What is the psychiatric management of empty nose syndrome?

Psychiatric Management of Empty Nose Syndrome

Empty Nose Syndrome (ENS) patients have a high prevalence of psychiatric comorbidities including depression and anxiety that require comprehensive management alongside surgical interventions for optimal outcomes.

Understanding the Psychiatric Burden in ENS

• Depression and anxiety are extremely common in ENS patients, with prevalence rates of 76.6% and 77.0% respectively, significantly higher than in patients with chronic rhinosinusitis 1
• ENS patients experience moderately severe depression (mean score 17.9) and moderate anxiety (mean score 12.7) that warrant treatment 2
• The psychological burden includes:
  • Reduced productivity at work (62% reduction) and daily activities (65% reduction) 2
  • Higher rates of somatic symptom disorder (53% of ENS patients vs. 14% of chronic rhinosinusitis patients) 3
  • Potential obsessive-compulsive tendencies (18.37% of ENS patients vs. 8.62% of chronic rhinosinusitis patients) 3

Assessment Approach for ENS Patients

• Use validated screening tools to quantify psychiatric symptoms:
  • Beck Depression Inventory II (BDI-II) for depression 4
  • Beck Anxiety Inventory (BAI) for anxiety 4
  • Patient Health Questionnaire-9 (PHQ-9) for depression 1
  • Generalized Anxiety Disorder-7 (GAD-7) for anxiety 1
• Assess quality of life impact using ENS-specific measures:
  • Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) 5
  • Sino-Nasal Outcome Test (SNOT) 5
• Evaluate for comorbid psychiatric conditions including somatic symptom disorder and obsessive-compulsive disorder 3

Treatment Algorithm

1. Integrated Surgical and Psychiatric Management

• Surgical intervention (primarily meatus augmentation implants) should be considered as first-line treatment for appropriate ENS patients 5
• Surgical treatment significantly improves both depression and anxiety symptoms:
  • BDI-II scores improve from moderate severity to normal range (p<0.001) 4
  • BAI scores improve from moderate severity to normal range (p<0.001) 4
• Patients with worse preoperative psychiatric scores and female patients may show greater improvement following surgical intervention 4

2. Psychiatric Medication Management

• For patients with moderate to severe depression or anxiety, consider:
  • Selective Serotonin Reuptake Inhibitors (SSRIs) as first-line pharmacotherapy for concurrent mood disorders 6
  • Low-dose tricyclic antidepressants (TCAs) for patients with predominant pain symptoms 6
• Follow a "start low, go slow" approach to medication dosing, similar to recommendations for other complex conditions with multiple comorbidities 6

3. Non-Pharmacological Interventions

• Brain-gut behavior therapies (BGBTs) can be adapted for ENS patients, including:
  • Cognitive Behavioral Therapy (CBT) to address catastrophizing and symptom-specific anxiety 6
  • Mindfulness-based stress reduction to improve symptom tolerance 6
  • Gut-directed hypnotherapy techniques modified for nasal symptoms 6
• Consider referral to mental health specialists when patients present with:
  • Moderate to severe symptoms of depression or anxiety
  • Suicidal ideation or hopelessness
  • Low social support systems
  • Impaired quality of life or avoidance behavior 6

Special Considerations

• The relationship between ENS symptoms and psychiatric symptoms appears bidirectional - ENS6Q symptom severity correlates with more severe depression (p<0.001), anxiety (p<0.001), and impairment in activities of daily living (p=0.003) 2
• A multimodal approach addressing both the physical tissue loss with surgery and the psychological burden with therapy may provide the most optimal outcome 2
• Patients may benefit from extended assessment visits to build therapeutic rapport and determine the full context of symptoms, especially if there is a history of trauma 6
• Monitor for potential substance use disorders, which may complicate treatment 6

Pitfalls to Avoid

• Don't attribute all symptoms to psychiatric causes - ENS is a physical condition with real physiological effects that can trigger psychological distress 2
• Avoid endless searches for physical causes when psychiatric illness is evident and treatable 6
• Don't overlook the impact of ENS on sleep - patients often experience significant daytime somnolence that can exacerbate psychiatric symptoms 2
• Be cautious about using medications that may worsen nasal dryness, a common complaint in ENS 6
• Don't delay psychiatric intervention while waiting for surgical treatment, as the conditions can be managed concurrently 5