Surgery of the turbinates and “empty nose” syndrome

The research study titled "Surgery of the Turbinates and Empty Nose Syndrome" provides a comprehensive examination of the surgical interventions performed on the nasal turbinates, which are structures within the nasal cavity that play a crucial role in regulating airflow, humidifying, and warming the air we breathe. The study highlights the complexities and challenges associated with turbinate surgery, particularly focusing on the phenomenon known as Empty Nose Syndrome (ENS).

Overview of Turbinate Surgery

Turbinate surgery is often performed to alleviate nasal obstruction caused by conditions such as chronic rhinitis or hypertrophy of the turbinates. The primary goal of these surgical procedures is to improve nasal airflow while preserving the mucosal function of the nasal cavity. However, the study notes that there is no universally accepted surgical technique for turbinate reduction, leading to variability in outcomes and patient experiences.

Empty Nose Syndrome (ENS)

One of the significant concerns raised in the study is the risk of developing Empty Nose Syndrome, a condition that can occur after the resection of turbinates. ENS is characterized by a paradoxical sensation of nasal obstruction despite the nasal passages being physically wide open. Patients with ENS often report a dry nose, crusting, and a feeling of inadequate airflow, which can be distressing and difficult to treat. The study emphasizes that ENS is a surgically irreversible condition, making it crucial for surgeons to carefully consider the extent of turbinate removal during surgery.

Findings from Clinical Studies

The research includes findings from a clinical study conducted at the ENT University Clinic in Ulm, which investigated the airflow dynamics in patients with ENS. Using MRI-based numerical flow simulations, the study found that patients with ENS had significantly higher temperatures of inhaled air at certain points in the nasal cavity compared to healthy individuals. Additionally, the absolute humidity of the air was lower in ENS patients, contributing to the sensation of dryness and increased crust formation. These findings underscore the importance of the nasal turbinates in conditioning inhaled air and maintaining mucosal health.

Conclusions and Lessons Learned

The study concludes that while turbinate surgery can provide relief for many patients suffering from nasal obstruction, it carries the risk of complications such as ENS. The authors stress the need for careful patient selection and thorough preoperative counseling to ensure that patients are aware of the potential risks and benefits of the procedure. Furthermore, the study highlights the importance of preserving as much mucosal tissue as possible during surgery to maintain the natural functions of the nasal cavity.

In summary, the research emphasizes the delicate balance that surgeons must strike between achieving adequate airflow and preserving the integrity of the nasal mucosa. The findings serve as a reminder of the complexities involved in nasal surgery and the need for ongoing research to better understand the long-term effects of turbinate reduction procedures. The study advocates for a more conservative approach to turbinate surgery, prioritizing patient safety and quality of life over aggressive surgical interventions.

The turbinates in nasal and sinus surgery: A consensus statement

### Summary of the Study: "The Turbinates in Nasal and Sinus Surgery: A Consensus Statement"

This study was a collaborative effort led by Dr. Dale H. Rice, along with several prominent otolaryngologists, to establish a consensus on the management of the middle and inferior turbinates in nasal and sinus surgeries. The discussion took place under the auspices of the American Rhinological Society during the Combined Otolaryngological Spring Meetings in May 2001. The main focus was to address the varying surgical approaches to the turbinates and to develop guidelines that balance the need for effective treatment with the risk of complications.

### Overview of Turbinate Surgery

The turbinates, particularly the middle and inferior ones, play a crucial role in nasal and sinus surgeries due to their influence on the anatomy and function of the nasal passages. The study acknowledges that the middle turbinates are involved in almost every operation on the paranasal sinuses, especially when treating chronic infections. The anatomy of the turbinates can vary, with some cases presenting challenges such as paradoxical curvatures or concha bullosa (an air-filled cavity within a turbinate), which can complicate surgical procedures.

#### Middle Turbinates

The study outlines several surgical options for managing the middle turbinates. While the routine resection of the middle turbinates is controversial, it is sometimes necessary depending on the specific anatomical variations and the patient's condition. The panel discusses different techniques, including partial resection, which is preferred over total resection to minimize the risk of complications like skull base injury. The management of a concha bullosa typically involves resecting the lateral wall to increase the space in the middle meatus while preserving anatomical landmarks.

### Inferior Turbinates

or the inferior turbinates, the study emphasizes the importance of medical management before considering surgery. Treatments might include antihistamines, decongestants, steroids, and immunotherapy. When surgery becomes necessary, there are several approaches, ranging from simple mechanical techniques like fracturing to more invasive procedures like resection or laser vaporization. The study highlights the utility of lasers, which can be effectively used in an office setting, and newer techniques like radiofrequency ablation that offer minimal bleeding risks.

### Conclusions and Consensus Recommendations

The panel reached a consensus that surgery on the turbinates should be approached conservatively. While subtotal or total resection of the middle turbinate might be appropriate in cases of paradoxical curvature, concha bullosa, or significant polyposis, it should not be done without a clear indication. For the inferior turbinates, conservative reduction is advised, and simultaneous resection of both the middle and inferior turbinates should be avoided in non-neoplastic diseases.

### Consideration of Empty Nose Syndrome

The study explicitly mentions the risk of "Empty Nose Syndrome" (ENS), a condition that can arise from excessive removal of turbinate tissue. ENS is characterized by symptoms like crusting, bleeding, difficulty breathing (often paradoxical sensations of obstruction), recurrent infections, nasal odor, pain, and even depression. The panel notes that symptoms of ENS might not appear until many years after the surgery, which underscores the importance of a conservative approach to turbinate surgery. Surgeons are advised to carefully balance the need for tissue removal against the long-term risks of complications like ENS.

### Final Takeaways

The key lesson from this study is the need for caution in turbinate surgeries. While surgical intervention can be necessary and beneficial in many cases, the risks associated with over-resection, particularly the development of Empty Nose Syndrome, should not be underestimated. The panel’s consensus underscores the importance of individualized patient care, meticulous surgical planning, and the use of the least invasive methods that achieve the desired therapeutic outcomes. This approach aims to minimize complications while effectively treating nasal and sinus conditions.