Clinical analysis of submucosal Medpor implantation for empty nose syndrome

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.

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.

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.

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.

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.

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.

Assessment of postsurgical outcomes between different implants in patients with empty nose syndrome: A meta-analysis

Objectives

The aim of this study was to evaluate the impact of surgery and different implant materials on subjective outcomes in patients with empty nose syndrome (ENS).

Methods

Postsurgical outcomes were assessed in a meta-analysis of patients with ENS who underwent treatment with different implants.

Results

We identified 122 relevant studies, and 6 were included in the meta-analysis (4 prospective trials and 2 randomized controlled trials). A significant difference was found between the preoperative and postoperative Sino-Nasal Outcome Test (SNOT) scores for different implants. With respect to implant materials, significant differences were observed between autografts/allografts (AG) and foreign material grafts (FGs). A subgroup analysis of different countries showed that more patients from China underwent surgical implant therapy than patients from other countries.

Conclusions

This meta-analysis suggests that surgery can improve the symptoms and SNOT scores of patients with ENS, AGs are more effective than FGs in patients with ENS, and that more patients from China undergo surgical implant therapy than patients from other countries.

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.

ß-Tricalcium Phosphate Implants in the Surgical Treatment of Empty Nose Syndrome

The objective of this study was to assess the efficacy and morbidity of a β-tricalcium phosphate implant in the treatment of empty nose syndrome after turbinectomy. Only patients with a history of inferior turbinectomy and a complaint of permanent paradoxical nasal obstruction were included. β-Tricalcium phosphate ceramic implants were implanted under the mucoperiosteal plane of the lateral nasal wall to replace the head of the inferior turbinate. Symptoms and quality of life were assessed by 2 questionnaires: the Nasal Obstruction Symptom Evaluation and Rhinosinusitis Quality of Life. Fourteen patients were included. The mean follow-up was 19.4 ± 13.4 months. Scores for the Nasal Obstruction Symptom Evaluation and Rhinosinusitis Quality of Life (frequency, bothersomeness, and impact) significantly improved after surgery (respectively, 73.9 ± 21.8 to 34.6 ± 28.6, 44.6 ± 17.1 to 34.8 ± 20.3, 43.6 ± 22.4 to 70.7 ± 21.5, and 59.9 ± 21.1 to 27.2 ± 25.3; P < .05). The use of ß-tricalcium phosphate seems efficient to repair empty nose syndrome by endonasal microplasty and shows a low complication rate.

Empty nose syndrome

Empty nose syndrome (ENS) is a rare, late complication of turbinate surgery. The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea. Little is known about the pathogenesis of ENS, though it is speculated that anatomical changes leading to alterations in local environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms are strongly implicated. The diagnosis is clinical, though often difficult to make due to the poor correlation between subjective and objective findings. Medical therapies include mucosal humidification, irrigations, and emollients. Surgical therapy should be reserved for refractory cases and may involve turbinate reconstruction, most commonly using implantable biomaterials. Ultimately, prevention of this feared complication through turbinate-sparing techniques is essential.

The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review

OBJECTIVE

To evaluate the outcomes of surgical intervention for empty nose syndrome (ENS).

DATA SOURCE

Cochrane Collaboration database, U.S National Institutes of Health database (ClinicalTrials), U.S National Library of Medicine (PubMed).

REVIEW METHODS

Structured search using medical subject-heading terms: nose, turbinate, surgery, atrophic rhinitis, and empty nose syndrome.

RESULTS

A total of 128 patients were collated from eight studies with an age range of 18 to 64 years. Most patients had been suffering with ENS for many years, up to 29.7 years. The most common surgical technique involved a transnasal approach with implant material secured within a submucosal pocket. Common implant material used in the studies included biosynthetic, and autologous cartilage. The weighted mean preoperative Sino-Nasal Outcome Test (SNOT)-20 and SNOT-25 scores were 48.3 and 65.9, respectively. At latest follow-up, these scores improved significantly to 24.4 and 33.3, respectively. Although all SNOT subdomains improved following surgery, the highest improvement was observed in ENS symptoms and psychological issues. SNOT scores improved by 3 months postsurgery and this trend continued over time, although available data was limited to only 12 months follow-up. Nevertheless, 10 patients had less than 10 points improvement, including three patients who had no change in SNOT scores. Extrusion of the implant occurred in six cases, and one developed chronic rhinosinusitis.

CONCLUSION

Surgical intervention for ENS appears to result in clinical improvement, although not all patients derived benefit. Long-term follow-up should be considered utilizing using both subjective (SNOT-25) and objective (rhinomanometry) measures of clinical outcome.