Empty Nose Syndrome: Comprehensive Overview
Relevant Anatomy 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. It is considered a form of secondary atrophic rhinitis resulting from excessive surgery to the nasal turbinates 1.
The pathophysiology of ENS is multifactorial and includes:
- Changes in physiological laminar airflow patterns
- Disruption of mucosal functions (humidification, warming, filtering)
- Deficient neural sensation from damaged trigeminal nerve function
- Loss of normal turbinate tissue that regulates airflow dynamics 2, 3
The inferior and middle turbinates play crucial roles in:
- Directing airflow through the nasal passages
- Creating resistance necessary for the sensation of normal breathing
- Humidifying and warming inspired air
- Filtering particles through mucociliary clearance
When these structures are excessively reduced or removed, the normal nasal physiology is disrupted, leading to the paradoxical symptoms of ENS.
Prevalence
ENS is considered rare, though exact prevalence figures are not well established in the literature. It occurs as a complication of turbinate reduction surgery, particularly following complete or radical turbinectomy procedures. The syndrome appears to be more common after inferior turbinate resection but can also occur after middle turbinate resection 4.
Clinical Presentation
The hallmark symptoms of ENS include:
- Paradoxical nasal obstruction - feeling of inability to breathe despite wide nasal passages
- Nasal dryness and crusting
- Persistent feeling of dyspnea or suffocation
- Nasal burning sensation
- Reduced nasal airflow sensation
- Comorbid psychiatric disorders (depression, anxiety)
- Sleep disturbances
- Decreased quality of life 2, 4
Symptoms typically develop weeks to months after turbinate surgery, though in some cases may appear years later.
Diagnostic Algorithm
Clinical History
- History of turbinate surgery
- Paradoxical nasal obstruction
- Nasal dryness, crusting, burning
- Sensation of suffocation or inability to feel airflow
Validated Questionnaires
Physical Examination
- Nasal endoscopy showing:
- Abnormally patent nasal passages
- Absent or significantly reduced turbinate tissue
- Mucosal atrophy
- Crusting and dryness
- Nasal endoscopy showing:
Cotton Test
- Placement of moistened cotton in areas of turbinate loss
- Improvement in symptoms during this test supports ENS diagnosis 3
Objective Measurements
- Acoustic rhinometry showing abnormally wide nasal passages
- CT imaging demonstrating absent or reduced turbinate tissue
- Nasal airflow studies showing altered airflow patterns
Current Treatment Guidelines
Conservative Management (First-Line)
Nasal Humidification and Irrigation
- Daily saline irrigation to moisturize nasal mucosa and remove crusts
- Can be delivered via squeeze bottle, Neti pot, or low-pressure irrigation
- Use of isotonic or hypertonic solutions 1-2 times daily 1
Topical Treatments
Environmental Modifications
- Humidifiers in living/sleeping spaces
- Avoidance of dry, polluted environments
Management of Comorbidities
- Treatment of associated depression and anxiety
- Patient education and counseling 3
Surgical Management (For Refractory Cases)
Turbinate reconstruction is the primary surgical approach for ENS, using various implant materials:
Autologous Implants
- Autologous dermal fat (ADF) - shown to significantly improve ENS6Q scores 6
- Auricular cartilage
- Rib cartilage
- Advantages: lower infection risk, biocompatibility
Allografts/Xenografts/Cadaveric Implants
- Acellular dermis
- Cadaveric costal cartilage (20% of reported cases) 5
Synthetic Implants
- Polyethylene implants (most commonly used - 23.3% of reported cases)
- Hyaluronic acid fillers
- Calcium hydroxyapatite 5
Implant Placement
- Most common site: anterior-inferior lateral nasal wall
- Goal: to recreate the contour and function of the missing turbinate tissue 5
Historical Treatments
Historically, treatment options for ENS were limited and primarily focused on symptom management:
- Nasal moisturizers and emollients
- Systemic medications for pain management
- Psychological support for associated mental health issues
- Early attempts at turbinate reconstruction using less sophisticated materials
Future Treatment Options
Emerging research suggests several promising approaches:
Stem Cell-Based Therapies
- Mesenchymal stem cells (MSCs) to stimulate mucosal regeneration
- Neural crest-derived stem cells (NCSCs) to restore nerve function and sensation
- Potential for tissue-engineered constructs combining cells and biomaterials 2
Advanced Biomaterials
- Development of bioactive scaffolds that better mimic natural turbinate structure
- Materials with improved integration with host tissue
Regenerative Medicine Approaches
- Growth factor delivery systems to promote tissue regeneration
- Combined approaches targeting both structural and functional restoration 5
Prevention
The most effective strategy for ENS is prevention through turbinate-sparing surgical techniques:
- Complete turbinectomy should be avoided in favor of submucous resection when turbinate reduction is necessary
- Preservation of mucosal tissue during turbinate procedures
- Consideration of alternative treatments for nasal obstruction before resorting to turbinate surgery 1, 4
Conclusion
ENS represents a challenging complication of turbinate surgery with significant impact on quality of life. Diagnosis relies on a combination of clinical history, validated questionnaires, and physical examination findings. Current treatment approaches range from conservative management to surgical reconstruction, with emerging regenerative medicine techniques showing promise for the future. Prevention through turbinate-sparing surgical techniques remains the most effective strategy.