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.