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.