Empty nose syndrome

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Right nasal airway passage

Empty nose syndrome (ENS) is a medical condition that is caused when too much inner nasal mucus-producing tissue (the turbinates) is cut out of the nose, leaving the nasal cavities too empty and wide, with severely diminished capabilities to perform their functions of conducting and preparing the inhaled air to the lungs.

[edit] Explanation

These operations, known as 'turbinate resections', 'turbinectomies', or nasal 'conchotomies', are performed by ear nose and throat surgeons or by plastic surgeons for different reasons.

The most common reason to operate is chronic inflammation of the turbinates, which can block too much of the nasal airways. A condition called “turbinate hypertrophy" is a condition in which turbinates swell and over-grow. Among the most common causes for this condition are allergies, hormonal imbalance, too much exposure to dust, smoke and other airborne irritants, nasal structural deformities like a deviated septum and prolonged use of nasal decongesting medications.

[edit] Terminology

Right inferior turbinate with its front cut off, showing the unique turbinated structure of the turbinate

The term "empty nose syndrome" was originally coined in the 1990's by Dr. E.B. Kern 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 that underwent turbinectomies seemed to developed symptoms of nasal obstruction even though their noses appeared to be wide open. Other symptoms were nasal dryness, shallow unrested sleep, difficulty concentrating, and quite often clinical depression. All the patients' CT scans showed that they had very wide and almost totally empty nasal cavities, thus they called it the "Empty Nose Syndrome". Dr. Kern then went on to give a series of lectures on ENS, and later summarized his findings in a medical article.^[1]

[edit] Effects

An 'empty nose' can have a huge impact on a person's quality of life, and it can cause depression, slow down and impair cognitive processes and inhibit sexual and social activities. It can also cause a person to feel weak and depleted of energy.

[edit] What happens when ENS occurs

Front cross CT sections of nasal cavities - Before and after a total inferior turbinectomy. Note how this patient's nasal mucosa is trying to compensate by thickening of the mucosa on the septum and the right middle turbinate. This patient now suffers from ENS

When too much of the turbinates are resected, the nose loses its capacities to properly pressurize, direct, temperature regulate, humidify, filter, smell and sense the inspired airflow. The natural synchronization of breathing between the nose, the mouth and the lungs is also interfered, and the result is an empty, dry and crippled nose, which feels too empty and at the same time obstructed. People suffering from Empty Nose Syndrome feel a constant shortness of breath, their sleep becomes very shallow and many also develop sleep apnea. ENS sufferers tend to be depressed and anxious, which may cause them to avoid social interactions. Some experience problems such as Sinus pressure, nasal or facial pain.

[edit] The main problem in ENS - paradoxical obstruction:

ENS is characterized initially by grossly enlarged airways, that change rapidly from being too obstructed to being too open. This has a dramatic impact on the inhaled air through the nose, which results in significant breathing difficulty known as "paradoxical obstruction". This obstruction is caused by three pathological factors that occur when the turbinates are removed:

a) The airflow becomes too turbulent, hence less air gets conducted efficiently through the nose to the lungs and doesn't stimulate enough mucosa surface.

b) The airflow motion receptors, embedded in the nasal mucosal layers, do not get stimulated enough, and this registers in the brain's breathing centers as a breathing obstruction.

c) The dramatic loss of humidifying, filtering, and air heating tissues of the turbinates reduce the quality of the air that does reach the lungs, and this results in less efficient gas exchange at the alveoli of the lungs.

[edit] ENS is not Atrophic Rhinitis, but can cause it:

The main danger with prolonged Empty Nose Syndrome is developing Atrophic Rhinitis, which is an inflammatory, degenerating disease of the nasal cavities and sinuses, characterized by degeneration of nasal bone and soft tissue, enlarged nasal cavities and totally dysfunctional remaining nasal mucosa, which is often accompanied by foul smelling secretions (known as “Ozaena”), nosebleeds and crusts.

For many years, people with ENS have been automatically labeled as suffering from Secondary Atrophic Rhinitis. "Secondary" - to imply that the chronic state of nasal atrophy was caused by surgery, as opposed to "Primary" in which the atrophy occurs from other reasons that are not induced by medical intervention. ENS is an iatrogenic condition too ("iatrogenic" = caused by medical procedure or therapy), but it is not Atrophic Rhinitis, although very similar and can definitely develop into it.

The main characteristics in ENS are the paradoxical breathing difficulties. to the naked eye - the remaining mucosal tissues usually seem healthy and normal (besides the fact that a large portion of the nasal mucosa's has been lost in the turbinectomy). Over the years, this remaining mucosa can become drier and drier, and there is a danger that it will go through metaplasia and become atrophic.

ENS is probably best described as an unduely patent nose (due to excessive loss of turbinate tissue) which in turn causes over turbulent nasal airflow which dries the remaining mucosa causing rhinitis sicca, which over the years can result in atrophic rhinitis.

[edit] Symptoms

ENS can cause a wide variety of symptoms, some directly relating to the nose and others relating to other parts of the body. All symptoms listed can significantly affect a person's quality of life.

Physical symptoms may include:

• Shortness of breath
• Tend to start hyperventilation at the slightest appearance of pressure (physical or mental).
• Difficulty breathing in deep
• Nasal dryness
• Nasal pain
• Chronic Sinusitis
• Annoying feeling of Nasal emptiness.
• Lack of nasal airflow sensation
• Feeling that the nose is not ventilated
• Diminished sense of smell and/or taste together with over-sensitivity to very strong smells like: fresh paint, perfume, cleaning detergents, gasoline.
• Speech problems (feeling as if the words escape out of your nose, some difficulty in punctuating words, especially with sounds like – “pee”, “dee”, “ta”, “la”, “na”, etc’…)
• Thick post nasal drip or dry sticky phlegm
• Hyper pulmonary sensitivity to airborne irritants and odors (such as smoke, dust, gasoline and paint fumes, etc').
• Dryness in the larynx, back of the mouth, palette, tongue.
• Dry eyes.
• Ear pressure and/or fluids in ear/ or unexplained ear dryness
• Facial pain (not from sinusitis)
• Sinus pressures and pain (even without clinical symptoms of sinusitis)
• Headaches/migraines
• Chronically elevated or unstable blood pressure
• Crusts in nasal airway.
• Occasional bleeding.
• Foul smell in nose.

Certain sleep problems are also symptoms:

• Unable to sleep through the night.
• Not feeling rested in the morning.
• Nightmares or night terrors.
• Sleep disordered breathing and sometimes full apnea.

Psychological symptoms:

• Depression.
• Anxieties.
• Social phobia (constantly avoiding social interaction)

Cognitive symptoms:

• Difficulty concentrating. ("aprosexia-nasalis")

[edit] Treatments

Once too much of a turbinate is resected it cannot recover, grow back, or be replaced. There are no donor sites in the human body with a similar kind of tissue. The turbinates and nasal mucosa are unique. ENS, can be improved to varying degrees of success, by trying to fabricate the structure and quality of the missing turbinate, with biomaterials such as Alloderm and/or SIS.

[edit] Non-surgical treatment

There are different types of treatment available for ENS. Saline (physiological salt water, 0.9% sodium-chloride) can be used to rinse out the dry mucus and moisten the nasal cavity, this could also prevent infection. Some people find relief by increasing nasal secretions by consuming large amounts of dairy products. Vitamin A and D might help with mucus production. Humidifiers can be used to help with the dryness, and in cases of sleep disordered breathing a continuous positive airway pressure (CPAP) machine with a built-in humidifier can be used. Acupuncture, shiatsu, inversion therapy, regular physical exercise - all these will improve the blood circulation to the nose and help preserve the remaining nasal mucosa.

All the above non-surgical treatments will help improve dryness conditions, and sustain the health of the remaining membranes, but they will not restore the lost functions or the nose and normal nasal sensations.

[edit] Surgical treatment

If a significant portion of a turbinate remains, it can be augmented with bio-materials such as acellular dermis ("Alloderm") and SIS, two known natural biomaterials with low absorption and rejection rates. Once either of these materials is implanted in the desired area, the implants incorporate into the surrounding tissue and adopt many of the host tissue's qualities. Even if the turbinates are totally resected there is still much that can be achieved by narrowing the nasal airway at key-strategic locations with submucosal implants that will normalize airway resistance, trap moisture and increase humidifcation, and will deflect the airflow to flow more calmly and steadily. The implants help to normalize the nasal pressures and aerodynamics of airflow, restore normal nasal sensations, and improve nasal humidity. Common places for effective implantation, other than to the turbinates, is opposite the resected turbinates, inot the septum or nasal floor (see example in pictures below). The nasal lateral wall can be augmented to. Other materials can be used as implants, but none have shown the same level of success as Alloderm. Today there is also a new approved form of micronized Alloderm, brand-named Cymetra, that can be injected in liquid form. Once it is in place it solidifies and becomes like regular Alloderm. It is difficult or virtually impossible to use Cymetra on its own to achieve a large volume implant, but it can be used successfully to further augment prior Alloderm implants, thus perfecting the initial result achieved with regular Alloderm.

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 can't fully cure ENS but can help alleviate the symptoms with various degrees of success, depending on the individual condition of each patient.

Dr. Steven Houser from Cleveland is a well-known American ENT surgeon who has gained quite a lot of experience with reconstructive implant surgery for ENS. He has a keen scientific interest in researching, understanding and treating ENS patients.

Hopefully, as doctors become more aware of ENS, they will reach a better understanding of its long-term effects on its sufferers' quality of life. This will hopefully encourage more surgeons to develop better ways of reconstructing resected nasal turbinates and to normalize the contours and function of the inner nasal airway anatomy and physiology.

[edit] Quotations

This is what a panel of top American rhinology experts from the American Rhinological Society had to say about Empty Nose Syndrome:

"… 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.”

(cited 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.)

This is what Dr. E.B. Kern (former president of the American and of the International Rhinological Societies) has to say about radical turbinectomies:

“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 page 496 of chapter 23, “Nasal Obstruction”, written by Dr. E Kern, Of the book: Otolaryngology – Head and Neck Surgery, by Dr. Meyyerhoff and Dr. Rice, published by the W.B. Saunders Company, 1992).

When reexamining groups of patients who had undergone total inferior turbinectomies, and were expected by their surgeons to be well in the long run, Moore et al’ found that that was not to be the case at all, as the grim reality of those post inferior turbinectomied patients revealed itself:

“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).

[edit] References

1. ^ Moore, E.J. & Kern, E.B. (2001). Atrophic rhinitis: A review of 242 cases. American Journal of Rhinology, 15(6)

[edit] External links

• Dr. Houser's tutorial pages on ENS
• Dr. Grossan's ear, nose and throat pages
• Listen to Dr. Kern's lecture on Empty Nose Syndrome
• Interactive Forum for ENS Patients
• The ENS book