Treatment Options for Empty Nose Syndrome
Definition and Pathophysiology
Empty nose syndrome (ENS) is a rare complication that develops after partial or complete turbinectomy, characterized by paradoxical nasal obstruction despite an objectively wide nasal airway 1. It is considered a form of secondary atrophic rhinitis, resulting from excessive surgery to the nasal turbinates 1. The pathogenesis is multifactorial, involving changes in physiological airflow, disruption of mucosal functions, and deficient neural sensation 2.
Clinical Presentation
Patients with ENS typically experience:
- Paradoxical nasal congestion
- Nasal dryness and crusting
- Epistaxis
- Sensation of suffocation
- Feeling of dyspnea
- Psychological disorders such as depression or anxiety 3, 2
Treatment Options
Conservative management is the first-line treatment for empty nose syndrome, with surgical options reserved for refractory cases. 4, 5
1. Conservative/Medical Management
Nasal saline irrigation: Daily irrigation helps moisturize the nasal mucosa and remove crusts 1
- Technique: Use isotonic or hypertonic solutions 1-2 times daily
- Can be delivered via various methods (squeeze bottle, Neti pot, low-pressure irrigation)
Topical intranasal corticosteroids: May help reduce inflammation 1
- Apply using proper technique (head tilted forward, aiming toward outer wall)
- Avoid aiming toward nasal septum to prevent irritation and bleeding
Mucosal humidification: Use of humidifiers, especially at night 5
Nasal emollients: Application of petroleum-based ointments or other moisturizing agents 5
Avoidance of irritants: Reducing exposure to smoke, pollution, and other nasal irritants
2. Surgical Management
For patients with persistent symptoms despite conservative management, surgical options may be considered:
Inferior meatus augmentation procedure (IMAP): The most common surgical approach 6, 3
Materials used include:
The anterior-inferior lateral nasal wall is the most frequent site for implantation 4.
3. Emerging Therapies
- Cell-based therapies: Still experimental but showing promise 2
- Mesenchymal stem cells (MSCs) may stimulate mucosal tissue regeneration
- Neural crest-derived stem cells (NCSCs) may help reconstitute nerve structure and function
Treatment Algorithm
Initial Management (First 3 months):
- Nasal saline irrigation 1-2 times daily
- Topical intranasal corticosteroids
- Mucosal humidification and emollients
- Environmental modifications (humidifiers, avoiding irritants)
If symptoms persist after 3 months:
- Reassess severity using validated tools (ENS6Q, SNOT)
- Consider psychological support for associated anxiety/depression
- Evaluate for surgical candidacy
Surgical Management (for refractory cases):
- IMAP using autologous tissue preferred due to lower infection risk
- Autologous dermal fat offers advantages: adjustable quantity, less invasive than rib cartilage, and better cosmetic outcomes 6
Outcomes and Follow-up
Most studies indicate that surgical intervention leads to significant improvements in:
- Clinical outcomes (endoscopic exams, acoustic rhinometry)
- Patient-reported nasal symptoms
- Psychological well-being
- Overall health-related quality of life 4
However, some physiological functions remain difficult to improve, with nasal dryness often persisting even after surgical intervention 6.
Prevention
The best approach to empty nose syndrome is prevention through turbinate-sparing techniques during initial nasal surgery. 5 Complete turbinectomy should be avoided in favor of submucous resection when turbinate reduction is necessary 1.
Common Pitfalls to Avoid
- Failure to recognize ENS as a potential complication of turbinate surgery
- Overaggressive turbinate reduction during initial surgery
- Relying solely on objective measures without considering patient symptoms
- Delaying treatment, which can lead to worsening psychological comorbidities
- Expecting complete resolution of all symptoms with any single intervention