Empty nose syndrome

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Empty nose syndrome (ENS), is a iatrogenic debilitating and crippling nasal disorder, which occurs when too much of the nasal turbinates (especially the inferior turbinates) are resected in operations known as 'turbinectomies'. Over aggressive turbinectomies cause the nasal passages to be too wide and too dry. This disrupts all normal nasal functions, desensitizes the remaining mucosa and above all - causes a huge loss of normal rates of nasal resistance - which are crucial for proper lung expansion and exhalation.

There are three subclasses of ENS:

• ENS-IT: Following over resection of the inferior turbinates: main charecteristic symptoms - shortness of breath due to loss of resistance to lungs and dryness of nasal mucosa and pharynx.
• ENS-MT: Following over resection of the middle turbinates: main charecteristic symptoms - Shortness of breath caused mainly by dryness of nasal mucosa, often sinus pain too.
• ENS-Both: Following over resection of both the middle and the inferior turbinates: The worse form of ENS - combines all symptoms above, with usually more severer signs of dryness and frequent nasal and sinus infections.

Symptoms

As breathing is a bodily function that has perhaps the most pronounced effect on both the physical and mental states of the patient - it is not surprising that ENS sufferers report a wide array of bothering symptoms which significantly impair their physical functions and sense of well-being:

Physical symptoms may include:

• Paradoxical Obstruction: Shortness of breath caused because of loss of adequate nasal resistance to the lungs and/or because of reduced sensitivity of the nasal mucosa to the sensation of airflow.
• Nasal dryness, with or without crusts, with or without bleeding.
• Low mucus production.
• Difficulty to expell secretions out of the nose.
• Annoying feeling of Nasal emptiness. Whole sections of the nose feel missing, amputated and hollow.
• Pain, associated with phanthom pain following resection or because of nerve damage caused by over exposure of the trigeminal nerve brunches that innervate the nose.
• Diminished sense of smell and/or taste together with over-sensitivity to highly volatile compounds such as: smoke, paint, perfume, cleaning detergents, gasoline.
• Speech problems. The nose and sinuses are the resonating chambers of voice. When their cavities are over enlarged it becomes harder to sound or articulate words. Patients report that their voice feels flat and weak. The loss of nasal resonance puts extra strain on the vocal chords, ahich are also somewhat irritated and dry from the constant flow of dry and cold air.
• Thick post nasal drip caused by reduced flow of mucus secretions, due to conditions of dryness and slow cilia action.
• Dryness in the larynx, back of the mouth, palette, tongue.
• Dry eyes.
• Elevated or unstable blood pressure
• Foul smell in nose, either from accumulated long standing crusts, or in worse cases because of the onset of Ozaena.
• Lethargic/apathetic behavior.
• Sleep disturbances: Very low quality of sleep, which is often associated with nasal obstruction. Can cause severe neurotic disorders and psychotic behaviour.

Psychological symptoms:

• Depression.
• Anxieties.
• Social phobia (constantly avoiding social interaction)
• Low self esteem.
• irritability.
• Acute stress.
• Prolonged adjustment disorder.

Cognitive symptoms:

• Difficulty concentrating. ("aprosexia-nasalis")

The long-term risks of nasal related breathing problems are well known and include a high risk of cardiovascular and pulmonary complications that stem out of long term breathing difficulties and sleep disordered breathing..

"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).

Etiology

The inferior and middle turbinates of the nose comprise the nose's most functional air-processing tissue. They fill up the entire cavity of the nasal airway and by their unique turbinal structure they form the airflow passages in the nose. They force the airflow to streamline itself over and between them, through very narrow passages, and by doing so - allow the air to be pressurized with a strong forward positive pressure for quick transfer rates to the lungs, and at the same time heat, humidify and filter the air to the optimal levels requested by the lungs for optimal pulmonary function (close to body temperature of 37 degrees Celsius, 98-99% humidity saturation, filtering particles as small as 3 mili-micron), no matter what the external conditions of the inspired air are. The nose is a highly effective and sophisticated life supporting organ, and the turbinates are it's most important organs.

Sometimes the turbinates become chronically swollen in such a way which causes too much nasal obstruction. ENT and plastic surgeons decrease their volume of tissue in procedures known as 'turbinectomis'. However this is a wide code name that might mean anything from minimal reduction to complete resection of an entire turbinate. While careful and judicial conservative reductions of a turbinate's volume can be beneficial to the patient, an aggressive turbinectomy, in which most or all of the main turbinal body is resected, can be a devastating procedure that causes ENS.

When too much of the inferior or middle turbinates are resected - the nasal passages of airflow become to wide and the remaining mucosa that coats them becomes ineffective, dry, cold and insensitive to airflow. The deeper ENS patients try to inhale the more obstructed they feel, as the remaining nasal mucosa cannot relay enough airflow sensation to the brain, and because the airflow loses much of it's positive pressure (forward moving drive) - like someone took their thumb off the end of the garden hose and the water is now dribbling at their feet.

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

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.

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.

Additional Citations

"… 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

• A schematic sketch of the Right nasal airway passage with all three turbinates intact.
  A schematic sketch of the Right nasal airway passage with all three turbinates intact.
• 
  Right inferior turbinate with its front cut off, showing the unique turbinated structure of the turbinate.
• An internal view of the front inferior part of the nasal airways, after total inferior turbinectomy. Note how empty the inferior passages are.
  An internal view of the front inferior part of the nasal airways, after total inferior turbinectomy. Note how empty the inferior passages are.
• 
  Empty Nose Syndrome after partial inferior turbinectomy (only 25% of inferior turbinates remaining).
• 
  Empty Nose Syndrome after total bilateral inferior turbinectomy + bilateral uncinectomy and destruction of the lower lateral walls.
• 
  All turbinates removed - Right lateral wall view.
• 
  Anatomy of the nasal cavity
• 
  The skull from the front.
• 
  Sagittal section of nose mouth, pharynx, and larynx.

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"