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.

Forskningen kring "Empty Nose Syndrome" (ENS): Komplikationer av näskirurgi

Forskningen kring "Empty Nose Syndrome" (ENS) handlar om en komplex och ofta förödande sjukdom som kan uppstå efter att man har opererat bort en betydande del av näsmusslorna, de strukturer som reglerar luftflödet genom näshålan. Begreppet myntades först av Kern och Stenkvist 1994 och beskriver tillståndet där näsan känns tom, vilket leder till en rad symtom som paradoxal obstruktion – en känsla av att inte kunna andas trots att näspassagen är öppen.

**Symptom och problematik:**

Patienter med ENS kan uppleva olika fysiska, kognitiva och emotionella symtom. Fysiska problem inkluderar andningssvårigheter, en känsla av kvävning, torrhet i näsan, kronisk näsblödning, och smärta. Kognitiva symtom kan innebära svårigheter att koncentrera sig, medan emotionella problem ofta handlar om ångest, depression och frustration. Symtomens svårighetsgrad varierar beroende på hur mycket av näsmusselvävnaden som har avlägsnats, samt individuella faktorer som kroppens respons på kirurgi och andra yttre faktorer.

**Patofysiologi och mekanismer:**

ENS orsakas av både strukturella och funktionella skador. Strukturellt leder avlägsnandet av näsmusselvävnad till störningar i näsans aerodynamik, vilket resulterar i ett onormalt luftflöde och minskad nasal motståndskraft. Detta kan förvärra andningssvårigheter och minska förmågan att uppleva luftflödet genom näsan, vilket är centralt för en normal andningsupplevelse.

Funktionellt innefattar ENS nervskador, vilket kan leda till förlust av sensoriska signaler och därmed en bristande upplevelse av luftflöde. Nervskadorna kan orsaka neuropati, där vissa delar av näsan blir överkänsliga för luftflöde, vilket kan leda till smärta och brännande känslor. Dessutom kan ENS innebära en försämrad eller frånvarande återväxt av nervvävnad, vilket ytterligare förvärrar problemen med att känna luftflöde och reglera andningen korrekt.

**Upptäckter och lärdomar:**

Forskningen har visat att ENS är en multifaktoriell sjukdom där både anatomiska förändringar och nervfunktion spelar en avgörande roll. ENS är inte enbart kopplad till den mängd vävnad som avlägsnats, utan också hur detta påverkar nervsystemet och näsans fysiologi. Den huvudsakliga lärdomen är att kirurgi på näsmusslor bör utföras med stor försiktighet, och att man bör undvika överdriven vävnadsborttagning för att minska risken för ENS.

**Slutsats:**

ENS är en allvarlig och komplex sjukdom som kan ha stor inverkan på livskvaliteten. Den huvudsakliga slutsatsen är att kirurgiska ingrepp i näsan måste utföras med försiktighet och att det är viktigt att förstå både de strukturella och funktionella aspekterna av näsans funktion för att undvika att utveckla detta tillstånd. Trots öppen näspassage kan ENS-patienter uppleva en känsla av kvävning och oförmåga att andas ordentligt, vilket är ett paradoxalt men centralt symtom i syndromet.

Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature

The study titled "Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature" by Tanja Hildenbrand, Rainer K. Weber, and Detlef Brehmer provides a comprehensive overview of the various conditions associated with the symptom of a dry nose (DN), such as rhinitis sicca, atrophic rhinitis, and Empty Nose Syndrome (ENS). The study examines the etiology, symptoms, diagnosis, and treatment options for these conditions, highlighting the complexity and variability in clinical presentation.

### Summary of Findings:

**1. Lack of Clear Definitions:**

The term "dry nose" lacks a precise definition and is used to describe a range of symptoms from a subjective sensation of dryness to visible crusting of the nasal mucosa. The term "rhinitis sicca" is commonly used by ENT specialists, though it too lacks a clear and consistent definition. The conditions discussed include rhinitis sicca anterior, primary and secondary atrophic rhinitis, and ENS, each with its own set of symptoms and underlying causes.

**2. Symptoms:**

Symptoms of dry nose can vary widely and may include:

- Sensation of dryness in the nose.

- Itching or a mild burning sensation.

- Nasal obstruction.

- Crusting or scabbing inside the nose, often accompanied by an unpleasant smell.

- Epistaxis (nosebleeds).

- Diminished sense of smell (hyposmia or anosmia).

**3. Causes:**

The causes of dry nose are multifaceted, involving various diseases, environmental factors, and physiological changes. Some common factors include:

- Mechanical irritation or trauma.

- Climatic or environmental factors such as dry air.

- Workplace conditions involving exposure to dust or chemicals.

- Side effects of medications, including those used to treat nasal congestion.

- Aging, which leads to anatomical changes and reduced mucociliary clearance.

- Anatomical changes due to surgery or trauma.

- Infections and systemic diseases like Wegener’s granulomatosis, sarcoidosis, or tuberculosis.

- The wound healing phase following nasal surgery.

**4. Empty Nose Syndrome (ENS):**

ENS is a particularly severe and complex condition resulting from over-resection of the nasal turbinates, which are crucial for proper airflow and humidification of the air we breathe. The study emphasizes that uncritical resection of these turbinates, particularly the inferior and middle turbinates, can lead to ENS, a form of secondary atrophic rhinitis (SAR). ENS is characterized by symptoms such as paradoxical nasal obstruction (a sensation of blocked nasal airflow despite having a physically enlarged nasal cavity), dry nose, pharyngeal dryness, dyspnea (difficulty breathing), and a disturbed sense of smell. Psychological symptoms like depression can also occur due to the chronic and distressing nature of the condition.

**5. Diagnosis:**

Diagnosing dry nose and its associated conditions requires a thorough patient history and a detailed examination of the external and internal nose using endoscopy and, if necessary, imaging techniques like CT scans. Allergies and infections should also be ruled out through appropriate tests.

**6. Treatment Approaches:**

The treatment of dry nose and associated conditions is primarily conservative and focuses on symptom management. Key recommendations include:

- **Moisturization:** Using nasal sprays, ointments, or saline solutions to keep the nasal mucosa hydrated.

- **Environmental Control:** Reducing exposure to dry air, dust, and other environmental irritants.

- **Cleansing:** Regular removal of crusts to prevent infection.

- **Avoidance of Irritation:** Patients are advised to avoid unnecessary manipulation of the nasal mucosa to prevent further irritation.

- **Surgical Correction:** In cases where there is an excessively large nasal cavity due to previous surgery, reconstructive procedures may be considered to restore normal airflow and improve symptoms.

**7. Importance of Nasal Turbinates:**

The study underscores the critical role of nasal turbinates in maintaining nasal health. These structures are essential for proper air conditioning (humidifying and warming the air) and should not be removed unless absolutely necessary, as their removal can lead to severe and often irreversible complications such as ENS.

**8. Recommendations for Medical Practice:**

The study advises against radical resection of nasal turbinates and emphasizes the importance of careful surgical planning and execution. It also highlights the need for more research into effective treatments for dry nose and ENS, as current therapeutic options are largely symptomatic and do not address the underlying pathophysiology.

### Conclusion:

The research provides a detailed exploration of the conditions associated with dry nose, particularly ENS, which is identified as a severe consequence of aggressive nasal surgery. The study concludes that preventive measures, particularly in surgical practice, are essential to avoid the development of these debilitating conditions. Moreover, while current treatments offer symptomatic relief, there is a clear need for more effective therapeutic strategies to manage and prevent these disorders. The study serves as a critical reminder of the delicate balance required in ENT surgery and the significant impact that nasal structure can have on overall respiratory health.

Summary from Eugene Kern,s book: Empty Nose Syndrome Evidence Based Proposals for Inferior Turbinate Management

Here’s a list of sections and descriptions from the book "Empty Nose Syndrome: Evidence-Based Proposals for Inferior Turbinate Management" where the author mentions and describes how Empty Nose Syndrome (ENS) affects quality of life, health, well-being, sleep, and the overall suffering it causes:

1. **Introduction and Overview**:

   - **Emotional and Psychological Impact**: The chapter introduces ENS and highlights the profound psychological and emotional distress it causes. It mentions that some patients have even committed suicide due to the horrific torment caused by the condition.

2. **Fundamental Features of ENS**:

   - **Physical and Emotional Suffering**: The author discusses the fundamental aspects of ENS, emphasizing the debilitating nature of the symptoms, which include severe emotional anguish and physical suffering. Patients experience breathing difficulties and other distressing symptoms.

3. **Pathophysiology of ENS**:

   - **Lack of Objective Testing**: The book mentions that the lack of objective preoperative studies to guide surgery often leads to ENS, which severely impacts the patient's quality of life. The condition arises when subjective patient reports and observational practices replace rigorous functional testing, leading to devastating outcomes.

4. **Treatment Options for ENS**:

   - **No Curative Therapies**: The chapter outlines that there are no curative or restorative therapies for ENS, leaving patients with debilitating symptoms. The only realistic management is providing emotional support and attempting to control the symptoms as much as possible.

   - **Psychological Support**: It is highlighted that over 50% of ENS patients suffer from significant anxiety and depression, necessitating psychiatric referral and compassionate mental health support.

5. **Final Thoughts and Review**:

   - **Profound Suffering**: In the concluding chapter, the author reiterates that ENS, while uncommon, is a critically important condition due to the severe physical suffering it causes, particularly with breathing difficulties. The emotional anguish is so intense that it includes a high incidence of suicidal ideation among patients.

   - **Need for Preventive Measures**: The text stresses the importance of preventing ENS through careful turbinate management, as the consequences of ENS are devastating and significantly impair the quality of life.

These sections describe the severe impact ENS has on an individual's physical and mental health, highlighting the deep suffering, anxiety, depression, and even suicidal thoughts that can result from this condition.