Evaluation of depression and anxiety in empty nose syndrome after surgical treatment

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.

Evaluation of Post-Intervention Outcomes in Patients with Empty Nose Syndrome

OBJECTIVES

To conduct a systematic review and meta-analysis of published articles to assess the impact of inferior turbinate/meatus augmentation in patients diagnosed with empty nose syndrome (ENS).

DATA SOURCES

PubMed, Cochrane database, Embase, Web of Science, SCOPUS, and Google Scholar.

REVIEW METHODS

Six databases were searched to December 2022. We retrieved studies evaluating improvements in refractory ENS-related symptoms based on various patient-reported outcome measures after inferior turbinate/meatus augmentation.

RESULTS

As a result of meta-analysis, Sinonasal Outcome Test, Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), and depression scores were measured at 1 week; 1, 3, and 6 months; and later than 12 months after intervention for patients with ENS. All scores revealed significant symptom improvement. By reference to the minimal clinically important difference of the ENS6Q (6.25), inferior turbinate/meatus augmentation relieved the nasal symptoms of ENS in the long term. Although the improvements in anxiety scores at 1 week (0.4133 [-0.3366; 1.1633], 0.00, I2 = NA) and 1 month (0.4525 [-0.0529; 0.9579], I2 = 0.0%) were not statistically significant, the scores differed significantly at 3 months (0.7351 [0.4143; 1.0559], I2 = 28.4%), 6 months (0.8297 [0.6256; 1.0337], I2 = 37.2%), and longer than 12 months (0.7969 [0.4768; 1.1170], I2 = 0.0%).

CONCLUSION

These data and analysis suggest that performing inferior turbinate/meatus augmentation on ENS patients may improve not only nasal symptom scores but also accompanying psychological problems such as anxiety and depression. Laryngoscope, 134:2005-2011, 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.

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.

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.

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.

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.

Development of Injectable Calcium Sulfate and Self-Setting Calcium Phosphate Composite Bone Graft Materials for Minimally Invasive Surgery

The demand of bone grafting is increasing as the population ages worldwide. Although bone graft materials have been extensively developed over the decades, only a few injectable bone grafts are clinically available and none of them can be extruded from 18G needles. To overcome the existing treatment limitations, the aim of this study is to develop ideal injectable implants from biomaterials for minimally invasive surgery. An injectable composite bone graft containing calcium sulfate hemihydrate, tetracalcium phosphate, and anhydrous calcium hydrogen phosphate (CSH/CaP paste) was prepared with different CSH/CaP ratios and different concentrations of additives. The setting time, injectability, mechanical properties, and biocompatibility were evaluated. The developed injectable CSH/CaP paste (CSH/CaP 1:1 supplemented with 6% citric acid and 2% HPMC) presented good handling properties, great biocompatibility, and adequate mechanical strength. Furthermore, the paste was demonstrated to be extruded from a syringe equipped with 18G needles and exerted a great potential for minimally invasive surgery. The developed injectable implants with tissue repairing potentials will provide an ideal therapeutic strategy for minimally invasive surgery to apply in the treatment of maxillofacial defects, certain indications in the spine, inferior turbinate for empty nose syndrome (ENS), or reconstructive rhinoplasty.

Anxiety and depression mood disorder in patients with nasal septal deviation: A systematic review and meta-analysis

BACKGROUND

Nasal septal deviation (NSD) is one of the most prevalent upper airway diseases causing airway obstruction, and it can negatively impact patients' quality of life (QoL).

OBJECTIVE

The aim of this study was to determine the risk of anxiety and depression mood disorders in patients with NSD.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA statement. An electronic search was performed on PubMed/MEDLINE, Scopus and Google Scholar. Raw affect size data were pooled comparing standardized between group mean differences.

RESULTS

A total of 625 patients (males: 53 %, n = 280/525) with a mean age of 32.4 years (n = 375, 95 % CI: 25.3-39.4) were included. The pooled standardized mean differences (SMD) for the prevalence of the anxiety disorder was 1.17 (n = 625, 95 % CI: 0.34-2.0). The pooled SMD for the prevalence of the depression disorder was 0.30 (n = 490, 95 % CI: 0.12-0.48).

CONCLUSION

Prevalence of anxiety and depression mood disorders is higher in patients with NSD compared to controls. These diseases should be investigated and considered during the diagnostic and therapeutic process to improve the QoL of patients with NSD.

The impact of preoperative psychological characteristics on postoperative satisfaction and quality of life in patients undergoing septoplasty and inferior turbinate ablation surgery

PURPOSE

To investigate the effect of preoperative mental state on postoperative satisfaction and quality of life in patients undergoing septoplasty and inferior turbinate ablation surgery.

METHODS

A total of 41 patients who underwent septoplasty and inferior turbinate ablation surgery due to nasal congestion were included in the study. Patients were asked to complete the Mental Symptoms Checklist Revised (SCL-90 R), World Health Organization Quality of Life Scale-Short Form (WHOQoL-BREF-TR), and Visual Analogue Scale (VAS) tests before and after their surgery. The surgical procedure for all patients was performed by a single ear-nose-throat physician. The preoperative and postoperative test results were then compared.

RESULTS

A significant decrease was noted in the postoperative SCL-90 R somatization (p < 0.001), additional items (p = 0.001), and global severity index (GSI) (p = 0.002) scores; a significant increase was observed in the postoperative WHOQoL-BREF-TR physical health score (p = 0.029); and a significant decrease was seen in the postoperative VAS scores (p < 0.001). The preoperative SCL-90 R GSI showed a negative correlation with the postoperative WHOQoL-BREF-TR total score and a significant positive correlation with the postoperative VAS scores (p < 0.05 for all). There was a significant difference between those with a postoperative VAS score of ≤ 2 and > 2 in terms of GSI and all preoperative SCL-90 R subscale scores, except for the additional items subscale. Increased preoperative psychological symptoms reported by the patients were associated with a lower perception of postoperative quality of life.

CONCLUSION

The preoperative mental state of patients undergoing septoplasty and inferior turbinate ablation surgery affects postoperative satisfaction and quality of life. In addition, the recognition of this parameter may contribute to the treatment management of these patients and the legal protection of physicians.

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.

Short report: nasal obstruction recovery after septoplasty in patients with nasal septal deviation affected by anxiety and depression

This research was aimed to explore whether the recovery of subjective symptoms and objective examination in nasal septum deviation (NSD) patients after septoplasty were related to the degree of preoperative anxiety or depression, in the hope of providing new ideas for clinical treatment. A total of 150 NSD patients were included in this prospective research. Visual analogue scale (VAS) scores, Nasal Obstruction Symptom Evaluation (NOSE) scores, self-rating anxiety scale (SAS) scores, self-rating depression scale (SDS) scores, total inspiratory and expiratory nasal resistance were recorded before and 6 months after operation. The results showed preoperative anxiety or depression was not statistically different between groups in terms of age, gender and course, but positively correlated with nasal obstruction (VAS and NOSE). The recovery of nasal obstruction in patients with anxiety or depression was worse than that in normal NSD patients 6 months after surgery, and was decreased with the increase of anxiety or depression degree. And no significant difference showed in the reduction of total inspiratory and expiratory nasal resistance between groups. In conclusion, anxiety and depression affected the improvement of nasal obstruction feeling in NSD patients after septoplasty, and the improvement was negatively correlated with the degree of anxiety and depression. It is necessary to evaluate the anxiety and depression of NSD patients before septoplasty.

Association of nasal septal deviation with the incidence of anxiety, depression, and migraine: A national population-based study

Background & aims

Nasal obstruction caused by nasal septal deviation is very bothersome and, therefore, can affect the patient’s emotional state. However, little is known about the effect of nasal septal deviation (NSD) on the neuropsychiatric aspects of patients. Therefore, this study aims to verify the higher incidence of anxiety, depression, and migraine in patients diagnosed with NSD compared to general populations using big data.

Methods

This retrospective cohort study collected subjects from the Korean National Health Insurance Service (NHIS) database. Adjustments were made to minimize the confounding of variables for age, sex, residence type, income levels, hypertension, diabetes, dyslipidemia, rhinitis, and chronic rhinosinusitis between the two groups. The primary endpoint of this study was newly diagnosed anxiety, depression, and migraine between January 2009 and December 2018. Kaplan-Meier survival curves, logarithmic rank test, and Cox proportional regression test were used for statistical analysis.

Results

Among a total of 135,769 subjects in the NHIS database, 48,495 patients with NSD (NSD group) and 54,475 control subjects (control group) were selected. Patients with NSD had an increased risk of anxiety, depression, and migraine compared to the control group. In the NSD group, the adjusted hazard ratios (HR) were 1.236 (95% CI, 1.198–1.276) for anxiety, 1.289 (95% CI, 1.238–1.343) for depression, and 1.251 (95% CI, 1.214–1.290) for migraine.

Conclusion

NSD is associated with a higher incidence of anxiety, depression, and migraine. Therefore, it is suggested that physicians carefully consider psychoneurological distress and employ therapeutic strategies to minimize these conditions.

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.

Empty nose syndrome pathogenesis and cell-based biotechnology products as a new option for treatment

Empty nose syndrome (ENS) is a rare complication that develops after partial or complete turbinectomy. The main feature of ENS is paradoxical nasal obstruction feeling despite objectively wide nasal airway. ENS pathogenesis is multifactorial and includes changes in laminar physiological airflow, disruption of mucosa functions and deficient neural sensation. This leads to the development of ENS symptomatology such as dyspnea, nasal dryness, nasal burning, nasal obstruction, feeling of suffocation and even comorbid psychiatric disorders that significantly impairs life quality. Specific effective treatment of ENS does not exist up to date. In this review we outline existing biomaterial for surgical reconstitution of nasal anatomy and discuss the perspective of stem cell-based technologies in ENS management. The main focus is directed to justification of rationality application of adult mesenchymal stem cells (MSCs) from different tissues origin and neural crest-derived stem cells (NCSCs) based on their intrinsic biological properties. MSCs transplantation may stimulate mucosa tissue regeneration via trophic factors secretion, direct transdifferentiation into epithelial cells and pronounced immunosuppressive effect. From the other hand, NCSCs based on their high neuroprotective properties may reconstitute nerve structure and functioning leading to normal sensation in ENS patients. We postulate that application of cell-based and tissue-engineered products can help to significantly improve ENS symptomatology only as complex approach aimed at reconstitution of nasal anatomy, recovery the nasal mucosa functionality and neural tissue sensation.

Depression in the Pediatric Otolaryngology Clinic Setting

OBJECTIVES/HYPOTHESIS

For most pediatric specialty clinics, mental health is not the primary presenting complaint, yet can portend unrecognized morbidity. We describe rates and risk factors of depression and suicidal ideation in adolescents seen at a pediatric specialty clinic and examine changes during COVID-19.

STUDY DESIGN

Retrospective database review.

METHODS

Outpatient pediatric otolaryngology clinic encounters of patients aged 12-19 years at a tertiary academic medical center were identified from October 2018 to July 2020. Demographic characteristics, ICD-10 primary diagnosis, Patient Health Questionnaire (PHQ)-2 score, and PHQ-9 score (if administered) were obtained. Multivariable regression examined risk factors for PHQ-9 administration, PHQ-9 scores ≥10, and suicidal ideation. Patient characteristics and PHQ scores were compared before and after March 23, 2020 (California COVID-19 Stay-at-Home order).

RESULTS

Three thousand six hundred nine encounters with PHQ-2 data were identified. Of these, 223 (6.2%) scored ≥3 and underwent PHQ-9 assessment, of which 121 (3.4% of 3,609) scored ≥10 on the PHQ-9 and 53 (1.5%) endorsed suicidal ideation. Factors associated with PHQ-9 administration were female gender (odds ratio [OR] 1.58, P = .001), obesity (OR 1.48, P = .043), and neck mass/neoplasm/cancer diagnosis (OR 1.99, P = .013). Female gender was also associated with suicidality (OR 2.47, P = .008). Comparison of pre-COVID-19 versus during COVID-19 showed no differences in depression or suicidality. However, subgroup analysis revealed some significant findings.

CONCLUSIONS

We demonstrate substantial prevalence of positive depression screening and suicidal ideation among adolescent pediatric otolaryngology clinic encounters. Depression rates were similar to pre-COVID-19 and during COVID-19, yet barriers to screening during this time were substantial. Pediatric specialty providers must remain vigilant for mental health issues in their patients.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

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.

Anxiety and depression in patients with nasal septal deviation

OBJECTIVE

Nasal septal deviation (NSD) has a significant impact on patients' quality of life; however, there have been limited studies examining the psychological status of NSD patients. In this study, symptoms of depression and anxiety were investigated between NSD patients and controls using a self-report questionnaire.

METHODS

A case-control study design was used to evaluate the psychological burden of NSD in patients who visited the general hospital. The control group comprised of ENT outpatients without a history of chronic nasal disease. The Zung Self-rating Anxiety/Depression Scale (SDS/SAS) was used to evaluate the prevalence and severity of anxiety and depression between the NSD and control group.

RESULTS

Seventy-six patients with NSD and 79 control patients were enrolled in the study. We found that depression and anxiety, as well as the co-morbidity of depression with anxiety, were more common in the NSD group in comparison to the control (39.5% vs 22.8%, p = 0.025; 38.2% vs 15.2%, p = 0.001; and 27.6% vs 11.4%, p = 0.011, respectively). The average SDS and SAS score was higher in NSD patients compared to controls (SDS: 49.7 ± 13.1 vs 45.2 ± 10.4, p = 0.019 and SAS: 48.1 ± 11.6 vs 41.3 ± 9.3, p < 0.001, respectively), and NSD patients were found to have more severe levels of anxiety and depression.

CONCLUSION

Depression and anxiety are more common and severe in patients with NSD. Therefore, psychological distress should be taken into consideration during the diagnostic and therapeutic process for patients with NSD.

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.

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.

Nasal nitric oxide in relation to psychiatric status of patients with empty nose syndrome

BACKGROUND

Although cases of empty nose syndrome (ENS) are not very common, the suffering that ENS causes patient is immense and could be very difficult to imagine. Nasal nitric oxide (nNO) is an airway disease biomarker, and its levels increase after endoscopic sinus surgery. The trend of nNO levels in ENS before and after surgical treatment remains unknown. This study aimed to evaluate the role of nNO in ENS.

METHODS

Patients with ENS who received surgical implantation and with chronic hypertrophic rhinitis (CHR) who underwent turbinoplasty and completed at least 1 year of follow-up were prospectively enrolled. nNO measurements and subjective assessments [SinoNasal Outcome Test (SNOT)-22, Beck Depression Inventory (BDI)-II, and Beck Anxiety Inventory (BAI)] were performed preoperatively and at 3, 6, and 12 months postoperatively.

RESULTS

We enrolled 19 ENS and 12 CHR patients. nNO levels were significantly lower in the ENS than in the CHR patients before surgical treatment (p < 0.001). nNO levels in the ENS patients significantly increased 3 months after implantation and remained plateaued (p = 0.015). BDI-II and BAI scores significantly improved after surgical treatment for the ENS patients but not for the CHR patients; changes in nNO levels correlated well with improvements in BDI-II and BAI scores (p = 0.025 and 0.035, respectively).

CONCLUSIONS

nNO significantly increased at third month after surgical treatment and remained plateaued in ENS patients. This increase correlated with improvements in BDI-II and BAI scores. Therefore, nNO may be important in assessing the psychiatric status of empty nose syndrome.

The Degree of Stress in Patients With Empty Nose Syndrome, Compared With Chronic Rhinosinusitis and Allergic Rhinitis

BACKGROUND

Depression is a mental health disease of growing public health concern because depressive mood affects the sufferer's daily life and is also associated with productivity decline. Depression that is caused by other diseases or substances is referred to as secondary depression, which is an important distinction because curing the underlying cause could subsequently regulate depressive mood. Empty nose syndrome (ENS), also known as "paradoxical obstruction of the nose," is a condition in which the major symptom is difficulty breathing, despite having sufficient breathing space in the nose. Empty nose syndrome has been increasing in prevalence in Korea. We found that patients with this ENS have a tendency toward depressive mood, which can escalate so far as to lead to suicide attempts. Thus, herein, we aimed to investigate the psychological burden on patients with ENS.

METHODS

We divided patients into 4 groups: ENS (group A), chronic rhinosinusitis with polyp (CRS c polyp, group B), chronic rhinosinusitis without polyp (CRS s polyp, group C), and allergic rhinitis (AR, group D). We estimated and compared Beck Depression Inventory (BDI) scores among the 4 groups, and we investigated the relationship between depression index and nasal cavity area in patients with ENS.

RESULTS

The ENS group (A) had depression prevalence of 71% with varying severity, which was much higher than group B (19%), group C (15%), and group D (27%). The correlation between nasal cavity volume and BDI score for the ENS group was not statistically significant.

CONCLUSION

The degree and severity of depression in patients with ENS was higher than in patients with CRS or AR. Furthermore, there was no relationship between depression severity and nasal cavity volume in the patients with ENS. Thus, physicians should be careful not to dismiss the accompanying mental health problems of patients with ENS.

Prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital

PURPOSE

To determine the prevalence of depression and anxiety among otolaryngology outpatients at Jordan University Hospital.

METHODS

A cross-sectional observational study was conducted between January 2017 and February 2018. The sample included 1328 otolaryngology adult outpatients, who completed (PHQ-9) and (GAD-7) questionnaires for depression and anxiety. Sociodemographic and clinical data were recorded.

RESULTS

Depression and anxiety prevalence rates were 36.1% and 22.9%. The significant risk factors found for them were: age range 30 to 50 years, female sex, divorced status, smoking, alcohol drinking, asthma, family history of psychiatric illness, chronic illnesses, negative life events, secondary education, unemployment, low income, globus pharyngeus, tinnitus, and dizziness.

PRACTICE IMPLICATIONS

Healthcare providers should have the vigilance to suspect and treat these disorders to improve patients' symptoms and quality of life.

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.

Somatization, Depression, and Anxiety Disorders in a Rhinology Practice

Background

Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms.

Methods

Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10.

Results

One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only.

Conclusions

Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.

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.

Investigation of the abnormal nasal aerodynamics and trigeminal functions among empty nose syndrome patients

BACKGROUND

Abnormal nasal aerodynamics or trigeminal functions have been frequently implicated in the symptomology of empty nose syndrome (ENS), yet with limited evidence.

METHODS

Individual computed tomography (CT)-based computational fluid dynamics (CFD) was applied to 27 ENS patients to simulate their nasal aerodynamics and compared with 42 healthy controls. Patients' symptoms were confirmed with Empty Nose Syndrome 6-item Questionnaire (ENS6Q), 22-item Sino-Nasal Outcome Test (SNOT-22), and Nasal Obstruction Symptom Evaluation (NOSE) scores. Nasal trigeminal sensitivity was measured with menthol lateralization detection thresholds (LDTs).

RESULTS

ENS patients had significantly lower (∼25.7%) nasal resistance and higher (∼2.8 times) cross-sectional areas compared to healthy controls (both p < 0.001). Despite inferior turbinate reductions, CFD analysis demonstrated that ENS patients had increased airflow concentrated in the middle meatus region (66.5% ± 18.3%) compared to healthy controls (49.9% ± 15.1%, p < 0.0001). Significantly less airflow (25.8% ± 17.6%) and lower peak wall shear stress (WSS) (0.58 ± 0.24 Pa) were found in the inferior meatus (vs healthy: 36.5% ± 15.9%; 1.18 ± 0.81 Pa, both p < 0.05), with the latter significantly correlated with the symptom scores of ENS6Q (r = -0.398, p = 0.003). Item-wise, complaints of "suffocation" and "nose feels too open" were also found to be significantly correlated with peak WSS around the inferior turbinate (r = -0.295, p = 0.031; and r = -0.388, p = 0.004, respectively). These correlations were all negative, indicating that less air-mucosal stimulations resulted in worse symptom scores. ENS patients (n = 12) also had impaired menthol LDT when compared to healthy controls (p < 0.0001).

CONCLUSION

This is the first CFD examination of nasal aerodynamics in a large cohort of ENS patients. The results indicated that a combination of loss of neural sensitivity and poorer inferior air-mucosal stimulation may potentially lead to ENS symptomology.

The functional and psychological burden of empty nose syndrome

BACKGROUND

Empty nose syndrome (ENS) is a debilitating disorder thought to arise as a postsurgical phenomenon from excessive loss of nasal tissues. Affected patients often report a profound impact on all aspects of life, but the extent of this burden has not been quantified. We sought to determine the association of ENS with mental health and functional impairments.

METHODS

A cross-sectional study was performed of individuals with ENS recruited from online ENS forums. ENS status was validated based on a positive 6-item Empty Nose Syndrome Questionnaire (ENS6Q) score and sinus computed tomography imaging or supporting medical documentation. Subjects completed the ENS6Q, the 9-item Patient Health Questionnaire (PHQ-9) for depression, the 7-item Generalized Anxiety Disorder questionnaire (GAD-7), the Epworth Sleepiness Scale for daytime somnolence (ESS), the Work Productivity and Impairment questionnaire (WPAI), and the 5-dimension EuroQol General Health State Survey (EQ-5D-5L). Pearson correlation analysis was performed with α = 0.05 to determine significance.

RESULTS

Fifty-three ENS individuals were included in the study. Overall, participants reported symptoms consistent with moderate anxiety (μ = 12.7; standard deviation [SD], 5.9) and moderately severe depression warranting treatment (μ = 17.9; SD, 6.8). Participants also noted a 62% reduction in productivity at work (n = 24) and 65% in all other activities (n = 53). ENS6Q symptom severity was correlated with more severe depression (p < 0.001), anxiety (p < 0.001), overall pain/discomfort (p = 0.002), and impairment in activities of daily living (p = 0.003).

CONCLUSION

ENS individuals carry a clinically significant psychological burden and experience marked difficulties with many activities of daily living. A multimodal approach to address the tissue loss with surgery and cognitive-behavioral therapy for the psychological burden may provide the most optimal outcome.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Prevalence of depression and depressive symptoms among outpatients: a systematic review and meta-analysis

OBJECTIVES

Depression and depressive symptoms are common mental disorders that have a considerable effect on patients' health-related quality of life and satisfaction with medical care, but the prevalence of these conditions varies substantially between published studies. The aim of this study is to conduct a systematic review and meta-analysis to provide a precise estimate of the prevalence of depression or depressive symptoms among outpatients in different clinical specialties.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND ELIGIBILITY CRITERIA

The PubMed and PsycINFO, EMBASE and Cochrane Library databases were searched to identify observational studies that contained information on the prevalence of depression and depressive symptoms in outpatients. All studies included were published before January 2016. Data characteristics were extracted independently by two investigators. The point prevalence of depression or depressive symptoms was measured using validated self-report questionnaires or structured interviews. Assessments were pooled using a random-effects model. Differences in study-level characteristics were estimated by meta-regression analysis. Heterogeneity was assessed using standard χ² tests and the I² statistic. The study protocol has been registered with PROSPERO under number CRD42017054738.

RESULTS

Eighty-three cross-sectional studies involving 41 344 individuals were included in this study. The overall pooled prevalence of depression or depressive symptoms was 27.0% (10 943/41 344 individuals; 95% CI 24.0% to 29.0%), with significant heterogeneity between studies (p<0.0001, τ²=0.3742, I²=96.7%). Notably, a significantly higher prevalence of depression and depressive symptoms was observed in outpatients than in the healthy controls (OR 3.16, 95% CI 2.66 to 3.76, I²=72.0%, χ ² =25.33). The highest depression/depressive symptom prevalence estimates occurred in studies of outpatients from otolaryngology clinics (53.0%), followed by dermatology clinics (39.0%) and neurology clinics (35.0%). Subgroup analyses showed that the prevalence of depression and depressive symptoms in different specialties varied from 17.0% to 53.0%. The prevalence of depression and depressive symptoms was higher among outpatients in developing countries than in outpatients from developed countries. Moreover, the prevalence of depression and depressive symptoms in outpatients slightly decreased from 1996 to 2010. Regarding screening instruments, the Beck Depression Inventory led to a higher estimate of the prevalence of depression and depressive symptoms (1316/4702, 36.0%, 95% CI 29.0% to 44.0%, I²=94.8%) than the Hospital Anxiety and Depression Scale (1003/2025, 22.0%, 95% CI 12.0% to 35.0%, I²=96.6%).

CONCLUSION

Our study provides evidence that a significant proportion of outpatients experience depression or depressive symptoms, highlighting the importance of developing effective management strategies for the early identification and treatment of these conditions among outpatients in clinical practice. The substantial heterogeneity between studies was not fully explained by the variables examined.

Surgical outcome for empty nose syndrome: Impact of implantation site

OBJECTIVE/HYPOTHESIS

Endonasal submucosal implantation has been confirmed to be beneficial for patients with empty nose syndrome (ENS). However, the optimal implantation site has not been defined. This study aimed to evaluate whether lateral nasal wall implantation is superior to inferior nasal wall implantation in terms of clinical benefits and improvements in quality of life.

STUDY DESIGN

Retrospective study in a tertiary medical center.

METHODS

Consecutive ENS patients between 2010 and 2015 with operative histories of inferior turbinectomies and indicated for surgical implantation were enrolled, with at least 1-year follow-up. Patients were divided into lateral and inferior nasal wall groups. SinoNasal Outcome Test (SNOT)-22, Beck Depression Inventory (BDI)-II, and Beck Anxiety Inventory (BAI) were applied before and 1 year after implantation.

RESULTS

Of the total 30 ENS patients analyzed, 14 were in the inferior nasal wall group and 16 were in the lateral nasal wall group. There were no significant intergroup differences in demographic data and preoperative SNOT-22, BDI-II, and BAI scores. Postoperative assessment revealed that the lateral nasal wall group had significantly better SNOT-22 score improvements than the inferior nasal wall group, particularly regarding rhinological symptoms and sleep function.

CONCLUSION

Lateral nasal wall implantation may provide significantly better clinical outcomes than inferior nasal wall implantation, and thus may be the preferred, more optimal site for implant placement in ENS patients.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:554-559, 2018.

Computational fluid dynamics and trigeminal sensory examinations of empty nose syndrome patients

OBJECTIVE

The precise pathogenesis of empty nose syndrome (ENS) remains unclear. Various factors such as nasal aerodynamics and sensorineural dysfunction have been suspected, although evidence is limited. This study reported the first examination of both nasal aerodynamics and trigeminal sensory factors in actual ENS patients.

STUDY DESIGN

Prospective case control.

METHODS

We enrolled six patients diagnosed with ENS. Three patients had pre- and post-inferior turbinate (IT) reduction computed tomography scans, which allowed comparison of their nasal aerodynamics changes through computational fluid dynamic (CFD) simulation. Their symptoms were confirmed through Sino-nasal Outcome Test-22, ENS 6-item Questionnaire, acoustic rhinometry, and rhinomanometry findings. Nasal trigeminal sensitivity that potentially mediates their perception of airflow was assessed via menthol lateralization detection thresholds (LDT) and compared with 14 healthy controls.

RESULTS

Post-surgical reductions in nasal resistance were observed and significantly lower than normal (P < 0.05). Computational fluid dynamic analysis showed that, paradoxically for all ENS patients, IT reduction did not draw more airflow to the airway surrounding the ITs, but rather resulted in nasal airflow forming into a narrow jet toward the middle meatus region, leaving the airway surrounding the IT with significantly reduced airflow intensity and air-mucosal interactions (inferior region flow percentage reduced from 35.7% ± 15.9% to post-surgery 17.7% ± 15.7%, P < 0.05; inferior wall-shear-stress reduced from 7.5 ± 4.2 × 10^-2 Pa to 3.4 ± 3.1 × 10^-2 Pa, P < 0.01). Empty nose syndrome patients also had significantly impaired menthol LDT compared to healthy controls (P < 0.005).

CONCLUSION

The results indicated that a combinatory of factors, including paradoxically distorted nasal aerodynamic, impaired sensorineural sensitivity, and potential predisposing conditions, may contribute to the development of ENS.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:E176-E184, 2017.