Empty nose syndrome

There are no objective physical examination findings that definitely diagnose ENS.[3] Patients begin to notice any of the following symptoms following surgery to their nose or nasal passages: lightheaded/dizziness, brain fog, tingling in hands/mouth, chest pain, muscle spasms, acid reflux, feelings of nasal obstruction, nasal dryness and crusting, dryness in throat and a sensation of being unable to breathe, a feeling of nasal obstruction and crusting, oozing, and foul smells inside the nose from infections.[3] A person with ENS may complain of pain in their nose or face, an inability to sleep, fatigue, and feeling irritated, depressed, or anxious; they may be constantly distracted by the sense that they are not getting enough air.[3]

A study, found that 77% of patients with empty nose syndrome have hyperventilation syndrome.[12] Hyperventilation symptoms can be explained in ENS patients due the change in nasal airflow. This is typically only relieved by correcting the airflow in the nose which is incredibly difficult and should be done carefully to avoid a failed revision surgery.

The cause of ENS is due to the body not accepting the new airflow in the nasal passages following surgical procedures. The nose is an incredibly complex area of the body and one that has been very poorly researched in terms of the effects on aerodynamics from surgical procedures. In many patients with ENS, the airflow is modeled as being more turbulent with less laminar flow across the mucosa. This change in airflow leads to an imbalance of CO₂/O₂ levels in the body, which will show hyperventilation-like symptoms in patients. This reduced amount of mucus in the nose can also be attributed to the change in airflow often resulting in dry cool air hitting the back of the patients throat.

One possible cause may be changes to the nasal mucous membrane and to the nerve endings in the mucosa resulting from chronic changes to the temperature and humidity of the air flowing inside the nose, caused in turn by removal or reduction of the turbinates.[3][4] Direct damage to the nerves may be a result of surgical intervention; however, as of 2015, there is no technology that allows the mapping of the sensory nerves within the nose, so it is difficult to determine whether this is causative of ENS.[3] Investigators have been unable to identify consistent diagnostic or precipitating features, psychological causes leading to a psychosomatic condition have been proposed.[3][8][9][11]

Squamous metaplasia of nasal respiratory epithelium.

No consensus criteria exist for the diagnosis of ENS and many ENTs will wait a year before diagnosing in hopes the patient accepts the new airflow; it is typically diagnosed by ruling out other conditions, with ENS remaining the likely diagnosis if the signs and symptoms are present.[3][4][8] A "cotton test" has been proposed, in which moist cotton is held where a turbinate should be or in various locations in the nasal passages, to see if it provides relief and an airflow pattern that allows for natural breathing; while this has not been validated nor is it widely accepted, it may be useful to identify which people may benefit from surgery.[3][4][8]

As of 2015, protocols for using rhinomanometry to diagnose ENS and measure response to surgery were under development,[4][8] as was a standardized clinical instrument (a well defined and validated questionnaire) to obtain more useful reporting of symptoms.[8]

A validated ENS-specific, 6-item questionnaire called the Empty Nose Syndrome 6-item Questionnaire (ENS6Q) was developed as an adjunct to the standard Sino-Nasal Outcome Test 22 (SNOT-22).[13] The ENS6Q is the first validated, specific, adjunct questionnaire to the SNOT-22. It can more reliably identify patients suspected of ENS.[14] The ENS6Q is gaining usage in studies on ENS.

Classification

All turbinates removed – Right lateral wall view.

Anatomy of the nasal cavity

Four types have been proposed:[3]

• ENS secondary to inferior turbinate resection
• ENS secondary to middle turbinate resection
• ENS secondary to both inferior and middle turbinate
• ENS after turbinate-sparing procedures

Attempt non surgical methods for an extended period of time prior to surgical intervention. Avoid any unnecessary nasal surgery, avoid any surgical treatment to the turbinates and septum, seek multiple consults for any nasal surgery, conduct imagery on the nasal passages prior to any surgical treatment, seek opinions from surgeons familiar with ENS.[3][15] Many surgeons will tell patients that ENS is only seen in patients that have excessive turbinate reduction, but studies have shown that any change in the airflow of the nose can potentially lead to ENS. For this reason it is critical that anyone planning any surgery to the nose for function or appearance should be aware of the high risk of ENS developing if the body does not accept the new airflow and exchange of gasses.

Treatment of ENS by many ENTs is extremely limited with very marginal success rates once diagnosed. Initial treatment is similar to atrophic rhinitis, namely keeping the nasal mucosa moist with saline or oil-based lubricants and treating pain and infection as they arise; adding menthol to lubricants may be helpful in ENS, as may be use of a cool mist humidifier at home but has limited success and many ENT patients seek treatment from the few ENTs well educated in ENS surgical techniques.[3] For people with anxiety, depression, or who are obsessed with the feeling that they can't breathe, psychiatric or psychological care may be helpful.[3][8]

In some people, surgery to restore missing or reduced turbinates or various fillers that correct the airflow in the nose may be beneficial.[3]

Before and after surgical restoration of the lateral wall (arrow in right-side image) to simulate the function of the missing inferior turbinate.

A 2015 meta-analysis identified 128 people treated with surgery from eight studies that were useful to pool, with an age range of 18 to 64, most of whom had been experiencing ENS symptoms for many years. The most common surgical approach was creating a pocket under the mucosa and implanting material - the amount and location were based on the judgement of the surgeon. In about half the cases a filler such as noncellular dermis, a medical-grade porous high-density polyethylene, or silastic was used and in about 40% cartilage taken from the person or from a cow was used. In a few cases hyaluronic acid was injected and in a few others tricalcium phosphate was used. There were no complications caused by the surgery, although one person was over-corrected and developed chronic rhinosinusitis and two people were under-corrected. The hyaluronic acid was completely resorbed in the three people who received it at the one year follow up, and in six people some of the implant came out, but this did not affect the result as enough remained. About 21% of the people had no or marginal improvement but the rest reported significant relief of their symptoms. Since none of the studies used placebo or blinding there may be a strong placebo effect or bias in reporting.[8]

Empty nose syndrome has been observed to affect a small proportion of people who have undergone surgery to the nose or sinuses, particularly those who have undergone turbinectomy (a procedure that removes some of the bones in the nasal passage). The incidence of ENS is variable and has not yet been quantified due to many ENTs failing to accept the condition until recently and could potentially be much more prevalent than once believed.[3][4][8][9][15]

Untreated, the condition can cause significant and longterm physical and emotional distress in some people; some of the initial presentations on the condition described people who committed suicide.[8] It is difficult to determine what treatments are safe and effective, and to what extent, in part because the diagnosis itself is unclear.[8]

As early as 1914, Dr Albert Mason reported cases of "a condition resembling atrophic rhinitis" with "a dryness of the nose and throat" following turbinectomy. Mason called the turbinates "the most important organ in the nose" and claimed they were "slaughtered and removed with discriminate abandon more than any other part of the body, with the possible exception of the prepuce."[16]

The term "Empty Nose Syndrome" was first used by Eugene Kern and Monika Stenkvist of the Mayo Clinic in 1994.[3] Kern and Eric Moore published a case study of 242 people with secondary atrophic rhinitis in 2001 and were the first to attribute the cause to prior sinonasal surgery in the scientific literature.[3][1] Whether the condition existed or not and whether surgery was a cause, was hotly debated at Nose 2000, a meeting of the International Rhinologic Society that occurs every four years, and continued to be debated thereafter at scientific meetings and in the literature;[3][17] as an example of how heated the debate became, in a 2002 textbook on nasal reconstruction techniques, two surgeons from University of Utrecht called turbinectomies a "nasal crime".[3]

As of 2016, according to Spencer Payne, a doctor who studies ENS, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological;[18] according to Subinoy Das, another doctor who studies ENS, recognition among rhinologists was growing.[19]

People who experience ENS have formed online communities to support one another[3] and to advocate for recognition, prevention, and treatments for ENS.[19]

• American Rhinologic Society: Empty nose syndrome
• United Kingdom National Health Service: Atrophic Rhinitis Causes