Empty nose syndrome
|Empty nose syndrome|
|Altered nasal anatomy after bilateral subtotal inferior turbinectomy|
Empty nose syndrome (ENS), one form of secondary atrophic rhinitis, is a rare clinical syndrome in which people who have clear nasal passages experience a range of symptoms, most commonly feelings of nasal obstruction, nasal dryness and crusting, and a sensation of being unable to breathe. People who experience ENS have usually undergone a turbinectomy (removal or reduction of turbinates, structures inside the nose) or other surgical procedures that interfere with turbinates; the overall incidence is unknown but it appears to occur in a small percentage of those who undergo nasosinal procedures. It appears to be a health care caused condition but its existence as a medical condition, cause, diagnosis and management are controversial. All aspects have been subject to debate, including whether it should be considered solely rhinologic, or may have neurological or psychosomatic aspects. As of 2015 many ear, nose, and throat doctors do not recognize the condition.
Four types have been proposed:
- ENS secondary to inferior turbinate resection
- ENS secondary to middle turbinate resection
- ENS secondary to both inferior and middle turbinate
- ENS after turbinate-sparing procedures
Signs and symptoms
There are no objective physical examination findings that definitely diagnose ENS. Generally, one or more turbinates may be reduced or absent when viewed in medical imaging or via endoscope with no sign of physical obstruction, the mucosa will be dry and pale, and there may be signs of secondary infection.
Symptoms of ENS include a sensation of being unable to breathe, a feeling of nasal obstruction and dryness, and crusting, oozing, and foul smells inside the nose from infections. A person with ENS may complain of pain in their nose or face, an inability to sleep and fatigue, and feeling irritated, depressed, or anxious; they may be constantly distracted by the sense that they are not getting enough air.
The cause may be changes to the nasal mucous membrane and to the nerve endings in the mucosa resulting from chronic changes to the temperature and humidity of the air flowing inside the nose, caused in turn by removal or reduction of the turbinates. Direct damage to the nerves may be a result of surgical intervention; however, as of 2015, there is no technology that allows the mapping of the sensory nerves within the nose, so it is difficult to determine whether this is causative of ENS. Because the occurrence of ENS is rare and investigators have been unable to identify consistent diagnostic or precipitating features, psychological causes leading to a psychosomatic condition have been proposed.
No consensus criteria exist for the diagnosis of ENS; it is typically diagnosed by ruling out other conditions, with ENS remaining the likely diagnosis if the signs and symptoms are present. A "cotton test" has been proposed, in which moist cotton is held where a turbinate should be, to see if it provides relief; while this has not been validated nor is it widely accepted, it may be useful to identify which people may benefit from surgery.
As of 2015, protocols for using rhinomanometry to diagnose ENS and measure response to surgery were under development, as was a standardized clinical instrument (a well defined and validated questionnaire) to obtain more useful reporting of symptoms.
A validated ENS-specific, 6-item questionnaire called the Empty Nose Syndrome 6-item Questionnaire (ENS6Q) was developed as an adjunct to the standard Sino-Nasal Outcome Test 22 (SNOT-22). The ENS6Q is the first validated, specific, adjunct questionnaire to the SNOT-22. It can more reliably identify patients suspected of ENS. The ENS6Q is gaining usage in studies on ENS.
Initial treatment is similar to atrophic rhinitis, namely keeping the nasal mucosa moist with saline or oil-based lubricants and treating pain and infection as they arise; adding menthol to lubricants may be helpful in ENS, as may be use of a cool mist humidifer at home. For people with anxiety, depression, or who are obsessed with the feeling that they can't breathe, psychiatric or psychological care may be helpful.
In some people, surgery to restore missing or reduced turbinates may be beneficial.
A 2015 meta-analysis identified 128 people treated with surgery from eight studies that were useful to pool, with an age range of 18 to 64, most of whom had been suffering ENS symptoms for many years. The most common surgical approach was creating a pocket under the mucosa and implanting material - the amount and location were based on the judgement of the surgeon. In about half the cases a filler such as noncellular dermis, a medical-grade porous high-density polyethylene, or silastic was used and in about 40% cartilage taken from the person or from a cow was used. In a few cases hyaluronic acid was injected and in a few others tricalcium phosphate was used. There were no complications caused by the surgery, although one person was over-corrected and developed chronic rhinosinusitis and two people were under-corrected. The hyaluronic acid was completely resorbed in the three people who received it at the one year follow up, and in six people some of the implant came out, but this did not affect the result as enough remained. About 21% of the people had no or marginal improvement but the rest reported significant relief of their symptoms. Since none of the studies used placebo or blinding there may be a strong placebo effect or bias in reporting.
Epidemiology and outcomes
Empty nose syndrome has been observed to affect a small proportion of people who have undergone surgery to the nose or sinuses, particularly those who have undergone turbinectomy (a procedure that removes some of the bones in the nasal passage). The incidence of ENS is variable and has not yet been quantified, but it is considered rare.
Untreated, the condition can cause significant and longterm physical and emotional distress in some people; some of the initial presentations on the condition described people who committed suicide. It is difficult to determine what treatments are safe and effective, and to what extent, in part because the diagnosis itself is unclear.
As early as 1914, Dr Albert Mason reported cases of "a condition resembling atrophic rhinitis" with "a dryness of the nose and throat" following turbinectomy. Mason called the turbinates "the most important organ in the nose" and claimed they were "slaughtered and removed with discriminate abandon more than any other part of the body, with the possible exception of the prepuce."
The term "Empty Nose Syndrome" was first used by Eugene Kern and Monika Stenkvist of the Mayo Clinic in 1994. Kerm and Eric Moore published a case study of 242 people with secondary atrophic rhinitis in 2001 and were the first to attribute the cause to prior sinonasal surgery in the scientific literature. Whether the condition existed or not and whether surgery was a cause, was hotly debated at Nose 2000, a meeting of the International Rhinologic Society that occurs every four years, and continued to be debated thereafter at scientific meetings and in the literature; as an example of how heated the debate became, in a 2002 textbook on nasal reconstruction techniques, two surgeons from University of Utrecht called turbinectomies a "nasal crime".
Society and culture
In October 2013, the chief physician of the otolaryngology department of a hospital in Wenling, China, was killed by a person who had been suffering from ENS symptoms for a year after having undergone a septoplasty; the person had been seen many times and nothing had been found wrong. The year before, several rhinology staff at a hospital in Shenzhen were stabbed by a patient there. As of 2016, according to Spencer Payne, a doctor who studies ENS, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological; according to Subinoy Das, another doctor who studies ENS, recognition among rhinologists was growing.
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