Empty nose syndrome

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Coronal CT slice depicting a normal nose. All turbinates intact.

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Coronal CT slice after total bilateral inferior turbinectomy.

Empty nose syndrome (ENS) is an iatrogenic nasal disorder that occurs when too much of the nasal turbinates are resected. The turbinates have many important roles in the respiratory system. They offer protection of heat, moisture and filtration to the nose the pharynx, larynx, trachea and lungs. They create an adequate level of nasal resistance that is crucial for deep pulmonary breathing. In addition they direct most of the airflow to flow through the middle meatus (the passage between the inferior and middle turbinate) and provide a heavily innervated surface area of pressure receptors to inform the brain that air is traversing the nose in a sufficient volume to sustain life.

When an inferior nasal turbinate, or a middle turbinate, are over resected the nose and the pharynx usually become chronically dry and irritated (perhaps even inflamed) and the lungs suffer from poorer quality of ventilation and gas exchange, in addition to a more shallow pattern of breathing that emerges. In addition, nasal airflow sensation is severely reduced and the patients feel as if their nose is not traversing enough air although it is is wide open. This sensation is known as 'paradoxical obstruction'. As years go by the dryness of the remaining nasal mucosa can get worse and this sensation will worsen accordingly.

ENS usually occurs after radical inferior turbinectomy, as the inferior turbinate is the largest nasal turbinate and processes most of the inspired airflow. The inferior turbinate is also responsible for deflecting most of the air to flow through the middle meatus (the passage between the middle and inferior turbinates). The middle meatus is the area of mucosa most sensitive to airflow sensation in the inner nose. If not enough air gets deflected into it, or if the air flows too slowly through it - 'paradoxical obstruction' sensation occurs. When ENS occurs because of inferior turbinate resection it is termed ENS-IT.

The middle turbinate plays a less important role than the inferior turbinates do, in all aspects of nasal functions. However it is crucial for protecting the superior olfactory regions of the nose and the sinus openings and harbors some olfactory nerve endings too. It's resection can shock these very sensitive superior areas of the nose and cause them to be chronically dry, and this in itself can cause ENS symptoms to emerge. ENS following middle turbinate resection is termed ENS-MT. When ENS appears after both types of turbinates have been over resected, it is termed ENS-both.

The main symptoms of ENS are:

• Annoying sensation of too much air entering the nose and pharynx.
• Dryness of the nasal cavities.
• Dryness of the pharynx, soft palate and back of the tonge.
• Feeling of needing more nasal resistance to breathe.
• Nasal cavities and sinuses over sensitive to cold air.
• Increased sensitivity to air-borne irritants and cold air.
• Breathing difficulties due to: nasal dryness and/or pharyngeal dryness and/or over taxation of bronchi with cold and dry air.
• Diminished nasal airflow sensation feedback ('paradoxical obstruction').
• Diminished sense of smell.
• Difficulty projecting or resonating speech.
• Feeling weak and depleted of energy.
• Poor quality of sleep.
• Difficulty concentrating ('aprosexia nasalis').
• Diminished sense of self and well-being, depressed mood and often clinical depression.

Terminology

The term "empty nose syndrome" was originally coined in the early 1990s by Dr. E.B. Kern (MD.) who was at the time head of the otolaryngology ward in the Mayo Clinic in Rochester, Minnesota, USA. He and his colleagues began to notice that more and more patients who had undergone aggressive resections of their inferior or middle turbinates seemed to develop symptoms of nasal obstruction and shortness of breath even though their noses appeared to be wide open, following partial or total turbinectomies. Other hallmark symptoms were chronic nasal dryness, difficulty concentrating, and often clinical depression. They found that all these symptoms and more, in all the patients examined, developed only after their inferior or middle turbinate were over aggressively resected.

All the patients had CT scans that showed abnormally wide and empty looking nasal cavities, thus they called it - "Empty Nose Syndrome".

ENS is often referred to also as 'secondary atrophic rhinitis', because it is believed that the over exposed and wide cavities may become atrophic over time ('secondary'= caused by surgery or other medical intervention, or direct trauma to the nose, as opposed to 'primary' which develops because of systemic illnesses). However, developing an atrophic mucosa on top of ENS is not a prerequisite for diagnosing a post-turbinectomy patient with ENS.

Treatment options

Non-surgical treatment options are meant to maintain and slightly improve the health of the remaining nasal mucosa in the ENS nose, by keeping it moist and free as possible from irritation and infection.

Surgical treatment is meant to try to permanently improve the severity of the symptoms.

Non-surgical treatment

Non-surgical treatments will not cure ENS, because it cannot restore the missing turbinates, but it can help control some of the symptoms and make the suffering more tolerable:

• Daily nasal irrigations of regular saline are always recommended.
• Sesame oil can help in cases of extreme dryness and crusts.
• Sleeping with a cool mist humidifier.
• Sleeping with a CPAP machine that has a built-in humidifier.
• Some patients respond well to orally taken vitamin A and D.
• Acupuncture meant to improve nasal blood supply and nerve function.

Surgical treatment

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

Turbinate tissue is unique and there are no potential donor sites in the body to harvest similar tissue from. 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 pressurize, streamline, heat, humidify, filter and sense the airflow.

By implanting different grafts and material underneath the patients' submucosa at the right places - the surgeon hopes to create a look alike turbinal structure which will do three things:

a) Restrict the amount of airflow, just enough to allow the nasal mucosa to cope better, while still allowing enough airb to pass through for all needs of breathing. This is referred to as normalizing the nasal rates of resistance.

b) To restore close to normal rates of nasal mucosal heat and humidity, as the implant projections trap the heat and moisture in the air returning from the lungs.

c) To normalize the post surgical disrupted airflow patterns of the nose and make sure that the vast majority of airflow is redirected into the middle meatus of the nose.

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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 resected and in most areas retains most of it's 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. Dr. Steven Houser from Cleveland is an American ENT surgeon who has gained probably the most extensive experience to date in surgically treating ENS.

The ideal implant material, other than real original turbinate tissue (which is still an impossibility at this time and age), 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.

Alex Potasnick has a terrible case of Empty Nose Syndrome because he picks his nose all day

Additional Citations

"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.)

“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.)

Additional images

• Internal view of the front inferior part of the nasal airways, after total inferior turbinectomy.
  Internal view of the front inferior part of the nasal airways, after total inferior turbinectomy.
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  Empty Nose Syndrome after sub-total inferior turbinectomy.
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  All turbinates removed - Right lateral wall view.
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  Anatomy of the nasal cavity
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  Sagittal section of nose mouth, pharynx, and larynx.
• Coronal CT slice After total bilateral middle turbinectomy.
  Coronal CT slice After total bilateral middle turbinectomy.

External links

• Dr. Houser's tutorial pages on ENS
• Dr. Grossan's ear, nose and throat pages on ENS
• Listen to Dr. Kern's lecture on Empty Nose Syndrome
• Interactive Forum for ENS Patients

• "Having nasal surgery - Don't you become an Empty-Nose Victim"