Why Am I Blowing Bubbles Out of Nose Nasal Track

Abstract

Intranasal pressures were measured in adults during nose blowing, sneezing, and coughing and were used for fluid dynamic modeling. Sinus CT scans were performed after instillation of radiopaque contrast medium into the nasopharynx followed by nose blowing, sneezing, and coughing. The mean (±SD) maximal intranasal pressure was 66 (±14) mm Hg during 35 nose blows, 4.6 (±3.8) mm Hg during 13 sneezes, and 6.6 (±3.8) mm Hg during 18 coughing bouts. A single nose blow can propel up to 1 mL of viscous fluid in the middle meatus into the maxillary sinus. Sneezing and coughing do not generate sufficient pressure to propel viscous fluid into the sinus. Contrast medium from the nasopharynx appeared in ≥1 sinuses in 4 of 4 subjects after a nose blow but not after sneezing or coughing.

Adults with early common colds have erratically distributed viscous fluid in the paranasal sinuses, which impairs sinus drainage and ventilation and may contribute to infectious sinusitis [1–5]. The source of this fluid is unknown. This study was conceived after observing bubbles in the maxillary sinuses of adults with common colds [1, 3] and seeing a recent patient with a pronounced example of this finding (figure 1). This patient characterized her illness as a "sneezy, nose blowing cold" and stated that when blowing her nose she "blows hard." The bubbles in the sinus cavity were believed to have resulted from the simultaneous introduction of air and fluid from the nasal cavity. To test this hypothesis, intranasal pressure was measured in healthy volunteers during sneezing, coughing, and nose blowing. In addition, iodinated contrast medium was instilled into the nasopharynx before these activities, and contrast de-position in the sinuses was determined by use of CT imaging.

Materials and Methods

Intranasal pressure measurements. Intranasal pressures were measured in 4 healthy adults during nose blowing, sneezing, and coughing, by use of a Millar SP-524 (Millar Instruments, Houston, TX) catheter pressure transducer (catheter diameter, 2.5 French; transducer diameter, 3.0 French) positioned above the inferior turbinate and a DSP Traq-Q data acquisition system (DFSP Technology, Fremont, CA). Data were sampled at 200 Hz, and antialiasing filtering was performed at 66 Hz. The effective bandwidth of sensor signals was ∼.02–66 Hz.

Nose blowing (both nostrils open or 1 occluded) and coughing were initiated voluntarily. Sneezing (both nostrils and mouth open or both nostrils and mouth occluded) was induced by touching the inferior turbinate with a cotton swab saturated with histamine (concentration, 25 mg/mL).

Mathematical modeling of nasal fluid flow. A simple fluid model incorporated a middle meatus, an infundibulum filled with viscous fluid, and a maxillary sinus partially filled with viscous fluid and partially filled with air. The infundibulum was assumed to have a diameter of ∼3 mm and a length of 7 mm. A logarithmic model of visco-elastic fluid was used in the simple model, on the basis of previous measurements of nasal mucus showing a viscosity >500 Pa-s at shear rates of 0.01 1/s and >0.02 Pa-s at shear rates of 100 1/s [6]. A half sine pressure transient with an amplitude equal to the average maximum pressure measured in the experiment was used in the model for both nose blowing and sneezing. The sine half period used for each activity was equal to the average duration of each event found experimentally.

CT examinations with intranasal contrast medium. Healthy adult volunteers with no history of nasal symptoms for 1 month were recruited. Limited coronal CT scans of the paranasal sinuses were obtained with subjects in the prone position by use of a standard clinical imager. Nonionic iodinated contrast media (Iohexol 350; Nycomed, Princeton, NJ) was instilled by way of the mouth into the nasopharynx immediately before nose blowing, coughing, or sneezing. The nasopharynx was selected because it is frequently colonized with bacteria that cause acute community-acquired bacterial sinusitis and is where rhinovirus is most often recovered during colds [7].

Nose blowing. Three volunteers had 3 mL of contrast instilled into the nasopharynx, who then blew their noses while remaining supine. This procedure was repeated 3 times, and then a limited, direct coronal CT image was obtained with the subject in the prone position.

A fourth volunteer was not able to cooperate with the application of contrast into the nasopharynx because of his gag reflex. Therefore, 5 mL of contrast was instilled onto the floor of each nasal cavity while he was supine; he then blew his nose, and a CT scan was obtained.

Coughing. One volunteer had 3 mL of contrast placed in the nasopharynx by way of the mouth and then voluntarily coughed repeatedly and forcefully. This procedure was repeated with 4 mL of contrast, and a CT was obtained with the subject prone. A second volunteer had 4 mL of contrast instilled into the nasopharynx once, then coughed forcefully and repeatedly for 2 bouts. A second application of contrast was not made because of a large amount of residual contrast in the nasopharynx after the first coughing episode. A third volunteer gagged excessively when the nasopharynx was stimulated, so 6 mL of contrast was applied onto the floor of the nasal cavity on each side; the volunteer then voluntarily coughed for 4 bouts while supine.

Sneezing. The general procedure for instilling contrast into the nasopharynx for sneezing was the same as above; however, contrast was only instilled once because repeated episodes of sneezing could not be elicited. One subject who received 2 mL of contrast while supine sneezed twice after histamine challenge. A second volunteer who received 4 mL of contrast sneezed once, and a third who received 6 mL of contrast sneezed 4 times. Simulated sneezes were studied in an additional 2 volunteers.

Results

Intranasal pressure measurements. The mean (±SD) maximum transient intranasal pressure measured in 4 subjects during multiple nose blows was 66 (±14) mm Hg (table 1). Pressure transients from nose blowing with both nostrils open (n = 21) did not differ from those with 1 nostril occluded (n = 14). Therefore, all nose blowing measurements were combined in the analysis (n = 35). The mean (±SD) peak intranasal pressure from 18 voluntary coughing bouts was 6.6 (±2.6) mm Hg, that from 13 histamine-induced sneezes was 4.6 (±3.8) mm Hg, and that from 1 min of tidal breathing by each of 4 subjects was 0.9 (±0.4) mm Hg. The mean pressure associated with nose blow-ing differed significantly (P<.01, Student's t test) from each of the other activities: coughing, sneezing, or calm breathing. The mean pressures associated with sneezing and coughing were significantly higher than those associated with quiet respiration (P<.01, Student's t test).

When a subject's mouth and nose were closed during a histamine-induced sneeze, large increases in transient intranasal pressure occurred. Two subjects did this by trapping a sneeze with a tissue, resulting in peak pressures of 176 and 128 mm Hg for 1 subject and 88 mm Hg for the other.

The mean (±SD) durations of the intranasal pressure transients were 1.9±0.6 s for nose blows, 2.2±0.6 s for coughing bouts, and 0.4±0.2 s for sneezes (table 1). Even when sneezing occurred with the subject's mouth closed and nose occluded, the mean duration of the pressure transient was only 0.56 s, which was considerably shorter than that observed with a typical nose blow. With tidal breathing, intranasal pressure transients were characterized by sinusoidal waves of long duration and very small amplitude (not shown). Representative time histories for each activity are compared in figure 2.

Modeling of nasal fluid flow into the maxillary sinus. Modeling of the parameters measured (table 1) indicated that 1 mL of viscous nasal fluid can be pushed into the maxillary sinus from the mean pressure transient associated with a nose blow (66.2 mm Hg). This is 20 times the volume of fluid contained in the lumen of the infundibulum (0.05 mL). On the other hand, a typical sneeze (with both nostrils open) generated an intra-nasal pressure (4.6 mm Hg) that could move into the sinus only an amount of viscous fluid less than the volume contained in the infundibulum. The difference in maximum pressure transients and durations between nose blows and sneezes accounts for a large part, but not all, of the difference in the amount of fluid flow into the sinus. Another significant contribution to fluid movement is the effect of shear rate on nasal fluid viscosity. In the model, nose blowing produced a maximum shear rate of >1500 1/s in the infundibulum. This shear rate would result in a low fluid viscosity in the range of 0.001 Pa-s. In contrast, sneezing produced a maximum shear rate of only ∼180 1/s, which resulted in a viscosity of >0.01 Pa-s. In addition, the low maximum shear rate with sneezing occurs over a much shorter time period than does the much higher shear rate associated with nose blowing (figure 2). During a normal sneeze, the nasal fluid remains considerably more viscous and resistant to flowing into the sinus than it does when subjected to the large shear rate that accompanies a nose blow.

CT examinations with intranasal contrast medium. After nose blowing, contrast was seen in the ostiomeatal complex and in the ethmoid and sphenoid sinuses of all 4 volunteers (table 2). Contrast was present in the infundibulum and maxillary and frontal sinuses of 2 of 4 subjects. Contrast outlined occasional bubbles in the maxillary and sphenoid sinuses of 1 of the subjects (figure 3).

After histamine-induced sneezes, contrast did not appear in the infundibulum or sinus cavities of any of the 3 volunteers. Similarly, contrast was not detected these areas in 2 volunteers who simulated sneezes.

After coughing, the CT scan of 1 of 3 subjects showed a small amount of contrast in the infundibulum bilaterally. Otherwise, cough was not associated with contrast the presence of contrast in the paranasal sinuses.

Discussion

The epithelial lining of the maxillary sinus is rich in mucus-producing goblet cells, whereas seromucous glands are sparse [8–10]. The frothy material present in the maxillary sinus of the patient described (figure 1) could not have originated from mechanical mixing of mucus and air in the sinus cavity. Achievable rates and amplitudes of head motion (>1 Hz and 0.1 m, respectively) cannot even corrugate the surface of mucus under shear from air [11]. The self-adhesion of the mucus and the adhesion of the mucus to the sinus wall [12] prevent the detachment necessary for bubble formation during agitation of the head. Other possibilities, for instance that the bubbles resulted from infection by a gas-forming microorganism, are unlikely.

Fluid dynamic simulations revealed that the high intranasal pressures generated by nose blowing would propel viscous fluid into the paranasal sinuses. The CT experiments confirmed fluid deposition in the paranasal sinuses after nose blowing. In addition to large intranasal pressure transients, the reduction of viscosity at the high shear rates with nose blowing enhances the formation of bubbles. In contrast, sneezing (with the nostrils open) and coughing only elevated intranasal pressure slightly and tenfold less than the mean pressure produced by nose blowing. Fluid modeling indicated that sneezing and coughing would not result in nasal fluid deposition in the paranasal sinuses. This was supported by the negative findings in the CT scan experiments.

During a cold, viscous fluid accumulates in the sinus; the degree to which this is attributable to nose blowing is unknown. However, there is the potential for nose blowing to introduce nasal fluid containing viruses, bacteria, and inflammatory mediators [13]. Subjects with experimental colds averaged 45 episodes of nose blowing during the first 3 days of illness [14]. Treatment of volunteers with first-generation antihistamines reduced nasal fluid weights by up to 37% and the use of nasal tissue by up to 38% [14–16]. It remains to be determined whether early treatment to reduce nasal fluid production will reduce sinus involvement during colds.

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Figures and Tables

Figure 1

Coronal CT scans of the maxillary sinus of an adult with a common cold. A, Fourth day of illness showing multiple bubbles in the sinus cavity (white arrow), occlusion of the infundibulum (black arrowhead), and homogenous abnormality along the medial wall and floor of the sinus cavity (black arrow). B, Seventh day of illness showing occlusion of the infundibulum (black arrowhead) and homogenous abnormality of the lower two-thirds of the sinus cavity (black arrow). Few bubbles are still present in this material, but most of those present earlier have burst (white arrow).

Figure 1

Figure 2

Intranasal pressure time histories for a representative nose blow, coughing bout, and sneeze shown on the same scale for comparison (dashed line, nose blow; solid line, coughing bout; and dotted line, sneeze).

Intranasal pressure time histories for a representative nose blow, coughing bout, and sneeze shown on the same scale for comparison (dashed line, nose blow; solid line, coughing bout; and dotted line, sneeze).

Figure 2

Figure 3

Sinus CT scan of an adult after instillation of contrast medium into the nasopharynx followed by nose blowing. A, Contrast in an anterior ethmoid sinus cell (short arrow) and in the floor of the nasal cavities (long arrow). B, Contrast in the infundibulum bilaterally (short arrows) and in the maxillary sinus outlining a bubble (long arrows). C, Contrast in the posterior ethmoid sinus (arrow), and D, contrast in sphenoid sinus outlining bubble (arrow).

Figure 3

Table 1

Intensity and duration of intranasal pressure transients and calculated mucus flow into the maxillary sinus in 4 volunteers during nose blowing, coughing bouts, and sneezing.

Table 1

Intensity and duration of intranasal pressure transients and calculated mucus flow into the maxillary sinus in 4 volunteers during nose blowing, coughing bouts, and sneezing.

Table 2

Sites of deposition of contrast medium from the nasopharynx into the ostiomeatal complex and paranasal sinuses in 4 volunteers after nose blowing.

Table 2

Sites of deposition of contrast medium from the nasopharynx into the ostiomeatal complex and paranasal sinuses in 4 volunteers after nose blowing.

Informed consent was obtained from each volunteer, and the protocol was approved by the human investigation committee of the University of Virginia.

Guidelines for human experimentation of the US Department of Health and Human Services and those of the University of Virginia were followed in the conduct of the clinical research.

Financial support: Support for this work was from discretionary funds of one of the investigators (J.M.G.).

Why Am I Blowing Bubbles Out of Nose Nasal Track

Source: https://academic.oup.com/cid/article/30/2/387/382446

Why Am I Blowing Bubbles Out of Nose Nasal Track

Abstract

Materials and Methods

Results

Discussion

References

Figures and Tables

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