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Indian Journal of Otolaryngology and Head & Neck Surgery logoLink to Indian Journal of Otolaryngology and Head & Neck Surgery
. 2021 Aug 28;74(Suppl 2):1675–1682. doi: 10.1007/s12070-021-02809-0

Do Mean Values of the Peak Inspiratory Nasal Flowmeter Vary According to the Severity, Direction and Type of Nasal Septum Deviation?

Adem Bora 1,✉, Yasin Aslan 1, Kasım Durmuş 1, Berat Baturay Demirkıran 1, Emine Elif Altuntas 1
PMCID: PMC9702492  PMID: 36452731

Abstract

The aim is to investigate the contribution of the PNIF test in daily clinical practices in the objective evaluation of the early postoperative functional results of septoplasty and the effect of the severity, direction, and type of nasal septum deviation on mean PNIF values. Nasal septum deviation (NSDs) of the cases were grouped according to the Mladina classification and the severity of NSDs. An objective evaluation of the nasal airway was conducted via a peak flowmeter device in the preoperative and postoperative first month. When examining the mean PNIF values according to genders, it was observed that the values determined in male cases in the preoperative and postoperative period were higher. In the intragroup evaluation performed according the Mladina classification, a statistically significant increase was observed in the preoperative and postoperative PNIF values of the cases in Types 1–4. In the intragroup evaluation performed according to the severity of NSD, there was a significant increase in the preoperative and postoperative PNIF values of the mild and moderate cases. When comparing the preoperative and postoperative PNIF values of the groups in terms of the severity of NSD, it was observed that there was a significant difference. The PNIF can be used in routine clinical practices to evaluate the septoplasty results objectively. In the evaluation of functional results, the change in the mean PNIF values may also vary according to the direction and severity of septum deviation and the Mladina classification other than age, gender and ethnic origin.

Keywords: Peak inspiratory nasal flowmeter, Septoplasty, Functional recovery, Mladina classification, Direction and severity of septum deviation

Introduction

Chronic nasal obstruction affects more than one third of society [1]. The aetiology of nasal obstruction is multifactorial and one of the leading anatomic causes is nasal septum deviation (NSD) [2]. The diagnosis of NSD is made via anterior rhinoscopy and endoscopic examination. Objective tests such as computed tomography (CT), acoustic rhinomanometry and rhinomanometry can also be used in the diagnosis, when necessary [3].

As the pathology causing nasal obstruction originates from changes in the anatomic structure, the treatment of NSDs is surgical. The goal of this treatment is to open the nasal passage and achieve adequate nasal airflow [4]. Objective and subjective evaluation methods are used in evaluating the effect of surgical treatment on the patient’s quality of life and the functional results [5]. The simplest one of subjective evaluation methods is calculation of the rate of patients who have undergone septoplasty and are satisfied with its functional results to all patients and one of the best examples is the Swedish septoplasty register [6]. Another simple subjective evaluation method that is often used in most clinics to measure the level of satisfaction with surgery and severity of symptoms is the visual analogue scale (VAS). However, in VAS, there is variation between the evaluators [7]. Other scales used for evaluating nasal symptoms more consistently are Nasal Obstruction Symptom Evaluation (NOSE), Fairley Nasal Symptom Questionnaire (FNQ), SNOT-22 and Glasgow Benefit Inventory (GBI) [8, 9]. The leading objective tests used in evaluating the septoplasty results include acoustic rhinomanometry and rhinomanometry. The results of these tests are accepted to be reliable; however, they have some disadvantages like being expensive, devices requiring calibration, difficulty of interpreting the results and taking too much time [10, 11]. In addition, it should be considered that it is not always possible to reach these objective evaluation methods outside research clinics [12]. Thus, the peak nasal inspiratory flow meter (PNIF) test which is a practical tool measuring the nasal airflow in a fast and cheap maximal inspiration, has begun to be used in evaluating the results of this patient group [12–14]. Normative data of the PNIF are available for the paediatric, adult and geriatric patient populations. Also, it is known that the results of this test are compatible with subjective tests like NOSE and objective tests like rhinomanometry and acoustic rhinomanometry [15]. In their review published in 2016, Ottaviano and Fokkens [15] recommended the regular use of the PNIF in every clinic treating patients with nasal obstruction. From this point of view, the aim of this study is to investigate the contribution of the PNIF test in daily clinical practices in the objective evaluation of the early postoperative functional results of our septoplasty patients and the effect of the severity, direction, and type of nasal septum deviation on mean PNIF values.

Material and Method

The study was conducted with a total of 103 cases [mean age 33.60 ± 12.98 years (min–max: 13–69 years)], who applied to the XXXX XXXX University Ear-Nose-Throat (ENT) Disorders clinic due to complaints of difficulty in breathing through the nose between December 2017-November 2019, were diagnosed with septum deviation during the anterior rhinoscopy and flexible endoscopic examination and were voluntary to participate in the study. Of the cases included in the study; 30.1% (n = 31) were female [mean age 36.13 ± 12.53 years (min–max: 13–64 years)] and 69.9% (n = 72) were male [mean age 32.51 ± 13.11 years (min–max: 17–69 years)].

The researcher informed all the voluntary cases and then their oral and written approval forms were obtained. Ethics committee approval of the study was obtained from the Sivas Cumhuriyet University Clinical Trials Ethics Committee (Date: 09.10.2019; Decree No: 2019–10/06).

Other than the cases who did not agree to participate in the study and did not give written informed forms; the cases who had severe pulmonary diseases like chronic obstructive pulmonary disease, cystic fibrosis and emphysema, had a positive history of taking oral or topical corticosteroids in the preoperative period (≥ 6 weeks), went through an acute bacterial or viral infection or sinusitis in the last two weeks, had a positive history of nasal surgery and were diagnosed with allergic rhinitis, were excluded from the study. Also, the cases, who had an active sinus or nasal infection during the evaluations, were excluded from the study.

The anterior rhinoscopic evaluation and endoscopic examination of all cases who were included in the study were performed by the same researcher (AB). NSDs identified in the cases were classified in seven groups according to the Mladina classification [16]. In addition, the cases were classified in three groups according to the severity of NSD as; mild NSD if NSD obstructed 1/3 of the nasal cavity; moderate NSD if NSD obstructed 2/3 of the nasal cavity and severe NSD if NSD obstructed the nasal cavity completely [17].

A radiological evaluation was performed on them via the axial and coronal Paranasal Sinus Computed Tomography (PNSCT) in the preoperative period in order to eliminate additional pathologies like concha bullosa in all cases for whom NSD was detected and who were decided to undergo an operation.

An objective evaluation of the nasal airway was performed via a peak flowmeter (PF) (Clement Clarke International Limited. Edinburg way, Horlow, CM 20 TT, England) device in the preoperative and postoperative first month. Prior to the PF application all cases were profoundly informed about the test. Before starting the test procedure all cases were asked to sit and rest for 30 min. In order to determine the highest PNIF value in all cases in a standard medium, the cases were all kept in a room with a constant temperature (19 °C—22 °C) and relative humidity (25%—35%) for at least ten minutes prior to the PF test application. Throughout the test, the cases were asked to take off their glasses and sit up straight. Then, all cases were made perform inspiration and expiration successively three times in order to conduct nasal resistance measurement in a standard way. The mask of the inspiratory PF device was placed fully on the face of the cases. They were asked to perform a deep inspiration from the nose and this process was repeated three times. During the repetitions, the highest value measured with maximum 10% difference was accepted to be the nasal inspiration airflow (L/min) resistance value. The change obtained in the preoperative and postoperative first month results was analysed.

For statistical evaluation, the “Statistical Package for Social Sciences (SPSS) 23.0” statistical package program was used. The Shapiro–Wilk normality test was applied to the preoperative and postoperative PNIF values. In order to evaluate mean scores of the groups; the Wilcoxon signed-rank test and Mann–Whitney u test were used for non-parametric variables and the Kruskal–Wallis h test was used for multi-category comparisons. The analyses were interpreted at confidence level of 95% and p value of < 0.05 was accepted to be significant.

Results

The mean PNIF value of all cases was 54.32 ± 25.53 L/min (min–max: 20–150 L/min) in the preoperative period and 67.04 ± 24.14 L/min (min–max: 30–150 L/min) in the postoperative period. This change observed in the mean PNIF value of the cases in the early postoperative period was statistically significant (p < 0.05).

The mean PNIF value of the cases according to genders was 58.61 ± 25.0 L/min (min–max: 25–150 L/min) for the males and 44.35 ± 16.01 L/min (min–max: 20–75 L/min) for the females in the preoperative period. Their mean PNIF value was 72.43 ± 24.02 L/min (min–max: 30–150 L/min) for the males and 54.252 ± 14.96 L/min (min–max: 30–100 L/min) for the females in the postoperative first month. When examining the PNIF values; it was determined that there was a statistically significant difference between the preoperative and postoperative mean PNIF values of the female and male cases (p < 0.05; p = 0.003 p < 0.001) and the mean PNIF values were higher in the male cases than the female cases. In the intragroup evaluation made according to genders, the change in the mean PNIF values was statistically significant in the postoperative period for both female and male cases, compared to the preoperative period (p < 0.05; p = 0.003; p < 0.001). In addition, when evaluating the preoperative and postoperative PNIF measurements of the genders within themselves; the values obtained for the males (Δµ = 13.82) were statistically significantly higher than the values obtained for the females (Δµ = 10.16).

When evaluating the cases according to the direction of NSD detected during the anterior rhinoscopic examination, 53.4% (n = 55) had right-sided deviation, 42.7% (n = 44) had left-sided deviation, and 3.9% (n = 4) had a S-shaped deviation. When comparing the preoperative and postoperative mean PNIF values according to the direction of NSD, it was determined that there was no statistically significant difference between the groups (p > 0.05; p = 0.527, p = 0.786). In the intragroup evaluation of the preoperative and postoperative mean PNIF values, it was observed that the right-sided and left-sided change in the NSD cases showed a statistically significant increase (p < 0.05; pright < 0.001, p < 0.05; pleft < 0.001); however, there was no statistically significant change in the cases with S-shaped deviation (p > 0.05;p = 0.102) (Table 1).

Table 1.

The change observed in the preoperative and postoperative PNIF values of the cases according to the direction of NSD identified during the anterior rhinoscopic examination

Deviation Direction Preoperative PNIF Postoperative PNIF P value
Mean ± SD Mean ± SD
Right-sided Deviation 55.45 ± 23.58 68.45 ± 24.15 0.001
Left-sided Deviation 53.98 ± 24.27 65.68 ± 21.77 0.001
S-shaped Deviation 42.50 ± 12.58 62.50 ± 28.72 0.102
P value 0.527 0.786
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PNIF Peak nasal inspiratory flowmeter

When examining NSDs according to the Mladina classification, it was observed that 11.7% (n = 12) of the cases had Type 1 NSD, 12.6% (n = 13) had Type 2 NSD, 22.3% (n = 23) had Type 3 NSD, 16.5% (n = 17) had Type 4 NSD, 11.7% (n = 12) had Type 5 NSD, 4.9% (n = 5) had Type 6 NSD and 20.4% (n = 21) had Type 7 NSD. Table 2 shows the change observed in the preoperative and postoperative PNIF values of the cases according to the Mladina classification. In the evaluation performed between the groups in terms of the change observed in the PNIF values, it was found that there was no statistically significant change (p > 0.05; p = 0.441, p > 0.05; p = 0.162). In the intragroup evaluation performed on the cases in Types 1, 2, 3 and 4, it was observed that there was a statistically significant increase in the preoperative and postoperative PNIF values (Type 1: p < 0.05; p = 0.011, Type 2: p < 0.05; p = 0.003, Type 3: p < 0.05; p = 0.0.023, Type 4: p < 0.05; p = 0.045). In the intragroup evaluation performed on the cases in Types 5, 6, and 7 with more severe deviation, it was observed that there was no statistically significant change in the preoperative and postoperative PNIF values (Type 5: p < 0.05; p = 0.104, Type 6: p < 0.05; p = 0.068, Type 7: p < 0.05; p = 0.0.057).

Table 2.

The change observed in the preoperative and postoperative PNIF values of the cases with NSD according to the Mladina classification

Mladina Classification Preoperative PNIF Postoperative PNIF P value
Mean ± SD Mean ± SD
Type 1 42.92 ± 15.88 58.33 ± 13.37 0.011
Type 2 59.23 ± 31.68 83.85 ± 30.08 0.003
Type 3 51.74 ± 18.68 60.22 ± 13.44 0.023
Type 4 53.53 ± 22.90 65.00 ± 19.53 0.045
Type 5 63.33 ± 33.87 68.33 ± 31.57 0.104
Type 6 50.00 ± 29.79 65.00 ± 23.45 0.068
Type 7 57.14 ± 17.51 70.48 ± 25.05 0.057
P value 0.441 0.162
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PNIF Peak nasal inspiratory flowmeter

When classifying the cases according to the severity of NSD, it was determined that 36.9% (n = 38) had mild NSD, 53.4% (n = 55) had moderate NSD and 9.7% (n = 10) had severe NSD. Table 3 shows the changes observed in the preoperative and postoperative PNIF values of the cases according to the severity of NSD. It was observed that there was a statistically significant increase in the mild and moderate cases in terms of the intragroup preoperative and postoperative PNIF values (p < 0.05; pmild < 0,001, pmoderate < 0.001), while there was no distinct increase in the severe cases (p > 0.05; p = 0.088). When comparing the groups in terms of the preoperative and postoperative PNIF values, it was observed that there was a statistically significant difference (p < 0.05; p = 0.020, p < 0.05; p = 0.025). This difference was caused by the fact that the PNIF value was significantly higher in the moderate and severe cases than the mild cases in the preoperative period (p < 0.05; ppre;mild-moderate = 0.013, ppre;mild-severe = 0.040) and the fact that the PNIF value was higher in the cases with moderate deviation than the cases with mild and severe deviation in the postoperative period (p < 0.05; ppre;mild-moderate = 0.011).

Table 3.

The change observed in the preoperative and postoperative PNIF values of the cases according to the severity of NSD

Severity of NSD Preoperative PNIF Postoperative PNIF P value
Mean ± SD Mean ± SD
Mild 45.92 ± 17.00 58.68 ± 15.32  < 0.001
Moderate 58.82 ± 26.40 72.36 ± 26.75  < 0.001
Severe 61.50 ± 20.55 69.50 ± 18.33 0.088
P value 0.020* 0.025*
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PNIF Peak nasal inspiratory flowmeter

Preoperative PNIF pmild-moderate = 0.013; pmild-severe = 0.040

Postoperative PNIF: pmild-moderate = 0.011

The PNSCT imaging in the preoperative period revealed that there was a natural appearance in the concha of 71.8% (n = 74) of the cases and a bullous appearance in the right concha of 15.5% (n = 16), the left concha of 7.8% (n = 8), and the bilateral middle concha of 4.9% (n = 5). Figure 1 shows the changes in the correlations between the concha bullosa detected in the PNSCT imaging of all cases and the preoperative and postoperative mean PNIF values. The PNIF value was found to be 57.16 ± 26.34 L/min (min–max: 20–150 L/min) preoperatively and 69.26 ± 24.43 L/min (min–max: 30–150 L/min) postoperatively for the cases whose middle concha was natural and 47.07 ± 11.46 L/min (min–max: 25–75 L/min) preoperatively and 61.38 ± 18.66 L/min (min–max: 30–100 L/min) postoperatively for the cases with concha bullosa. When evaluating the cases in two groups on the basis of the presence of concha bullosa, it was observed that there was no statistically significant difference between the groups in terms of the preoperative and postoperative mean PNIF values (p < 0.05; ppre = 0.093, ppost = 0.209). However, in the intragroup evaluation it was determined that there was a statistically significant increase in the postoperative mean PNIF values in both groups (p < 0.001; pnatural < 0.001, pavailable < 0.001). In addition, when evaluating the 29 cases with concha bullosa according to the bullous concha being unilateral or bilateral, it was observed that there was no statistically significant difference between the groups in terms of the preoperative and postoperative mean PNIF values (p > 0.05; p = 0.413, p > 0.05; p = 0.261). In the intragroup evaluation, it was observed that the postoperative mean PNIF values caused a statistically significant increase in all three groups, compared to the preoperative period (p < 0.005; pright = 0.023, p < 0.05; pleft = 0.027 and p < 0.05; p = bilateral0.039) (Table 4).

Fig. 1.

Fig. 1

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Correlation between concha bullosa and the preoperative and postoperative PNIF values

Table 4.

Evaluating the correlation between concha bullosa and PNIF

Concha bullosa Preoperative PNIF Postoperative PNIF P value
Mean ± SD Mean ± SD
Right 46.56 ± 11.79 57.50 ± 19.75 0.023
Left 48.75 ± 12.17 66.88 ± 20.17 0.027
Bilateral 46.00 ± 11.40 65.00 ± 11.18 0.039
P value 0.413 0.261
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PNIF Peak nasal inspiratory flowmeter

Discussion

NSD is one of the pathologies frequently causing nasal obstruction. The most frequent symptom encountered in NSD cases is nasal obstruction. As is known, treatment of septum pathologies is surgical. The most important criterion used in evaluating the success of surgical operations which are performed to improve the nasal physiology and anatomy is to evaluate the nasal obstruction symptom via objective and subjective methods. In recent years, there has been a trend toward evaluating the functional results of surgeries via not only subjective evaluation methods but also via objective methods in the preoperative and postoperative period, due to the increase in medicolegal problems and for the reliability of scientific studies conducted [18]. Indeed, since the symptoms of patients are not always correlated with clinical findings in our daily clinical practice, it will be the most appropriate approach to objectively evaluate the nasal airway openness in order to get a true diagnosis and evaluate the results of the surgical intervention applied. Thus, it is of prime importance for rhinologists to measure the nasal airflow via objective methods such as rhinomanometry, acoustic rhinometry, rhinostereometry, rhinohygrometry, laser doppler velocimetry, manometric rhinometry, forced oscillation rhinomanometry and nasometry in the evaluation of functional results of surgical therapy [10, 19, 20]. However, since these methods have disadvantages such as being expensive, requiring calibration in every use and requiring auxiliary staff in general; they are not used routinely in most clinics. Thus, there was a need for more practical evaluation methods and the PNIF test was developed by Youlten [21] in 1980. Today, this test is one of the practical, affordable, fast, non-invasive, objective and reliable test tools most frequently used in measuring the nasal airway resistance. Various studies in the literature have revealed that the results of the PNIF test are compatible with the results of objective and subjective evaluation methods in evaluating nasal obstruction [22–24]. However, since the PNIF is a measurement technique which is dependent on the patient’s effort, there may be variations in the measurement results obtained. In line with the results obtained in the studies it is recommended that a good patient compliance be provided and the value of three successive measurements with less than 10% variation between be taken at the highest level in order to minimize these variations. In the present study, we performed our preoperative and postoperative measurements on the basis of this recommendation.

The PNIF test has no normative values and since it can be used by comparing the preoperative and postoperative values of patients, it is increasingly becoming a common objective evaluation method used in clinics today [24]. The study conducted by Ozkul et al. [25] in a population in the same age group with the present study, stressed the importance of this test in determining the normative PNIF measurements of the healthy population in Turkey and evaluating the surgical results in cases with NSD. In this study, the mean PNIF value was found to be 102.10 ± 21.39 L/min preoperatively and 139.20 ± 28.48 L/min postoperatively for the cases with NSD and 137.87 ± 43.65 L/min for the healthy population. The values were statistically significantly lower than the healthy population in the preoperative period and were similar with the healthy population in the postoperative period. In the objective evaluation, the PNIF was found to be effective. Among different studies on mean values of the PNIF in the healthy population, the mean PNIF value was found to be 129 L/min in a study conducted in Italy and 136 L/min in a study conducted in Finland, 87.5 L/min for individuals with VAS score of ≥ 8 and 84.7 L/min for individuals with VAS score of < 8 in a study conducted in France [26–28]. The mean PNIF value obtained in the present study was 54.32L/min in the preoperative period and 67.04 L/min in the postoperative period, which was highly lower than the results of previous studies. It was thought that this difference might be associated with the measurement technique, educational level of patients, inadequate informing by the implementer of the test to the patient or his/her lack of experience and inadequate patient compliance. Since the PNIF values are a product of mandatory inspiration, patients should certainly be informed very well before the test and the test should be conducted in a correct position. Also, mean PNIF values are affected by individual factors like age, gender, height, weight and ethnic origin [15]. It should be considered that this difference observed in results of the present study might have been caused by such factors that are less likely to be standardized. Thus, it is thought that it is crucial for every clinic to determine a normative data range for their own population, in order to use an evaluation method that is affected by such multi factors in the routine clinical practice.

In our literature reviews, various studies evaluating the functional results of septoplasty via the PNIF have been encountered [25, 29–31]. When examining the results obtained from the studies in general, it was determined that there was a significant increase in the postoperative mean PNIF values compared to the preoperative mean PNIF values. In addition, in the evaluation of the mean PNIF values obtained both in these studies and in the present study according to genders; it was found that the male cases had higher values than the female cases. This difference is not undoubtedly surprising. This is because PNIF values are affected by factors such as height and lung capacity between genders. When evaluating the results of these studies in the literature and of the present study as a whole; it was revealed that the PNIF provided important data in evaluating the preoperative and postoperative functional results of cases undergoing a septoplasty.

As far as we know, the present study, in contradistinction to the studies showing that the PNIF may be used as an objective evaluation method in the evaluation of functional results in septoplasty cases, is the first study evaluating the results according to the direction and severity of septum deviation and the Mladina classification [25, 29–31]. In the cases with S-shaped deviation according to the direction of septum deviation identified in the anterior rhinoscopic examination, it was observed that there was no significant difference in the mean PNIF values in the preoperative and postoperative period. Although there was a significant increase in the postoperative PNIF values of the cases with unilateral deviation, no statistically significant increase was observed in the S-shaped deviation, which makes us think that the increase of deviation severity may not cause a distinct increase in functional results of patients in the early period. Another point distinguishing the present study from similar studies in the literature is that our study investigated the PNIF change in the preoperative and postoperative period by grouping NSDs according to the Mladina classification. The results of the present study showed that there was no statistically significant change in the preoperative and postoperative PNIF values of the cases with more severe deviation (Types 5, 6, and 7). Also when classifying our cases as mild, moderate, and severe according to the severity of NSD, it was observed that there was no significant change in the preoperative and postoperative mean PNIF values of the severe cases. One of the weaknesses in the present study is that the effects of the operation were evaluated only in the early period. When evaluating all these results together; we can ask the question, ‘Does the change in the nasal physiology and functions affect the PNIF results in the late period in cases who have S-shaped deviation, suffer from a more severe deviation according to the Mladina classification or have severe NSD?’. Thus, it is believed that this question should be answered in further studies which follow cases, who have S-shaped deviation, suffer from more severe deviation according to the Mladina classification or have severe NSD, for a longer time in the postoperative period via the PNIF.

Conclusion

Results obtained from the studies on mean PNIF values in the literature may vary. This variation may arise from a number of factors. In order to use the test results as an objective evaluation parameter, it is necessary to minimize these factors.

Although mean PNIF values of the present study were lower than the studies in the literature, the change in the preoperative and postoperative mean values was statistically significant in the present study as well. Thus, we believe that via these data acquired, the present study has contributed to the thought that the PNIF can be used in routine clinical practices to evaluate the septoplasty results objectively. We also believe that the present study may contribute to the literature because it is the first study stressing that the change in mean PNIF values may also vary according to the direction and severity of septum deviation and the Mladina classification besides age, gender and ethnic origin, in the evaluation of functional results in septoplasty cases.

Consequently, the PNIF test can easily be applied in clinic in the evaluation of functional results of individuals undergoing septoplasty, because it is fast, cheap, non-invasive and produces case-based comparable results. However, in order to use this measurement method as an objective evaluation criterion in the future, we believe that it is necessary to evaluate the normative data range of every clinic via a study on a broader healthy population for both genders, besides the young and old population.

Acknowledgements

We would like to thank Selim Çam for his contribution to statistical evaluation.

Author Contributions

Concept—EEA, AB, KD; Design—EEA, KD, AB; Supervision—EEA, AB, KD; Resource—EEA; Materials—AB, BBD, YS; Data Collection and/or Processing—AB, KDBBD, YS; Analysis and/or Interpretation—EEA, AB; Literature Search—KD, ABBBD, YS; Writing—EEA, AB; Critical Reviews—EEA, KD, AB.

Declarations

Conflict of interest

The authors have no conflicts of interest to declare.

Ethical Approval

Ethics approval of this study was obtained from Cumhuriyet University Clinical Trials Ethics Committee (dated 09.10.2019 with decision no. ve 2019–10/06).

Informed Consent

Written informed consent was obtained from the patients who participated in this study.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Adem Bora, Email: adembora2016@gmail.com.

Yasin Aslan, Email: yasinaslan1966@hotmail.com.

Kasım Durmuş, Email: kasimdurmus58@gmail.com.

Berat Baturay Demirkıran, Email: baturaydemirkiran@gmail.com.

Emine Elif Altuntas, Email: ealtunta@yahoo.com.

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