In otolaryngology, empty nose syndrome describes a nose that has been physiologically crippled
by excessive surgical removal of turbinates in the nose in a surgical procedure known
as 'turbinectomy' or 'conchotomy'. It is therefore an iatrogenic condition that can and should
be avoided.
Main symptoms The main physical symptoms are:
Chronic nasal dryness Often leads to chronic mucosal inflammation and pain. Chronic inflammation
can cause areas of the mucosa to atrophy and this is why some studies refer to this condition
as "secondary atrophic rhinitis". At least one large study concluded that it can take
7.1 years, on average, for symptoms of atrophic rhinitis to appear and urges the examining
physician to look for early signs and to try to counter them with self-administered daily
nasal irrigations and moisturization by the patient.
Paradoxical obstruction - The feeling that the nose is stuffy, often accompanied by a
constant or frequently occurring troubling feeling of suffocation generated by poor airflow
feedback from the nasal mucosa, either because of atrophy of the trigeminal nerve endings
that are supposed to generate this sensation, their lack of responsiveness because of the
mucosa becoming too dry or going through metaplasia, or simply because of the loss of normal nasal
aerodynamics following the turbinectomy. Without good and constant airflow sensation of the
air flowing through the nose, the nervous feedback to the central nervous system is
that of suffocation and or undifferentiated breathing difficulties arise.
Neuropathic pain - Chronic inflammation and neurophatic pain in pharynx, eustachian tube,
throat, larynx, trachea, in more severe cases - in bronchi and lungs. Chronic hoarse voice
and cough can also take place. This is caused by insufficiently processed air passing through
the respiratory system. ENS can also serve as an prerequisite for asthma.
Other predominant symptoms are lack of a good night's sleep and chronic fatigue. The chronic
nature of the physical symptoms has a significant impact on the patient's quality of life and
sense of well-being, causing difficulty concentrating, pre-occupation with symptoms, anxiety, and
clinical depression. Also, development of asthma and chronic bronchitis is not uncommon,
as the nose is the guardian of the lungs. Etiology
The turbinates are known as the main humidifying, heat exchanging, air-filtering, airflow controlling
and airflow sensing structures of the nose. They control heat, humidify and filter the
airflow by streamlining it around them as it progresses through the nose, thus significantly
increasing the mucosal surface that comes into contact with the airflow. Their integrity
and function is crucial for maintaining nasal and sinus health and physiology. Built aerodynamically
from anterior to posterior they are designed to not over obstruct breathing while processing
the airflow. The turbinates play a vital role in protecting
the inner nasal mucosa and allowing it to recuperate and regenerate. A normal nose of
an adult processes on average 10,000 liters of air in 24 hours, it therefore needs some
form of resting period to recuperate and maintain good health and integrity of the delicate
respiratory epithelium layer that lines the entire nasal airway and sinuses. The recuperation
of the nose is achieved by a phenomenon known as the 'nasal cycle'. Every 3–6 hours one
side of the nose congests with blood while the other remains decongested - thus the majority
of the workload of breathing is done through the decongested side while the congested side
rests and recuperates. When the inferior turbinates are resected the nasal cycle can no longer
fully congest the side of the nose where they were resected and therefore much of the natural
recuperation capability on that side is lost. There are typically three pairs of turbinates
in the human nose - the inferior concha, the middle concha and the superior concha. Each
pair is very different in size and in shape, and each protect a different region of the
nasal cavity: The inferior turbinates are the largest and extend all across the lower
part of the nasal cavity, from the very front of the nose almost up to the nasopharynx.
As the inferior turbinates are the largest and the first to mitigate the inspired air,
their loss has the most profound effect on the physiology of the remaining mucosa. The
middle turbinates hover above the inferior turbinates and begin from approximately the
midsection of the nasal cavity. They are much smaller and unlike the inferior turbinates
harbour some olfactory nerve axons and protect the upper regions of the cavity, in particularly
the olfactory bundle of nerves at the roof of the nose and the openings of the ethmoid
and frontal sinuses. Their loss will play a lesser role in the overall reduction of
the retained heat and humidity in the nose, but it might impact the quality of the sense
of smell and the health of the ethmoid and frontal sinuses. The superior turbinates are
tiny in comparison to the inferior and middle ones and have the sole role of being the last
line of protection around the olfactory bulb. The loss of too much turbinate tissue may
cause the remaining mucosa at the vicinity of the site of resection, and directly behind
and above that area, to gradually become more and more inflamed, dry, go through metaplasia,
endertitis and eventually atrophy. As a result all four major functions of the nose become
impaired: breathing, defense, olfaction, and phonology. This can take many years to fully
develop, which may complicate the proper diagnosis. ENS is sometimes seen in patients who have
lost relatively little of their turbinate tissue and whose turbinates appear to be almost
normal in size; this is especially true in cases of anterior inferior turbinate resection
because of its important role in the internal nasal valve. ENS symptoms are often felt by
patients soon after turbinectomy procedures. Diagnosis
The clinician should suspect ENS when the following findings are present: The patient
complains of poor nasal breathing and often a relentless sensation of suffocation or shortness
of breath despite having a patent nasal airway. The patients typically complain of nasal dryness
too. These symptoms appeared only after the patient underwent a turbinate reductive procedure.
Sometimes, many years later. On examination the nasal cavity should look
abnormally spacious, lacking one or both turbinates. Mucosal pathology varies greatly. In some
patients, the mucosa is dry and pale because of metaplasia; in others, it is red because
of chronic infection. Crusting may range from absent to severe. The symptoms and findings
are believed to be caused by abnormal aerodynamics, chronic inflammation and dryness leading to
loss of airflow sensation that feels like dyspnea.
The diagnosis is often complicated because it is common to find that the remaining tissues
are hypertrophied. Prognosis
There has been very little research conducted on this condition and hardly any long-term
follow-ups. For many years this condition was overlooked or mistaken because of secondary
problems that usually occur after radical nasal turbinectomies. For instance, the remaining
mucosal structures often hypertrophy, causing actual physical obstruction on top of the
already existing paradoxical obstruction. The lack of long-term follow-ups of patients
with this condition makes it difficult to estimate what percentage of patients, if any,
will enjoy a spontaneous recovery or at least a significant enough improvement in their
symptoms. But, given that the main cause of the symptoms is the gross loss of normal inner
nasal anatomy, it is not likely that this condition can cure itself.
Dr. Eugene Kern, who coined the term "empty nose syndrome", claims that this condition
often gets worse over the years through increasing wear and tear of the remaining mucosa in the
nasal cavity, because the lack of turbinates leaves the mucosa overexposed to unduly patent
currents of unfiltered, and under-conditioned airflow on every inspiring breath. In fact,
he maintains that there is an unknown threshold of loss of turbinate tissue from which the
nasal mucosa can not recuperate from the daily onslaught of direct airflow. Kern and Moore
conducted a large retrospective study of 242 patients which they carefully examined over
several years at the Mayo Clinic in Rochester, all of whom had undergone some form of partial
or radical turbinectomy, following which they had developed symptoms of atrophic rhinitis.
They called this condition "empty nose syndrome" to depict how unnatural these noses looked
in CT findings and upon physical examination. They emphasized how negatively this condition
had affected their quality of life and sense of well being and the fact that in many of
the patients the symptoms seemed to worsen over the years, indicating further damage
and wear and tear due to the loss of turbinate protection, as there was no other cause that
could explain this. Their findings corroborated early conclusions about turbinectomies that
were adopted by ENT communities world-wide after these surgeries first started in the
late 19th century and are further more supported by several prominent other studies from the
late 20th century following patients that had undergone radical inferior turbinectomies,
but some supporters of turbinectomies remain unconvinced as there have been several long-term
follow-up studies that claim to have found no major long-term ill effect. So, the controversy
remains, although the pendulum has nowadays shifted back amongst most nasal surgeons towards
the importance of keeping as much as turbinate tissue possible when performing turbinate
reductive procedures. The patients can replace some of the lost
moisture to reduce the risks of mucosal atrophy by coating their nasal lining with protective
gels and using saline mist sprays and irrigations, but it seems that unless the turbinates are
functionally reconstructed there is little hope to fully recover from this condition.
In recent years there have been several reports of attempts to reconstruct the inferior turbinates
of the nose through submucusal implantation of various implant materials, in an attempt
to restore normal nasal aerodynamics and physiology. The sample of patients reported on was very
small and the follow-up was relatively short, but the results showed some promise. A study
published in 2010 concluded that surgical reduction of the open cross-section of an
'empty nose' in order to positively influence aerodynamics and to increase airway-resistance
does not, however, alter the conditioning function of the nose, which is irreversibly
damaged. Another study reported that when ciliated cells have been lost because of degeneration
of the nasal mucosa, even surgical closure of the nostrils does not make the number of
cilia increase again. There is hope among patients that with recent
advances made in regenerative medicine otolaryngologists will begin to explore ways to use stem cells
and tissue engineering technology to fully reconstruct the inferior turbinates of the
nose and restore it back to normal. A clinical registry has been opened in 2014 to support
future clinical trials in regenerative medicine specifically intended to treat patients with
ENS. Currently available treatment options
Non-surgical treatment Non-surgical treatment options are meant to
maintain and improve the health of the remaining nasal mucosa in the ENS nose by keeping it
moist and free of infection and irritation and by maintaining a good blood supply:
Keeping the nasal passages moist with saline-based mist sprays or gels.*
Nasal irrigations of regular saline. Irrigations of saline with 80 mg of gentimycin
if ozena occurs. Systemic medication as indicated for pain
and or depression which is common in patients with this syndrome.
Sleeping with a cool mist humidifier. Regular daily physical exercise and maintaining
good general health to reduce the risk of deterioration of symptoms.
Surgical treatment
Surgical treatment involves narrowing back the over enlarged nasal cavity—either by
bulking up the partially resected turbinates with biological implant material or by creating
neo-turbinates through submucosal implantation between the submucosa and bone in key locations
in the nasal cavity. Of course, in some cases a combined approach is the best choice. The
main difficulty with implant surgery is to achieve a long lasting bulk that will not
get absorbed over time. Sometimes a procedure has to be repeated several times to get a
sustainable result. The most physiological location for an implant is the lateral wall
of the nasal cavity, where the inferior turbinate used to project from. An easier location to
implant is the septum, but it is less favorable as it is not the natural location of the turbinates
and may over obstruct the airflow. The underlying rationale of surgery is to
restore the natural inner nasal geometrical contours of the nasal passages of air, as
much as possible, to mitigate the airflow just enough to restore normal rates of inner
nasal humidity and temperature that will allow the mucosa to recuperate and sense the airflow
well enough. It is paramount to do so while trying to restore the normal aerodynamics
of the airflow in the nose, otherwise nasal obstruction will occur.
Pre-surgical planning has a tremendous impact on the success of the procedure. The surgeon
is advised to perform a cotton test prior to the implantation: the surgeon places saline
soaked chunks of cotton wool at the pre-planned site of implantation to simulate the implant.
By doing so, he restricts and normalizes the nasal airflow patterns. This restores nasal
aerodynamics. By trying different locations in accordance to the patient's feedbacks regarding
the quality of his breathing and other ENS symptoms, it is possible to pinpoint the exact
placement for the implants and their estimated shape and size.
Turbinate tissue is unique and there are no potential donor sites in the body from which
to harvest similar tissue. However, in the nose, form equals function. It is therefore
possible to restore some function by restoring the natural contours and proportions of the
nasal passages: It is possible to create an artificial look-alike structure of a turbinate
in the nasal cavities, and thus to regain some of the nose's capabilities to adequately
resist, streamline, heat, humidify, filter, and sense the airflow.
A video demonstrating lateral wall implantation to create a bulk of tissue that will simulate
the shape and function of the resected inferior turbinate.
Implant materials
The bulking up of the sub-mucosa and mucosa to create a neo-turbinate structure can be
achieved through implanting some supporting material between the bone/cartilage and also
into the submucosal layer. Many materials have been tried over the past 100 years. In
most cases this operation was used to restore heat and humidity to atrophic noses.
Generally speaking, the implant materials can be divided into 3 groups:
autografts: bone, cartilage, fat, etc. from one site to another in the same patient. The
problems here are relative shortage of tissue, and long term studies have shown high absorption
rates in the nose. A Chinese study reported long-term success using iliac bone autografts.
foreign materials: such as fibrin glue, Teflon, Gore-Tex, and plastipore, which solve the
problem of shortage of autografts, are easy to shape and do not tend to get absorbed.
However they have a high extrusion rate, and sometimes cause infection. A case study of
good retention of hydroxyapatite cement in one patient has been reported in 2000, but
the follow-up was only 1 year long. allografts: In the last two decades scientists
have been able to harvest and remove away genetic markers of some basic human tissues
from donors, and thus supplying a human natural implant material which does not stimulate
the immune system to reject it. A good example for such material is acellular dermis. It
does not get rejected and in most areas retains most of its volume over long periods.
The ideal implant material, other than real original turbinate tissue should be something
with low extrusion and rejection rates, minimal infection risk, and—very importantly—that
will provide a strong and durable enough structure that at the same time allows good permeability
for blood vessel incorporation, which seems to be the key against long term absorption.
Additional images
References
External links Empty Nose Syndrome Association
US Institute for Advanced Sinus Care and Research Dr. Houser's tutorial pages on ENS
Internet support forum for ENS sufferers "Sniffing At Empty Nose Idea"
Dr. Dondè's pages on ENS not surgical treatment by platelet grown factor