Morphology, Not Only Volume: A Study on Empty Nose Syndrome and Inferior Turbinates

OBJECTIVES

Empty nose syndrome (ENS) is an underdiagnosed but burdensome clinical condition. Studies that have addressed the impact of remnant inferior turbinate volume (ITV) on ENS are scarce. We aimed to evaluate the impact of ITV and phenotyping on the severity and presentation of ENS.

METHODS

All the enrolled patients underwent the following subjective assessments: the ENS 6-Item Questionnaire (ENS6Q), Sino-Nasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI). The ITV was obtained from finely cut (1-mm-thick slices) sino-nasal computed tomography scan images and analyzed using ImageJ. The correlation between ITV, subjective measurements, and morphology of inferior turbinates was evaluated. ENS was categorized as torpedo type (balanced tissue volume) or pistol type (posterior dominance) based on the morphology.

RESULTS

Overall, 54 patients met the inclusion criteria. The ITV was positively correlated with the ENS6Q score and domain of ENS symptoms in SNOT-25. Neither BDI-II nor BAI scores had a significant correlation with ITV. Based on their morphological classification, the torpedo type exhibited diverse manifestations in the SNOT-25 analysis in response to changes in ITV, while the pistol type demonstrated an elevated rhinologic symptom burden and ENS-specific symptoms as their ITV increased. Nasal resistance did not correlate with the ITV in either type of ENS.

CONCLUSIONS

Symptoms were paradoxically worse in ENS patients with greater remnant ITV, and distinct morphological phenotypes in the nasal cavities may result in different presentations. Further investigation into the correlation between remnant inferior turbinates and nerve function is warranted.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3060-3066, 2024.

Computed Tomographic Evaluations in Patients with Empty Nose Syndrome

OBJECTIVE

We aimed to evaluate computed tomography (CT) images of patients with empty nose syndrome (ENS), investigate the impact of reconstruction surgery on sinus inflammation, and identify the optimal airspace diameter after surgery.

METHODS

We conducted a retrospective case series analysis, identifying and enrolling patients with ENS with perioperative CT findings. The clinical characteristics of the participants were collected, and the modified Lund-Mackay (mLM) CT scores were determined. The anterior airspace diameter was evaluated by measuring the distance between the septum and the lateral nasal wall on the coronal plane at the level of the nasolacrimal duct.

RESULTS

Twenty patients with ENS and perioperative CT images were enrolled. The mean total mLM CT score and all subsite scores showed no significant changes after surgery. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) score, Sino-nasal Outcome Test-25 (SNOT-25) score, sleep symptoms domain, psychological domain, and empty nose symptoms domain were significantly associated with anterior airspace diameter in the regression analysis.

CONCLUSION

There was no significant difference in sinus inflammation between preoperative and postoperative CT evaluations. The anterior airspace diameters were significantly associated with ENS6Q and SNOT-25 scores.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2105-2110, 2024.

Functional Exercise Capacity and Perceived Exertion in Patients with Empty Nose Syndrome

Empty nose syndrome (ENS) is a complex condition characterized by symptoms such as dyspnea, nasal discomfort, and emotional challenges. This study aimed to evaluate functional exercise capacity and perceived exertion in patients with ENS. Patients with ENS who presented with a range of severe symptoms were prospectively enrolled. Pulmonary function was evaluated using spirometry, and functional exercise capacity was measured via the 6 min walk test (6-MWT). Perceived exertion was quantified using the Borg scale, and cardiopulmonary function was evaluated by monitoring peripheral oxygen saturation (SpO2). These parameters were assessed before and after nasal reconstruction surgery. A total of 44 patients with ENS were enrolled and classified into mild-to-moderate (n = 20) and severe (n = 24) symptom groups. Spirometry results showed no significant differences before and after surgery in the entire cohort. Perceived exertion showed significant postoperative improvement (p = 0.006). The severe ENS symptom group experienced significant improvement in SpO2 (p = 0.013) and perceived exertion (p = 0.002) at the end of the 6-MWT after surgery. Surgical intervention significantly enhanced functional exercise capacity (p = 0.038) in patients with mild-to-moderate ENS symptoms. Surgical reconstruction positively affected perceived exertion and SpO2 at the end of the 6-MWT in patients with ENS. The severity of ENS symptoms, as assessed by SNOT-25 scores, influenced these outcomes. These findings underscore the potential benefits of surgical intervention for enhancing exercise tolerance and respiratory efficiency.

Comprehensive Assessment of the Functional Outcomes of Partial Turbinectomy: A Prospective Clinical Trial

OBJECTIVES

The inferior and middle turbinates have crucial roles in nasal function, but their enlargement can cause obstructive effects, which can lead to breathing difficulties, sleep and smell disorders, and headaches. Partial turbinectomy is a common surgical technique used to address this issue during septorhinoplasty, but it carries risks such as empty nose syndrome. A clinical trial was designed to evaluate the functional outcomes of middle and inferior partial turbinectomy with a holistic approach.

METHODS

Patients with NOSE questionnaire scores of 30 or higher, and grade 4 inferior turbinates and/or advanced middle concha bullosa were included. Patients completed questionnaires related to breathing, empty nose syndrome, headache, and olfaction preoperatively and at one-month, three-month, six-month, and first-year periods postoperatively. The partial excisions of the inferior and middle turbinates were carried out with serrated scissors while trying to preserve adequate turbinate size to maintain function.

RESULTS

This study found that NOSE scores, headache frequency, and severity improved postoperatively. The olfactory-related quality of life of the patients with impairments in this area significantly improved found to be improved at all postoperative evaluations. None of the patients experienced prolonged bleeding requiring surgical intervention. No cases of anosmia and empty nose syndrome were reported.

CONCLUSION

Partial turbinectomy of middle and inferior turbinates during septorhinoplasty can alleviate symptoms of turbinate hypertrophy, such as breathing issues, olfactory disorders, and headaches. It is an easy, reliable, and efficient surgical maneuver. Proper technique can minimize the risk of empty nose syndrome and other complications of turbinectomy surgery.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A 3-year follow-up study after nasal reconstruction surgery in patients with empty nose syndrome

KEY POINTS

Empty nose syndrome (ENS) is characterized by a patent nasal airway and a sense of nasal obstruction. ENS and psychological symptoms improved after surgery and remained stable for up to three years. Identifying residual disease is necessary for enhancing therapeutic outcomes in ENS patients.

The Serpentine Sign: A Reliable Endoscopic and Radiographic Finding in Empty Nose Syndrome

OBJECTIVE

Empty nose syndrome (ENS) is a relatively uncommon disease that greatly impacts the quality of life and presents diagnostic challenges. We sought to identify objective clinical findings unique to patients with ENS, and in doing so identified compensatory mucosal hypertrophy in an alternating, undulating swelling on endoscopy and coronal computerized tomography (CT) that we have termed the "Serpentine Sign." Here, we investigated whether this radiographic finding is a reliable manifestation in ENS patients.

METHODS

Retrospective review was undertaken to identify ENS patients with past turbinoplasty, an ENS6Q score of at least 11/30, and symptomatic improvement with the cotton placement test. Control patients without complaints of ENS symptoms (ENS6Q < 11) were identified for comparison. ENS and control patients had coronal CT imaging available to evaluate for the Serpentine Sign, as well as ENS6Q scores, and histologic analysis of nasal tissue.

RESULTS

34 ENS and 74 control patients were evaluated for the presence of the Serpentine Sign. Of the 34 patients with ENS, 18 exhibited this radiographic finding on CT imaging (52.9%) compared to 0 of the 74 control patients (p < 0.0001). Further analysis demonstrated that ENS patients with the Serpentine Sign had lower median scores on ENS6Q than ENS patients without (17.5 vs. 22, p = 0.033). Histology revealed disorganized subepithelium rich in seromucinous glands similar to the nasal septum swell body.

CONCLUSION

The "Serpentine Sign" is a unique presentation of hypertrophic change to the nasal septum soft tissue that is specific to ENS patients and may serve as a reliable radiographic and endoscopic finding in diagnosis.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1089-1095, 2024.

Using platelet-rich fibrin scaffolds with diced cartilage graft in the treatment of empty nose syndrome

Empty nose syndrome (ENS) is a rare entity in patients who undergo sinonasal surgery due to over-resection of the turbinate. This syndrome leads to debilitating symptoms that include dry nose, painful nasal breathing, paradoxical nasal obstruction, crusting, and sleep disorder. The goal of surgical treatment is to reestablish the volume of the turbinates to rehabilitate the nasal resistance. Endonasal microplasty with cartilage implants on the lateral wall of the nasal cavity is useful for creating the neoturbinate. Here, we present 2 cases that describe the management of empty nose syndrome by endonasal microplasty using platelet-rich fibrin (PRF) scaffolds embedded with a diced cartilage graft. The integration of the PRF scaffolds with diced cartilage efficiently facilitated the reestablishment of the neoturbinate. This autologous biomaterial is suitable for the treatment of ENS.

Evaluation of sinonasal-related quality of life of 49 patients undergoing endoscopic skull base surgery

OBJECTIVE

This study aimed to evaluate the sinonasal-related Quality of Life (QoL) in patients undergoing endoscopic skull base surgery.

METHODS

A retrospective study was performed, including patients with benign and malignant tumors at a single institution. Each patient completed the 22-Item Sino-Nasal Outcome Test (SNOT-22) and the Empty Nose Syndrome 6 Item Questionnaires (ENS6Q) to assess their perceived QoL at least 2-months after treatment.

RESULTS

Forty-nine patients were enrolled in this study. The average score was 25.1 (Stander Deviation [SD] 14.99) for SNOT-22 and 6.51 (SD=5.58) for ENS6Q. Analysis of the overall results for the SNOT-22 showed that olfactory damage was the most serious syndrome. The most frequently reported high-severity sub-domains in SNOT-22 were nasal symptoms and sleep symptoms. Nasal crusting was the most severe item in ENS6Q according to the report. Nine patients (18.4%) had a score higher than 10.5 which indicates the high risk of Empty Nose Syndrome (ENS). SNOT-22 score was related to the history of radiotherapy (p< 0.05), while the ENS6Q score was not.

CONCLUSIONS

The possibility of patients suffering from ENS after nasal endoscopic skull base surgery is at a low level, although the nasal cavity structure is damaged to varying degrees. Meanwhile, patients undergoing endoscopic skull base surgery were likely to suffer nasal problems and sleep disorders. Patients who had received radiotherapy have a worse QoL than those without a history of radiotherapy.

LEVEL OF EVIDENCE

Level 3.

Autologous fat injection for empty-nose syndrome

AIMS

Inferior meatus augmentation by injection or implants is one of the treatments for empty-nose syndrome (ENS), but levels of evidence of efficacy are low. We present the technique and evaluate our experience. The primary objective was to analyze changes in Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores after treating patients with ENS by autologous fat injection. Secondary objectives were the analysis of the evolution of each of the six ENS6Q items and identification of complications. Eleven patients underwent a minimally invasive approach to limit nasal airflow using fat injection between March 2021 and December 2022.

RESULTS

Ten of the 11 patients showed a decrease in overall ENS6Q score (P=0.0058); 6 had a final ENS6Q score<11. Ten were satisfied with the procedure, but remained symptomatic. The procedure did not result in any complications.

CONCLUSION

These encouraging results confirm the data in the literature suggesting that fat injection improves symptomatology in empty nose syndrome. However, like other minimally invasive approaches to limit nasal airflow, it does not eliminate all symptoms. These results need to be confirmed by studies on larger cohorts with longer follow-up, preferably in a multicenter setting.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Identifying Residual Psychological Symptoms after Nasal Reconstruction Surgery in Patients with Empty Nose Syndrome

Background: Empty nose syndrome (ENS) is a syndrome of paradoxical nasal obstruction that is thought to be mostly caused by inappropriate turbinate procedures. This study aimed to investigate depression- and anxiety-associated psychological symptoms in patients with ENS before and after surgical reconstruction, and to compare them with those of control subjects. Methods: Patients with ENS were prospectively enrolled. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item questionnaire (ENS6Q), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate the participants before and after reconstruction surgery with submucosal Medpor implantation (Stryker, Kalamazoo, MI), as well as control subjects at enrollment. Results: Forty patients with ENS and forty age- and sex-matched controls were recruited. Patients with ENS experienced significant improvement in SNOT-25, ENS6Q, BDI-II, and BAI scores after surgery, but all were significantly greater than those in the control group. Nine patients with ENS (22.5%) had postoperative residual psychological symptoms. Preoperative BDI-II and BAI scores were significant predictors of postoperative residual psychological symptoms. The optimal cut-off value was BDI-II > 28.5 (sensitivity, 77.8%; specificity, 77.4%) in receiver operating characteristic curve analysis. Conclusions: The nasal and psychological evaluations in patients with ENS significantly improved after nasal reconstruction surgery, but both were significantly greater than those in the control group. Identifying individuals who may experience postoperative residual symptoms and providing a multimodal approach, including surgical reconstruction and psychiatric treatment, are suggested.

Sleep impairment in patients with empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) is characterized by paradoxical nasal obstruction that usually occurs after turbinate surgery. Patients with ENS may also experience significant psychiatric symptoms and sleep dysfunction, which negatively affect the quality of life of affected subjects. This study aimed to evaluate sleep impairment and sleepiness in patients with ENS.

METHODS

Patients with ENS and control participants were recruited prospectively. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Epworth Sleepiness Scale (EpSS), and modified sleep quality index (MSQI) were used to evaluate the participants before and after nasal surgery.

RESULTS

Forty-eight patients with ENS and forty-eight age- and sex-matched control subjects were enrolled. The SNOT-25, ENS6Q, EpSS, and MSQI scores in the ENS group were all significantly higher than those in the control group before and after surgery. After surgery, ENS patients all exhibited significant improvements in SNOT-25, ENS6Q, EpSS, and MSQI scores. Regression analysis revealed that SNOT-25 score was a significant predictor of EpSS and MSQI in preoperative evaluations. ENS patients experiencing daytime sleepiness suffered from significantly more "dryness of nose" and "suffocation" than those not experiencing daytime sleepiness.

CONCLUSIONS

Patients with ENS experienced significantly impaired sleep quality and sleepiness. Nasal reconstruction surgery improved the sleep quality of ENS patients. The severity of sleep dysfunction is associated with the severity of ENS symptoms. Recognizing individuals with significant sleep impairment and sleepiness and providing appropriate management are critical issues for ENS patients.

[Adaption of the "Empty Nose 6 Item Questionnaire" (ENS6Q) into German language]

OBJECTIVE

The English "Empty-Nose-6-Item-Questionnaire" (ENS6Q) is a validated tool to assess subjective and disease-specific complaints of patients suffering from empty nose syndrome. The aim of this study was to create a validated German adapted version (GAV) of the ENS6Q.

MATERIAL AND METHODS

The ENS6Q was translated into German language using a multistage process. Subsequently the translated questionnaire was completed twice by a group of patients suffering from empty nose syndrome (n = 36), a healthy control group (n = 77) and a group of patients with a symptomatic pathology of the nasal septum (n = 78). Additionally, the NOSE© questionnaire was completed twice by all groups. The ENS6Q was then examined regarding internal consistency, test-retest reliability, discriminant validity, sensitivity and specificity.

RESULTS

The ENS6Q-GAV shows high internal consistency with Cronbachs α = 0,760 and α = 0,795. It also shows good test-retest reliability with an interclass correlation coefficient of 0,947 [0,930 - 0,961]. The ENS6Q-GAV discriminated significantly between empty nose syndrome patients and the control group. The receiver-operating characteristics curve showed a sensitivity of 83,3 % and a specificity of 88,3 % using a cut-off point of 8,5. The area-under-the-curve threshold score was 0,914 ± 0,029 [0,856 - 0,971].

CONCLUSIONS

The ENS6Q-GAV is the first validated disease-specific questionnaire in German to help identify patients suspected of developing ENS more reliably.

Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis

BACKGROUND

Empty nose syndrome (ENS) is characterized by the paradoxical perception of nasal obstruction despite patent sinonasal anatomy after surgery. We investigated the relationship between ENS, and anxiety, depression, obsessive-compulsive disorder, and somatic symptom disorder (SSD) compared to individuals with chronic rhinitis (CR) and chronic rhinosinusitis (CRS).

METHODS

This cross-sectional survey study compared ENS and CR and CRS patients. A total of 116 patients participated: 58 ENS patients from digital support groups, and 58 CRS and CR patients from tertiary rhinology clinics. Study participants completed four validated surveys: (1) Empty Nose Syndrome 6-Item Questionnaire, (2) Rhinosinusitis Disability Index (RSDI), (3) Obsessive Compulsive Inventory - Revised (OCI-R), and (4) PRIME MD Patient Health Questionnaire (PHQ).

RESULTS

ENS patients exhibited a mean RSDI of 78.6, 95% confidence interval [CI] 72.8-84.5, compared to 25.2, 95% CI 18.6-31.8 for CRS/CR patients (p < 0.0001). This difference was seen across all subdomains. Using the PHQ, 53% of ENS patients met diagnostic thresholds for SSD compared to 14% of CRS patients (p < 0.0001). In relation to obsessive compulsive disorder (OCD), 18.37% of ENS patients compared to 8.62% of CRS/CR patients scored above the diagnostic threshold (>21) on the OCI-R questionnaire (p = 0.159).

CONCLUSION

ENS patients had diminished sinonasal quality of life and a higher prevalence of comorbid anxiety and depression, compared to CR and CRS. ENS patients were more likely to exceed thresholds for OCD and SSD compared to controls. Future studies are needed to assess the role of SSD in ENS to help optimize treatment for these complex patients.

Surgical Treatment for Empty Nose Syndrome Using Autologous Dermal Fat: Evaluation of Symptomatic Improvement

Background: Empty nose syndrome (ENS) is caused by nasal turbinate surgery. The standard treatment for ENS is an inferior meatus augmentation procedure (IMAP) in which autologous tissue such as auricular cartilage, rib cartilage, or artificial material is transplanted into the nasal cavity. However, some challenges like a very small auricular cartilage are associated with these autologous tissue types. Moreover, since using rib cartilage is a highly invasive technique, the scar on the chest from where the harvesting is done is easily visible, and the artificial material is susceptible to infection. We used autologous dermal fat (ADF) in IMAPs in our study for the following reasons: the quantity of ADF could be increased or reduced as needed, ADF is considered a safer option than rib cartilage because it is harvested from superficial tissue, it is superior in terms of cosmetic appearance to harvested rib cartilage, and it has a lower risk of infection than any artificial material.Objective: The purpose of our study was to investigate the efficacy and safety of IMAPs using ADF.Methods: We included nine patients with ENS who underwent an IMAP using ADF. The patients' backgrounds and responses to the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) were recorded. Changes in each item of the ENS6Q before and after surgery (up to 3 months) were analyzed.Results: The postoperative ENS6Q total score and parameters were significantly better than their preoperative counterparts. Nasal dryness improved slightly less than other symptoms. There were no complications.Conclusions: The IMAP using ADF was effective in improving ENS symptoms; however, some physiological functions were difficult to improve, and dryness persisted. Autologous dermal fat is larger than auricular cartilage, less invasive than rib cartilage, and has a lower risk of infection than artificial material.

Identifying Obstructive Sleep Apnoea in Patients with Empty Nose Syndrome

Obstructive sleep apnoea (OSA) is characterised by repetitive episodes of upper airway collapse and breathing cessation during sleep. Empty nose syndrome (ENS) is a surgically iatrogenic phenomenon of paradoxical nasal obstruction despite an objectively patent nasal airway. This study aimed to investigate sleep quality and the presence of OSA in ENS patients. Forty-eight ENS patients underwent full-night polysomnography. Total nasal resistance (TNR) was determined using anterior rhinomanometry. Symptoms and quality of life were evaluated by the empty nose syndrome 6-item questionnaire (ENS6Q), Sino-Nasal Outcome Test-22 (SNOT-22), and Epworth Sleepiness Scale questionnaires (ESS). Fourteen, twelve, and fourteen patients had mild, moderate, and severe OSA, respectively. The apnoea–hypopnoea index (AHI) and the lowest SpO₂ were 23.8 ± 22.4/h and 85.9 ± 11.1%, respectively. N1, N2, N3 and rapid-eye-movement sleep comprised 30.2 ± 16.9%, 47.3 ± 15.5%, 2.1 ± 5.4%, and 20.0 ± 8.1% of the total sleep time. Body mass index, neck circumference, serum total immunoglobulin E, and ENS6Q score were significantly associated with AHI in the regression analysis. The ENS6Q scores correlated positively with AHI, arousal index, and ESS score, but negatively with TNR. ENS patients showed a high OSA prevalence and significant sleep impairment. The extent of OSA was associated with obesity levels and ENS symptom severity. The ENS6Q scores correlated negatively with nasal resistance, and positively with arousal frequency and daytime sleepiness. The recognition of individuals experiencing marked OSA and provision of appropriate intervention is critical to preventing long-term morbidity and mortality, and improving therapeutic outcomes in ENS patients.

Suicidal thoughts in patients with empty nose syndrome

OBJECTIVES

Patients with empty nose syndrome (ENS) suffer from paradoxical nasal obstruction with a patent objective nasal airway. ENS may result from the excessive surgical reduction of the turbinate tissue. ENS patients also experience significant psychological symptoms such as anxiety and depression. In this study, we aimed to evaluate the prevalence of suicidal thoughts in ENS patients and to characterize these patients for early identification.

STUDY DESIGN

Prospective case series.

METHODS

Patients with ENS were prospectively recruited for this study. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II) were used to assess ENS patients before and 6 months after nasal reconstruction surgery.

RESULTS

Sixty-two patients with ENS were enrolled. Suicidal thoughts were identified in 23 ENS patients preoperatively and in four patients postoperatively. ENS patients with suicidal thoughts rated significantly higher in the SNOT-25, ENS6Q, BDI-II, and BAI total scores than those without suicidal thoughts (all P < .05). "Nose feels too open" was the item in ENS6Q that was significantly more severe in ENS patients with suicidal thoughts than those without suicidal thoughts (P < .001).

CONCLUSIONS

Suicidal thoughts are frequently identified in patients with ENS. ENS patients with suicidal thoughts experienced significantly more severe symptoms, impaired quality of life, and psychological burden than those without suicidal thoughts. Recognizing individuals who may carry suicidal thoughts and provide appropriate psychological interventions is critical to prevent tragedy.

LEVEL OF EVIDENCE

4.

Serum High-Sensitivity C-Reactive Protein Is Associated with Postoperative Psychiatric Status in Patients with Empty Nose Syndrome

Many patients diagnosed with empty nose syndrome (ENS) later develop mental illness. The literature addressing biomarkers associated with postoperative psychiatric status is limited. This study aimed to assess the association between high-sensitivity C-reactive protein (hs-CRP) and psychiatric status after surgery in ENS. We recruited patients with ENS undergoing endonasal submucosal implantation. Their pre- and postoperative psychiatric status was evaluated using the Beck depression inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). Serum hs-CRP was analyzed one day before and one year after surgery. Of the 43 patients enrolled, all subjective measurements had improved (symptom scores decreased) significantly by the third month postoperatively and remained plateaued till 12 months. Those with preoperative hs-CRP levels > 2.02 mg/L were likely to remain depressive 1 year postoperatively. The regression model showed that a preoperative hs-CRP level > 2.02 mg/L was significantly correlated with postoperative depression in patients with ENS (odds ratio, 19.9). Hs-CRP level seems to be a feasible predictor of surgical outcome regarding improved depression in patients with ENS. Patients with higher preoperative hs-CRP levels should be monitored closely after surgery.

Demographic Variation in Chronic Rhinosinusitis by Subtype and Region: A Systematic Review

BACKGROUND

Chronic rhinosinusitis (CRS) describes a heterogenous group of diseases including CRS with (CRSwNP) or without nasal polyps (CRSsNP), aspirin-exacerbated respiratory disease (AERD), and allergic fungal rhinosinusitis (AFRS). It affects 10 to 15% of the US population and is more common in women and White patients. However, these estimates are based on survey and database studies with innate diagnostic inaccuracy. Additionally, few studies report subtype-specific demographics. We explore the demographic differences of CRS in the U.S. by subtype and region.

OBJECTIVE

To characterize demographic differences between the CRS population and the overall US population, and also between different CRS subtype populations.

METHODS

We performed a systematic review for articles reporting on US demographics of adults with CRS. Study participants were required to have been diagnosed using consensus criteria. Data on demographics, geographic region, and CRS subtype were analyzed.

RESULTS

Our study analyzed 31 unique studies representing 8409 patients with 50.7% females and weighted mean age of 48.0 years. Compared to the overall US population, CRS patients were predominantly White (78.5%) and non-Hispanic (94.5%) with under-representation of other races. Grouped by subtype, CRSwNP affected a significantly higher proportion of men (59.8%). AFRS affected a significantly higher proportion of Black patients (53.8%) while CRSsNP was more prevalent in White patients (84.2%). When grouped by region, the South had a significantly higher proportion of female (53%) and Black (17.8%) CRS patients. The West had a significantly higher proportion of Asian (4.5%) and Hispanic (12.3%) patients.

CONCLUSIONS

Significant demographic differences exist in CRS patients based on subtype and region. These data provide an estimation of the demographic make-up of CRS, but further high-level demographic studies are needed.

Long-Term Outcomes of Inferior Meatus Augmentation Procedure to Treat Empty Nose Syndrome

OBJECTIVES/HYPOTHESIS

We sought to report the long-term, symptom-focused, prospective outcomes in empty nose syndrome (ENS) patients after undergoing inferior meatus augmentation procedure (IMAP) through use of four validated questionnaires: Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-Item Scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9).

STUDY DESIGN

Prospective case series.

METHODS

A single-center prospective case series was performed for patients diagnosed with ENS who underwent IMAP between July 2017 and February 2020. Diagnosis of ENS was based on the following criteria: 1) reported discomfort with nasal breathing and/or paradoxical nasal obstruction after inferior turbinate reduction, 2) a positive ENS6Q score of at least 11, and 3) a positive cotton test. Questionnaire responses were recorded prior to surgery as well as 1, 3, 6, and 12 months postoperatively.

RESULTS

Seventeen eligible patients were included. Mean ENS6Q scores were significantly reduced at all postoperative time points (p < .0001, p < .0001, p < .0001, p = .0003). Of the six ENS6Q subdomains, five (suffocation, dryness, sense of diminished airflow, nasal crusting, and nasal burning) were significantly reduced 1-year postoperatively (p < .0001, p = .0004, p = .0136, p = .0114, p = .0080, respectively). SNOT-22 scores were significantly reduced at all time points (p = .0021, p = .0227, p = .0004, and p = .0025). Of the SNOT-22 subdomains, the sleep subdomain was significantly reduced 1-year postoperatively (p = .0432). Low baseline GAD-7 and PHQ-9 scores were recorded at 7 and 9.4, respectively, and although scores at all postoperative time points were reduced, there was no statistical significance.

CONCLUSION

IMAP via implant of cadaveric rib cartilage provides significant, long-term improvements in ENS-specific and general sinonasal symptoms.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2736-E2741, 2021.

Empty Nose Syndrome Pathophysiology: A Systematic Review

OBJECTIVE

The pathophysiology of empty nose syndrome (ENS) remains unclear despite significant research. The pathophysiologic mechanism of ENS was systematically reviewed.

DATA SOURCES

MEDLINE and Embase.

REVIEW METHODS

Data were systematically reviewed for studies that provided original data on pathophysiology.

RESULTS

A total of 2476 studies were screened, and 19 met the inclusion criteria: 13 case-control and 6 cross-sectional. Nine pathophysiologic themes were identified.• Demographics: ENS symptoms had no relationship with climatic factors.• Symptomatology: ENS patients demonstrated high symptom severity.• Mental health: Anxiety and depression including hyperventilation were reported in >50% of ENS patients and correlated with ENS symptom severity.• Anatomic features: Structural changes in response to turbinate surgery were similar between ENS and non-ENS patients.• Airflow analysis: Airflow parameters were similar between ENS and non-ENS patients after turbinate surgery. On computational fluid dynamic analysis, differences were found on multiple outcomes.• Diagnostic testing: The menthol detection test was impaired in ENS, and cotton placement in the airway improved ENS symptoms.• Cognitive function: Functional magnetic resonance imaging showed activation in emotional processing area during breathing.• Olfactory function: Subjective impairment was reported in ENS, but quantitative measures were similar to non-ENS patients.• Mucosal physiology/innate immunity: Turbinate histopathology in ENS showed a tissue-remodeling pattern. Nasal nitric oxide level was lower in ENS patients.

CONCLUSION

There is evidence of high comorbid mental health disorders in ENS patients. An abnormal trigeminal-thermoreceptor response may be present in some patients. The influence of altered airflow and the evidence of surgery as the cause for ENS are unclear.

Outcomes of olfaction in patients with empty nose syndrome after submucosal implantation

BACKGROUND

Olfactory dysfunction, such as hyposmia, is a significant symptom of empty nose syndrome (ENS). The efficacy of surgical intervention in olfaction improvements for ENS has not been investigated extensively.

OBJECTIVE

The aim of this study was to evaluate changes in olfaction after surgical treatment for ENS.

METHODS

This prospective cohort study at a tertiary medical center enrolled patients with ENS indicated for surgical treatment between June 2015 and June 2019. The Sniffin' Sticks 12-items odor identification test (SS-12) and subjective olfaction rating were completed by patients before and after surgery to assess olfaction.

RESULTS

A total of 40 patients completed the survey both before and after surgical treatment. Prior to surgery, 25% of the patients had olfactory dysfunction detected by SS-12, whereas 80% of the patients reported a reduction in olfactory function by subjective rating. The degree of olfactory dysfunction by both assessments significantly improved following surgery. The age was a significant predictor of postoperative improvement.

CONCLUSION

Surgical treatment is helpful in improving olfaction in patients with ENS who commonly suffer from olfactory dysfunction. Younger patients may benefit more from surgical intervention in aspect of olfaction.

Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively

PURPOSE

Empty nose syndrome (ENS) is characterized by nasal dryness, crusting, and paradoxical nasal obstruction most commonly after inferior turbinate resection. ENS has also been reported to occur after middle turbinate resection (MTR), and concern for causing ENS is a possible reason surgeons preserve the MT during endoscopic sinus surgery (ESS). The objective was to determine whether MTR during ESS led to ENS.

MATERIALS AND METHODS

This was a prospective case series of 95 consecutive patients that underwent bilateral subtotal MTR during ESS with either Draf IIB or Draf III frontal sinusotomies, for chronic rhinosinusitis with or without nasal polyps, and frontal sinus inverted papillomas. Demographic data and postoperative Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores were obtained. Nasal crusting was also documented on last postoperative nasal endoscopy.

RESULTS

Pathologies included chronic rhinosinusitis with nasal polyps (69), without nasal polyps (12), and inverted papillomas (14). Fifty-six patients underwent subtotal MTRs during ESS with Draf IIB, and 39 with Draf III. Mean follow-up was 19.4 months (range 12-49). Mean postoperative ENS6Q score was 2.1. Only 2.1% had ENS6Q scores ≥ 11, and 6.3% had nasal crusting at last follow-up. None of the patients with ENS6Q scores ≥ 11 had nasal crusting at last follow-up. There were no significant differences in outcomes between ages, genders, surgery types, or pathologies.

CONCLUSIONS

Patients who underwent bilateral subtotal MTR during ESS were unlikely to develop ENS by at least 1 year postoperatively, based on patients rarely experiencing ENS6Q scores ≥ 11 or persistent nasal crusting.

Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling

BACKGROUND

Empty nose syndrome (ENS) is a controversial upper airway disorder most commonly associated with tissue loss from the inferior turbinates. The inferior meatus augmentation procedure (IMAP) has been shown to effectively reduce ENS symptoms in a durable manner, but the precise mechanisms that may govern this symptomatic improvement remain unknown.

METHODS

Five patients with ENS who underwent bilateral IMAP via submucosal costal cartilage implant were assessed. Pre-implant and 6 months post-implant computed tomography (CT) imaging for each ENS patient was analyzed in a blinded fashion using computational fluid dynamics (CFD) modeling to investigate intrapatient changes in airflow parameters.

RESULTS

Following surgery, ENS patients have significantly improved symptoms as indexed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) scoring (pre-implant: 14.00 ± 4.06 [mean ± standard deviation]; 95% confidence interval [CI], 10.44 to 17.56; post-implant: 4.8 ± 2.77; 95% CI, 2.37 to 7.23; Cohen's d = 2.64; p = 0.02). Using CFD, a significant shift in nasal airflow patterns was observed, where airflow deviates away from the middle meatus upon hitting the implant (pre-implant: 67.13% ± 11.14%; 95% CI, 60.22% to 74.04%; post-implant: 46.18% ± 12.81%; 95% CI, 38.23% to 54.12%; d = 1.74; p < 0.05) toward the inferior meatus (pre-implant: 30.55% ± 11.29%; 95% CI, 23.55% to 37.55%; post-implant: 42.59% ± 9.60%; 95% CI, 36.63 to 48.54%; d = 1.14; p < 0.05). No significant changes were found in nasal resistance (pre-implant: 0.102 ± 0.015; 95% CI, 0.092 to 0.112 Pa*s/mL; post-implant: 0.105 ± 0.041; 95% CI, 0.081 to 0.130 Pa*s/mL). In addition, the improvement of ENS6Q scoring significantly correlated with percent reduction in aberrant airflow through the middle meatus (R² = 0.60, p = 0.04).

CONCLUSION

This study supports our prior working hypothesis that disordered vectors of nasal airflow congregate in the middle meatus contribute to ENS symptoms, not nasal resistance. Moreover, these data illuminate a paradoxical, but consistent, restoration of nasal airflow to the inferior meatus following the replacement of turbinate tissue volume in the inferior meatus via IMAP surgery, potentially due to the Coandă effect.

The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate-sparing techniques: a prospective self-controlled study

BACKGROUND

Individuals affected by empty nose syndrome secondary to turbinate-sparing techniques (ENS-type) experience decreased productivity and lifestyle disruption owing to considerable nasal-associated discomfort. This study aimed to evaluate the effect of psychosomatic intervention on ENS-type.

METHODS

A prospective self-controlled study was conducted, and 28 patients suffering from ENS-type who met the diagnostic criteria for somatic symptom disorder (SSD) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) received cognitive and behavioral therapy (CBT) plus antidepressants. Nasal symptom burden was evaluated using the 25-item Sino-Nasal Outcome Test (SNOT-25). Somatic symptom burden, anxiety severity, and depression severity were assessed by the 25-item Patient Health Questionnaire (PHQ-15), the 9-item PHQ (PHQ-9), and the 7-item Generalized Anxiety Disorder (GAD-7) scale, respectively. Patient assessments were completed prior to treatment and 3 and 12 months after the intervention.

RESULTS

The total scores of the SNOT-25 declined posttreatment, showing a significant difference at the 3-month and 12-month follow-ups compared with the baseline scores (p < 0.001). The severity of the 5 most common subjective symptoms, including "nose is too open," "waking up at night," "lack of a good night's sleep," "difficulty falling asleep," and "reduced concentration," declined significantly at 3 and 12 months posttreatment compared to baseline levels. Statistically significant changes in the PHQ-15, PHQ-9, and GAD-7 scores were observed at 3 and 12 months posttreatment compared to baseline scores (p < 0.001).

CONCLUSION

This study showed that some patients with ENS-type meeting the diagnostic criteria for SSD might benefit from psychiatric treatment.

Impact of Psychologic Burden on Surgical Outcome in Empty Nose Syndrome

OBJECTIVES /HYPOTHESIS

Empty nose syndrome (ENS) is a complicated condition currently thought to be caused by excessive surgical resection of turbinate tissue. Patients with ENS experienced significant psychological symptoms, such as depression and anxiety. This study aimed to evaluate the impact of the psychological burden on the surgical outcome of ENS.

STUDY DESIGN

Prospective case series in a tertiary medical center.

METHODS

Patients with ENS were prospectively recruited between 2015 and 2018. Validated instruments including the Sinonasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate patients with ENS prior to and 3, 6, and 12 months after nasal reconstruction surgery with submucosal Medpor implantation.

RESULTS

A total of 54 ENS patients were enrolled during the study period. All three evaluations revealed significant improvement, and symptoms stabilized 3 months after surgery. Six months post-operatively, SNOT-25 scores were significantly associated with the pre-operative BDI-II and BAI scores (β = 0.64 and 0.87; P = .006 and <.001, respectively). Multivariate regression model revealed that only BAI scores were significantly associated with the six-month post-operative SNOT-25 scores (adjusted β = 0.49, P = .036). Moreover, Spearman's correlation found close relationships between the post-operative SNOT-25 and the post-operative BDI-II and BAI scores (r_s = 0.751 and 0.884, both P < .001).

CONCLUSIONS

Psychological evaluation can help predict surgical outcomes and identify patients with residual disease. These findings emphasize the importance of screening for psychological symptoms and structuring care by including psychological therapy in addition to surgery.

LEVEL OF EVIDENCE

4. Laryngoscope, 131:E694-E701, 2021.

Distinct Histopathology Characteristics in Empty Nose Syndrome

OBJECTIVES/HYPOTHESIS

Empty nose syndrome (ENS) is a controversial disorder and the change of histopathology has never been discussed. This study aimed to conduct a structured histological review to improve the diagnosis and understanding of ENS. Further immunohistochemical staining of transient receptor potential channel melastatin 8 (TRPM8) was performed.

STUDY DESIGN

A prospective case-control study in a tertiary medical center.

METHODS

Consecutive patients with ENS who were diagnosed and received surgical intervention after failure of conservative management were included. Patients with benign pituitary gland tumor receiving transsphenoidal excision were enrolled as control group. Biopsy of inferior turbinate was obtained during surgery for histological review and immunohistochemical staining.

RESULTS

Seventeen patients with ENS and six patients as a control group were established for structured histological review. Patients with ENS presented significantly more squamous metaplasia, a higher rate of submucosal fibrosis, and a lower submucosal gland number grading. Additionally, a unique histological change called goblet cell metaplasia was found in the ENS group. The respiratory epitheliums of ENS were mostly intact with preservation of ciliated cells and goblet cells. The ENS group had a significantly lower expression level of TRPM8.

CONCLUSIONS

The nasal mucosa of ENS experienced some airway remodeling and thermoreceptors downregulation, which contribute to clinical symptoms. The distinct histology of ENS included preserved respiratory epithelium and goblet cell metaplasia, accompanying with characteristics similar to atrophic rhinitis. Biopsy of the inferior turbinate may help diagnose ENS.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E14-E18, 2021.

Management of Postsurgical Empty Nose Syndrome

Empty nose syndrome (ENS) is a controversial condition associated with disruption of nasal airflow caused by excessive loss of turbinate tissue. ENS arises after total or near-total inferior turbinate resection. Patients present with intense fixation on the perception of nasal obstruction. Diagnostic tools to assess for empty nose syndrome include a validated patient questionnaire and the office cotton test. Treatment involves topical moisturization, behavioral/psychiatric assessment/treatment, and surgical reconstruction. Current data show promising long-term efficacy after surgical intervention. Postprocedural ENS is best prevented by minimizing inferior and middle turbinate tissue loss.

The cotton test redistributes nasal airflow in patients with empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) remains a controversial disease primarily associated with inferior turbinate tissue loss. Cotton placement into the inferior meatus often alleviates ENS symptoms within minutes, but the physiologic explanation for this phenomenon is unknown. Computational fluid dynamics (CFD) was employed to evaluate the mechanisms of altered nasal airflow conferred by cotton testing.

METHODS

Six ENS patients (12 sides) with pre-existing sinus computed tomography (CT) imaging were enrolled after marked symptomatic improvement (decrease in score on the Empty Nose Syndrome 6-Item Questionnaire [ENS6Q] of >7 points) with office-based cotton testing. The fashioned cotton plug was labeled in situ with iohexol contrast spray, and sinus CT was immediately obtained to detect cotton contouring in the inferior meatus. CT imaging from pre- and post-cotton placement was analyzed using comparative CFD techniques.

RESULTS

After cotton placement, significant symptomatic improvement and reduced ENS6Q scores (16.8 ± 4.1 to 3.1 ± 2.4; p < 0.001) were recorded. Using CFD, cotton placement produced an expected 21% increase in upper airway resistance (p < 0.05). However, a significant shift in the nasal airflow distribution was also detected, with a transition of airflow vectors away from a middle meatus jetstream (-41%; p < 0.002).

CONCLUSION

Objective CFD assessment confirmed that the cotton test not only increases nasal resistance, but also restores airflow distribution to the inferior meatus in symptomatic ENS patients. These results highlight the potential efficacy of cotton test in ENS patients and further bolster the utility of this tool in identifying appropriate candidates for the inferior meatus augmentation procedure.

Inferior Meatus Augmentation Procedure (IMAP) to Treat Empty Nose Syndrome: A Pilot Study

Our understanding of empty nose syndrome (ENS) continues to evolve. Prior studies evaluating airway augmentation to treat ENS did not use validated disease-specific questionnaires, making the true impact of these surgeries unclear. We present a case series of 10 patients with ENS (11 procedures) who underwent the inferior meatus augmentation procedure (IMAP) between September 2014 and May 2017. Subjective outcomes of IMAP included comparisons of preoperative and postoperative assessments (1 week, 1 month, 3 months, 6 months) using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder 7-item Scale (GAD-7), and Sino-Nasal Outcome Test-22 (SNOT-22). The decrement in ENS6Q scores observed maintained statistical significance at 6 months (P ≤ .001). Similar results were achieved with PHQ-9, GAD-7, and SNOT-22 (P ≤ .01, P ≤ .01, P ≤ .001, respectively). IMAP can dramatically improve the quality of life of ENS patients regarding both ENS-specific symptoms and psychological well-being.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies

PURPOSE OF REVIEW

To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS.

RECENT FINDINGS

Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials.

SUMMARY

The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.

Patient-Reported Outcome Measures and Provocative Testing in the Workup of Empty Nose Syndrome-Advances in Diagnosis: A Systematic Review

Background

The last 5 years have seen a surge of both clinical and scientific interest in empty nose syndrome (ENS). Although ENS is still considered a controversial diagnosis plagued by a lack of standardized diagnostic criteria, ENS is increasingly becoming recognized as a legitimate, physiologic disease entity. As such, it is important for clinicians to understand the most up-to-date diagnostic tools to assess ENS, confirm the diagnosis, and create a more standardized means to counsel these complex patients.

Objective

Contemporary literature review to discuss diagnostic modalities in the evaluation of ENS, in order to introduce evidence-based diagnostic criteria.

Methods

A systematic review was conducted in PubMed and Embase (2013–2019) using the search term “empty nose syndrome” to identify peer-reviewed articles on the topic of ENS. Articles advancing contemporary methods of ENS diagnosis and testing were included. A quality assessment was conducted using The Rational Clinical Examination Levels of Evidence.

Results

The novel development of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) offers the clinician a validated patient-reported outcome measure to supplement history and physical examination. The in-office cotton test, performed by placing an endoscopically directed cotton plug in the site of tissue loss, may help to identify patients who may benefit from turbinate augmentation. Tools such as the sinus computed tomography scan, computational fluid dynamics, and intranasal trigeminal nerve function testing currently have insufficient evidence to support routine use in the workup of ENS. Up to 66% of ENS patients present with comorbid anxiety or depression.

Conclusion

The ENS6Q and cotton test assist in creating a standardized approach to the evaluation of patients suspected of ENS. These instruments should be used as an adjunct, rather than the sole criteria, on which to ascertain the presumptive diagnosis. Patients suspected of ENS should be screened for comorbid psychological dysfunction.

Functional relevance of computational fluid dynamics in the field of nasal obstruction: A literature review

BACKGROUND

Nasal airway obstruction (nasal obstruction) is a common symptom affecting the quality of life of patients. It can be estimated by patient perception or physical measurements. Computational fluid dynamics (CFD) can be used to analyse nasal ventilation modalities. There is a lack of comparative studies investigating the correlations between CFD variables and patient perception or physical measurements.

OBJECTIVE OF THE REVIEW

Our goal was to define correlations between CFD variables and patient perception and physical measurements. We also aimed to identify the most reliable CFD variable (heat flux, WSS, total pressure, temperature…) characterising nasal breathing perception.

TYPE OF REVIEW

Systematic literature review using PRISMA guidelines.

SEARCH STRATEGY

The selected studies were obtained from the US National Library of Medicine (PubMed) online database, MEDLINE (Ovid), Google Scholar and the Cochrane Library using a combination of MeSH terms (nose, paranasal sinus, fluid dynamics, rhinology) and non-MeSH terms (CFD, nasal airway, nasal airflow, numerical, nasal symptoms). Studies that did not incorporate objective or subjective clinical assessment were excluded.

EVALUATION METHOD

We compared all results obtained by authors regarding CFD variables and assessment of nasal airway obstruction (clinical or physical).

RESULTS

To compare nasal obstruction with CFD variables, most authors use CFD-calculated nasal resistances, airflow, heat flux, wall shear stress, total pressure, velocities and streamlines. We found that heat flux appears to be the CFD variable most closely correlated with patient perception. Total pressure, wall shear stress and velocities are also useful and show good correlations. Correlations between CFD-calculated nasal resistances and patient perception are stronger after correction of the nasal cycle.

CONCLUSIONS

The growing number of CFD studies on the nose has led to a better understanding of nasal obstruction. The clinical interpretation of previously unknown data, such as WSS and heat flux, is opening up new horizons in the understanding of this symptom. Heat fluxes are among the best CFD values correlated with patient perception. More studies need to be performed including temperature and humidity exchanges.

Complications Are Rare From Middle Turbinate Resection: A Prospective Case Series

Background

When chronic rhinosinusitis with nasal polyps (CRSwNP) fails to respond to medical therapy, endoscopic sinus surgery (ESS) plays an integral role in management. Some studies have shown that middle turbinate resection (MTR) during ESS leads to decreased polyp recurrence and revision ESS rates. Other studies suggest MTR can lead to complications.

Objective

The purpose of this study was to assess the safety of MTR during ESS for CRSwNP by determining the incidences of intraoperative cerebrospinal fluid (CSF) leak, postoperative epistaxis requiring operative intervention, and postoperative complete frontal stenosis.

Methods

A multiinstitutional, prospective case series of 91 adult CRSwNP patients was conducted. Patients with medically refractory CRSwNP underwent primary or revision ESS plus MTR by 3 surgeons. Two of the surgeons performed partial MTRs, and one of the surgeons performed complete MTRs. Patients were evaluated for the following complications: intraoperative CSF leak during MTR, postoperative epistaxis requiring operative intervention, and postoperative complete frontal ostial stenosis. Secondary outcomes included changes from preoperative to postoperative 22-item Sinonasal Outcome Test (SNOT-22) scores and revision ESS rates.

Results

Unilateral or bilateral complete ESSs with MTRs were performed on 91 CRSwNP patients. In total, 173 MTRs were performed. Two surgeons performed 97 partial MTRs on 49 patients, and the third surgeon performed 76 complete MTRs on 42 patients. One CSF leak occurred during partial MTR (1/173, 0.57%). No patients suffered postoperative epistaxis requiring operative intervention, and no patients developed complete frontal stenosis. From preoperatively to postoperatively, mean SNOT-22 scores decreased from 53.7 to 13.1 ( P = .001). No revision ESS was needed during the follow-up period. Mean follow-up time was 7.5 ± 5.4 months.

Conclusions

Partial and complete MTR during ESS for CRSwNP in this cohort resulted in very low, acceptable intraoperative and short-term postoperative complication rates and no detriment to SNOT-22 scores.

Computational fluid dynamic analysis of aggressive turbinate reductions: is it a culprit of empty nose syndrome?

BACKGROUND

Empty nose syndrome (ENS) remains highly controversial, with aggressive inferior turbinate reduction (ITR) or mucociliary dysfunction frequently implicated. However, the appropriate degree of ITR is highly debatable.

METHODS

We applied individual computed tomography (CT)-based computational fluid dynamics (CFD) to 5 patients receiving relatively aggressive ITR but with no ENS symptoms, and compared them to 27 symptomatic ENS patients who all had histories of aggressive ITRs, and 42 healthy controls. Patients' surgical outcomes were confirmed with 22-item Sino-Nasal Outcome Test (SNOT-22) (ITR: 6.40 ± 4.56; ENS: 58.2 ± 15.9; healthy: 13.2 ± 14.9), Nasal Obstruction Symptom Evaluation (NOSE) scores (ITR: 4.00 ± 2.24; ENS: 69.4 ± 17.1; healthy: 11.9 ± 12.9), and Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) (≥11 for ENS).

RESULTS

Both aggressive ITR without ENS symptoms and symptomatic ENS patients had significantly lower nasal resistance (ITR: 0.059 ± 0.020 Pa·s/mL; ENS: 0.052 ± 0.015 Pa·s/mL; healthy: 0.070 ± 0.021 Pa·s/mL) and higher cross-sectional areas surrounding the inferior turbinate (ITR: 0.94 ± 0.21 cm² ; ENS: 1.19 ± 1.05 cm² ; healthy: 0.42 ± 0.22 cm² ) than healthy controls. The lack of significant differences among patient groups indicated similar degrees of surgeries between ITR with and without ENS symptom cohorts. However, symptomatic ENS patients have paradoxical significantly less airflow in the inferior meatus (ITR: 47.7% ± 23.6%; ENS: 25.8% ± 17.6%; healthy: 36.5 ± 15.9%; both p < 0.01), but higher airflow around the middle meatus (ITR: 49.7% ± 22.6%; ENS: 66.5% ± 18.3%; healthy: 49.9% ± 15.1%, p < 0.0001) than aggressive ITR without symptoms and controls. Aggressive ITR patients have increased inferior meatus airflow as expected (p < 0.05). This imbalanced airflow produced less inferior wall-shear-stress distribution among symptomatic ENS patients only (ITR: 42.45% ± 11.4%; ENS: 32.2% ± 12.6%; healthy: 49.7% ± 9.9%). ENS patients (n = 12) also had impaired nasal trigeminal function, as measured by menthol lateralization detection thresholds (ITR: 15.2 ± 1.2; ENS: 10.3 ± 3.9; healthy: 13.8 ± 3.09, both p < 0.0001). Surprisingly, aggressive ITR patients without ENS symptoms have better menthol lateralization detection thresholds (LDTs) than healthy controls.

CONCLUSION

Although turbinate tissue loss is linked with ENS, the degree of ITR that might distinguish postoperative patient satisfaction in their nasal breathing vs development of ENS symptoms is unclear. Our results suggest that a combination of distorted nasal aerodynamics and loss of mucosal sensory function may potentially lead to ENS symptomology.

Impact of endoscopic craniofacial resection on simulated nasal airflow and heat transport

BACKGROUND

Endoscopic craniofacial resections (CFR) are performed for extensive anterior skull base lesions. This surgery involves removal of multiple intranasal structures, potentially leading to empty nose syndrome (ENS). However, many patients remain asymptomatic postoperatively. Our objective was to analyze the impact of CFR on nasal physiology and airflow using computational fluid dynamics (CFD). This is the first CFD analysis of post-CFR patients.

METHODS

Three-dimensional sinonasal models were constructed from 3 postoperative images using Mimics^TM . Hybrid computational meshes were created. Steady inspiratory airflow and heat transport were simulated at patient-specific flow rates using shear stress transport k-omega turbulent flow modeling in Fluent^TM . Simulated average heat flux (HF) and surface area where HF exceeded 50 W/m² (SAHF50) were compared with laminar simulations in 9 radiographically normal adults.

RESULTS

Three adults underwent CFR without developing ENS. Average HF (W/m² ) were 132.70, 134.84, and 142.60 in the CFR group, ranging from 156.24 to 234.95 in the nonoperative cohort. SAHF50 (m² ) values were 0.0087, 0.0120, and 0.0110 in the CFR group, ranging from 0.0082 to 0.0114 in the radiographically normal cohort. SAHF50 was distributed throughout the CFR cavities, with increased HF at the roof and walls compared with the nonoperative cohort.

CONCLUSION

Average HF was low in the CFR group compared with the nonoperative group. However, absence of ENS in most CFR patients may be due to large stimulated mucosal surface area, commensurate with the nonoperative cohort. Diffuse distribution of stimulated area may result from turbulent mixing after CFR. To better understand heat transport post-CFR, a larger cohort is necessary.

Environmental Triggers Associated With Empty Nose Syndrome Symptoms: A Cross-Sectional Study

OBJECTIVES

Empty nose syndrome (ENS) is thought to have multiple etiologies, one of which is a postsurgical phenomenon resulting from excessive loss of nasal tissues, particularly the inferior turbinate. Given that the inferior turbinate is instrumental in maintaining nasal homeostasis in different environments, it is believed that ENS symptoms arise only in more arid regions of the world. The aim of this study was to recruit an international population of individuals with ENS to investigate the association of local climate factors on the incidence and severity of ENS-specific symptoms.

METHODS

A cross-sectional study was performed of individuals from an international ENS database. ENS status was determined on the basis of a positive ENS questionnaire score (Empty Nose Syndrome 6-Item Questionnaire) and sinus computed tomographic imaging with supporting medical documentation. Participants completed a survey encompassing demographic, geographic, and symptom indicators. Climate variables were collected from global climate databases. Participant location was classified according to the Köppen-Geiger climate system. Pearson correlation analysis was performed using α = 0.05 to determine significance.

RESULTS

Fifty-three individuals with ENS were included. Participants were distributed across 5 continents and 15 countries (representing 4 distinct Köppen-Geiger zones). Although local climate factors varied significantly within this cohort, no significant association was found between Empty Nose Syndrome 6-Item Questionnaire symptom severity and these climate factors. However, most study participants reported exacerbation of their ENS symptoms in response to dry air (94%), air conditioning (64%), changes in season and weather (60%), and transitioning between indoors and outdoors (40%). This suggests that everyday local environmental factors may influence the well-being of these patients more than global, climate-level shifts.

CONCLUSIONS

ENS symptom severity does not appear to be related to climate or geographic factors. These findings deviate from the traditional dogma that ENS is experienced only in arid regions (or precluded in humid regions) and highlight the importance of recognizing this condition independent of geographic location.

Use of intranasal submucosal fillers as a transient implant to alter upper airway aerodynamics: implications for the assessment of empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) is a debilitating condition associated with inferior turbinate tissue loss. Surgical augmentation of the inferior meatus has been proposed to treat ENS, although efficacy data with validated, disease-specific questionnaires is limited. Instead we evaluated submucosal injection of a transient, resorbable filler into the inferior meatus to favorably alter nasal aerodynamics in ENS patients.

METHODS

Patients with a history of inferior turbinate reduction, diagnosed with ENS via Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) and cotton testing, were enrolled and underwent submucosal injection of carboxymethylcellulose/glycerin gel (Prolaryn®) into the inferior meatuses between July 2014 and May 2018. This material likely resorbs over several months. Outcomes included comparisons of preinjection and postinjection symptoms at 1 week, 1 month, and 3 months using the ENS6Q, 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-item scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Fourteen patients underwent injections. Mean ENS6Q scores significantly decreased from baseline at 1 week (20.8 vs 10.5; p < 0.0001), and remained reduced but upward-trending at 1 month (13.7, p = 0.002) and 3 months (15.5, p > 0.05) following injections. Mean SNOT-22 scores significantly decreased at 1 week (p = 0.01) and 1 month (p = 0.04), mean GAD-7 at 1 month (p = 0.02) and 3 months (p = 0.02), and mean PHQ-9 at 1 week (p = 0.01) and 1 month (p = 0.004) postinjection.

CONCLUSION

Transient, focal airway bulking via submucosal filler injection at sites of inferior turbinate tissue loss markedly benefits ENS patients, suggesting that aberrant nasal aerodynamics from inferior turbinate tissue loss contributes to (potentially reversible) ENS symptoms.

Computational fluid dynamics after endoscopic endonasal skull base surgery-possible empty nose syndrome in the context of middle turbinate resection

BACKGROUND

Empty nose syndrome (ENS) is a rare and debilitating disease with a controversial definition, etiology, and treatment. One puzzling fact is that patients who undergo an endoscopic endonasal approach (EEA) often have resection of multiple anatomic structures, yet seldom develop ENS. In this pilot study, we analyzed and compared the computational fluid dynamics (CFD) and symptoms among post-EEA patients, ENS patients, and healthy subjects.

METHODS

Computed tomography scans of 4 post-EEA patients were collected and analyzed using CFD techniques. Two patients had significant ENS symptoms based on results of the Empty Nose Syndrome 6-item Questionnaire (score >11), whereas the other 2 were asymptomatic. As a reference, their results were compared with previously published CFD results of 27 non-EEA ENS patients and 42 healthy controls.

RESULTS

Post-EEA patients with ENS symptoms had a similar nasal airflow pattern as non-EEA ENS patients. This pattern differed significantly from that of EEA patients without ENS symptoms and healthy controls. Overall, groups with ENS symptoms exhibited airflow dominant in the middle meatus region and a significantly lower percentage of airflow in the inferior turbinate region (EEA with ENS, 17.74 ± 4.00% vs EEA without ENS, 51.25 ± 3.33% [t test, p < 0.02]; non-EEA ENS, 25.8 ± 17.6%; healthy subjects, 36.5 ± 15.9%) as well as lower peak wall shear stress (EEA with ENS, 0.30 ± 0.13 Pa vs EEA without ENS, 0.61 ± 0.03 Pa [p = 0.003]; non-EEA ENS, 0.58 ± 0.24 Pa; healthy subjects, 1.18 ± 0.81 Pa).

CONCLUSION

These results suggest that turbinectomy and/or posterior septectomy may have a varying functional impact and that ENS symptoms go beyond anatomy and correlate with aerodynamic changes. The findings open the door for CFD as a potential objective diagnosis tool for ENS.

Partial resection of the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis does not lead to an increased risk of empty nose syndrome: a cohort study of a tertiary practice

BACKGROUND

The treatment of the middle turbinate (MT) during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS) remains a contentious issue with arguments both for and against its resection. The purpose of this study was to examine the clinical impact of partial MT resection (PMTR) during ESS, paying particular attention to the risk of developing empty nose syndrome (ENS) and alteration to olfaction.

METHODS

This cohort study was performed on prospectively collected data. A total of 177 patients underwent ESS for CRS; 93 had PMTR and 84 MT preservation (MTP). Preoperative data collection included subjective symptom scores as per the Adelaide Disease Severity Score (ADSS), Lund-Mackay scores, and nasal polyp status. The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) was administered by telephone consultation and analyzed alongside postoperative symptom scores.

RESULTS

There was no difference in ENS6Q scores in patients who underwent PMTR vs those who had MTP. Patients who underwent PMTR had a higher baseline disease on Lund-Mackay scoring, and were more likely to be nasal polyp patients and be undergoing revision surgery. ADSS scores demonstrated significant improvements in all rhinologic symptoms, with no difference between the cohorts.

CONCLUSION

PMTR is an adjunctive procedure to ESS. This study has established that PMTR as performed by the senior author carries no additional risk of developing ENS symptoms as defined by the ENS6Q, and that it carries no additional risk to olfaction or other rhinologic symptoms. PMTR can be safely considered at time of ESS, especially in patients at risk of lateralization of the MT.