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Empty nose syndrome

Empty nose syndrome (ENS) is a medical term coined by Dr. Kern and Dr. Stenquist (1996) to describe a cluster of symptoms that often occurs when a nose is crippled by over resection of the inferior and/or middle turbinates of the nose. ENS can be considered as a form of secondary atrophic rhinitis.

Overresection of the turbinates leaves the nose incapable of satisfyingly pressurizing, streamlining, heating, humidifying, filtering and sensing the air that flows through it. The remaining nasal mucosa may become chronically dry, less responsive, partially inflamed and partially atrophic.

The patients feel that they don't have enough nasal resistance to properly inflate their lungs. They also feel that they have lost much of their ability to sense the air flowing through their noses. Further symptoms are pharyngeal and laryngeal dryness, hypersensitivity to cold air, to strong scents and to smoke. Hyposmia or dysosmia are common; nasal pain or burning may be present, sleep disordered breathing (shallow sleep, or sleep apnea), a constant feeling of grogginess and difficulty concentrating ("aprosexia nasalis").

ENS sufferers report a massive reduction is their sense of well being and are very distressed. One study found that 52% of the patients examined were clinically depressed.

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. But, generally speaking, ENS patients are true "nasal cripples".

Empty nose syndrome is an iatrogenic condition that can and should be completely avoided, as there is no justification for radical resection of the turbinates except for the rare cases of cancerous tumours in the nasal cavity, in which case radical resection of nasal structures may be mandatory.

Diagnosis

Upon physical inspection, the nasal cavity seems abnormally spacious, as too much of the turbinates have been resected/reduced. The remaining mucosa may seem chronically dry (with or without crusting), and its color may seem too reddish (indicating infection), or too pale (indicating squamous metaplasia). The final diagnosis of ENS is tricky, however, and has to rely mostly on the patient's self-reported symptoms.

For proper examination the examining physician needs to listen carefully to the patient's complaints, as there is little that can verify this syndrome objectively. One of the interesting things that only ENS patients seem to feel is that when their nose gets congested (like after much alcohol consumption, or during the flu), they feel that they get back some of the resistance they are normally missing and breathing is improved.

Something known as a "cotton test" can help verify that the breathing difficulty that the patient reports is because of an over-enlarged nasal cavity and not because of the opposite - an over-congested one: When placing saline soaked pieces of cotton in different locations of the nasal cavity to try and simulate the resistance of the resected turbinates the patient often feels a marked improvement. However, failing to feel improvement cannot altogether rule out ENS.

Nasal rhinomanometric resistance rates in an ENS nose are expected to be lower than normal. However this is not a very reliable test as while the resected areas of the nose might generate lower than normal resistance, the other non resected areas, that may be inflamed due to increased dryness, will present higher than normal resistance; thus one area cancels the other in the total measurement of resistance. It is therefore advised to de-congest the patient's nose before measuring and to use acoustic rhinomanometry in conjunction with resistance rhinomanometry).

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 as possible from irritation, inflammation, infection and further metaplasia:

  • Premarin (in topical spray and/or orally) 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 (ie infection).
  • 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, Ringer's Lactate, or hyaluronic acid based - nasal mist sprays, or gels, are always helpful when proper irrigation is not possible.
  • Sesame oil applied topically. Very good for mucosal protection from drying. Un-medicated nasal salves (Nisita.co.uk)protectants function well to reduce drying and improve protection of the exposed rostral cavity.
  • Drinking lots of hot soups and beverages. Caffeine is best avoided.
  • Sleeping with a cool mist humidifier.
  • Sleeping with a CPAP machine (lubricating the nasal passages with sesame oil just before going to bed will help prevent dryness if the CPAP makes the dryness worse). The CPAP restors the lost negative pressure of air to the lungs and improves nasal sensation of airflow. It also improves the nasal resistnace to the lungs in exhalation, allowing for a more lengthy interval of gas exchange in the alveoli.
  • Acupuncture and shiatsu meant to improve nasal blood supply and nerve function.
  • Dressing warmly and sleeping in a warm environment.
  • Regular physical activity and a healthy lifestyle.

Surgical treatment

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.


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.

What lies ahead

A full cure of ENS will only be available if and when the situation is reversed and the actual real tissues of the resected turbinates are regenerated or returned to the nose through means of regenerative medicine and/or tissue-engineering.

Hopefully tissue engineering and regenerative scientists will begin to take more interest in functional inner nasal reconstruction, as the complication rates of functional nasal surgery are amongst the highest rates compared to most other types of elective surgery.

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.)

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