Christopher Supalla, yet another Empty Nose Syndrome victim

Evaluation of sinonasal-related quality of life of 49 patients undergoing endoscopic skull base surgery

This study aimed to assess the impact of endoscopic skull base surgery on sinonasal-related quality of life (QoL). In this summary, we focus on the effects of turbinate removal and its implications for sleep quality.

**Types of Surgery and Procedure Details:**

Endoscopic skull base surgery is a technique used to address various conditions affecting the base of the skull and surrounding areas. This procedure sometimes also involves the removal of nasal turbinates. The types of surgeries and procedures included:

**Removal of Tumors:** Both benign and malignant tumors located at the skull base.

**Reconstruction:** Repair of defects using grafts or flaps.

**Turbinate Surgery:** Partial or total removal of nasal turbinates 

**Methods:**

The study included 49 patients who completed two questionnaires:

- **Sinonasal Outcome Test-22 (SNOT-22):** Measures various aspects of sinonasal health and their impact on quality of life, including nasal symptoms, facial pain, sleep disturbances, and emotional well-being.

- **Empty Nose Syndrome 6 Item Questionnaire (ENS6Q):** Assesses symptoms related to Empty Nose Syndrome, such as nasal dryness, diminished airflow, and nasal crusting.

**Results:**

1. **Overall Quality of Life Scores:**

   - The average SNOT-22 score was 25.1, indicating moderate to severe impact on health and overall quality of life.

   - The average ENS6Q score was 6.51, with 18.4% of patients scoring above 10.5. Displaying a high risk of getting Empty Nose Syndrome (ENS) after Turbinectomy and turbinate reduction.

To get diagnosed with Empty Nose Syndrome (ENS) based on the ENS6Q, a score of 11 or higher is generally used as the threshold. The total score ranges from 0 to 30, with each of the six questions scoring up to 5 points. A score above this threshold suggests that the patient is experiencing symptoms severe enough to be considered as having ENS.

2. **Impact on Sleep:**

   - Sleep-related symptoms were notably severe across the board. Patients frequently reported issues such as difficulty falling asleep, waking up during the night, and feeling tired during the day.

   - Among the different groups, those with a history of re-radiotherapy had significantly higher scores for sleep-related issues compared to patients with no history of radiotherapy. This suggests that radiotherapy may have a long-term impact on sleep quality. These patients also had a higher SNOT-22 score related to emotional well-being.

**Conclusions / summary:**

**Turbinate Removal and Sleep:** According to the study, 18.4% of patients who had their turbinates removed or reduced by radio frequency had a score higher than 10.5 on the Questionnaire: (ENS6Q), indicating a high risk of Empty Nose Syndrome (ENS). It was also noted that turbinectomy and radiofrequency treatment led to noticeable sleep disturbances. Patients experienced significant sleep issues, which were further exacerbated in those with a history of radiofrequency treatment

**Overall Quality of Life:** The study highlights that patients undergoing this surgery generally experience moderate to severe nasal symptoms and sleep disturbances. 

**Radiotherapy Impact:** A history of radiotherapy negatively impacts quality of life, particularly affecting sleep and emotional health. Patients with re-radiotherapy history experienced worse outcomes in these areas compared to those without such history.

Surgical Treatment for Empty Nose Syndrome

This research study, led by Dr. Steven M. Houser, delves into the complex and often misunderstood condition known as Empty Nose Syndrome (ENS), an iatrogenic disorder that arises as a consequence of nasal surgeries, particularly turbinate resections. ENS is characterized by a paradoxical situation where patients, despite having a seemingly open nasal airway, experience a profound sense of nasal obstruction and difficulty breathing. This condition is perplexing because it lacks clear, objective diagnostic criteria, making it a challenge for otolaryngologists to diagnose and treat.

### Understanding Empty Nose Syndrome

ENS is primarily caused by the excessive removal of turbinate tissue during nasal surgeries, which disrupts the normal nasal airflow and impairs the function of the nasal mucosa. Turbinates are crucial structures in the nasal cavity that regulate airflow, humidify, filter, and warm the air before it reaches the lungs. When these structures are removed or significantly reduced, patients often lose the sensation of airflow in their noses, leading to symptoms that can be as distressing as they are difficult to describe. Common symptoms include a sensation of nasal obstruction despite an open airway, shortness of breath, dryness, crusting, and a feeling of suffocation. These symptoms are often accompanied by significant psychological distress, including anxiety, depression, and a reduced quality of life.

### The Study’s Approach and Methods

The study involved eight patients diagnosed with ENS, who were treated with a surgical intervention aimed at alleviating their symptoms. The intervention involved the submucosal implantation of acellular dermis, a tissue graft material designed to simulate the missing turbinate tissue. The patients’ symptoms were evaluated before and after the surgery using the Sino-Nasal Outcome Test (SNOT-20), a validated questionnaire that measures the severity of nasal symptoms.

### Key Findings and Discoveries

The results of the study demonstrated a statistically significant improvement in the patients' symptoms following the surgical intervention. The SNOT-20 scores, which assess various nasal symptoms including nasal obstruction, facial pain, and sleep quality, showed marked improvement after the implantation of the acellular dermis. Importantly, the study also noted improvements in symptoms related to mental health, such as sadness, irritability, and sleep disturbances, which are often exacerbated by ENS.

The study highlighted several critical insights:

1. **Subjective Improvement**: Most patients reported a subjective improvement in their breathing and overall quality of life after the surgery, even though the physical changes in their nasal anatomy were subtle.

2. **Psychological Impact**: The psychological burden of ENS is profound, with many patients experiencing depression and anxiety due to the persistent and distressing nature of their symptoms.

3. **Challenges in Diagnosis and Treatment**: The study underscored the difficulties in diagnosing ENS due to the lack of objective tests and the reliance on patients’ subjective experiences. However, it also pointed out that these symptoms are real and stem from a physical alteration in the nasal anatomy.

### Conclusions and Implications

The study concludes that reconstructive surgery using acellular dermis can offer significant relief to patients suffering from ENS. However, it also emphasizes the importance of careful patient selection and thorough preoperative assessment, including the use of the cotton test to predict the potential benefits of the surgery. The findings suggest that, while ENS is a challenging condition to treat, surgical interventions that aim to restore the nasal anatomy can lead to meaningful improvements in patients' symptoms and quality of life.

### Reflections on ENS and Future Directions

ENS remains a complex and multifaceted condition, with significant implications for patients' physical and psychological well-being. This study contributes to the growing body of evidence that ENS is a legitimate and serious complication of nasal surgery, one that requires careful consideration and management. The authors suggest that future research should focus on developing more precise diagnostic criteria and exploring additional treatment options that can further improve the outcomes for patients with ENS.

In summary, this research provides valuable insights into the nature of ENS and highlights the potential for surgical intervention to offer relief for patients who suffer from this debilitating condition. It also calls for greater awareness among clinicians about the risks of turbinate surgery and the need for conservative approaches to avoid the development of ENS.