The research article presents a systematic review of the pathophysiology of Empty Nose Syndrome (ENS), a condition characterized by paradoxical nasal obstruction and a sensation of emptiness in the nasal cavity, often following surgical interventions aimed at relieving nasal obstruction. The review aimed to consolidate existing knowledge regarding the mechanisms underlying ENS, which remain poorly defined despite significant research efforts.
The authors conducted a comprehensive search of the literature, yielding 2,476 studies after removing duplicates. Ultimately, 19 studies were included in the qualitative analysis. These studies varied in design, including case-control and cross-sectional studies, and involved a total of 489 adult patients diagnosed with ENS. The definition of ENS varied across studies, with some relying on self-identification, while others used specific questionnaires like the Empty Nose Syndrome 6 Questionnaire (ENS6Q) or defined it by the presence of paradoxical obstruction.
Key findings from the review highlighted several important themes:
Symptomatology: Patients with ENS reported a range of symptoms, including nasal obstruction, dryness, and a lack of sensation. The severity of these symptoms was often comparable to those experienced by patients with chronic rhinitis, indicating a significant impact on quality of life.
Mental Health: A notable correlation was found between ENS symptoms and mental health issues, such as anxiety and depression. The burden of these psychological conditions was significant, with some patients experiencing severe distress and a diminished quality of life.
Anatomical and Physiological Changes: The review noted that while patients with ENS often had a patent nasal airway, structural changes in the nasal cavity could still be present. However, the relationship between these anatomical changes and the symptoms of ENS was not straightforward, as many patients did not exhibit typical signs of nasal obstruction.
Airflow Dynamics: The influence of altered airflow on the perception of nasal patency was discussed, with some theories suggesting that changes in airflow dynamics could contribute to the sensation of emptiness experienced by ENS patients.
Neurosensory Dysfunction: The review also explored the possibility of neurosensory decline, where patients may have an altered perception of nasal sensations, leading to the symptoms associated with ENS.
Psychogenic Factors: Psychogenic dysfunction was identified as a potential contributor to ENS, with some patients experiencing heightened awareness of their symptoms, which could exacerbate their condition.In conclusion, the systematic review underscored the complexity of ENS, revealing that it is not merely a result of anatomical changes following surgery but is also influenced by psychological, sensory, and airflow-related factors. The findings emphasize the need for a multidisciplinary approach to understanding and managing ENS, considering both the physical and psychological aspects of the condition. The authors advocate for further research to clarify the pathophysiological mechanisms of ENS and improve diagnostic and therapeutic strategies for affected patients.
Over three decades have passed since Dr. Eugene Kern first identified Empty Nose Syndrome (ENS), yet the number of people developing this condition post-septoplasty, sinus surgery, turbinate reduction, rhinoplasty, and spreader graft surgery continues to rise.
Now let's start the video by listening shortly to What Eugene Kern has to say about the condition
Since the 1980s, improvements in endoscopic cameras have led to the development of various instruments for turbinate reduction. Medical device manufacturers have mass-produced tools for Coblation, Radiofrequency, and Laser Ablation, aiming to maximize profit.
One instrument after another has been increasingly effective at destroying and shrinking the nasal turbinates. Unfortunately, this process has completely disregarded the fact that nerves, receptors, blood vessels, cilia, and goblet cells are destroyed in the process. When a significant number of these receptors are damaged, the individual loses the ability to sense airflow in the nose, leading to a constant fight-or-flight response. The nose also becomes severely dry, and over time, the nasal mucosa may degenerate into a condition known as atrophic rhinitis.
Furthermore, these processes open up the nose to an abnormal level where the lungs don't get enough air resistance in the nose to inflate fully. Air flows in and out too fast without proper nasal resistance, causing hyperventilation and severe problems with gas exchange in the lungs. For example, we have seen a case where an overly open nose led to nightly hypoventilation and carbon dioxide poisoning.
Advancements in technology have led to an increase in nasal surgeries for congestion, turning them into routine practice. Despite numerous reports of adverse outcomes, the medtech industry and ENT surgeons are hesitant to confront these problems. Their main concern seems to be maintaining business operations rather than ensuring patient health. To protect the ENT field, surgeons are quick to attribute complications to poor healing or dismiss them as psychological issues. While some surgeons may be uninformed, most are aware of the essential role nasal turbinates play; they just keep quiet to not reject potential income.
Unfortunately, it is becoming more common for these surgeries to lead to suicides due to severe suffering. One would think that suicides linked to ENS would lead to a reevaluation of nasal surgeries, but this has not been the case. Whether there are ten or thousands of suicides, surgeons appear indifferent as long as their practice is not affected.
Now, let's listen to yet another ENS-related death. This is the testimony of Robert Priscilla, who passed away on August sixth, 2015, due to Empty Nose Syndrome.
Everything started in 2009. I suffered from sinus infections all year long. While on sick leave, my doctor referred me to specialists, an allergist and an ophthalmologist, because of severe eye pain. It turned out I also had asthma. Eventually, my general practitioner sent me to an ENT specialist who diagnosed swollen turbinates. Initially, he suggested laser treatment. In March, I underwent the procedure to burn the turbinates. Unfortunately, I didn't notice any improvement in my breathing post-surgery.
Four weeks later, I returned to the ENT specialist, still dissatisfied with my condition. He then recommended removing the lower turbinates and performing a septoplasty to correct my nasal septum. The surgery took place in April, followed by nasal packing. The next day, I experienced a minor hemorrhage from my left nostril after the packing was removed. Despite assurances from the nurse that I should be able to breathe better, I continued to face obstruction. The pain in my nose intensified, and my headaches worsened. Anxiety attacks became frequent, and I struggled to stand due to severe discomfort.
The situation escalated to the point where I needed emergency care. However, the on-call ENT specialist refused to acknowledge any connection to my recent surgeries. After discharge, I sought a second opinion, only to be turned away due to concerns over a colleague's work. In desperation, I traveled to Paris for a third opinion and underwent a sleep study revealing poor sleep quality, snoring, and atrophic rhinitis.
Since 2011, my life has been a nightmare. I barely eat, and I can no longer sleep. I've lost my sense of smell, and my nose is even more blocked than before the surgeries. Exertion is nearly impossible. I live in constant hyperventilation with a perpetually dry nose. The cold burns, and even speaking is excruciating. Pressure from my nose to my forehead feels like my head is being crushed. Lying down is torture; I feel like I'm suffocating. I am utterly exhausted, isolated, and deeply depressed. This is not how someone my age should live, it's not living at all.
My condition has only deteriorated since the surgeries. Had I known the risks, I would have never consented. I found solace in an association that provides emotional support, though many countries don't recognize this syndrome. Why? I share my story hoping others can avoid my suffering. The laser treatment and turbinectomy destroyed my life. Once active and engaged, I am now confined, semi-reclined, and condemned to suffer. Only one ENT specialist had the courage to tell me that turbinates never regenerate.
Priscilla Robert’s testimony reminds us that she passed away on August 6, 2015, due to Empty Nose Syndrome. Her story is just one of hundreds of patients whose lives have been irreparably damaged to the point where they could no longer bear to stay alive. More information about Prisilla can be found in the video description.
