What is Empty Nose Syndrome (ENS) and how is it diagnosed and treated?

Empty Nose Syndrome: Diagnosis and Management

Empty Nose Syndrome (ENS) is a rare, debilitating condition characterized by paradoxical nasal obstruction, nasal dryness, and persistent dyspnea sensation, typically occurring after excessive turbinate tissue removal during sinonasal surgery. 1

Definition and Pathophysiology

• ENS is considered an acquired condition that develops as a late complication of turbinate surgery, particularly after aggressive inferior turbinate reduction 1
• The condition is characterized by the "empty nose" appearance on examination, where nasal cavities appear abnormally wide with absence of identifiable turbinates on CT scans 2
• The pathogenesis likely involves anatomical changes leading to alterations in local environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms 1

Clinical Presentation

• Cardinal symptoms include:

  • Paradoxical nasal obstruction (feeling of inability to breathe despite objectively patent nasal passages) 1
  • Nasal dryness and crusting 1
  • Persistent sensation of dyspnea or air hunger 1
  • Nasal burning sensation 3
  • Impaired air sensation through nasal cavities 3

• Additional symptoms may include:

  • Facial pain/pressure 2
  • Decreased sense of smell 2
  • Psychological disturbances including depression and anxiety 4

Diagnosis

Diagnosis of ENS is primarily clinical and often challenging due to poor correlation between subjective symptoms and objective findings 1.

Diagnostic Criteria:

• History of prior turbinate surgery (especially inferior turbinate reduction) 5
• Characteristic symptoms persisting for at least 12 weeks 2
• Endoscopic findings showing abnormally wide nasal cavities and reduced/absent turbinate tissue 2
• CT scan showing signs of prior surgery and absence of identifiable turbinates 2, 5

Validated Assessment Tools:

• Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) - the first validated, specific questionnaire to identify ENS patients 3

  • Assesses six common ENS symptoms: nasal suffocation, nasal burning, nasal openness, crusting, dryness, and impaired air sensation 3
  • Helps differentiate ENS from chronic rhinosinusitis and healthy controls 3

• Sino-Nasal Outcome Test (SNOT) - used as a complementary assessment tool 4

Advanced Diagnostic Methods:

• Computational Fluid Dynamics (CFD) analysis can help refine ENS diagnosis by analyzing nasal airflow resistance and symmetry 5
• CFD can classify ENS patients into subgroups:
  • Low resistance with normal symmetry (typical ENS)
  • Evident asymmetry (unilateral ENS)
  • Normal CFD parameters 5

Management

Treatment of ENS should follow a stepwise approach, starting with conservative measures and progressing to surgical interventions for refractory cases.

Conservative Management:

• Mucosal humidification and hydration:

  • Saline nasal irrigations to moisturize the nasal mucosa 1
  • Nasal emollients and lubricants to reduce dryness and crusting 1
  • Environmental humidification 1

• Medical therapy:

  • Topical medications to reduce inflammation and improve mucosal health 4
  • Management of concurrent conditions like allergic rhinitis if present 2

• Psychological support:

  • Assessment and treatment of associated anxiety and depression 4
  • Cognitive behavioral therapy may be beneficial 4

Surgical Management:

Surgical intervention should be reserved for cases refractory to conservative management 1.

• Inferior meatus augmentation procedure (IMAP) - the standard surgical approach 6:

  • Aims to reconstruct the turbinate structure and restore nasal physiology 4
  • Various implantable materials can be used:
    • Autologous tissues:
      • Autologous dermal fat (ADF) - offers advantages of being adjustable in quantity, less invasive than rib cartilage, and having lower infection risk than artificial materials 6
      • Auricular cartilage - limited by small size 6
      • Rib cartilage - effective but more invasive 6
    • Artificial implant materials - effective but with higher risk of infection 4, 6

• Outcomes of surgical intervention:

  • Significant improvements in ENS6Q scores have been reported post-surgery 6
  • Nasal dryness tends to improve less than other symptoms 6
  • Benefits can persist for follow-up periods of up to 1 year 4

Prevention

• The most effective approach to ENS is prevention through turbinate-sparing surgical techniques 1
• When turbinate reduction is necessary, conservative approaches should be employed to preserve mucosal function 1
• Surgeons should be aware of the risk of ENS when performing turbinate surgeries 1

Prognosis

• ENS is a chronic condition that significantly impacts quality of life 4
• With appropriate management, symptomatic improvement is possible but complete resolution may be difficult to achieve 6
• Some physiological functions, particularly related to nasal dryness, may remain difficult to fully restore 6