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Surgical Treatment for Empty Nose Syndrome

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Surgical Treatment for Empty Nose Syndrome ORIGINAL ARTICLE Surgical Treatment for Empty Nose Syndrome Steven M. Houser, MD Objectives: To detail empty nose syndrome (ENS), an Intervention: Acellular dermis was implanted submu- iatrogenic disorder characterized by a patent airway but cosally to simulate missing turbinate tissue. a subjective sense of poor nasal breathing, and to ex- plore repair options for patients with ENS. Main Outcome Measures: Symptoms and symptom scores for the 20-item Sino-Nasal Outcome Test com- Design: A case series of 8 patients with ENS detailing pleted before and after the implantation were gathered. symptoms before and after submucosal implantation of acellular dermis. Results: A statistically significant improvement in symp- tom scores for the Sino-Nasal Outcome Test was noted Setting: Academic medical center. (PՅ.02). Patients: Subjects who were evaluated for abnormal na- Conclusions: Careful assessment allows reconstruc- sal breathing and determined to have ENS. Patients were tive surgery through submucosal implantation of acel- diagnosed as having ENS if they described characteris- lular dermis. Symptoms of patients with ENS can im- tic symptoms, had evidence of prior nasal turbinate sur- prove with surgical therapy. gery, and their symptoms improved after they under- went a cotton test. Arch Otolaryngol Head Neck Surg. 2007;133(9):858-863 VER THE PAST 6 YEARS I tion because of its important role in the in- have sought to better ternal nasal valve. The rate of occurrence understand the entity of ENS after turbinectomies is not known. termed empty nose syn- Potentially, many patients with ENS are not drome (ENS) by engag- diagnosed because most rhinologists are ing in discussions over the Internet with trained to look for physical signs of dry- O 1 potential patients with ENS. I have evalu- ness and atrophy after turbinectomies— ated hundreds of symptoms and sinus com- the only possible long-term complica- puted tomographic (CT) scans to screen tions—and may thus ignore the patients’ for ENS. Dozens of patients with ENS from subjective complaints of nasal obstruc- many states and several foreign countries tion or shortness of breath. Like many other have been seen at MetroHealth Medical otolaryngologic disorders (eg, tinnitus), the Center (Cleveland, Ohio) for a full evalu- fact that the symptoms are subjective and ation of ENS. Eleven patients have under- cannot be verified objectively does not mean gone nasal submucosal acellular dermis im- they are not real and valid symptoms origi- plantation in an effort to rebuild the inside nating in a physical abnormality. of their nose and to reverse some of their Manometric studies or acoustic rhi- symptoms. This article describes ENS and nometry will indicate a fully patent air- presents the results of those patients who way that contrasts greatly with the pa- have undergone submucosal acellular der- tient’s breathing complaints. Such flow mis implantation. studies might denote an overly patent nose It is difficult to diagnose ENS because with below-normal rates of resistance. there are no reliable objective tests. The oto- When this is accompanied by a CT scan laryngologist must rely on the patient’s sub- that suggests that a turbinate reductive pro- jective symptoms to diagnose ENS. It is cedure took place, the physician’s suspi- caused by too much turbinate tissue loss, cion for ENS should be raised; however, which is revealed fully by a CT scan. Al- the fact that a patient has an overly patent though perhaps in a milder form, ENS is nose does not necessarily mean that he or sometimes seen even in patients who have she has ENS. A healthy nose provides Author Affiliation: Department lost relatively little of their turbinate tis- about half of the resistance of the entire of Otolaryngology–Head and sues and whose turbinates appear to be al- respiratory tract. A serious decline in this Neck Surgery, MetroHealth most normal in size (hereinafter, ENS- resistance might considerably upset the Medical Center, Cleveland, type patients); this is especially true in cases balance of resistance needed for deep pul- Ohio. of anterior inferior turbinate (IT) resec- monary inspiration and result in short- (REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133 (NO. 9), SEP 2007 WWW.ARCHOTO.COM 858 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 ness of breath, just as patients with ENS notice that even went surgical procedures, but 3 were lost to follow-up. The ages though their noses are completely open and air reaches their of the 8 remaining study subjects at the time of submucosal im- lungs, they cannot seem to breathe in deeply enough to feel plantation of acellular dermis ranged from 18 to 45 years. One satisfied.2 It is well known that even though 50% more ef- patient was female, and 7 were male. One patient was Asian; 1, fort is required to breathe through the nose than through Hispanic; and 6, white. The durations of their follow-up ranged from 6 months to 4 years. Patients were asked to express their the mouth, nasal breathing is much more satisfying and 3 symptoms as free text and to complete Sino-Nasal Outcome Test effective than mouth breathing. Resection of the turbi- (SNOT-20) surveys to assess their symptoms before and after im- nates, which are the main intranasal structures that pro- plantation. The postimplantation symptoms were assessed 3 to vide this much-needed respiratory resistance, makes the 6 months after surgery. The SNOT-20 is a validated 20-item sur- nose both less effective and less efficient. vey that examines general nasal symptoms and can be used as a The symptom that most often indicates ENS is para- comparator before and after some type of intervention; each item doxical obstruction: subjects may have an impressively large is scored from 0 (no symptoms) to 5 (severe symptoms).6 nasal airway because they lack turbinate tissue, yet they Patients were diagnosed as having ENS based on physical state they feel they cannot breathe well. There is no clear examination and symptoms consistent with ENS: paradoxical way to describe the breathing sensation that patients with airway obstruction, dyspnea, dryness, and often depression. Pa- ENS experience. Some patients may state that their nose tients were evaluated for ENS with a head mirror and a zero- feels “stuffy,” for lack of a better word, whereas others state degree rigid endoscope with no anesthesia or decongestant that would interfere with a subsequent cotton test. Patients were their nose feels too open, yet they cannot seem to prop- assigned to subcategories within ENS based on their anatomic erly inflate the lungs; they feel they need some resistance characteristics. The designations indicate the type of tissue that to do so. Patients with ENS do not sense the airflow pass- was resected; hence “ENS-IT” indicates that the IT was fully ing through their nasal cavities, whereas their distal struc- or subtotally resected and “ENS-MT” notes a similar insult to tures (pharynx, lungs) do detect inspiration; the patients’ the middle turbinate, whereas “ENS-both” indicates both the central nervous systems receive conflicting information. IT and MT were at least partially resected. Finally, as already These patients seem to be in a constant state of dyspnea described in the second paragraph of this article, “ENS-type” and may describe the sensation of suffocating. The con- designates patients who appear to have adequate turbinate tis- stant abnormal breathing sensations cause these patients sue, yet their concerns seem to fully emulate ENS; they have to be consistently preoccupied with their breathing and all undergone some type of turbinate procedure in the past, and they improve with the cotton test. All patients with ENS are nasal sensations, and this often leads to the inability to con- treated medically with maximal moisturization (eg, use of a hu- centrate (aprosexia nasalis), chronic fatigue, frustration, midifier, isotonic sodium chloride solution spray, emollients) irritability, anger, anxiety, and depression. Simple advice before considering any implantation, and such care is contin- to breathe through the mouth is woefully inadequate to ued afterward according to their subjective dryness concerns. overcome these sensations and, quite frankly, disrespect- Generally, a patient needs to allow a year to elapse after their ful to the patient. Viscous phlegm, heightened sensitivity last turbinate surgery to await any possible recovery of func- to volatile compounds (eg, gasoline, perfume), cold air, tion before implantation is considered. and air-borne irritants cause pulmonary irritation and During evaluation, a cotton test is performed to gauge the worsen the feeling of dyspnea. Patients with ENS often re- size and location of a potential implant in a particular indi- port a quantitative decrease in their ability to smell, al- vidual. This test is performed by placing cotton moistened with isotonic sodium chloride solution within the nonanesthetized though their qualitative identification of odors remains in- nasal cavity in a region where an implant would be feasible (eg, tact. The greater the impact on the remaining nasal mucosa along the septum opposite the site of a missing MT). The pa- by dry and cold air, the more it tends to get so irritated tient is then asked to breathe comfortably with this in place and dry that squamous metaplasia takes place. Patients with for approximately 30 minutes and to gauge any change in sen- ENS may develop pharyngitis and laryngitis.4 They may sation or symptoms. Multiple pieces of cotton can be placed to also develop patulous eustachian tubes. Many of them ex- aid in planning the size and location of a potential implant. Al- perience sleep-disordered breathing and tend to snore fre- ternatively, an injection of isotonic sodium chloride solution quently and switch to oral breathing only.
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