Empty nose syndrome (ENS) is a medical term used to describe a nose crippled by over resection of the inferior and/or middle turbinates of the nose.[1]

Over resection of the inferior or middle turbinates leaves the nose in a chronic state of dryness (lack of mucus/moisture production) and incapable of streamlining, sensing (motion and temperature wise) and processing the inhaled air in a satisfactory manner. [2]

The main symptoms are chronic dryness of the nose and pharynx, upsetting nasal sensations switching between over openness and congestion of the remaining nose, difficulty sleeping, difficulty concentrating and a generally depressed and irritated mood.

The patients feel confusing sensations of too much air entering their nose and the nose and pharynx are subsequently very dry, yet at the same time they feel that they need more nasal resistance to breathe-in satisfactorily.

ENS is a physically, cognitively and emotionally debilitating condition as satisfying nasal breathing is essential for a good health, cognitive functions, and sense of well-being.

Symptoms

physical symptoms
Nose feels too empty/hollow/absent.
Diminished nasal airflow sensation feedback ('paradoxical obstruction').
Extreme sensation of dryness of the nasal cavities, with or without crusting.
Not enough moisture/mucus production.
Dryness of the pharynx, soft palate and back of the tongue ("dry pharyngitis" and "dry laryngitis"[3]).
Feeling of needing more nasal resistance (or nasal membrane responsiveness) to breathe.
Increased pulmonary sensitivity to air-borne irritants, strong scents and cold air. Causes much uneasiness in breathing and sometimes even long-periods (can last hours) of severe shortness of breath, depending on the degree of exposure.
Diminished sense of smell and/or taste. Can be confusing - because although there is diminished sense of smell there is also hyper-responsiveness to light and volatile airborne chemicals, fumes and irritants.
Difficulty projecting or resonating speech. The voice seems weak and requires some straining to sound loud and articulate well, which causes uneasiness in speech.
Feeling weak and depleted of energy.
Very poor quality of sleep. Not necessarily full sleep apnea, but shallow and dry breathing, which often switches entirely to mouth breathing only, waking up a lot very dry, with headaches, severe dizziness and very little REM sleep.
Relatively dry skin and eyes.


cognitive symptoms

Difficulty concentrating ('aprosexia nasalis').
Difficulty performing mental tasks.


emotional symptoms

Marked reduction in sense of self and very crippled sense of well-being.
Irritated and/or depressed mood. Often clinical depression.
Anxieties.
Avoidance of social interactions.




Other characteristic physical symptoms that many ENS patients develop

irritating sensation of thick stagnant mucus stuck at the back of the throat. Because of the dryness of the mucosa the mucus propelled to the throat (on the way to the stomach - the nasal mucociliary clearance that occurs in all humans) simply becomes too dry and sticks to the sides of the throat instead of sliding smoothly unfelt.
Chronic sinusitis.
Worsening of pre surgical nasal symptoms, such as allergic rhinitis, etc'.
Epistaxis.
Hardly any mucus production, or the opposite – episodes of excessive rhinoreah.
Foul smell from nasal cavities.
Elevated levels of blood pressure.
Hormonal and metabolic imbalances.
Significant weight gain.

Etiology

The nasal turbinates are elongated bony structures, covered with nasal mucosa, that project off the nasal side walls and stretch across the entire nasal airway. In adults - the inferior turbinate is about the size of an index finger and the middle turbinate is about the size of the small finger. They are the most important mucosal and moisture secreting structures of the nose and they serve to heat regulate (to body temperature), humidify (to 98% humidity), to filter, to pressurize, elevate and streamline the air that flows through the nose.[4] They provide most of the nasal mucosa for the air to flow over and by doing so they act as the radiators, the humidifiers and filters of the nose. The unique air-conditioning and processing conditions that the turbinates supply are not important only for proper lung function but also for keeping the health, function and integrity of the rest of the nasal mucosa, which is essentially the organ-system of the nose, as it covers all the inner nasal chambers and sinus cavities. The turbinates, in particularily the inferior ones, also play a crucial role in protecting the pharynx and larynx from the effect of direct insult of airflow and dryness.

The turbinates are also heavily innervated with pressure sensing receptors (of the trigeminal cranial nerve) that sense the airflow and thus notify the brain that enough air is traversing the nose to sustain life. If too much of these receptors are gone nasal breathing becomes unsatisfying, even though there is no structural blockage. This is called 'paradoxical obstruction' and is very common in ENS.

The turbinates, especially the inferior ones, also provide most of the nasal resistance to the lungs. The lungs need some resistance to allow them to reach their proper inflation and deflation rates during inhalation and exhalation. The nose supplies 50% of the entire resistance to the lungs. The turbinates supply most of these 50%. This is a poorly understood and hardly researched subject. But, it is well known from clinical observations that too little nasal resistance can cause pulmonary breathing difficulties and shortness of breath just like too much resistance will. Healthy nasal breathing is essential for maintaining all aspects of physical and mental health.[5]

The turbinates also trap more than 75% of the water vapor returning from the lungs upon exhalation and thus help protect the body from dehydration.

Sometimes the turbinates become chronically swollen in such a way which causes too much nasal obstruction. ENT and plastic surgeons often decrease their volume 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.[6] [7] [8] [9] [10] [11] [12] [13]. In many patients, ENS-type like symptoms develop even after what seems to be conservative reductions of the turbinates, especially if they include the anterior portion of the inferior turbinates, which are essentially a vital part of the inner nasal valve. However these symptoms will not be as severe as in over agressive reductions of the turbinates.

When taking nasal anatomy and physiology into account it is very easy to see how over resection of nasal inferior and/or middle turbinates (also known as 'conchae') will cause the nasal chambers to be too empty, too wide and too dry, resulting in a marked decline of all nasal functions and sensations and this has a profound effect on the sufferer's quality of life and sense of well-being.


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".[14]

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.

In ENS the mucosa in the over exposed cavities, where the turbinates were over resected, becomes chronically dry and in some cases even atrophic. But, unlike in atrophic rhinitis, this dryness or atrophy is caused directly by the direct impact of over turbulent and dry airflow and not because of chronic inflammation of the mucosa that occurs in atrophic rhinitis. So, perhaps a more accurate description, when comparing the two, would be to say that ENS symptoms can appear do be similar to those of atrophic rhinitis, but unlike the latter the dryness or atrophy in ENS is not of a progressive inflammatory sort.

From a histological point of view the clinical picture in ENS tends to resemble a form of rhinitis sicca with perhaps some areas of atrophy at the front of the nose, rather than full blown atrophic rhinitis.

Having said all that, it is important to note that prolonged ENS runs a risk of developing into atrophic rhinitis of the progressive type. Although there has not been enough long-term research to asses the true probability of this risk, it is quite probable that prolonged exposure of the cavities to too much airflow, causes chronic vascular constriction of the mucosa and this predisposes the mucosa to progressive atrophy. Therefore the proper management of ENS and attempts to cure it permanently are of the utmost importance.[15]


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. Many patients prefer to use Ringer's Lactate solution instead, as they find it's easier on the mucosa 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 can help in cases of extreme dryness and crusts.
Drinking lots of hot soups and beverages. Caffeine is best avoided.
Sleeping with a cool mist humidifier.
Sleeping with a CPAP machine that has a built-in humidifier.
Some patients respond well to vitamin A and vitamin D.
Acupuncture and shiatsu meant to improve nasal blood supply and nerve function.
Dressing warm and sleeping in a warm environment.
Regular physical activity and a healthy life style are most important too.

Surgical treatment

The underlying rational of surgery is to restore the inner nasal geometrical structure of the nasal passages of air (the inferior, middle and superior meatuses).

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.

By implanting different grafts and material underneath the patients' submucosa at the right places - the surgeon hopes to create a look alike turbinal structure which will do four things:[16]


a) Restrict the amount of airflow, just enough to allow the nasal mucosa to cope better, while still allowing enough air to pass through for all needs of breathing. This is referred to as normalizing the nasal rates of resistance.

b) Restore close to normal rates of nasal mucosal heat and humidity, as the implant projections trap the heat and moisture in the air returning from the lungs.

c) Normalize the post surgical disrupted airflow patterns of the nose and make sure that the vast majority of airflow is redirected into the middle meatus of the nose.

d) Increase the mucosal surface in the nose that comes in contact with the airflow. This increases airflow sensation, amongst all the other things that are mentioned above that help improve the sensation too.





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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 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.

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 100% complete cure 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. The technology and know-how knowledge of how to do so exist. The application, like in so many other physical disorders, is another matter altogether.

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.)




"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.)





Additional images

Internal view of the front inferior part of the nasal airways, after total inferior turbinectomy.

Empty Nose Syndrome after partial inferior turbinectomy. Many doctors might think that there is enough inferior turbinates remaining here, but the degree of resection is certainly radical enough to cause ENS.

All turbinates removed - Right lateral wall view.

Anatomy of the nasal cavity


Sagittal section of nose mouth, pharynx, and larynx.



References

^ Rice, Kern, Mabry, Friedman. The turbinates in nasal and sinus surgery: A consensus statement. Ear Nose & Throat Journal, Feb' 2003.
^ Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863.
^ Thomson St. C & Negus VE. Inflammatory diseases. Chronic Rhinitis. Diseases of the nose and throat, 6th edition. London: Cassel & Co. Lmt. 1955; 124-145
^ Elad D, Naftali S, Rosenfeld M, Wolf M. Physical stresses at the air-wall interface of the human nasal cavity during breathing. J Appl Physiol. 2006 Mar;100(3):1003-10.
^ Cottle MH. Nasal Breathing Pressures and Cardio-Pulmonary Illness. The Eye, Ear Nose and throat Monthly. Volume 51, September 1972.
^ Berenholz L, et al'. Chronic Sinusitis: A sequela of Inferior Turbinectomy. American Journal of Rhinology, July-August 1998, volume 12, number 4.
^ Grutzenmacher S, Lang C and Mlynski G. The combination of acoustic rhinometry, rhinoresistometry and flow simulation in noses before and after turbinate surgery: A model study. ORL (Journal) volume 65, 2003, pp 341-347.
^ Passali D, et al'. Treatment of hypertrophy of the inferior turbinate: Long-term results in 382 patient randomly assigned to therapy. by in Ann' Otol' Rhinol' Laryngol', volume 108, 1999.
^ Chang and Ries W. Surgical treatment of the inferior turbinate: new techniques: in Current Opinion in Otolaryngology & Head and Neck Surgery, volume 12, 2004 (pp 53-57).
^ Moore GF, Freeman TJ, Yonkers AJ, Ogren FP. Extended follow-up of total inferior turbinate resection for relief of chronic nasal obstruction. by in Laryngoscope, volume 95, September 1985.
^ Oburra HO. Complications following bilateral turbinectomy. East African Medical Journal, volume 72, number 2, February 1995.
^ Houser SM. Empty nose syndrome associated with middle turbinate resection. Otolaryngol Head Neck Surg. 2006 Dec;135(6):972-3.
^ May M, Schaitkin BM. Erasorama surgery. Current Opinion in Otolaryngology & Head and Neck Surgery, 2002, volume 10, pp: 19-21.
^ Moore, E.J. & Kern, E.B. (2001). Atrophic rhinitis: A review of 242 cases. American Journal of Rhinology, 15(6)
^ Cottle MH. Nasal Atrophy, Atrophic Rhinitis, Ozena: Medical and Surgical Treatment. Journal of the International College of Surgeons. Volume 29, pages: 472-84, 1958.
^ Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863.


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