Kirurgi av näsmusslorna och Empty Nose Syndrome - Marc Oliver Scheithauer

Detta är en översättning av kapitel 8 i forskningsrapporten 

doi: 10.3205/cto000067: Surgery of the turbinates and empty nose syndrome - Marc Oliver Scheithauer. / Institutionen för Otorhinolaryngologi, Huvud- och Halskirurgi, Universitetssjukhuset, Ulm, Tyskland 

Detta kapitel handlar specifikt om atrofisk rinit (degenerering av näsans slemhinna och Empty Nose Syndrome till följd av näskirurgi på näsmusslorna.

Empty” nose syndrome

Termen ”Empty nose syndrome” (ENS), eller mer exakt ”empty nose syndrome of Stenkvist”, myntades ursprungligen 1994 av Kern och Stenkvist. När de undersökte CT-bilder av bihålorna, upptäckte de en betydande vävnadsförlust i området kring de nedre och mellersta näsmusslorna, och beskrev detta tillstånd som ”empty nose” 

Kern och Stenkvist observerade kliniskt att patienter som fått sina nedre och mellersta näsmusslor delvis eller helt borttagna ofta led av symtom som kännetecknas av nedsatt näsandning och torrhet samt sårbildning i näsan. Trots att det intranasala utrymmet utvidgades genom borttagningen av näsmusslan, inträffade en motsatt effekt, så kallad ”paradoxal näsblockering”.

Inom anglo-amerikansk terminologi delas ENS upp i tre undertyper: ENS nedre näsmussla (ENS-IT) hänvisar till tillståndet när den nedre näsmusslan har tagits bort. ENS mellersta näsmussla (ENS-MT) beskriver tillståndet efter borttagning av den mellersta näsmusslan, och ENS-båda syftar på borttagning av alla näsmusslor. ENS definieras som ett iatrogent orsakat tillstånd, vilket även kallas sekundär atrofisk rinit, och ska särskiljas från primär atrofisk rinit. Ytterligare orsaker till sekundär atrofisk rinit är kronisk rinosinuit, granulomatoser, näs-trauma eller strålbehandling.

Primär atrofisk rinit börjar ofta spontant utan någon tydlig orsak och kännetecknas av en långsamt framskridande sjukdomsprocess. Histologiskt kännetecknas det av brist på bägarceller och flimmerhår, samt förekomst av inflammatoriska infiltrat. En endarterit obliterans, som innebär en förtjockning av blodkärlen och vidgade kapillärer under slemhinnan, leder till försämrad regenerering av slemhinnan och ökad sårbarhet hos epitelet. De histologiska förändringarna förklarar den nedsatta mukociliära transporten. Fuktigheten i näsan minskar då de slembildande cellerna saknas och nässekretionen minskar. Det vätskiga solskiktet på cellens yta och det mer trögflytande gel-lagret minskar, vilket gör att de flimmerhår som normalt omges av denna vätska slutar fungera. Detta leder till stagnation av nässekretionen och bildning av bakterieinfekterade skorvor. Sammanfattningsvis bidrar denna situation med nedsatta lokala försvar mot infektioner till rinit och sinusit.

Etiologin bakom primär atrofisk rinit är okänd, och många hypoteser om dess utveckling diskuteras: hormonella faktorer, näringsbrister samt bakterieinfektioner med Klebsiella ozaena, Bacillus foetidus, Staphylococcus aureus, Proteus mirabilis och Escherichia coli. Förekomsten av dessa sjukdomar är okänd; det är dock känt att primär atrofisk rinit är vanligare i utvecklingsländer än i högutvecklade industriländer. Detta kan bero på bristfällig näring och otillräckligt antibiotikabruk. Primär atrofisk rinit är nära kopplad till återkommande sinusit, näsblod, luktbortfall, perforation av nässkiljeväggen och smärta i mitten av ansiktet. Tillståndet kännetecknas av progressiv atrofi av slemhinnan, med symtom som torrhet, skorpbildning och dålig lukt från näsan. Dessa symtom kan även förekomma hos patienter med ENS. Det ledande symtomet hos ENS-patienter är dock den paradoxala näsblockeringen, som ofta åtföljs av andnöd och ospecifika andningssvårigheter. I litteraturen varierar terminologin inkonsekvent mellan atrofisk rinit, rhinitis sicca och ozaena. 

Rhinitis sicca beskriver kroniskt torr nässlemhinna med hypertrofi. Ozaena är också en kronisk sjukdom i nässlemhinnan, kännetecknad av en progressiv atrofi av slemhinnan i samband med benresorption vid den nedre näsmusslan och vid den bony upphängningen av den mellersta näsmusslan vid frontalbasen. På så sätt skiljer sig ozaena från atrofisk rinit, som sällan påverkar submukosal vävnad. Rhinoskopiskt kan en förstoring av tvärsnittet av näshålan ses, särskilt i de bakre delarna och i de nedre och mellersta näsgångarna. Precis som vid en ökning av det intranasala utrymmet sker skorpbildning i de mellersta och bakre delarna av näsan. Ett av huvud symptomen på ozaena är en illaluktande näslukt som kan vara så överväldigande att social isolering blir ett hot. Patienter med ozaena lider av sekundär anosmi, vilket innebär att de inte är medvetna om den dåliga lukten. Förekomsten av ozaena i industriländer har minskat avsevärt de senaste åren på grund av antibiotika. 

De huvudsakliga funktionerna hos den mänskliga näsan är att värma, fukta och rengöra den inandade luften. En frisk näsa anpassar den inandade luften på några sekunder för att uppfylla kraven för en optimal gasutbyte i lungorna. För att denna funktion ska fungera korrekt måste både de anatomiska och de morfologiska förhållandena vara i balans. Näsans inre geometri, särskilt med avseende på den laterala näsväggen (där den nedre näsmusslan börjar) och frontalbasen (där den mellersta näsmusslan börjar), samt den fungerande slemhinnan, bidrar främst till detta. Det är allmänt känt att följande faktorer är särskilt relevanta för luftkonditionering i näsan:

• Den funktionella slemhinneytan

• Förhållandet mellan slemhinneyta och näsvolym

• Kontaktens varaktighet mellan andningsluften och slemhinnan

• Luftflödets egenskaper

• Temperatur- och fuktighetsförändringar mellan näsväggen och strömmande luft

Näsmusslorna, särskilt de nedre näsmusslorna, fungerar som diffusorer för luftflödet som övergår från laminar till turbulent flöde när det träffar näsmusslans spets. Denna effekt är mycket viktig för uppvärmning och fuktning av luften vid gränsen till slemhinnan. Ett bra luftflöde är synonymt med lägre motstånd i näsgångarna. Om luftvägsmotståndet ökar, antingen på grund av anatomiska förändringar i näsan eller på grund av onaturligt flödesbeteende hos den inandade luften, börjar man omedelbart andas genom munnen. I detta fall kan inte näsan längre utföra sin andningsfunktion. Funktionsstörningar påverkar därför luftkonditioneringen direkt negativt. Orsaker till att detta känsliga system bryts ned kan vara många anatomiska och patologiska förändringar i näsöppningarna (t.ex. vestibulär stenos, bred kolumella och kolumella retraktion med nästippptos, etc.), i nässkiljeväggen (t.ex. septumavvikelse, näsventilstenos, perforation av septum) och/eller i den laterala näsväggen (t.ex. näsmusslehypertrofi, frånvaro av en eller alla näsmusslor, yttre deformationer av näsan). Dessa kan förekomma enskilt eller i kombination.

ENS, en speciell form av sekundär atrofisk rinit, uppstår ofta efter borttagning av en eller alla näsmusslor och är ett tydligt exempel på den symptomvariation som drabbar de som är påverkade. Fokus ligger på subjektivt nedsatt näsandning, vilket först verkar ologiskt eftersom den inre näsan är vidöppen. Detta kallas för en ”paradoxal näsblockering”. 

För öron-näsa-hals-specialister är det svårt att behandla de kroniskt sjuka patienterna eftersom de terapeutiska möjligheterna är begränsade, och patientens efterlevnad är därför inte tillräcklig. Eftersom ENS innebär en kirurgiskt irreversibel situation rekommenderas ofta konservativ terapi. Denna är i stor utsträckning begränsad till vård av slemhinnan genom dagliga inhalationer och salvor. Vid kraftig skorpbildning, med eller utan ozaena, kan långvarig antibiotikabehandling vara indicerad. Även om de terapeutiska åtgärderna kan vara effektiva, kan endast lindring uppnås, ingen permanent lösning på problemet. Exakta demografiska siffror för förekomsten i Tyskland är inte tillgängliga, då det kliniska profilbilden är heterogen och den exakta diagnosen ofta inte kan fastställas trots klassisk anamnes av tidigare endonasal kirurgi. Den orsaksmässiga länken mellan patologiskt luftflöde och luftkonditionering vid ENS beskrivs nedan. 

I en klinisk studie vid Öron-näsa-hals-kliniken vid universitetet i Ulm undersöktes för första gången näsans luftkonditioneringsfunktion in vivo på en grupp av 10 ENS-patienter. Luftflödets dynamik under inandning och utandning presenterades genom MRI-baserade numeriska flödesimuleringar. För närvarande finns det inga liknande studier med samma höga fallantal inom detta forskningsområde. 

Resultaten från studien visar att temperaturen på den inandade luften vid mätpunkterna i näsvalvet och den mellersta näsmusslan var signifikant högre jämfört med den friska kontrollgruppen. Vid näsborrarna mynning och yttre del hade ENS drabbade dock lägre temperatur på utandad luft. Den absoluta luftfuktigheten vid alla mätpunkter var lägre i ENS-gruppen än i kontrollgruppen. Den torra näskänslan hos ENS-patienter förklaras av de sänkta fuktighetsvärdena hos den inandade luften. Ökad skorpbildning kan också förklaras av den nedsatta konditioneringsfunktionen. Om vi betraktar flödeshastigheten i relation till lufttemperaturen, ser vi att i områden med höga lufttemperaturer sker lägre flödeshastigheter samtidigt. Å andra sidan, låga lufttemperaturer åtföljs av höga flödeshastigheter. Denna observation förklarar varför temperaturen vid näsborrarna var lägre hos ENS-patienter än i de bakre delarna av näsan. Lindemanns forskargrupp drog samma slutsatser. Fenomenet ”paradoxal näsblockering” vid ENS har multifaktoriella orsaker.

Detta innebär att flera patologiska förändringar vilket negativt påverkar näsans andningsfunktion. Dessa förändringar består av.

• Minskad nasal resistans / luftmotstånd

• Onaturligt flödesmönster vid avsaknad av näsmusslor

• Bristen på fungerande slemhinneområden samtidigt som luft volym ökar

• Minskad kontakt tid mellan luften och slemhinnan.

Näsa-andningen står för cirka 50 % till 80 % av allt luftvägsmotstånd. Detta motstånd uppstår på grund av friktionen mellan strömmande luft och slemhinnan. Genom att näsans vidgas minskar motståndet och därmed också tryckskillnaden vid gränsen mellan luft och slemhinna. Detta leder till en störning i den naso-pulmonära bronkomotorreflexen, vilket kan orsaka en försämring av lungfunktionen. I motsats till detta är en optimal näsresistens ansvarigt för en utvidgning av de perifera bronkiolerna och ett förbättrat gasutbyte i alveolerna. Existensen av en naso-pulmonär reflex misstänktes först hos astmatiker och patienter som lider av rinit (inflammation i nässlemhinnan). 

Det är välkänt att det finns mekanoreceptorer, proprioceptorer, termoreceptorer och nervändar i nässlemhinnan, varav de flesta finns i området runt de nedre och mellersta näsmusslorna. Särskilt aktivering av temperaturreceptorer genom inandning av kall luft verkar vara en huvudstimulans för aktivering av den naso-pulmonära reflexen. Näsan fungerar därför som "första försvarslinjen" för de djupare luftvägarna genom att framkalla en bronkokonstriktion (sammandragning av luftrören).

Samtidigt misstänks en ytterligare neurofysiologisk koppling mellan lungorna och näsan. I detta fall visade djurstudier att näsans blodkärl reflexmässigt kontrolleras genom lungornas sträckreceptorer. Den möjliga reflexbågen löper från lungornas sträckreceptorer via vagusnerven till det centrala nervsystemet och når sedan nässlemhinnans blodkärl via efferenta nerver i vidianerven.

Wrobel rapporterar att plattepitelet (ett slags tunn cellager) i näsborrarna har den högsta känsligheten för luftflöde, så att hela andningssystemet tidigt kan anpassas till förändringar i luftflödet. Efter borttagning av näsmusslorna minskar antalet receptorer, vilket gör det troligt att minskad känselstimulans stör signalerna till hjärnan. 

Trots den betydligt förstorade volymen av huvudnäsan kan en ENS-patient inte uppnå ett högre totalflöde vid inandning. Detta har bevisats i en studie genom mätresultat från aktiv främre rinomanometri (en metod för att mäta näsmotstånd) och akustisk rinometri (en metod för att mäta näsans anatomi).

Relationen mellan volymen av näshålan och slemhinnans yta är därför i funktionell obalans. 

Lindemann och kollegor har beräknat att efter en ensidig borttagning av näsmusslan under tumörkirurgi i bihålorna, var förhållandet mellan näshålans volym och slemhinnans yta 0,8 på den opererade sidan och 0,3 på den icke-opererade sidan. Volymökningen medför samtidigt en förändring i luftflödet, vilket leder till störningar i luftkonditioneringen. I denna studie mättes diskret högre temperaturvärden i ENS-näsan, men den absoluta luftfuktigheten i hela näsan var dock reducerad. Nässlemhinnan hos ENS-patienter är således varmare och torrare, vilket gör att man kan anta att både den naso-pulmonära reflexmekanismen och den fria näsandningen påverkas samtidigt. Symtomet på subjektiv andnöd hos ENS-patienter kan också förklaras av detta.

I en studie som publicerades 2005, konstaterade Naftali och kollegor att effektiviteten i näsans konditioneringsfunktion minskade med 23% när de nedre och mellersta näsmusslorna avlägsnades. En av orsakerna till störd luftkonditionering hos ENS-patienter är, som redan nämnts, ett onaturligt luftflöde. Medan luftflödet hos en frisk person saktar ner på näsmusselområdet och blir mer turbulent i mitten av näspassagen, kan man hos ENS-patienter se ett långsamt, laminarflöde (jämnt och parallellt) i de övre två tredjedelarna av näsan. Luftflödet beter sig exakt motsatt. En statisk turbulensbildning vid inandning hos ENS-patienter uppstår endast i de vidöppna käkhålorna. Luftflödet i käkhålan under inandning hos den friska kontrollgruppen kunde inte avbildas. Detta bevisar att den öppnade käkhålan inte bidrar till luftkonditioneringen.

En effektiv uppvärmning och fuktning av inandad luft på slemhinnan kan inte ske, eftersom det inte finns någon mikro-turbulens då flödet istället är laminärt. Detta stöder också resultaten från Lindemanns forskargrupp. Ungefär en tredjedel av temperaturen och luftfuktigheten som avges till slemhinnan via konvektion under inandning, tas tillbaka från slemhinnan igen under utandning genom kondensation.

Intressant nog visade flödesimuleringar att det bildades betydande virvlar i området kring choanae, det vill säga den fysiologiska förträngningen mellan den breda nasofarynx (den övre delen av svalget bakom näsan) och näsans bakre öppningar samt huvudnäsans bakre hålrum. Detta förklarar varför ENS-patienter inte bara klagar över en torr näsa, utan även uttorkning av slemhinnan i svalget.

Normalt sett är utandningsluften från lungorna fuktig och varm. När denna luft möter ett klimat i näsan som är torrt och varmt innebär detta att kondensering inte kan ske. vilket innebär att näsan inte kan återuppta den fukt som transporteras från lungorna. Anledningen till detta är att slemhinnans yta har minskat till följd av reduktionen an näsmusslorna, vilket gör att tillräcklig kondensation inte kan ske. 

Denna teori stöds av observationer från flödesimuleringar: hos ENS-patienter accelereras inandningsluften in i de bakre delarna av näsan, vilket innebär att luften passerar genom de bakre öppningarna och träffar bakväggen av näsan (nasofarynx) med högre hastighet än hos en frisk person med intakta näsmusslor. Hos friska personer uppstår turbulenta flöden som, genom sidledsrörelser, säkerställer att partiklar som flödar åt sidan lämnar slemhinnans yta medan de som flödar centralt behåller kontakten med slemhinnan. Detta leder till en blandning av molekyler med högre och lägre temperatur, vilket resulterar i termisk konvektion.

Enligt Venturi-effekten ändras flödeshastigheten hos en inkomprimerbar vätska, som till exempel luft, i direkt proportion när den passerar genom en föränderlig tvärsnittsyta. Luftens flödeshastighet är därför som lägst där tvärsnittet är som störst. En utvidgning av näsans tvärsnitt leder till en minskning av flödeshastigheten, vilket redan har påvisats i tidigare studier inom rinologi (läran om näsans sjukdomar). Det långsamma luftflödet ökar visserligen tiden för luftens kontakt med slemhinnan, vilket vid första anblicken tyder på en hög effektivitet i denna fysiska process. Samtidigt sker dock ett laminärt flöde (ett jämnt och parallellt flöde) vid denna yta hos ENS-patienter, vilket hindrar en omfattande blandning av luftpartiklarna.

Normalt sett leder en förlängd kontakttid till att luften blir ordentligt klimatkonditionerad. Keck och kollegor har kallat denna relation för "subtropiska förhållanden" (växlande varm-fuktig och kall-torr luft) och identifierat dessa som optimala för luftkonditionering i näsan och de djupare luftvägarna.

Om slemhinnans funktion är nedsatt på grund av en minskad slemhinneyta efter att näsmusslor har tagits bort, medför detta en minskning av luftfuktighetens mättnad, vilket i sin tur leder till en ökning av lufttemperaturen samtidigt som den absoluta luftfuktigheten minskar. ENS-patienter kan inte uppnå optimal klimatkonditionering av luften genom att skapa "subtropiska" förhållanden i näsan och därmed förbereda den för luftstrupen och lungorna.

Om man tittar på de skjuvkrafter (krafter från luftflöde som verkar parallellt med ytan) som uppstår på slemhinnans yta, ser man att de är linjärt relaterade till flödeshastigheten. Vid lugn andning är trycket på slemhinnan ungefär 1 pascal (Pa).

Områden där ökade skjuvkrafter uppstår är till exempelvis främre delarna av den mellersta näsmusslan. Elad och kollegor ser en direkt koppling mellan tryckskillnaderna i skjuvkrafterna, temperaturgradienten i näsan och den subjektiva upplevelsen av fri näsandning. Detta beror inte bara på nervstimuli som lufttemperatur och volym, utan också på mängden och den funktionella effektiviteten hos bäggecellernas slemproduktion i näsmusslan, vilka aktiveras av specifika tryckförhållanden och därmed bestämmer slemutsöndringen. 

Det anses att ett optimalt tryckvärde på de skjuvkrafter som vidrör slemhinnan hos friska personer utlöser sekret produktion från bägar celler vilket leder till en fuktig och välmående slemhinna. Dessa skjuvkrafter leder också till ökad rörelse av cilierna (små hår på slemhinnans yta) vilket ökar transporten av sekret mot svalget. Förutsättningen för denna process är en korrekt balans av tryckvärden eller skjuvkraft på nässlemhinnan. (kraft som uppstår när flödande luft vidrör slemhinnan)

Hos patienter med ENS är dessa regleringsmekanismer störda på grund av förändrade skjuvkrafter; tryckkurvorna visar en snabbare nedgång i tryckgradienten mellan de främre och bakre delarna av näsan. En kirurgisk minskning av näsans tvärsnitt (genom implantat) för att positivt påverka aerodynamiken och öka luftvägsmotståndet förändrar dock inte näsans klimatkonditioneringsfunktion, som är oåterkalleligt skadad till följd av reduktion av näsmusslorna. Återuppbyggnad eller transplantation av den saknade slemhinnan är inte möjlig i dagsläget. Av denna anledning har patienter endast begränsad nytta av så kallad "endonasal augmentation surgery" (kirurgiska ingrepp som syftar till att förstora eller återställa strukturer i näsan). Det har rapporterats att åtminstone dålig lukt från näsan minskar, men skorpbildning verkar dock förbli oförändrad.

Eftersom ENS-behandlingen är otillfredsställande för både patient och läkare, förblir minimalt invasiv kirurgi på näsmusslan som bevarar slemhinnan en av de viktigaste principerna för kirurgisk behandling av nässjukdomar.

Surgery of the turbinates and empty nose syndrome - Marc Oliver Scheithauer. 

Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Ulm, Germany

Christopher Supalla, yet another Empty Nose Syndrome victim

Evaluation of sinonasal-related quality of life of 49 patients undergoing endoscopic skull base surgery

This study aimed to assess the impact of endoscopic skull base surgery on sinonasal-related quality of life (QoL). In this summary, we focus on the effects of turbinate removal and its implications for sleep quality.

**Types of Surgery and Procedure Details:**

Endoscopic skull base surgery is a technique used to address various conditions affecting the base of the skull and surrounding areas. This procedure sometimes also involves the removal of nasal turbinates. The types of surgeries and procedures included:

**Removal of Tumors:** Both benign and malignant tumors located at the skull base.

**Reconstruction:** Repair of defects using grafts or flaps.

**Turbinate Surgery:** Partial or total removal of nasal turbinates 

**Methods:**

The study included 49 patients who completed two questionnaires:

- **Sinonasal Outcome Test-22 (SNOT-22):** Measures various aspects of sinonasal health and their impact on quality of life, including nasal symptoms, facial pain, sleep disturbances, and emotional well-being.

- **Empty Nose Syndrome 6 Item Questionnaire (ENS6Q):** Assesses symptoms related to Empty Nose Syndrome, such as nasal dryness, diminished airflow, and nasal crusting.

**Results:**

1. **Overall Quality of Life Scores:**

   - The average SNOT-22 score was 25.1, indicating moderate to severe impact on health and overall quality of life.

   - The average ENS6Q score was 6.51, with 18.4% of patients scoring above 10.5. Displaying a high risk of getting Empty Nose Syndrome (ENS) after Turbinectomy and turbinate reduction.

To get diagnosed with Empty Nose Syndrome (ENS) based on the ENS6Q, a score of 11 or higher is generally used as the threshold. The total score ranges from 0 to 30, with each of the six questions scoring up to 5 points. A score above this threshold suggests that the patient is experiencing symptoms severe enough to be considered as having ENS.

2. **Impact on Sleep:**

   - Sleep-related symptoms were notably severe across the board. Patients frequently reported issues such as difficulty falling asleep, waking up during the night, and feeling tired during the day.

   - Among the different groups, those with a history of re-radiotherapy had significantly higher scores for sleep-related issues compared to patients with no history of radiotherapy. This suggests that radiotherapy may have a long-term impact on sleep quality. These patients also had a higher SNOT-22 score related to emotional well-being.

**Conclusions / summary:**

**Turbinate Removal and Sleep:** According to the study, 18.4% of patients who had their turbinates removed or reduced by radio frequency had a score higher than 10.5 on the Questionnaire: (ENS6Q), indicating a high risk of Empty Nose Syndrome (ENS). It was also noted that turbinectomy and radiofrequency treatment led to noticeable sleep disturbances. Patients experienced significant sleep issues, which were further exacerbated in those with a history of radiofrequency treatment

**Overall Quality of Life:** The study highlights that patients undergoing this surgery generally experience moderate to severe nasal symptoms and sleep disturbances. 

**Radiotherapy Impact:** A history of radiotherapy negatively impacts quality of life, particularly affecting sleep and emotional health. Patients with re-radiotherapy history experienced worse outcomes in these areas compared to those without such history.

Surgical Treatment for Empty Nose Syndrome

This research study, led by Dr. Steven M. Houser, delves into the complex and often misunderstood condition known as Empty Nose Syndrome (ENS), an iatrogenic disorder that arises as a consequence of nasal surgeries, particularly turbinate resections. ENS is characterized by a paradoxical situation where patients, despite having a seemingly open nasal airway, experience a profound sense of nasal obstruction and difficulty breathing. This condition is perplexing because it lacks clear, objective diagnostic criteria, making it a challenge for otolaryngologists to diagnose and treat.

### Understanding Empty Nose Syndrome

ENS is primarily caused by the excessive removal of turbinate tissue during nasal surgeries, which disrupts the normal nasal airflow and impairs the function of the nasal mucosa. Turbinates are crucial structures in the nasal cavity that regulate airflow, humidify, filter, and warm the air before it reaches the lungs. When these structures are removed or significantly reduced, patients often lose the sensation of airflow in their noses, leading to symptoms that can be as distressing as they are difficult to describe. Common symptoms include a sensation of nasal obstruction despite an open airway, shortness of breath, dryness, crusting, and a feeling of suffocation. These symptoms are often accompanied by significant psychological distress, including anxiety, depression, and a reduced quality of life.

### The Study’s Approach and Methods

The study involved eight patients diagnosed with ENS, who were treated with a surgical intervention aimed at alleviating their symptoms. The intervention involved the submucosal implantation of acellular dermis, a tissue graft material designed to simulate the missing turbinate tissue. The patients’ symptoms were evaluated before and after the surgery using the Sino-Nasal Outcome Test (SNOT-20), a validated questionnaire that measures the severity of nasal symptoms.

### Key Findings and Discoveries

The results of the study demonstrated a statistically significant improvement in the patients' symptoms following the surgical intervention. The SNOT-20 scores, which assess various nasal symptoms including nasal obstruction, facial pain, and sleep quality, showed marked improvement after the implantation of the acellular dermis. Importantly, the study also noted improvements in symptoms related to mental health, such as sadness, irritability, and sleep disturbances, which are often exacerbated by ENS.

The study highlighted several critical insights:

1. **Subjective Improvement**: Most patients reported a subjective improvement in their breathing and overall quality of life after the surgery, even though the physical changes in their nasal anatomy were subtle.

2. **Psychological Impact**: The psychological burden of ENS is profound, with many patients experiencing depression and anxiety due to the persistent and distressing nature of their symptoms.

3. **Challenges in Diagnosis and Treatment**: The study underscored the difficulties in diagnosing ENS due to the lack of objective tests and the reliance on patients’ subjective experiences. However, it also pointed out that these symptoms are real and stem from a physical alteration in the nasal anatomy.

### Conclusions and Implications

The study concludes that reconstructive surgery using acellular dermis can offer significant relief to patients suffering from ENS. However, it also emphasizes the importance of careful patient selection and thorough preoperative assessment, including the use of the cotton test to predict the potential benefits of the surgery. The findings suggest that, while ENS is a challenging condition to treat, surgical interventions that aim to restore the nasal anatomy can lead to meaningful improvements in patients' symptoms and quality of life.

### Reflections on ENS and Future Directions

ENS remains a complex and multifaceted condition, with significant implications for patients' physical and psychological well-being. This study contributes to the growing body of evidence that ENS is a legitimate and serious complication of nasal surgery, one that requires careful consideration and management. The authors suggest that future research should focus on developing more precise diagnostic criteria and exploring additional treatment options that can further improve the outcomes for patients with ENS.

In summary, this research provides valuable insights into the nature of ENS and highlights the potential for surgical intervention to offer relief for patients who suffer from this debilitating condition. It also calls for greater awareness among clinicians about the risks of turbinate surgery and the need for conservative approaches to avoid the development of ENS.

Empty Nose Syndrome: When the Nose Is Worse After Surgery (Archives of Otorhinolaryngology-Head & Neck Surgery)

This research study provides an in-depth exploration of Empty Nose Syndrome (ENS), a rare but serious condition that can occur following nasal or sinus surgery, particularly after procedures that remove or reduce the size of the nasal turbinates. ENS is characterized by a paradoxical sensation where patients feel as though they cannot breathe, despite having wide nasal passages and normal oxygen saturation levels. This condition not only severely impacts the physical well-being of patients but also profoundly affects their mental health and overall quality of life.

**Key Functions of the Nasal Turbinates:**

The nasal turbinates play a crucial role in the respiratory system. They are responsible for warming, humidifying, and filtering the air we breathe before it reaches the lungs. Additionally, they help direct the airflow within the nasal cavity to ensure that air reaches specific sensors that communicate to the brain that breathing is occurring properly. These functions are essential for maintaining a healthy respiratory system and ensuring the body's proper oxygenation.

**Pathophysiology of ENS:**

When the turbinates are removed or excessively reduced, as in the case of ENS, the nasal cavity becomes abnormally wide. This alteration leads to significant changes in air pressure and flow, disrupting the sensory feedback mechanisms that are essential for normal breathing perception. Patients with ENS often report a sensation of suffocation or an inability to get enough air, even though their nasal passages are physically unobstructed. This mismatch between the physical state of the nose and the patient's sensory experience can lead to severe anxiety, distress, and a decreased quality of life.

**ENS and the Limbic System:**

Recent studies suggest a connection between ENS symptoms and the limbic system, the part of the brain involved in emotional processing. The distress experienced by ENS patients may be linked to a disruption in the normal sensory input that the brain expects from the nasal passages. Additionally, the lack of stimulation of certain nerve fibers, particularly those from the Cranial Fifth Nerve, may contribute to the sensation of not being able to breathe, further exacerbating the patient's discomfort and anxiety.

**Complications Associated with ENS:**

ENS is not only a sensory disorder but can also lead to physical complications. The absence of the turbinates disrupts the normal mucociliary clearance system, which is responsible for trapping and expelling bacteria, dust, and other particulates from the nasal passages. Without this protective mechanism, patients are more prone to recurrent infections, crusting, and other respiratory issues. These complications can further diminish the quality of life and contribute to ongoing physical discomfort.

**Treatment Approaches:**

The treatment of ENS is challenging and often requires a multidisciplinary approach. Various methods have been employed to alleviate symptoms, though results can be inconsistent. Some of the treatment options include:

1. **Education and Cognitive Therapy:** Patients are often initially dismissed or misdiagnosed due to the paradoxical nature of their symptoms. Educating patients about the condition and providing cognitive therapy can help reduce anxiety and improve their understanding of their symptoms, which may lead to some relief.

2. **Moisturizing and Irrigation:** Regular use of saline sprays, Lactated Ringer’s solutions, and pulsed nasal irrigation can help keep the nasal passages moist, reduce crusting, and mimic the function of the absent cilia, which helps clear debris and bacteria from the nasal cavity.

3. **Infection Management:** In cases where infections are common, topical antibiotics such as 2% mupirocin ointment can be effective. Additionally, other topical treatments like Premarin Vaginal Cream have been used to thicken the nasal membranes and increase mucus production, providing some symptomatic relief.

4. **Surgical and Injectable Interventions:** In more severe cases, hyaluronic acid gel injections into the nasal cavity may temporarily restore proper airflow and provide relief. For more permanent solutions, surgical reconstruction using materials like AlloDerm to simulate the missing turbinate tissue has been explored.

**Conclusions and Learnings:**

The study underscores the importance of understanding the complex role that nasal turbinates play in both respiratory function and sensory perception. The removal or reduction of turbinates, while sometimes necessary to improve airflow in cases of obstruction, can lead to devastating consequences if not carefully considered. ENS is a reminder of the delicate balance required in nasal surgeries and highlights the need for cautious surgical planning and patient education.

Moreover, the findings suggest that treating ENS requires a holistic approach, addressing both the physical and psychological aspects of the condition. While the current treatments provide varying levels of relief, the ongoing distress and reduced quality of life experienced by many patients indicate a need for further research into more effective and lasting solutions. The study also emphasizes the importance of early recognition and intervention to prevent the progression of symptoms and to support patients in managing this life-altering condition.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies

This research study provides a comprehensive overview of Empty Nose Syndrome (ENS), a rare and often misunderstood condition characterized by the paradoxical sensation of nasal obstruction despite having a physically open nasal airway. ENS typically emerges after surgical procedures that reduce or remove parts of the nasal turbinates, which are structures inside the nose that help with air filtration, humidification, and regulation of airflow.

### Key Findings of the Study

1. **Understanding ENS and Its Mechanisms**:

   - Traditionally, ENS was thought to result solely from the removal or reduction of nasal turbinates. This procedure can lead to a significant loss of nasal tissue, which disrupts the normal function of the nose.

   - However, the study highlights that ENS may also involve impaired function of the trigeminal nerve, which plays a critical role in sensing airflow and humidity in the nasal passages. This impairment might contribute to the paradoxical feeling of nasal obstruction, even when the nasal passages are clear.

2. **Diagnostic Tools**:

   - Two diagnostic tools have gained recognition for their ability to help clinicians diagnose ENS more accurately:

     - The **Empty Nose Syndrome 6-Item Questionnaire (ENS6Q)**: A set of six questions that assess the severity of symptoms specific to ENS, such as nasal dryness and a sense of suffocation.

     - The **Cotton Test**: This test involves placing a small piece of cotton in the nasal passage to simulate the presence of a turbinate. Improvement in symptoms during this test may indicate ENS, suggesting that surgical augmentation of the turbinate area could be beneficial.

3. **Surgical and Non-Surgical Treatments**:

   - Non-surgical treatments primarily focus on **nasal humidification** to alleviate symptoms. These include nasal saline sprays, irrigations, and the use of humidifiers to maintain moisture in the nasal passages.

   - **Surgical treatments** are still evolving. The study notes that recent approaches involve using various implant materials (such as autologous cartilage or synthetic implants) to reconstruct or augment the nasal turbinates. While some patients have experienced improvements in their symptoms, the study cautions that there is insufficient long-term data to fully support these surgical methods. The risk of complications, such as implant extrusion, remains a concern.

4. **Impact on Quality of Life**:

   - ENS has a profound impact on the quality of life, often leading to significant physical discomfort and psychological distress. Patients frequently report feelings of suffocation, nasal burning, and constant dryness, which can severely impair daily functioning.

   - The study also emphasizes the high prevalence of **depression and anxiety** among patients with ENS. Approximately two-thirds of patients with ENS exhibit clinically significant levels of these conditions, which highlights the importance of mental health screening and support in the management of ENS. The study suggests that cognitive-behavioral therapy (CBT) and the use of antidepressants may be beneficial for some patients.

5. **The Controversy and Challenges**:

   - Despite advancements in diagnostic tools and treatment options, the diagnosis of ENS remains controversial. Not all patients who undergo turbinate reduction surgery develop ENS, and some studies have found no correlation between turbinate surgery and the development of ENS symptoms. This inconsistency makes it difficult to standardize treatment and diagnosis across all patients.

   - The study advocates for the **preservation of at least 50% of the inferior turbinate** during any nasal surgery to minimize the risk of developing ENS. However, it also acknowledges that more research is needed to understand the full spectrum of ENS and to develop more reliable treatments.

### Conclusions and Lessons Learned

The study underscores the complexity of ENS and the challenges in diagnosing and treating this condition. It brings attention to the need for prevention, particularly in surgical procedures involving the nasal turbinates. The use of the ENS6Q and Cotton Test has been shown to be valuable in diagnosing ENS, but the authors recommend using these tools in conjunction with a thorough clinical evaluation.

While surgical implants to restore turbinate function offer a potential treatment pathway, the current evidence is insufficient to fully endorse these methods. As such, conservative treatments focusing on humidification remain the first line of therapy.

Importantly, the study highlights the significant psychological burden that ENS can impose on patients, calling for routine mental health screening and appropriate interventions to address the emotional and psychological aspects of the condition.

In summary, the research points to a need for ongoing studies to better understand ENS, improve diagnostic accuracy, and develop more effective treatments, both surgical and non-surgical. It also reinforces the critical role of mental health care in managing the overall well-being of patients with ENS.

Morphology, Not Only Volume: A Study on Empty Nose Syndrome and Inferior Turbinates

The research study titled *"Morphology, Not Only Volume: A Study on Empty Nose Syndrome and Inferior Turbinates"* explores the relationship between the volume and morphological patterns of the remnant inferior turbinates (ITV) and the severity of symptoms in patients with Empty Nose Syndrome (ENS). ENS is a complex and often underdiagnosed condition that causes significant discomfort for those who suffer from it. Despite having a seemingly patent airway, patients with ENS experience a paradoxical sensation of nasal obstruction, along with a variety of other symptoms that can severely impact their quality of life.

### Objectives and Background

The primary aim of the study was to assess how the ITV and the morphological phenotype of the inferior turbinates influence the severity and manifestation of ENS symptoms. Previous studies have largely focused on the anatomical changes in the nasal cavity following turbinectomies as the cause of ENS. However, this study sought to go beyond simply measuring the volume of the remnant turbinates, exploring how their shape and distribution within the nasal cavity might affect patient outcomes.

### Methods

The study enrolled 54 patients who had previously undergone inferior turbinectomies and met specific criteria for ENS diagnosis, including a positive cotton test and high scores on the ENS 6-Item Questionnaire (ENS6Q). The patients were evaluated using several subjective assessment tools: ENS6Q, Sino-Nasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI). Computed tomography (CT) scans were used to measure the ITV by carefully analyzing finely cut images of the nasal cavity using ImageJ, a Java-based image processing program.

The researchers also categorized the patients into two distinct morphological groups based on the distribution of their remnant turbinates: **torpedo type** (balanced tissue volume) and **pistol type** (posterior dominance).

### Results

The study found several key results:

1. **Correlation Between ITV and Symptoms**: Contrary to what might be expected, patients with a higher volume of remnant inferior turbinates (ITV) did not have reduced symptoms. In fact, a positive correlation was observed between ITV and ENS-specific symptoms, particularly in the SNOT-25 domain.

2. **Morphological Differences**: Patients classified as the pistol type (with posterior dominance of turbinate tissue) had a higher burden of rhinologic symptoms compared to those in the torpedo type. This suggests that not just the volume, but the specific morphological distribution of the remnant turbinates, significantly affects symptom severity.

3. **Nasal Resistance**: There was no significant correlation between nasal resistance and ITV in either morphological type. This indicates that traditional methods of measuring nasal resistance may not be effective in evaluating ENS severity or predicting symptom burden.

4. **Psychological Impact**: Despite the complex interplay between physical and psychological symptoms in ENS patients, the study found no significant correlation between ITV and psychological assessment scores (BDI-II and BAI). This highlights that factors other than the physical presence of turbinate tissue, such as neurosensory function or patient perception, may contribute to the psychological aspects of ENS.

### Conclusions

The study concludes that the severity of ENS symptoms cannot be fully explained by the volume of remnant turbinate tissue alone. The shape and distribution of this tissue play a crucial role in determining symptom severity. Patients with a pistol type of turbinate morphology, characterized by a posterior concentration of tissue, tend to experience more severe rhinologic symptoms, even if their nasal resistance appears normal.

The findings suggest that treatment approaches for ENS should consider the specific morphological characteristics of the patient's nasal cavity, rather than focusing solely on restoring tissue volume. Moreover, the lack of correlation between nasal resistance and symptom severity calls into question the effectiveness of traditional objective measurements in diagnosing and managing ENS.

### Key Takeaways and Future Directions

- **Morphology Matters**: The study highlights the importance of considering the shape and distribution of remnant turbinate tissue in assessing ENS symptoms. This could influence future surgical and non-surgical treatment strategies aimed at alleviating ENS symptoms.

  

- **Limitations of Traditional Measurements**: The study challenges the reliance on nasal resistance measurements for ENS evaluation, suggesting the need for more sophisticated diagnostic tools that can better capture the nuances of ENS symptomatology.

- **Complex Pathophysiology**: The pathophysiology of ENS is complex, involving not just anatomical changes, but also neurosensory dysfunction and possibly psychological factors. This underscores the need for a multidisciplinary approach to diagnosis and treatment.

- **Future Research**: Further research is needed to explore the role of neurosensory mechanisms, including nerve function and thermoreceptor activity, in the development and progression of ENS. Computational fluid dynamics (CFD) studies could also provide deeper insights into how changes in nasal airflow patterns contribute to ENS symptoms.

In summary, this study provides valuable insights into the multifaceted nature of ENS, emphasizing the need for personalized treatment strategies that take into account the unique morphological and functional characteristics of each patient’s nasal anatomy.

Forskningen kring "Empty Nose Syndrome" (ENS): Komplikationer av näskirurgi

Forskningen kring "Empty Nose Syndrome" (ENS) handlar om en komplex och ofta förödande sjukdom som kan uppstå efter att man har opererat bort en betydande del av näsmusslorna, de strukturer som reglerar luftflödet genom näshålan. Begreppet myntades först av Kern och Stenkvist 1994 och beskriver tillståndet där näsan känns tom, vilket leder till en rad symtom som paradoxal obstruktion – en känsla av att inte kunna andas trots att näspassagen är öppen.

**Symptom och problematik:**

Patienter med ENS kan uppleva olika fysiska, kognitiva och emotionella symtom. Fysiska problem inkluderar andningssvårigheter, en känsla av kvävning, torrhet i näsan, kronisk näsblödning, och smärta. Kognitiva symtom kan innebära svårigheter att koncentrera sig, medan emotionella problem ofta handlar om ångest, depression och frustration. Symtomens svårighetsgrad varierar beroende på hur mycket av näsmusselvävnaden som har avlägsnats, samt individuella faktorer som kroppens respons på kirurgi och andra yttre faktorer.

**Patofysiologi och mekanismer:**

ENS orsakas av både strukturella och funktionella skador. Strukturellt leder avlägsnandet av näsmusselvävnad till störningar i näsans aerodynamik, vilket resulterar i ett onormalt luftflöde och minskad nasal motståndskraft. Detta kan förvärra andningssvårigheter och minska förmågan att uppleva luftflödet genom näsan, vilket är centralt för en normal andningsupplevelse.

Funktionellt innefattar ENS nervskador, vilket kan leda till förlust av sensoriska signaler och därmed en bristande upplevelse av luftflöde. Nervskadorna kan orsaka neuropati, där vissa delar av näsan blir överkänsliga för luftflöde, vilket kan leda till smärta och brännande känslor. Dessutom kan ENS innebära en försämrad eller frånvarande återväxt av nervvävnad, vilket ytterligare förvärrar problemen med att känna luftflöde och reglera andningen korrekt.

**Upptäckter och lärdomar:**

Forskningen har visat att ENS är en multifaktoriell sjukdom där både anatomiska förändringar och nervfunktion spelar en avgörande roll. ENS är inte enbart kopplad till den mängd vävnad som avlägsnats, utan också hur detta påverkar nervsystemet och näsans fysiologi. Den huvudsakliga lärdomen är att kirurgi på näsmusslor bör utföras med stor försiktighet, och att man bör undvika överdriven vävnadsborttagning för att minska risken för ENS.

**Slutsats:**

ENS är en allvarlig och komplex sjukdom som kan ha stor inverkan på livskvaliteten. Den huvudsakliga slutsatsen är att kirurgiska ingrepp i näsan måste utföras med försiktighet och att det är viktigt att förstå både de strukturella och funktionella aspekterna av näsans funktion för att undvika att utveckla detta tillstånd. Trots öppen näspassage kan ENS-patienter uppleva en känsla av kvävning och oförmåga att andas ordentligt, vilket är ett paradoxalt men centralt symtom i syndromet.

Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature

The study titled "Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature" by Tanja Hildenbrand, Rainer K. Weber, and Detlef Brehmer provides a comprehensive overview of the various conditions associated with the symptom of a dry nose (DN), such as rhinitis sicca, atrophic rhinitis, and Empty Nose Syndrome (ENS). The study examines the etiology, symptoms, diagnosis, and treatment options for these conditions, highlighting the complexity and variability in clinical presentation.

### Summary of Findings:

**1. Lack of Clear Definitions:**

The term "dry nose" lacks a precise definition and is used to describe a range of symptoms from a subjective sensation of dryness to visible crusting of the nasal mucosa. The term "rhinitis sicca" is commonly used by ENT specialists, though it too lacks a clear and consistent definition. The conditions discussed include rhinitis sicca anterior, primary and secondary atrophic rhinitis, and ENS, each with its own set of symptoms and underlying causes.

**2. Symptoms:**

Symptoms of dry nose can vary widely and may include:

- Sensation of dryness in the nose.

- Itching or a mild burning sensation.

- Nasal obstruction.

- Crusting or scabbing inside the nose, often accompanied by an unpleasant smell.

- Epistaxis (nosebleeds).

- Diminished sense of smell (hyposmia or anosmia).

**3. Causes:**

The causes of dry nose are multifaceted, involving various diseases, environmental factors, and physiological changes. Some common factors include:

- Mechanical irritation or trauma.

- Climatic or environmental factors such as dry air.

- Workplace conditions involving exposure to dust or chemicals.

- Side effects of medications, including those used to treat nasal congestion.

- Aging, which leads to anatomical changes and reduced mucociliary clearance.

- Anatomical changes due to surgery or trauma.

- Infections and systemic diseases like Wegener’s granulomatosis, sarcoidosis, or tuberculosis.

- The wound healing phase following nasal surgery.

**4. Empty Nose Syndrome (ENS):**

ENS is a particularly severe and complex condition resulting from over-resection of the nasal turbinates, which are crucial for proper airflow and humidification of the air we breathe. The study emphasizes that uncritical resection of these turbinates, particularly the inferior and middle turbinates, can lead to ENS, a form of secondary atrophic rhinitis (SAR). ENS is characterized by symptoms such as paradoxical nasal obstruction (a sensation of blocked nasal airflow despite having a physically enlarged nasal cavity), dry nose, pharyngeal dryness, dyspnea (difficulty breathing), and a disturbed sense of smell. Psychological symptoms like depression can also occur due to the chronic and distressing nature of the condition.

**5. Diagnosis:**

Diagnosing dry nose and its associated conditions requires a thorough patient history and a detailed examination of the external and internal nose using endoscopy and, if necessary, imaging techniques like CT scans. Allergies and infections should also be ruled out through appropriate tests.

**6. Treatment Approaches:**

The treatment of dry nose and associated conditions is primarily conservative and focuses on symptom management. Key recommendations include:

- **Moisturization:** Using nasal sprays, ointments, or saline solutions to keep the nasal mucosa hydrated.

- **Environmental Control:** Reducing exposure to dry air, dust, and other environmental irritants.

- **Cleansing:** Regular removal of crusts to prevent infection.

- **Avoidance of Irritation:** Patients are advised to avoid unnecessary manipulation of the nasal mucosa to prevent further irritation.

- **Surgical Correction:** In cases where there is an excessively large nasal cavity due to previous surgery, reconstructive procedures may be considered to restore normal airflow and improve symptoms.

**7. Importance of Nasal Turbinates:**

The study underscores the critical role of nasal turbinates in maintaining nasal health. These structures are essential for proper air conditioning (humidifying and warming the air) and should not be removed unless absolutely necessary, as their removal can lead to severe and often irreversible complications such as ENS.

**8. Recommendations for Medical Practice:**

The study advises against radical resection of nasal turbinates and emphasizes the importance of careful surgical planning and execution. It also highlights the need for more research into effective treatments for dry nose and ENS, as current therapeutic options are largely symptomatic and do not address the underlying pathophysiology.

### Conclusion:

The research provides a detailed exploration of the conditions associated with dry nose, particularly ENS, which is identified as a severe consequence of aggressive nasal surgery. The study concludes that preventive measures, particularly in surgical practice, are essential to avoid the development of these debilitating conditions. Moreover, while current treatments offer symptomatic relief, there is a clear need for more effective therapeutic strategies to manage and prevent these disorders. The study serves as a critical reminder of the delicate balance required in ENT surgery and the significant impact that nasal structure can have on overall respiratory health.

Summary from Eugene Kern,s book: Empty Nose Syndrome Evidence Based Proposals for Inferior Turbinate Management

Here’s a list of sections and descriptions from the book "Empty Nose Syndrome: Evidence-Based Proposals for Inferior Turbinate Management" where the author mentions and describes how Empty Nose Syndrome (ENS) affects quality of life, health, well-being, sleep, and the overall suffering it causes:

1. **Introduction and Overview**:

   - **Emotional and Psychological Impact**: The chapter introduces ENS and highlights the profound psychological and emotional distress it causes. It mentions that some patients have even committed suicide due to the horrific torment caused by the condition.

2. **Fundamental Features of ENS**:

   - **Physical and Emotional Suffering**: The author discusses the fundamental aspects of ENS, emphasizing the debilitating nature of the symptoms, which include severe emotional anguish and physical suffering. Patients experience breathing difficulties and other distressing symptoms.

3. **Pathophysiology of ENS**:

   - **Lack of Objective Testing**: The book mentions that the lack of objective preoperative studies to guide surgery often leads to ENS, which severely impacts the patient's quality of life. The condition arises when subjective patient reports and observational practices replace rigorous functional testing, leading to devastating outcomes.

4. **Treatment Options for ENS**:

   - **No Curative Therapies**: The chapter outlines that there are no curative or restorative therapies for ENS, leaving patients with debilitating symptoms. The only realistic management is providing emotional support and attempting to control the symptoms as much as possible.

   - **Psychological Support**: It is highlighted that over 50% of ENS patients suffer from significant anxiety and depression, necessitating psychiatric referral and compassionate mental health support.

5. **Final Thoughts and Review**:

   - **Profound Suffering**: In the concluding chapter, the author reiterates that ENS, while uncommon, is a critically important condition due to the severe physical suffering it causes, particularly with breathing difficulties. The emotional anguish is so intense that it includes a high incidence of suicidal ideation among patients.

   - **Need for Preventive Measures**: The text stresses the importance of preventing ENS through careful turbinate management, as the consequences of ENS are devastating and significantly impair the quality of life.

These sections describe the severe impact ENS has on an individual's physical and mental health, highlighting the deep suffering, anxiety, depression, and even suicidal thoughts that can result from this condition.

American Rhinologic Society about Empty Nose Syndrome

### Empty Nose Syndrome: An Overview

#### Introduction

Empty Nose Syndrome (ENS) is a rare but significant complication arising from nasal surgery, notably following the removal of lower turbinate tissue. Turbinates, key structures within the nasal passages, are essential for filtering, humidifying air, and sensing airflow. Conditions like allergic rhinitis or excessive use of decongestant sprays can cause turbinates to swell, leading to nasal obstruction. Surgical interventions are employed when medical treatments fail, aiming to enhance nasal airflow by altering the size and position of the turbinates. While surgery often alleviates nasal obstruction and reduces medication dependency, it can sometimes lead to ENS—a condition marked by a sensation of nasal dryness, crusting, and obstructive symptoms despite open nasal passages. The development of ENS is linked to aggressive tissue removal and nerve damage. Surgeons have adapted more conservative approaches to reduce ENS risk, utilizing techniques like submucous resection and radiofrequency ablation. However, the precise incidence of ENS remains unclear, with many patients still affected. Available treatments aim to improve quality of life for those suffering from this condition.

#### Symptoms

The hallmark of ENS is the perception of reduced nasal airflow. Despite open nasal passages, patients often feel their nose is too open due to decreased nasal resistance. Common symptoms include dryness in the nasal passages and throat, burning sensations, and crusting. Some patients report a suffocating feeling, accompanied by anxiety, depression, and poor sleep quality, which can significantly impact their daily life and work performance.

#### Causes

Nasal turbinates, composed of thin bone and mucosal lining with a rich blood supply, play a crucial role in warming and humidifying inhaled air. They also contain erectile tissue that periodically swells, creating alternating resistance patterns that may prevent pressure ulcers during sleep. The exact functions of turbinates are not fully understood, but they are believed to contribute to nasal resistance and airflow regulation. Removing large portions of turbinates can destroy many of the sensory nerves responsible for detecting air movement, leading to impaired regulation of nasal warmth and humidity. This results in dryness, crusting, and an increased presence of unhealthy bacteria. The altered airflow can also diminish the sense of smell and contribute to shallow breathing, potentially affecting oxygen exchange and causing a sensation of suffocation.

#### Diagnosis

Diagnosis of ENS often involves a thorough evaluation using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), which assesses the severity and impact of symptoms. Nasal endoscopy and computed tomography (CT) scans can help visualize nasal structures and identify any mucosal atrophy or other conditions. The Cotton Test, where saline-soaked cotton is placed in the nasal passages, may be used to determine if symptoms improve with added moisture, guiding potential nasal enhancement procedures.

#### Treatments

Conservative treatments focus on nasal hygiene and moisturization through saline sprays, gels, oils, and irrigations. Humidifying the environment and using menthol in topical treatments can offer temporary relief. However, these methods may need frequent application and can disrupt natural mucosal protection. In cases of bacterial overgrowth, topical antibiotics may help, and topical steroids can reduce inflammation. Other treatments like estrogen creams and phosphodiesterase inhibitors aim to promote mucosal growth. Living in a humid coastal climate can also alleviate symptoms. Despite these options, many patients find inconsistent relief from conventional therapies.

#### Surgical Options

For severe ENS cases, surgery may be considered after failed conservative treatments. Surgical approaches involve augmenting the remaining turbinate tissue or implanting materials in the nasal passages to restore resistance and improve airflow patterns. Temporary materials such as hyaluronic acid may be used initially to gauge effectiveness before more permanent implants are considered. Various implant materials, including Gore-Tex, acellular dermis, hydroxyapatite, and cartilage, have shown efficacy in improving ENS symptoms. However, complications, though infrequent, may include symptom persistence, eye tearing, implant extrusion, or chronic rhinosinusitis. Some centers offer regenerative therapies like platelet-rich plasma and stem cell treatments, though their effectiveness remains uncertain.

#### Psychological Impact and Support

ENS often leads to significant psychological distress, including anxiety and depression, due to the chronic discomfort and its impact on daily life. Insurance coverage for ENS treatments may be limited, exacerbating the stress for affected individuals. Cognitive behavioral therapy and counseling can provide support for managing anxiety and depression, and medications may also be beneficial.

#### Further Information

For more detailed information or to find a rhinology specialist, visit the American Rhinologic Society's website at [American Rhinologic Society](https://www.american-rhinologic.org/).

The cotton test redistributes nasal airflow in patients with empty nose syndrome

Summary of the Study on Nasal Airflow Redistribution in Empty Nose Syndrome (ENS) Using the Cotton Test

#### Background

Empty Nose Syndrome (ENS) is a condition that can arise after sinonasal surgery, particularly following the excessive removal of inferior turbinate tissue. Patients with ENS often experience debilitating symptoms such as a paradoxical sensation of nasal obstruction, suffocation, burning, dryness, and crusting. These symptoms can severely impact their quality of life and lead to psychosocial issues, including anxiety and depression. Despite various treatments available, including submucosal implants, there remains a lack of understanding about the exact mechanisms driving symptom relief. The cotton test, involving the placement of a cotton plug in the inferior meatus of the nose, has been observed to provide rapid symptomatic relief. However, the physiological reasons behind this improvement were not well understood until now.

#### Objective

The goal of this study was to investigate the physiological mechanisms underlying the symptomatic relief provided by the cotton test. Specifically, the researchers aimed to understand how cotton placement affects nasal airflow dynamics and resistance in patients with ENS.

#### Methods

The study involved six patients diagnosed with ENS who had previously experienced symptomatic improvement from the cotton test, evidenced by a significant reduction in their ENS6Q scores. Each patient underwent sinus computed tomography (CT) scans both before and after the placement of a cotton plug in the inferior meatus. The cotton plug was marked with iohexol contrast spray for visibility in CT imaging. Computational fluid dynamics (CFD) was then employed to analyze changes in nasal airflow patterns, resistance, and distribution resulting from the cotton placement.

#### Results

1. **Symptomatic Improvement:** Post-cotton placement, patients showed a significant reduction in ENS6Q scores, dropping from an average of 16.8 ± 4.1 to 3.1 ± 2.4 (p < 0.001). This confirms the subjective improvement reported by the patients.

2. **Nasal Resistance:** CFD analysis revealed a 21% increase in nasal resistance following cotton placement (p < 0.05). This aligns with the understanding that the presence of the cotton plug reduces nasal airflow volume due to increased resistance.

3. **Airflow Distribution:** A key finding was a significant shift in airflow distribution. Before cotton placement, airflow was predominantly directed through the middle meatus. After placement, there was a 41% decrease in airflow through the middle meatus, and airflow became more evenly distributed between the middle and inferior meatuses (p < 0.05). This shift indicates that cotton placement restores a more balanced airflow pattern.

4. **Flow Patterns and Pressure Gradient:** The airflow trajectory changed from a jetstream predominantly through the middle meatus to a more dispersed pattern that improves airflow in the inferior meatus. The pressure gradient in the nasal cavity also became smoother and more linear after cotton placement, suggesting improved nasal resistance and airflow distribution.

#### Conclusions

The study demonstrated that the cotton test effectively increases nasal resistance and alters airflow distribution in ENS patients. The significant reduction in middle meatus airflow and the increase in airflow resistance suggest that the cotton plug helps in redistributing airflow to mimic a more normal pattern, which alleviates ENS symptoms.

#### Implications

The findings validate the use of the cotton test as a diagnostic and therapeutic tool for ENS. The study highlights the importance of understanding nasal airflow dynamics and resistance in designing and implementing treatments for ENS. The insights gained from CFD analysis can help in optimizing surgical procedures, such as inferior meatus augmentation, by providing a better understanding of how airflow changes with different interventions.

Overall, this research underscores the potential of the cotton test in managing ENS and emphasizes the need for further studies to refine treatment approaches based on these physiological insights.

 

Computational fluid dynamic analysis of aggressive turbinate reductions: is it a culprit of empty nose syndrome?

 ### Summary of the Study: Computational Fluid Dynamics of Aggressive Turbinate Reductions and Empty Nose Syndrome

#### **Background**

Empty Nose Syndrome (ENS) is a controversial condition associated with nasal surgeries, particularly aggressive inferior turbinate reductions (ITR). Despite common knowledge that ITR aims to alleviate nasal obstruction, some patients report paradoxical symptoms like nasal dryness, pain, and obstruction post-surgery. 

#### **Objective**

This study aimed to explore the relationship between aggressive ITR and ENS by analyzing nasal airflow dynamics and mucosal sensory function in patients who had undergone ITR. The goal was to identify specific factors that might contribute to the development of ENS.

#### **Methods**

- **Study Design**: The research involved a comparative analysis using computational fluid dynamics (CFD) based on CT scans of the nasal cavity.

- **Participants**: 

  - **Aggressive ITR without ENS Symptoms**: 5 patients who had undergone aggressive ITR but showed no ENS symptoms.

  - **Symptomatic ENS**: 27 patients with documented ENS symptoms post-ITR.

  - **Healthy Controls**: 42 individuals with no nasal issues.

- **Evaluations**:

  - **CFD Analysis**: Compared airflow dynamics, cross-sectional areas, and nasal resistance among the groups.

  - **Questionnaires**: Utilized SNOT-22, NOSE, and ENS6Q to assess nasal symptoms and quality of life.

  - **Trigeminal Function**: Measured through menthol lateralization detection thresholds (LDTs) to assess sensory function.

#### **Results**

1. **Nasal Airflow and Resistance**:

   - Both aggressive ITR patients without ENS and symptomatic ENS patients had lower nasal resistance and larger cross-sectional areas around the inferior turbinate compared to healthy controls. 

   - However, ENS patients exhibited significantly less airflow in the inferior meatus but more airflow in the middle meatus compared to both healthy controls and aggressive ITR patients without symptoms.

   - This imbalance in airflow distribution suggests altered nasal aerodynamics in ENS patients.

2. **Wall Shear Stress**:

   - ENS patients had significantly lower wall shear stress in the inferior meatus, indicating reduced interaction between airflow and the nasal mucosa in this region.

   - This contrasts with both aggressive ITR patients without ENS and healthy controls, who had more evenly distributed shear stress.

3. **Mucosal Sensory Function**:

   - ENS patients showed significantly impaired trigeminal sensory function, as indicated by lower menthol LDTs, compared to both aggressive ITR patients without symptoms and healthy controls.

   - Interestingly, aggressive ITR patients without ENS had slightly better sensory function compared to healthy controls, a surprising finding that may warrant further investigation.

#### **Conclusions**

- **Link Between Turbinate Reduction and ENS**: The study supports that aggressive ITR can alter nasal airflow patterns and mucosal function, which may contribute to ENS development. However, ENS symptoms are not solely attributable to the degree of turbinate reduction as similar degrees of turbinate reduction were observed in both ENS patients and those without symptoms.

- **Nasal Aerodynamics and Sensory Function**: The combination of distorted nasal aerodynamics and impaired mucosal sensory function appears to play a significant role in the development of ENS symptoms. ENS patients showed an abnormal distribution of airflow and reduced sensory feedback, which may contribute to their symptoms.

- **Implications for Surgery**: The findings suggest that while aggressive ITR can alter nasal airflow, careful consideration of how these changes impact mucosal function is crucial in preventing ENS. Balancing airflow distribution and preserving sensory function could be key in improving surgical outcomes and avoiding ENS.

#### **Key Learnings**

- **Airflow Dynamics**: Disrupted airflow patterns in ENS patients indicate that the condition may arise from more complex interactions between nasal anatomy and airflow, rather than just the extent of turbinate reduction.

- **Sensory Function**: Sensory impairment in ENS patients highlights the importance of maintaining nasal mucosal function during surgery.

- **Further Research**: More research is needed to refine surgical techniques and preventive strategies to mitigate ENS risk, potentially involving a more nuanced approach to turbinate reduction and sensory preservation.

This study provides valuable insights into the mechanisms underlying ENS and emphasizes the need for a balanced approach to turbinate reduction in nasal surgeries.

Inferior meatus augmentation procedure IMAP normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics CFD modeling

 ### Summary of the Research Study on Empty Nose Syndrome and Inferior Meatus Augmentation Procedure

#### Background

Empty Nose Syndrome (ENS) is a controversial and often debilitating condition that arises from significant tissue loss in the nasal cavity, particularly affecting the inferior turbinates. Patients with ENS experience distressing symptoms such as nasal dryness, obstruction, burning, and crusting, which often occur after surgical procedures intended to widen the nasal passages by removing or reducing the inferior turbinates. Despite the apparent physical openness of the nasal passages post-surgery, patients with ENS report a paradoxical sense of nasal obstruction and discomfort.

The study in question investigates the efficacy of the Inferior Meatus Augmentation Procedure (IMAP) in alleviating ENS symptoms. IMAP involves the implantation of submucosal rib cartilage to restore the volume and contour of the nasal cavity, particularly in the inferior meatus. This study sought to understand the mechanisms behind the symptom relief provided by IMAP using advanced computational fluid dynamics (CFD) modeling.

#### Methods

The study involved five patients diagnosed with ENS who had undergone bilateral IMAP surgery. The procedure entailed the insertion of rib cartilage implants into the inferior meatus. Pre-operative and post-operative computed tomography (CT) scans were analyzed using CFD modeling to assess changes in nasal airflow patterns. The patients’ symptoms were evaluated using the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) both before and after surgery.

#### Results

1. **Symptom Improvement**: There was a significant reduction in ENS symptoms following IMAP surgery. The ENS6Q scores improved from a mean of 14.00 (indicating severe symptoms) to 4.80 (indicating mild symptoms), with a Cohen’s d value of 2.64 (p = 0.02), reflecting a substantial effect size.

2. **Airflow Dynamics**: CFD modeling revealed a notable shift in airflow patterns post-IMAP. Airflow distribution changed significantly, with a reduction in airflow through the middle meatus and an increase in airflow through the inferior meatus. This shift was observed across different slices of the nasal cavity:

   - **Anterior to the Implant**: Airflow through the middle meatus decreased from 67.13% to 46.18%, while airflow through the inferior meatus increased from 30.55% to 42.59% (p < 0.05).

   - **At the Implant**: A decrease in middle meatus airflow was noted (from 52.42% to 38.45%), although this was not statistically significant (p = 0.08).

   - **Posterior to the Implant**: No significant changes in airflow distribution were observed.

3. **Nasal Resistance**: There were no significant changes in nasal resistance pre- and post-IMAP, indicating that the improvement in symptoms was not due to changes in airflow resistance.

4. **Correlation with Symptom Relief**: A significant correlation was found between reduced airflow through the middle meatus and improved ENS6Q scores, suggesting that the shift in airflow patterns contributed to symptom relief.

#### Conclusions

The study supports the hypothesis that the symptoms of ENS are not solely related to nasal resistance but are significantly influenced by the abnormal distribution of nasal airflow. IMAP surgery effectively alters the airflow dynamics in the nasal cavity by redistributing airflow away from the middle meatus and enhancing airflow through the inferior meatus. This improvement in airflow patterns is associated with a reduction in ENS symptoms.

#### Key Findings and Implications

- **Mechanisms of Symptom Relief**: The symptom relief experienced by patients following IMAP surgery appears to be linked to the normalization of airflow patterns rather than changes in nasal resistance. The Coandă effect, where airflow adheres to the curvature of surfaces, may play a role in redistributing airflow towards the inferior meatus. 

- **Restoration of Nasal Function**: The augmentation of the inferior meatus via IMAP restores a more natural airflow pattern, providing patients with a more satisfying sensation of airflow and potentially addressing the root causes of ENS symptoms.

- **Future Directions**: While this study provides valuable insights into the benefits of IMAP, further research is needed to explore the exact mechanisms behind the observed airflow changes and to validate these findings in larger patient populations.

In summary, the research demonstrates that IMAP is a promising surgical intervention for ENS, providing significant symptomatic relief through the restoration of normal nasal airflow patterns.

Complications of Novel Radiofrequency Device Use in Rhinology: A MAUDE Analysis

This study, titled "Complications of Novel Radiofrequency Device Use in Rhinology: A MAUDE Analysis," investigates the adverse events (AEs) associated with the use of intranasal radiofrequency (RF) devices. These devices have gained popularity in otolaryngology, particularly for procedures related to the nasal airways, such as turbinate reduction and treatment of chronic rhinitis. The study primarily draws from the U.S. Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database to identify and analyze complications reported by physicians, patients, and manufacturers.

### Background and Objectives

Intranasal RF devices, including Celon® (Olympus), VivAer® (Aerin Medical), RhinAer® (Aerin Medical), and NeuroMark® (Neurent Medical), have been increasingly adopted in clinical practice. While these devices are marketed as minimally invasive options for nasal procedures, concerns have emerged regarding their safety, particularly the risk of tissue damage and other complications. The study aims to assess the safety profile of these devices by reviewing adverse events reported in the MAUDE database, thereby providing insights that could guide safer clinical use.

### Methods

The researchers queried the MAUDE database for adverse events related to the four mentioned RF devices. The data collected spanned from the inception of the database to February 2, 2023. Three reviewers independently analyzed the data, resolved discrepancies through discussion, and categorized the adverse events. The study did not undergo Institutional Review Board (IRB) approval as the data used is publicly available.

### Results

A total of 24 adverse events related to the use of RF devices were identified:

- **Celon® (11 events, 45.8%)**: The most common complication was tissue necrosis, accounting for 63.6% of Celon®-related events, often attributed to user error (e.g., high power settings). A notable case involved pediatric ocular palsy.

- **VivAer® (3 events, 12.5%)**: Complications included synechiae formation, mucosal perforation due to tissue necrosis, and a case of Empty Nose Syndrome (ENS).

- **RhinAer® (8 events, 33.3%)**: The majority of events (87.5%) were severe cases of epistaxis (nosebleeds), with many requiring surgical intervention, such as sphenopalatine artery ligation or blood transfusions.

- **NeuroMark® (2 events, 8.3%)**: Both events involved severe epistaxis, with one case necessitating septoplasty and cautery.

### Discussion

The study reveals that while RF devices are generally considered safe, they are not without risks. The low number of reported adverse events might suggest overall safety in trained hands, but certain severe complications underscore the need for caution. Specifically:

- **Tissue Necrosis**: The most common issue with Celon® was tissue necrosis, often linked to operator error. This suggests that RF energy settings need to be carefully managed to avoid damaging the surrounding tissues.

- **Epistaxis**: The frequent occurrence of severe nosebleeds, particularly with RhinAer® and NeuroMark®, indicates that the posterior nasal nerve ablation these devices perform can provoke significant bleeding, sometimes weeks after the procedure. This necessitates thorough patient counseling and preparedness for potential complications.

The study also highlights a unique case of Empty Nose Syndrome (ENS) reported with VivAer®, a debilitating condition where the nasal passages feel too open, leading to a sensation of suffocation and other symptoms despite normal airflow.

### Conclusions and Lessons Learned

The findings suggest that while RF devices offer innovative treatment options in rhinology, they carry risks that must be carefully managed. Surgeons should be vigilant in adjusting device settings to avoid tissue damage, particularly in sensitive areas. The study calls for more extensive long-term data and suggests that early adopters of such technologies should closely monitor patient outcomes to ensure safety.

The occurrence of severe epistaxis, tissue necrosis, and rare but severe complications like ocular palsy or ENS underscores the need for cautious and informed use of these devices. The researchers advocate for better training, careful patient selection, and thorough postoperative follow-up to mitigate these risks. Additionally, as the MAUDE database relies on voluntary reporting, the actual incidence of complications may be underreported, indicating a need for more rigorous safety monitoring in clinical practice.

 

Empty Nose Syndrome as an Iatrogenic Condition from Surgery

Comprehensive Summary of the Study on Empty Nose Syndrome as an Iatrogenic Condition from Surgery

**Overview**

The study, titled "Empty Nose Syndrome as an Iatrogenic Condition from Surgery," published in *Current Otorhinolaryngology Reports* (2023), provides an in-depth review of Empty Nose Syndrome (ENS), focusing on its sjukdomsutveckling, diagnosis, and management. The researchers examine the role of surgical interventions, particularly turbinate surgery, in the development of ENS, highlighting recent advancements in computational fluid dynamics (CFD) that have shed light on the condition's underlying mechanisms.

**Introduction**

ENS, first described in 1994, is a rare and often debilitating condition that occurs primarily after partial or total resection of the nasal turbinates, structures responsible for regulating airflow and humidifying inhaled air. Despite having a patent nasal airway, patients with ENS experience paradoxical nasal obstruction and a range of other distressing symptoms. Historically, the condition was controversial and often dismissed as a psychological issue due to its rarity and elusive pathophysiology. However, recent studies, particularly those using CFD, have provided a more scientific understanding of ENS, reinforcing the notion that it is an iatrogenic (medically induced) condition.

**Key Findings**

1. **Pathogenesis and Nasal Airflow Alterations**

   - ENS is associated with significant changes in nasal airflow dynamics. Normally, nasal airflow is turbulent and distributed across the nasal cavity, allowing for proper air conditioning and stimulation of thermoreceptors that signal nasal patency.

   - After turbinate surgery, the airflow becomes laminar and more concentrated in the middle meatus, bypassing the inferior and superior parts of the nasal cavity. This change reduces the effectiveness of air conditioning and impairs the sensation of airflow, contributing to ENS symptoms.

   - CFD studies have shown that patients with ENS experience increased airflow velocity and decreased nasal resistance, yet paradoxically suffer from a sensation of nasal obstruction. This is because the airflow is no longer distributed evenly across the nasal cavity, leading to inadequate stimulation of the mucosal receptors responsible for detecting airflow.

2. **Sensorineural Dysfunction**

   - ENS also involves neurosensory abnormalities, particularly involving the trigeminal nerve, which plays a critical role in sensing nasal airflow. Damage to this nerve, either during surgery or as a result of altered airflow patterns post-surgery, can impair the sensation of nasal patency.

   - Histopathological studies have shown decreased expression of thermoreceptors (TRPM8) in the nasal mucosa of ENS patients, further supporting the role of sensorineural dysfunction in the disease.

3. **Psychological Impact**

   - ENS has a profound psychological impact, with a significant proportion of patients experiencing anxiety, depression, and sleep disturbances. Studies have shown that ENS patients have much higher rates of moderate to severe depression compared to those with other nasal conditions, such as chronic rhinosinusitis.

   - Suicidal ideation has been reported in a notable percentage of ENS patients, underscoring the severe psychological burden of the condition. 

4. **Diagnosis**

   - The diagnosis of ENS involves a combination of clinical assessment and specialized tools. The Empty Nose Score 6-Questionnaire (ENS6Q) is a validated tool that helps differentiate ENS from other nasal conditions based on symptoms like nasal dryness, a sensation of diminished airflow, and the feeling that the nose is "too open."

   - The cotton wool test, where a small piece of cotton is placed in the nasal cavity to temporarily restore turbinate bulk, can provide diagnostic insight by significantly reducing symptoms in ENS patients.

5. **Management and Treatment**

   - Management of ENS is challenging, as the condition often requires a multifaceted approach. Medical treatments focus on symptom relief through nasal moisturization and psychological support, including cognitive-behavioral therapy and pharmacotherapy for anxiety and depression.

   - Surgical interventions are considered for patients who do not respond to medical therapy. These include inferior meatal augmentation procedures (IMAP) to restore nasal airflow dynamics and submucosal filler injections to temporarily alleviate symptoms by increasing tissue bulk in the nasal cavity.

   - The success of surgical treatments supports the notion that ENS is indeed an iatrogenic condition, as these procedures aim to reverse the changes caused by the initial surgery.

**Conclusions**

The study concludes that ENS is a complex, multifactorial condition primarily resulting from surgical alterations to the nasal turbinates. The insights provided by CFD have improved the understanding of ENS, highlighting the critical role of nasal airflow dynamics and sensorineural function in its pathogenesis. Despite advances in diagnosis and management, ENS remains a challenging condition, with a need for further research to identify patients at risk and optimize treatment strategies. The study emphasizes the importance of a careful pre-operative assessment to prevent the occurrence of ENS and the need for ongoing research to refine surgical techniques and therapeutic approaches.

**Empty Nose Syndrome in Focus**

The study confirms that ENS is a genuine, physically based condition, not merely a psychological phenomenon, though it has significant psychological ramifications. The findings also highlight the importance of recognizing ENS as a potential risk when considering turbinate surgery and suggest that preventive measures and patient education are crucial in managing expectations and outcomes.

**Final Thoughts**

This comprehensive review underscores the importance of understanding ENS as both a physiological and psychological condition. The recognition of its iatrogenic origins calls for greater caution in nasal surgeries and a more holistic approach to patient care, incorporating both physical and mental health support to manage this debilitating condition effectively.

Distinguishing computed tomography findings in patients with empty nose syndrome

This study, conducted by Andrew Thamboo and colleagues, addresses the challenge of diagnosing Empty Nose Syndrome (ENS), a controversial condition often arising after nasal surgeries such as inferior turbinate reduction (ITR). ENS is characterized by a range of debilitating symptoms, including a paradoxical sensation of nasal obstruction despite a clear nasal passage, dryness, pain, and even psychological distress. However, due to the lack of standardized diagnostic criteria, identifying ENS has been challenging for clinicians.

The researchers aimed to determine whether specific radiographic features, particularly those visible on computed tomography (CT) scans, could be used to objectively differentiate ENS patients from those who had undergone ITR but did not develop ENS, as well as from healthy individuals with no history of sinonasal procedures. The study involved analyzing CT scans from three groups: 65 patients diagnosed with ENS, patients with a history of ITR without ENS symptoms, and control patients with no sinonasal disease history.

Key measurements were taken at the level of the nasolacrimal duct, including the thickness of the mucosa in the nasal septum, inferior turbinate, nasal floor, and lateral nasal wall, across different segments of the nasal cavity (anterior, central, and posterior). The study found that the mucosal thickness in the central and posterior segments of the septum was significantly greater in ENS patients compared to both ITR without ENS patients and controls. Specifically, a septal mucosal thickness greater than 2.64 mm in the central nasal region and greater than 1.32 mm in the posterior nasal region were identified as potential markers for ENS, offering high sensitivity and specificity.

The findings support the notion that ENS is a distinct pathophysiological entity with measurable differences in nasal mucosa that can be identified through CT imaging. The study also suggested that the nasal septum, particularly in the central and posterior regions, exhibits dynamic hypertrophy in ENS patients, potentially contributing to their symptoms.

However, the study acknowledges limitations, including the retrospective design and the small sample size, particularly in the ENS group. Moreover, the role of excessive nasal hygiene practices in contributing to mucosal swelling in ENS patients was speculated but not proven. Despite these limitations, the study provides valuable insights into the potential for developing objective diagnostic criteria for ENS, which could greatly benefit patients suffering from this underrecognized condition.

The study did discuss Empty Nose Syndrome (ENS) extensively, highlighting the difficulties in diagnosing the condition and the need for objective criteria. The conclusions emphasize that specific CT findings, particularly related to mucosal thickness in the central and posterior nasal septum, could serve as important diagnostic markers for ENS. This could lead to better recognition and management of the condition, offering hope for patients who suffer from its often debilitating symptoms.