respective fields. This chapter covers the latest research techniques and outcomes in airflow and conditioning in the nasal cavity; fluid and particle dynamics from sniffing; nasal obstruction and empty nose syndrome; nasal nitric oxide (nNO) dynamics and the ostiomeatal complex.

There is an enormous range of anatomical variants of the nasal cavity and paranasal sinuses, and these can be influenced by gender, age and ethnic adaptations to local climate. A further factor is pneumatization of the paranasal sinuses which is highly variable between individuals. When significant deviations occur from typical airway geometries, this can lead to nasal airway obstruction having the potential to significantly reduce quality of life in patients. This chapter presents the main factors affecting anatomy geometry, and common disorders, diseases, and its management.

A good understanding of the normal human nose anatomy and function is critical to perform human respiratory system computer modelling and computational fluid dynamic (CFD) analysis. This chapter provides a broad overview of the function and organisation of the human respiratory system, including essential anatomical definitions, anatomy and naming conventions, as well as particular areas of surgical interest. The topics include Functions and Organisation of the Respiratory System, and the nasal cavity anatomy, function, physiology, and histology.

Background The aim of this study was to use computational fluid dynamics (CFD) to investigate the effects on nasal heat exchange and humidification of two different surgical techniques for reducing the inferior turbinate under different environmental conditions. Methods Virtual surgery using two techniques of turbinate reduction was performed in eight nasal airway obstruction patients. Bilateral nasal airway models for each patient were compared: 1) Pre-operative 2) Post inferior turbinoplasty 3) Post total inferior turbinate resection (ITR). Two representative healthy models were included. Three different environmental conditions were investigated 1) ambient air 2) cold, dry air 3) hot, humid air. CFD modelling of airflow and conditioning was performed under steady-state, laminar, inspiratory conditions. Findings Nasal conditioning is significantly altered following inferior turbinate reduction surgery, particularly with ITR under cold, dry inspired air (CDA). The degree of impairment is minor under the simulated range of environmental conditions (temperature = 12–40 °C; relative humidity = 13–80%). Streams of significantly colder air are found in the nasopharynx and more prevalent under CDA in ITR. These are related to high velocity flow streams, which remain cool in their centre throughout the widened inferior nasal cavity. Interpretation Reduced air-mucosal heat exchange and moisture carrying capacity occurs under cooler temperatures in patients following inferior turbinate surgery. The clinical impact in extremely cold and dry conditions in groups with poor baseline respiratory function, respiratory illness, or endurance athletes is of special interest.

Background Despite functional endoscopic sinus surgery (FESS) being the standard of care in medically recalcitrant chronic rhinosinusitis (CRS), its effect on sinus ventilation has not been fully characterized. Airflow simulations can help improve our understanding of how surgical strategies affect post-surgical sinus ventilation. Methods Eight postoperative sinonasal cavity models were reconstructed from a wide spectrum of CRS patients who had undergone FESS. Computational fluid dynamics modeling of steady-state, laminar, inspiratory airflow was performed. Ventilation was quantified and observed for all the sinuses in each model. Results Sinus aeration was enhanced following FESS, particularly in the maxillary and ethmoid sinuses. The degree of improvement was related to the extent of surgery performed. This finding was accentuated at a higher inhalational flow rate of 15L/min. The relationship between ostium size and corresponding sinus inflow was stronger for the maxillary and sphenoid sinuses. Maxillary inflow reached 50% in a mega-antrostomy patient, while negligible flow occurred in the frontal sinuses for except one whom had undergone a modified Lothrop procedure. Conclusions This study has quantified sinus airflow in the largest set of post-FESS patients to date, to show that with increasing extensive surgery, the sinus and nasal cavity become more interconnected and functionally interdependent. Accordingly, sinus ventilation is improved. This may have important consequences for pre- and post-surgical assessment and planning, and on predicting how drug delivery treatments and devices can be designed to target the postoperative sinuses.

BACKGROUND Optimizing intranasal distribution and retention of nasal sprays is essential in the management of patients with chronic rhinosinusitis (CRS), including those that have had functional endoscopic sinus surgery (FESS). Despite multiple existing distribution studies, there remains a need for a technique that allows regionalization of particle deposition within a patient's unique 3-dimensional (3D) geometry without exposing the patient to radiation. METHODS Seven participants delivered normal saline containing a gadolinium-based contrast agent (GBCA) by either saline irrigation or nasal sprays on 1 side of the nasal cavity. The saline irrigation group included 2 participants (both healthy) while the nasal spray group included 5 participants (2 healthy, 2 post-FESS patients, 1 CRS patient without any sinus surgery). The distribution of new signal enhancement was assessed on each participant using magnetic resonance imaging (MRI). Serial scans were performed over an interval of 4 minutes in the nasal spray group to assess changes in intranasal distribution over time. RESULTS Signal enhancement was widespread within the nasal cavities and maxillary sinuses of participants (both healthy) that underwent sinus irrigation. For the nasal spray participants, the hotspots for signal enhancement were similar regardless of disease status or previous history of surgery. These included the internal nasal valve, anterior septum, inferior surface of the inferior turbinate, nasal floor, and nasopharynx. No signal enhancement was detected with nasal sprays in either unoperated or operated paranasal sinuses. CONCLUSION A technique has been developed using MRI evaluation of radioopaque contrast to characterize the temporospatial distribution of topical drug delivery within the sinonasal cavities.

Optimizing intranasal distribution and retention of topical therapy is essential in the management of patients with chronic rhinosinusitis, including those that have had functional endoscopic sinus surgery (FESS). Computational fluid dynamics analysis has not previously been used to investigate sinus nasal spray delivery in the complete post-operative sinonasal geometries of patients who have undergone FESS. Models of sinonasal cavities were created from postoperative magnetic resonance imaging scans in four patients, three of whom underwent a comprehensive FESS, the other a modified endoscopic Lothrop procedure. Spray simulations were conducted at different flow rates (5 L/min, 10 L/min and 15 L/min) using sixteen particle sizes ranging from 4 μm to 70μm, spray velocity of 10 m/s and plume angle of 15°. Two different spray insertion angles were compared. Airflow distribution in the sinuses was closely related to the patient's nasal geometry and surgical intervention, in particular a unique crossflow between nasal chambers was present for the Lothrop patient. Sinus deposition was generally more effective with inhalational transport of low-inertia particles outside of the range produced by many standard nasal sprays or nebulizer. This was true except in the Lothrop patient, since previous surgery had been performed removing most of the septum where high-inertia particles would normally deposit. For sinuses receiving minimal airflow, particle penetration was diminished and successful deposition in the region became more restricted by device parameters. Further research is needed to validate these findings and explore other spray variables in a wider spectrum of patients to ascertain a multi-level approach to optimizing drug delivery in the sinuses.

Background: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract and make up 1–2% of all gastrointestinal malignancies. Traditionally, the treatment of choice for primary disease is surgical resection; however, no single surgeon or institution gets extensive exposure to these patients so appropriate decision-making is difficult, particularly since the introduction of the tyrosine kinase inhibitor imatinib, which has become an important additional management tool. Method: All patients were diagnosed and treated for GISTs in Christchurch Hospital (Christchurch, New Zealand) between 1 January 2000 and 31 December 2010. We maintain a prospective database of all patients with GISTs. Data on clinical and histopathological variables, management and survival outcomes were recorded. These were then reviewed. Results: There were 93 patients in this study. Fifty were women. Median age was 69 (interquartile range (IQR) 59–76) years. Fifty-one tumours were located in the stomach, 27 in the small bowel, six in the colon, three in the oesophagus, one in the rectum and five were extra-gastrointestinal. In total, 22 patients received imatinib therapy; four patients with metastatic disease had imatinib as sole therapy. The median follow-up was 58 (IQR 30–90) months. The 5-year overall survival and disease-free survival (DFS) for the entire study population was 69% and 64%, respectively. The 5-year DFS was higher for all patients who have localized disease when compared with those who have metastatic disease (76% versus 28%, P-value 0.001). Conclusion: Surgery aiming at an R0 resection remains the mainstay of treatment. We propose the most effective way to grow the knowledge base in New Zealand is the establishment of a national register, thereby allowing better clinical decision-making by interpretation of a larger data set.