What is the initial approach to managing empty nose syndrome?

Management of Empty Nose Syndrome

The initial approach to managing empty nose syndrome should focus on conservative measures including nasal saline irrigation, topical moisturizers, and humidification, followed by surgical interventions such as inferior meatus augmentation procedures if conservative management fails. 1, 2

Understanding Empty Nose Syndrome

Empty nose syndrome (ENS) is an iatrogenic disorder resulting from excessive resection of nasal turbinate tissue, particularly the inferior turbinates. It is characterized by:

• Paradoxical nasal congestion (feeling of nasal obstruction despite anatomically patent airways) 1, 3
• Nasal dryness and crusting 1, 2
• Sensation of suffocation or inability to feel airflow 4
• Psychological symptoms including anxiety and depression 3

Initial Conservative Management

The first-line approach should be non-surgical and focus on symptom relief:

• Nasal saline irrigation - Regular irrigation helps moisturize the nasal cavity and remove crusts. This is supported by evidence for nasal saline irrigation in various forms of rhinitis and rhinosinusitis 4
• Topical moisturizers - Nasal gels, sprays, and ointments to combat dryness 2
• Environmental humidification - Using humidifiers, especially during sleep 2
• Avoidance of irritants - Including cigarette smoke, pollutants, and dry environments 2

Medical Management Options

If initial conservative measures provide insufficient relief:

• Topical corticosteroids - May help reduce inflammation but should be used cautiously as they can potentially worsen dryness 4
• Hyaluronic acid gel injections - Temporary submucosal injections can provide relief for several months by increasing tissue volume 5
• Psychological support - Address anxiety and depression that commonly accompany ENS 3

Surgical Management

When conservative and medical management fail to provide adequate symptom relief, surgical options should be considered:

• Inferior meatus augmentation procedures (IMAP) - The most common surgical approach involving implantation of various materials to restore nasal anatomy 1, 3
• Materials used for augmentation include:
  • Polyethylene implants (most commonly used, 23.3% of cases) 1
  • Autologous, homologous, or cadaveric costal cartilage (20% of cases) 1
  • Autologous dermal fat grafts 6
  • Hyaluronic acid and other injectable fillers (for less severe cases) 5

Proposed Management Algorithm

1. Initial assessment:

   • Confirm diagnosis through history of prior turbinate surgery
   • Evaluate severity using validated tools like Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) or Sino-Nasal Outcome Test (SNOT) 3
   • Nasal endoscopy to assess the extent of tissue loss 1

2. First-line treatment (3-6 month trial):

   • Nasal saline irrigation 2-3 times daily 4
   • Topical moisturizers and emollients 2
   • Environmental humidification 2

3. Second-line treatment (if inadequate response):

   • Consider hyaluronic acid gel injections 5
   • Address psychological components with appropriate therapy 3

4. Surgical intervention (for persistent symptoms):

   • Inferior meatus augmentation with appropriate implant material based on severity and anatomical considerations 1, 3
   • Post-surgical follow-up should continue for at least 12 months 1

Monitoring and Follow-up

• Regular follow-up to assess symptom improvement using standardized questionnaires 3
• Endoscopic examination to evaluate implant position and mucosal health 1
• Adjustment of conservative measures as needed 2

Important Considerations and Pitfalls

• Prevention is critical - Turbinate tissue should be preserved whenever possible during nasal surgery 2
• Realistic expectations - Complete symptom resolution may not be achievable; the goal is significant improvement 3
• Implant complications - Monitor for infection, extrusion, or migration of implant materials 1
• Persistent dryness - Even after successful surgery, some degree of nasal dryness often persists and requires ongoing management 6