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The Egyptian Journal of Otolaryngology
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Empty nose syndrome: etiopathogenesis and management

The Egyptian Journal of Otolaryngology volume 32, pages 119–129 (2016)Cite this article

Abstract

Empty nose syndrome (ENS) is an iatrogenic disorder most often recognized by the presence of paradoxical nasal obstruction despite an objectively wide patent nasal cavity. It occurs after inferior and/or middle turbinate resection; however, individuals with normal turbinates and intranasal volume may also complain of ENS. Its pathophysiology remains unclear, but it is probably caused by wide nasal cavities affecting the neurosensitive receptors and inhaled air humidification. Neuropsychological involvement is also suspected. Not every patient undergoing radical turbinate resection experiences the symptoms of ENS. ENS can affect the normal breathing function of the nasal cavity, with subsequent deterioration in patients’ quality of life. The diagnosis is made on the basis of the patients’ history, endoscopic examination of the nasal cavity, imaging (computed tomography imaging and functional MRI), and rhinomanometry. Prevention is the most important strategy; thus, the inferior and middle turbinate should not be resected without adequate justification. Management is problematic including nasal cavity hygiene and humidification, with surgery reserved for the most severe cases. The surgery aims at partial filling of the nasal cavity using different techniques and implant materials. In this paper, we review both the etiology and the clinical presentation of ENS, and its conservative and surgical management.

Core tip

Empty nose syndrome (ENS) is encountered after inferior and/or middle turbinate resection; however, it can occur in patients with seemingly normal turbinates. Rhinologists should avoid routine resection of the inferior and middle turbinates. It is not certain why some patients develop ENS, whereas others do not. The frequent association with psychiatric disorders and possibly psychosomatic pathologies indicate the possible role of psychological stress in some patients. Its diagnosis relies on clinical suspicion and physical examination. Nasal augmentation surgery can improve the quality of life of patients by restoring nasal anatomy toward the premorbid state.

References

  1. Scheithauer MO. Surgery of the turbinates and ‘empty nose’ syndrome. GMS Curr Top Otorhinolaryngol Head Neck Surg 2010;9:Doc 03.

  2. Sozansky J, Houser SM. Pathophysiology of empty nose syndrome. Laryngoscope. 2015; 125: 70–74.

    PubMed  Google Scholar 

  3. Chhabra N, Houser SM. The diagnosis and management of empty nose syndrome. Otolaryngol Clin North Am 2009; 42: 311–330.

    PubMed  Google Scholar 

  4. Houser SM. Surgical treatment for empty nose syndrome. Arch Otolaryngol Head Neck Surg 2007; 133: 858–863.

    PubMed  Google Scholar 

  5. Payne SC. Empty nose syndrome: what are we really talking about? Otolaryngol Clin North Am 2009; 42: 331–337.

    PubMed  Google Scholar 

  6. Amin MR, Koufman JA. Vagal neuropathy after upper respiratory infection: a viral etiology? Am J Otolaryngol 2001; 22: 251–256.

    CAS  PubMed  Google Scholar 

  7. Gracely RH, Petzke F, Wolf JM, Clauw DJ. Functional magnetic resonance imaging evidence of augmented pain processing in fibromyalgia. Arthritis Rheum 2002; 46: 1333–1343.

    PubMed  Google Scholar 

  8. Yepes-Nuñez JJ, Bartra J, Muñoz-Cano R, Sánchez-López J, Serrano C, Mullol J et al. Assessment of nasal obstruction: correlation between subjective and objective techniques. Allergol Immunopathol (Madr) 2013; 41: 397–401.

    Google Scholar 

  9. Yaniv E, Hadar T, Shvero J, Raveh E. Objective and subjective nasal airflow. Am J Otolaryngol 1997; 18: 29–32.

    CAS  PubMed  Google Scholar 

  10. Naito K, Kondo Y, Ohoka E, Komori M, Takeuchi M, Iwata S. New aerodynamic aspects of nasal patency. Rhinology 1995; 33: 26–29.

    CAS  PubMed  Google Scholar 

  11. Saafan ME. Acellular dermal (alloderm) grafts versus silastic sheets implants for management of empty nose syndrome. Eur Arch Otorhinolaryngol 2013; 270: 527–533.

    PubMed  Google Scholar 

  12. Coste A, Dessi P, Serrano E. Empty nose syndrome. Eur Ann Otorhinolaryngol Head Neck Dis 2012; 129: 93–97.

    CAS  PubMed  Google Scholar 

  13. Houser SM. Empty nose syndrome associated with middle turbinate resection. Otolaryngol Head Neck Surg 2006; 135: 972–973.

    PubMed  Google Scholar 

  14. Freund W, Wunderlich AP, Stöcker T, Schmitz BL, Scheithauer MO. Empty nose syndrome: limbic system activation observed by functional magnetic resonance imaging. Laryngoscope 2011; 121: 2019–2025.

    PubMed  Google Scholar 

  15. Passàli D, Lauriello M, Anselmi M, Bellussi L. Treatment of hypertrophy of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol 1999; 108: 569–575.

    PubMed  Google Scholar 

  16. Naftali S, Rosenfeld M, Wolf M, Elad D. The air-conditioning capacity of the human nose. Ann Biomed Eng 2005; 33: 545–553.

    PubMed  Google Scholar 

  17. Elad D, Wolf M, Keck T. Air-conditioning in the human nasal cavity. Respir Physiol Neurobiol 2008;163(1–3):121–127.

    PubMed  Google Scholar 

  18. Baraniuk JN Subjective nasal fullness and objective congestion. Proc Am Thorac Soc 2011;8:62–69.

    PubMed  PubMed Central  Google Scholar 

  19. Baraniuk JN, Kim D. Nasonasal reflexes, the nasal cycle, and sneeze. Curr Allergy Asthma Rep 2007; 7: 105–111.

    PubMed  Google Scholar 

  20. Lindemann J, Tsakiropoulou E, Scheithauer MO, Konstantinidis I, Wiesmiller KM. Impact of menthol inhalation on nasal mucosal temperature and nasal patency. Am J Rhinol 2008; 22: 402–405.

    PubMed  Google Scholar 

  21. McBride B, Whitelaw WA. A physiological stimulus to upper airway receptors in humans. J Appl Physiol Respir Environ Exerc Physiol 1981; 51: 1189–1197.

    CAS  PubMed  Google Scholar 

  22. Burgess KR, Whitelaw WA. Reducing ventilatory response to carbon dioxide by breathing cold air. Am Rev Respir Dis 1984; 129: 687–690.

    CAS  PubMed  Google Scholar 

  23. Elad D, Naftali S, Rosenfeld M, Wolf M. Physical stresses at the air-wall interface of the human nasal cavity during breathing. J Appl Physiol (1985) 2006;100:1003–1010.

    PubMed  Google Scholar 

  24. Grützenmacher S, Lang C, Mlynski G. The combination of acoustic rhinometry, rhinoresistometry and flow simulation in noses before and after turbinate surgery: a model study. ORL J Otorhinolaryngol Relat Spec 2003; 65: 341–347.

    PubMed  Google Scholar 

  25. Swift AC, Campbell IT, McKown TM. Oronasal obstruction, lung volumes, and arterial oxygenation. Lancet 1988;1(8577):73–75.

    CAS  PubMed  Google Scholar 

  26. Aasvang EK, Kehlet H. Persistent sensory dysfunction in pain-free herniotomy. Acta Anaesthesiol Scand 2010; 54: 291–298.

    CAS  PubMed  Google Scholar 

  27. Wu X, Myers AC, Goldstone AC, Togias A, Sanico AM. Localization of nerve growth factor and its receptors in the human nasal mucosa. J Allergy Clin Immunol 2006; 118: 428–433.

    CAS  PubMed  Google Scholar 

  28. Sofroniew MV, Howe CL, Mobley WC. Nerve growth factor signaling, neuroprotection, and neural repair. Annu Rev Neurosci 2001; 24: 1217–1281.

    CAS  PubMed  Google Scholar 

  29. Modrzyński M. Hyaluronic acid gel in the treatment of empty nose syndrome. Am J Rhinol Allergy 2011; 25: 103–106.

    PubMed  Google Scholar 

  30. Jang YJ, Kim JH, Song HY. Empty nose syndrome: radiologic findings and treatment outcomes of endonasal microplasty using cartilage implants. Laryngoscope 2011; 121: 1308–1312.

    PubMed  Google Scholar 

  31. Mikkelsen T, Werner MU, Lassen B, Kehlet H. Pain and sensory dysfunction 6 to 12 months after inguinal herniotomy. Anesth Analg 2004; 99: 146–151.

    PubMed  Google Scholar 

  32. Piccirillo JF, Merritt MG Jr, Richards ML. Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg 2002;126:41–47.

    PubMed  Google Scholar 

  33. Tam YY, Lee TJ, Wu CC, Chang PH, Chen YW, Fu CH, Huang CC. Clinical analysis of submucosal Medpor implantation for empty nose syndrome. Rhinology 2014; 52: 35–40.

    CAS  PubMed  Google Scholar 

  34. Hildenbrand T, Weber RK, Brehmer D. Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature. Eur Arch Otorhinolaryngol 2011; 268: 17–26.

    PubMed  Google Scholar 

  35. Berenholz L, Kessler A, Sarfati S, Eviatar E, Segal S. Chronic sinusitis: a sequela of inferior turbinectomy. Am J Rhinol 1998; 12: 257–261.

    CAS  PubMed  Google Scholar 

  36. Freund W, Wunderlich AP, Stuber G, Mayer F, Steffen P, Mentzel M et al. Different activation of opercular and posterior cingulate cortex (PCC) in patients with complex regional pain syndrome (CRPS I) compared with healthy controls during perception of electrically induced pain: a functional MRI study. Clin J Pain 2010; 26: 339–347.

    PubMed  Google Scholar 

  37. Eccles R, Morris S, Tolley NS. The effects of nasal anaesthesia upon nasal sensation of airflow. Acta Otolaryngol 1988;106(1–2):152–155.

    CAS  PubMed  Google Scholar 

  38. Brunworth J, Holmes J, Sindwani R. Inferior turbinate hypertrophy: review and graduated approach to surgical management. Am J Rhinol Allergy 2013; 27: 411–415.

    PubMed  Google Scholar 

  39. Kennedy DW. Middle turbinate resection: evaluating the issues − should we resect normal middle turbinates? Arch Otolaryngol Head Neck Surg 1998; 124: 107.

    CAS  PubMed  Google Scholar 

  40. Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol 2001; 15: 355–361.

    CAS  PubMed  Google Scholar 

  41. Eccles R, Jawad MS, Morris S. The effects of oral administration of (−)-menthol on nasal resistance to airflow and nasal sensation of airflow in subjects suffering from nasal congestion associated with the common cold. J Pharm Pharmacol 1990; 42: 652–654.

    CAS  PubMed  Google Scholar 

  42. Eccles R. Menthol: effects on nasal sensation of airflow and the drive to breathe. Curr Allergy Asthma Rep 2003; 3: 210–214.

    PubMed  Google Scholar 

  43. Goldenberg D, Danino J, Netzer A, Joachims HZ. Plastipore implants in the surgical treatment of atrophic rhinitis: technique and results. Otolaryngol Head Neck Surg. 2000; 122: 794–797.

    CAS  PubMed  Google Scholar 

  44. Rice DH. Rebuilding the inferior turbinate with hydroxyapatite cement. Ear Nose Throat J 2000; 79: 276–277.

    CAS  PubMed  Google Scholar 

  45. Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome. Laryngoscope 2013; 123: 1106–1111.

    PubMed  Google Scholar 

  46. Bastier PL, Bennani-Baiti AA, Stoll D, de Gabory L. β-Tricalcium phosphate implant to repair empty nose syndrome: preliminary results. Otolaryngol Head Neck Surg 2013; 148: 519–522.

    PubMed  Google Scholar 

  47. Jiang C, Wong F, Chen K, Shi R. Assessment of surgical results in patients with empty nose syndrome using the 25-item Sino-Nasal Outcome Test Evaluation. JAMA Otolaryngol Head Neck Surg 2014; 140: 453–458.

    PubMed  Google Scholar 

  48. Jung JH, Baguindali MA, Park JT, Jang YJ. Costal cartilage is a superior implant material than conchal cartilage in the treatment of empty nose syndrome. Otolaryngol Head Neck Surg 2013; 149: 500–505.

    PubMed  Google Scholar 

  49. Ly TH, deShazo RD, Olivier J, Stringer SP, Daley W, Stodard CM. Diagnostic criteria for atrophic rhinosinusitis. Am J Med 2009; 122: 747–753.

    PubMed  Google Scholar 

  50. Michael Friedman HI, Lee G. A simplified technique for treatment of atrophic and hypotrophic rhinitis. Oper Tech Otolaryngol Head Neck Surg 2002;13:211–214.

    Google Scholar 

  51. Cook PR, Begegni A, Bryant WC, Davis WE. Effect of partial middle turbinectomy on nasal airflow and resistance. Otolaryngol Head Neck Surg 1995; 113: 413–419.

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Otolaryngology and Head & Neck Surgery, Tanta University Hospitals, Tanta, Egypt

    Magdy Eisa Saafan, Hassan Moustafa Hegazy MD & Osama A. Albirmawy

Authors
  1. Magdy Eisa Saafan
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  2. Hassan Moustafa Hegazy MD
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  3. Osama A. Albirmawy
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Correspondence to Hassan Moustafa Hegazy MD.

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Saafan, M.E., Hegazy, H.M. & Albirmawy, O.A. Empty nose syndrome: etiopathogenesis and management. Egypt J Otolaryngol 32, 119–129 (2016). https://doi.org/10.4103/1012-5574.186540

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