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.

Management of Postsurgical Empty Nose Syndrome

The research study presented in the document focuses on the management of Postsurgical Empty Nose Syndrome (ENS), a condition that can arise after surgical procedures involving the nasal turbinates, particularly when excessive tissue is removed. The study provides a comprehensive overview of ENS, its pathophysiology, diagnosis, treatment options, and the psychological implications associated with the condition.

Overview of Empty Nose Syndrome

Empty Nose Syndrome is characterized by a paradoxical sensation of nasal obstruction despite a patent nasal airway. This condition often occurs after aggressive surgical interventions aimed at improving nasal airflow, such as turbinate resection. The inferior turbinates play a crucial role in regulating airflow, conditioning the air we breathe, and providing sensory feedback about nasal airflow. When these structures are excessively removed, patients may experience a range of symptoms, including a feeling of emptiness, dryness, and anxiety related to their nasal breathing.

Historical Context

The term "Empty Nose Syndrome" was first coined in the mid-1990s, although the complications associated with turbinate resection had been observed for decades prior. The study highlights the evolution of surgical practices, noting that while some surgeons have moved towards more conservative approaches to turbinate surgery, others continue to perform extensive resections in pursuit of maximizing nasal airway opening. This has led to a growing awareness of the potential for ENS as a significant postoperative complication.

Diagnosis and Symptoms

Patients with ENS typically report symptoms that are disproportionate to the physical examination findings. Common complaints include feelings of suffocation, a persistent sensation of nasal obstruction, and dryness in the nasal passages and throat. The study emphasizes the importance of recognizing these symptoms as they can significantly impact a patient's quality of life. Tools such as the Empty Nose Syndrome 6-item Questionnaire (ENS6Q) are mentioned as useful diagnostic aids.

Treatment Approaches

The management of ENS can be divided into medical and surgical treatments. Medical therapy focuses on alleviating symptoms through methods such as nasal moisturization with saline sprays and emollients. Inhaled menthol solutions may also provide temporary relief by stimulating sensory receptors in the nasal lining. However, the study notes that these treatments often require frequent reapplication and may not provide long-term relief.

For patients who do not achieve sufficient relief from medical therapies, surgical options may be considered. These can include procedures aimed at restoring turbinate volume or function. Importantly, even after surgical intervention, ongoing medical management is recommended to address the persistent symptoms associated with ENS.

Psychological Considerations

The study also highlights the psychological aspects of ENS, noting that many patients experience significant anxiety and depression related to their condition. It is crucial for healthcare providers to address these psychological factors during treatment planning. The research suggests that cognitive-behavioral therapy and psychiatric consultation may be beneficial for patients suffering from comorbid mental health issues. Notably, surgical interventions for ENS have been shown to improve not only physical symptoms but also psychological well-being.

Conclusions and Lessons Learned

The study concludes that Empty Nose Syndrome is a complex condition that requires a multifaceted approach to management. Key takeaways include:

Awareness of ENS: Surgeons and healthcare providers must be aware of the potential for ENS following turbinate surgery and recognize its symptoms to provide appropriate care.

Importance of Conservative Surgery: There is a growing consensus on the need for mucosal-sparing surgical techniques to minimize the risk of ENS.

Holistic Treatment Approach: Effective management of ENS should include both medical and surgical treatments, as well as psychological support to address the emotional and mental health aspects of the condition.

Need for Further Research: The study underscores the necessity for more longitudinal studies to better understand the long-term outcomes of patients with ENS and to refine treatment strategies.

In summary, this research study provides valuable insights into the complexities of Empty Nose Syndrome, emphasizing the importance of careful surgical planning, comprehensive treatment approaches, and the consideration of psychological factors in patient care.

Physiologic Concerns During Rhinoplasty by Eugene Kern

The document titled "Physiologic Concerns During Rhinoplasty" provides an in-depth examination of the physiological aspects and potential complications associated with rhinoplasty, particularly focusing on the nasal valves and the phenomenon known as "empty nose syndrome." The author, Dr. E.B. Kern, draws on nearly five decades of clinical experience and extensive research, including data from approximately 9,000 patients, to present a comprehensive overview of nasal function and the implications of surgical interventions.

Overview of Nasal Function

The study emphasizes the critical roles of the nose in respiration, olfaction (sense of smell), and defense against pathogens. The author categorizes the primary functions of the nose into four main areas:

Airway Function: The nose serves as the primary pathway for airflow, filtering and humidifying the air before it reaches the lungs.

Olfaction: The nasal cavity is essential for the sense of smell, which is closely linked to taste and overall quality of life.

Defense Mechanisms: The nose plays a vital role in protecting the respiratory system from environmental pollutants and pathogens through mucosal secretions and ciliary action.

Regulation of Airflow: The nasal valves, both internal and external, are crucial for regulating airflow and maintaining optimal breathing function.

Importance of Nasal Valves

A significant portion of the document is dedicated to the anatomy and physiology of the nasal valves. The internal nasal valve, in particular, is highlighted as a critical structure that influences breathing. The author discusses various abnormalities that can occur in the nasal valves, which may lead to postoperative complications, including breathing difficulties.

Empty Nose Syndrome

One of the key findings of the study is the association between aggressive surgical techniques and the development of "empty nose syndrome." This condition is characterized by a paradoxical sensation of nasal obstruction despite an open nasal airway. Patients with empty nose syndrome may experience a range of symptoms, including:

Crusting

Bleeding

Anosmia (loss of smell)

Difficulty breathing

Pain and headaches

Disturbed sleep

Emotional changes, such as anxiety and depression

The author expresses concern over the aggressive resection of turbinate tissues, which can lead to these debilitating symptoms. The study advocates for a more conservative approach to turbinate surgery, emphasizing the importance of preserving nasal structures to maintain physiological function.

Research Findings and Conclusions

Throughout the document, Dr. Kern presents a wealth of evidence from clinical studies and personal experience. Key conclusions drawn from the research include:

Surgical Technique Matters: The choice of surgical technique significantly impacts postoperative breathing function. A thorough understanding of nasal anatomy and careful handling of the nasal valves are essential to minimize complications.

Preoperative Assessment: Comprehensive preoperative evaluations, including rhinomanometry and olfaction testing, are crucial for identifying potential issues and tailoring surgical approaches to individual patients.

Patient Education: The importance of educating patients about the risks and benefits of rhinoplasty is underscored. Clear communication regarding the goals of surgery and potential complications can help manage patient expectations and improve satisfaction.

Long-term Follow-up: The study highlights the need for long-term follow-up of rhinoplasty patients to monitor for complications such as empty nose syndrome and to assess the overall success of the surgical intervention.

In summary, the document provides a thorough exploration of the physiological concerns associated with rhinoplasty, particularly focusing on the implications of nasal valve surgery and the risks of empty nose syndrome. The findings emphasize the importance of preserving nasal function through careful surgical techniques and comprehensive preoperative assessments, ultimately aiming to enhance patient outcomes and satisfaction.