CT pictures depicting different types of abnormal nasal anatomy following turbinectomies that result in ENS.

Empty Nose Syndrome (ENS) is a iatrogenic debilitating condition caused by over resection of the inferior and/or middle turbinates of the nose, which as a result has become chronically dry and/or even atrophic.

The two most common symptoms of such a nose are - chronic dryness and even some mucosal atrophy, with or without crusting and paradoxical obstruction - a debilitating feeling that the nose needs more resistance in order to pass on the air to the lungs, and this is despite having a wide open nose. Other common symptoms are - pharyngeal dryness, disordered sense of smell (not anosmoia), poor quality of sleep (due to nasal dryness), groginess, difficulty concentrating ("approsexia nasalis"), anxieties and depression.¹²³

Upon physical examination the nasal cavities are found to be over spacious and the nasal mucosa usually seems too reddish (indicating infection), too pale (indicating squamous metaplasia), or simply too dry, with or without crusts. Sometimes the remaining mucosal tissue may react to the over exposure to cold and dry air, resulting in chronic inflammation and hypertrophy that complicate the diagnosis, as the patient reports of conflicting sensations of the nose being too open at some places and too blocked in others.

ENS is known to occur mainly after total or subtotal inferior turbinectomy. Even partial inferior turbinectomies which reduce the turbinates more than their natural size and proportions, may cause some nasal dryness and ENS-type symptoms, but they seem to be temporary in those cases, as the turbinates have enough tissue left to compensate over time. However, there seems to be a thresh-hold from which the nose does not seem to be able to compensate for the loss of turbinate tissue and the symptoms become more pronounced and chronic. This thresh-hold is not fully agreed upon in the medical literature but it is largely accepted that as a rule of thumb turbinate reductive procedures should always try to preserve as much of the turbinate's tissue and natural shape as possible.⁴⁵⁶

When only the middle turbinates are resected – a different and more ambiguous form of ENS occurs. The main symptoms are dryness, sinus pressure, and sometimes pain.

When both the inferior and middle turbinates are resected - the symptoms are the most severe with extreme chronic dryness and breathing obstruction being the most dominant ones.

The severity of the symptoms differs considerably between patients, as it depends largely on the degree of resection and is influenced by individual anatomical differences that may increase or decrease distress.

There is very little research published about this syndrome, therefore not much is known about the prognosis for spontaneous recovery or deterioration over the years. But what is known that often patients will develop ENS symptoms only years after their turbinectomy. This is thought to occur because of late on set of mucosal atrophy due to the persisting conditions of dryness in the nose and underlines the importance of keeping the nose artificially moist when ENS is suspected and even more when it has been confirmed.

ENS is a iatrogenic condition that can and should be completely avoided.⁷⁸

Terminology

Turbinectomies have been performed for over 100 years. However, ENT specialists (otolaryngologists) were traditionally taught to respect the nasal turbinates as a vital part of the nasal anatomy and physiology. Only in the late 20th century did they begin breaking from this tradition and treating the turbinates as structures that can be radically and even totally resected without any serious consequence to nasal physiology. This caused a dramatic surge in the number of patients who have been crippled by this type of surgery. Some of them flocked to the Mayo Clinic, as one of the world's top medical facilities, to see if their relentless symptoms could be treated. Thus came to be the term "empty nose syndrome" (1994) that was coined by Dr. Eugene Kern, who was at the time the chief of otolaryngolgy at the Mayo Clinic in Rochester, Minnesota (USA). The idea came to him through a remark made by a visiting colleague from Sweden (Dr. Stenquist) who while examining the CT scans of these patients said that their nasal cavities seemed "empty".

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:

• A rich vitamin A diet.
• Prescribed estrogen (in topical spray/drops/gel) has been found to somewhat improve the state of the remaining mucosa in ENS.
• Irrigations of saline with 80mg of gentimycin when there is foul odor in the nose.
• Systemic medication as indicated for pain and or depression which is common (about 50%) in patients with this syndrome.
• Daily nasal irrigations of regular saline are always recommended (Make sure that the salt does not contain iodine, as iodine can irritate the mucosa). Many patients prefer to use Ringer's Lactate solution instead, as they find it soothes the mucosa more than regular saline, and there are some empirical studies that back up that claim.
• Saline based mist sprays for the nose, or gels, are always helpful to keep the nose moist at all times.
• Sesame oil or extra fine virgin olive oil (not over 5% acidity) applied topically. For protection in a dry environment
• Drinking lots of hot soups and beverages. Caffeine is best avoided.
• Sleeping with a cool mist humidifier. or -
• Sleeping with a CPAP machine, with a built in humidifier.
• Acupuncture and shiatsu meant to improve nasal blood supply and nerve function.
• Regular physical activity and a healthy lifestyle.

Surgical treatment

Right partially reduced inferior turbinate before cotton test to verify ENS symptoms

Cotton apllied to simulate the resistance that an implant will add to the over reduced inferior turbinate.

Surgical treatment involves narrowing back the over enlarged nasal cavity—either by bulking up the partially resected turbinates with biological implant material (in cases where at least 50% of the inferior turbinate remain from anterior to posterior) or by creating neo-turbinates by submucosal implants to the septum, nasal floor, or lateral wall (in cases when not enough turbinate is left to augment). Of course, in many cases a combined approach is the best choice.

The underlying rationale of surgery is to restore the inner nasal geometrical structure of the nasal passages of air (the inferior, middle, and superior meatuses).

Pre-surgical planning in this type of operation 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 implantation location to simulate the implant. By doing so, he restricts and normalizes the nasal airflow patterns. This restores nasal resistance and improves nasal airflow sensation. By trying different locations in accordance to the patient's sensations and feedback, it is possible to pinpoint the exact placement for the implants and their estimated sizes.

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 = 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.⁹

• A video demonstrating a typical implant (Alloderm) procedure for ENS.

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 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.
• foreign materials: such as hydroxyapatite, fibrin glue, Teflon, gortex, and plastipore, which solve the shortage problem of autografts, are easy to shape and don't tend to get absorbed. However they have a high extrusion rate, and sometimes cause infection.
• allografts: In the last decade scientists have been able to harvest and remove away genetic markers of some basic human tissues (like skin dermis) from donors, and thus supplying a human natural implant material which will not stimulate the immune system to reject it. A good example for such material is acellular dermis (brand named "Alloderm"). It does not get rejected and in most areas retains most of its volume over long periods.

Alloderm implants have already been implanted successfully for a few years now in a small but growing number of ENS patients. At four years follow-up, results seem stable and encouraging. It seems that Alloderm implants cannot fully cure ENS but can help alleviate much of the suffering, with various degrees of success, depending on the individual condition of each patient.

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 endurable enough structure and at the same time allow good permeability for blood vessel incorporation, which seems to be the key against long term absorption.

So far the best known ones are cancellous bone¹⁰ and Alloderm.

Before and after implantation of the lateral wall with Alloderm to simulate the function of the missing inferior turbinate

Citations from the medical literature

"The symptom that most often indicates ENS is paradoxical obstruction: subjects may have an impressively large nasal airway because they lack turbinate tissue, yet they state they feel they cannot breathe well. There is no clear way to describe the breathing sensation that patients with ENS experience. Some patients may state that their nose feels “stuffy,” for lack of a better word, whereas others state their nose feels too open, yet they cannot seem to properly inflate the lungs; they feel they need some resistance to do so. Patients with ENS do not sense the airflow passing through their nasal cavities, whereas their distal structures (pharynx, lungs) do detect inspiration; the patients’ central nervous systems receive conflicting information. These patients seem to be in a constant state of dyspnea and may describe the sensation of suffocating. The constant abnormal breathing sensations cause these patients to be consistently preoccupied with their breathing and nasal sensations, and this often leads to the inability to concentrate (aprosexia nasalis), chronic fatigue, frustration, irritability, anger, anxiety, and depression."

(Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863).

"… The excess removal of turbinate tissue might lead to empty-nose syndrome. Excess resection can lead to crusting, bleeding, breathing difficulty (often the paradoxical sensation of obstruction), recurrent infections, nasal odor, pain, and often clinical depression. In one study, the mean onset of symptoms occurred more than 8 years following the turbinectomies.”

(From: “The turbinates in nasal and sinus surgery: A consensus statement.” By D. H. Rice, E. B. Kern, B. F. Marple, R. L. Mabry, W. H. Friedman. ENT – Ear, Nose & Throat Journal, February 2003, pp. 82-83.)

"Turbinate Reduction and Resection:

Unfortunately, a wide nasal cavity syndrome due to reduction or resection of the inferior turbinate (and/or middle turbinate) is still frequently seen. When caused by (subtotal) turbinectomy, it can hardly be considered a complication. In our opinion, it is a "nasal crime". This iatrogenic condition can easily be avoided by reducing a hypertrophic turbinate using one of the intraturbinal function-preserving techniques." (From: "Functional Reconstructive Nasal Surgery". By Egbert H. Huizing, John De Groot. Hard-cover publication by Thieme, 2003. page 285).

"Empty nose syndrome: Some patients who have had excision of the inferior and/or middle turbinates may report increased symptoms thereafter. They may report a reduction in nasal mucus, nasal dryness or sensation of nasal obstruction or blockage and a general reduction in their sense of well-being.

Out of concern for this problem, many surgeons are now reluctant to perform any significant amount of surgical turbinectomy. As a result, preservation of as much turbinate tissue as is possible is now considered by many to be an important part of surgical management. Many surgeons will only remove a very small portion of the middle turbinate if absolutely necessary in order to achieve adequate visualization or to remove devitalized tissue. Operative descriptions of the extent of resection may be variable, and the endoscopist should make an independent assessment of the amount of resection performed. Radiofrequency ablation of the turbinates (e.g. Somnoplasty) has not caused the same problems as surgical turbinate reduction."

(Wellington S. Tichenor, MD; Allen Adinoff, MD; Brian Smart, MD; and Daniel Hamilos, MD. The American Academy of Allergy Asthma Immunology Work Group Report: Nasal and Sinus Endoscopy for Medical Management of Resistant Rhinosinusitis, Including Post-surgical Patients November, 2006. Prepared by an Ad Hoc Committee of the Rhinosinusitis Committee.)

“Removal of an entire inferior turbinate for benign disease is strongly discouraged because removal of an inferior turbinate can produce nasal atrophy and a miserable person. Such people unfortunately are still seen in the author’s offices; these people are nasal cripples.”

(From: "Otolaryngology – Head and Neck Surgery", Page 496, chapter 23. Chapter written by Dr. Kern. Book by Dr. Meyyerhoff and Dr. Rice, published by the W.B. Saunders Company, 1992).

“Total inferior turbinectomy has been proposed as a treatment for chronic nasal airway obstruction refractory to other, more conservative, methods of treatment. Traditionally, it has been criticized because of its adverse effects on nasophysiology. In this study, patients who had previously undergone total inferior turbinectomy were evaluated with the use of an extensive questionnaire. It confirms that total inferior turbinectomy carries significant morbidity and should be condemned.”

(from – “Extended Follow-Up Of Total Inferior Turbinate Resection For Relief Of Chronic Nasal Obstruction”, G. F. Moore, T. J. Freeman, F. P. Ogren & A. J. Yonkers., Laryngoscope, September 1985, pp. 1095-1099.)

"... The inferior turbinal should never be entirely removed... Excessive removal allows a jet of inspired ventilation, the mucus evaporates and becomes so viscid as to impede ciliary action... In some cases where the inferior turbinal has been too freely removed, the loss of valvular action and undue patency of the nostril produce the discomfort of dry pharyngitis and laryngitis, with difficulty in expelling stagnant secretion from the nose. The loss of the turbinal may lead to a condition simulating atrophic rhinitis or even ozaena."

(Thomson St. C & Negus VE. Inflammatory diseases. Chronic Rhinitis. Diseases of the nose and throat, 6th edition. London: Cassel & Co. Lmt. 1955; 124-145).

"...Resistance to air currents on inspiration and during expiration is necessary to maintain elasticity of the lungs."

(Cottle MH. Nasal Breathing Pressures and Cardio-Pulmonary Illness. The Eye, Ear Nose and throat Monthly. Volume 51, September 1972.)

"Middle turbinectomy may disrupt this neural network and lead to mucosal desiccation, crusting and bleeding; a sense of airway obstruction; and intractable face pain and headache.

Although there is debate among rhinologists regarding whether air flow through the nose is laminar or diffusely turbulent, it is incontrovertible that normal breathing requires a certain degree of air-flow resistance, which the turbinates provide. Combined middle and inferior turbinectomy can cause the "empty nose syndrome", a debilitating and usually untreatable condition."

(A Plea for Preservation of the Middle Turbinate During Dacryocystorhinostomy. Ophtalmic Plastic and Reconstructive Surgery. Vol. 15, No. 2, pp 75-76, 1999. an editorial article.)

Additional images

Internal view of the front inferior part of the nasal airways, after total inferior turbinectomy.

Empty Nose Syndrome after subtotal inferior turbinectomy.

All turbinates removed - Right lateral wall view.

Anatomy of the nasal cavity

References

External links

• Dr. Grossan's ear, nose and throat pages on ENS.
• Dr. Houser's tutorial pages on ENS.
• A video demonstrating a typical implant (Alloderm) procedure for ENS.
• Internet support forum for ENS patients.

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• This page was last modified on 7 January 2009, at 21:55.

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