Empty Nose Syndrome

Origins of ENS

• The origin of ENS remains unknown, but several hypotheses can be found in the literature that try to explain why a turbinate reduction surgery can end in this pathology.
  The consequences of having a nasal cavity with too much space and less mucosa surface in air passages is the inability in generating a laminar airflow and a faulty heating and humidification sensation of inhaled air. The air thus passes too “fast», too cold and too dry to the next anatomical cavities (nasopharynx and lungs) causing additional side effects.
• After inferior/middle turbinate reduction internal nasal mucosa cool thermoreceptors may become less stimulated. When high-speed air moves through the nasal cavity it induces cooling by evaporation of water from the epithelial lining.»Cool» message is processed by the brain as «open airway». Lack of cool stimuli causes the brain to receive the message «airway is closed». This malfunction is caused by several problems such as altered airway pattern, structural mucosal deficits and/or by altered mucous production.
• Nerve damage derived from turbinate reduction or poor healing of nerve endings can be associated with an altered airway sensation. Cold sensation threshold in ENS patients is usually increased when compared with unoperated patients.

Symptoms and diagnosis of Empty Nose Syndrome

Often the diagnosis of ENS is missed because physicians look for physical signs of dryness and atrophy after turbinectomies and neglect the patients’ subjective complaints. ENS symptoms can be quite varied in their presentation and severity. The characteristic presenting symptom is the paradoxical nasal obstruction, sometimes associated with sensations of suffocation, breathlessness, dyspnea, or difficult breathing. Other symptoms such as pain, headache, face pain, loss of the concentration, fatigue, frustration, anxiety and depression are also reported. These symptoms can be quite similar to that shown in atrophic rhinitis with onset occurring at an interval of months or years after the surgical procedure. Quality of life can be greatly affected by the severity and intensity of symptoms and symptoms such as «fatigue», «dryness», «sadness» or «my nose is hollow» are not uncommon.

ENS is a diagnosis of exclusion and is often based on physical examination, endoscopy, CT scans and information provided by heath questionnaires. Health questionnaires are valuable instruments to determine the impact of disease in the patient’s quality of life and evaluate results after treatment. An interesting fact is that patients suffering from ENS often experience symptoms improvement in the presence of nasal cavities congestion (this is called paradoxical obstruction). Thus “Cotton Test” is a valuable adjunct in diagnosis and treatment planning.
On physical exam patients with ENS often have varying degrees of:

• Loss of inferior or middle turbinates volume.
• Mucosal atrophy with loss of its pinkish appearance and presence of crusting. Mucosa is usually pale and dry.
• The presence of septal perforations or internal valve malfunction, coexisting with ENS, can aggravate the symptoms and influence outcomes after a successful treatments.

Treatment of Empty Nose Syndrome:

We know that ENS can cause a multitude of associated psychological disorders. It is therefore extremely important that these disorders are properly controlled and treated before patients undergo any treatment.

Symptomatic treatment are usually based on the use of mucosa moisturizers, nasal hygiene (preferably by direct irrigation better than with sprays), humidifiers and psychological support. Inhalation of menthol can improve subjective sensation without actually modifying airflow. However the aim of ENS treatment must be focused on improving airflow passage and quality of mucosa.

• Lack of resistance to airflow is one of the most important factors causing this pathology. Improving volume inside affected nasal cavity generates friction and resistance to airflow and improves symptoms. This improvement can be tested preoperatively inserting cotton swabs along internal nasal cavity. Target areas for internal volume improvement are usually base of nasal septum, lateral nasal walls, nasal floor and anterior portion of inferior turbinates.
• Quality of mucosa must be improved, if possible, so subjective feeling via neuroreceptors of resistance, speed, temperature, etc return to a normal state. Treating coexisting pathologies, as septal perforations, which would negatively influence the outcomes.

Patients with ENS should know that this entity does not have a «cure» at present date and that current treatments (surgical and non-surgical) are an aid to partially relieve symptoms.

Obviously, there are patients with ENS whose anatomical alteration is not as serious and who may be more likely to improve than those who have a more severe anatomical disruption.
There are surgical and minimally invasive treatments that serve these purposes. Surgical treatments have shown to be highly effective for adding volume to nasal cavities but usually have no impact in mucosa quality. Medical treatments are less aggressive but have shown to be moderately effective because they often require multiple sessions to maintain results.

• Surgical treatments: consist of submucosal implantation of skin regeneration matrices, cartilage grafts, swine intestinal submucosa xenograft or synthetic implants such as Medpore® or GoreTex. The purpose of these options is to generate a new internal volume. We prefer the use of autologous rib cartilage grafts (taken from the own patient) due to their reliable volume increments that can be tailored to each patient. Non-autologous cartilage (cartilage from donors) may have unpredictable results due to variable degrees of resorption. We never recommend this approach in patients with a negative test volume (cotton test).
• Non-surgical options are based on the use of injectable materials: – PRP (platelet rich plasma). – Hyaluronic acid. – Micronized Dermal Matrices.
• Other minimally invasive techniques:
  • Fat grafting.
  • Fat grafting with PRP (also known as PRL).
  • Fat grafting enriched with regenerative cells (stem cells).
  • Direct treatment with regenerative cells.

We generally recommend fat grafting to improve middle and posterior portions of the lower turbinate and to increase the volume of the head of inferior turbinates when there isn’t a drastic reduction in size.

This was our preferred approach to ENS:

• The use of autologous rib cartilage grafts. They are especially useful if the cotton test is clearly positive and in all cases where there is a great loss in the anterior and middle portions of the inferior turbinates. Our preference is the use of autologous cartilage because we can harvest muscle fascia and perichondrium. Autologous cartilage have a more reliable survival outcome that non-autologous cartilage for stress loaded areas of the nose (such as the tip or middle vault) and less potential complications than synthetic materials. For non stress-loaded areas (such as the turbinates) donor cartilage behaves mostly like autologous cartilage in terms of survival, final volumes, structure, resilience, etc.
• Performing fat grafting, with/without regenerative cells, in middle and posterior segments of the inferior turbinates and nasal septum itself. In the anterior segment of inferior turbinates this can be done if enough turbinate remnants persist. The advantage of this type of treatment is twofold:
  • It is possible to obtain effective volumes wherever they are needed without requiring complex dissections. The grafts are selectively implanted in different amounts and may be targeted to various places including the septum itself.
  • It is possible to provide some regeneration of the mucosa. Several fat grafting sessions are usually required in specially severe cases, with thin, atrophic and adherent mucosal lining to the underlying bone component. Since the graft survival depends on their early nutrition, excessive infiltration of fat, even if enriched, or inadequately distributed in the nasal mucosa prevent graft «take» and generates only a temporary improvement. Serial fat grafting sessions provide incremental volumes and permanent thickness.

Conclusions.

• ENS may be encountered after inferior and/or middle turbinate resection.
• It is not clear why some patients develop ENS, whereas others do not.
• The hallmark complaint of the patients is paradoxical nasal obstruction.
• ENS is a disease entity that may have a major impact on the quality of life of the patients.
• Prevention of ENS is very important and can be addressed by performing less aggressive turbinate surgeries.
• ENS has no cure as of today. Mitigation of symptoms and improvement of quality of life can be obtained through a combination of augmentation turbinoplasty and regenerative treatments.
• You should not undergo any form of ENS treatments if you’re suffering from any psychological disturbance.

Updated note on Dr. Monreal treatments:

• • Please not that Dr. Monreal doesn’t admit new patients for ENS treatment.

For more information: There are numerous online resources and self-help groups with information about ENS, such as: http://www.emptynosesyndrome.org  –  Empty Nose Syndrome Self-Help Website.

To view images from nasal anatomy dissections performed by Dr. Juan Monreal you can access this link (WARNING: Contains very sensitive images that could offend you sensibilities).