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

Medial Flap Turbinoplasty is Unlikely to Cause Empty Nose Syndrome

BACKGROUND

Empty nose syndrome (ENS) is a poorly understood condition that affects a minority of patients who undergo inferior turbinate (IT) surgery. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) was validated to diagnose ENS following IT reduction, with an ENS6Q ≥ 11 being suggestive of ENS. Medial flap turbinoplasty (MFT) involves IT bone removal ± submucosal reduction (SMR) and is highly effective at surgically treating IT hypertrophy. This study's purpose was to determine the incidence of ENS following MFT by comparing ENS6Q scores preoperatively and postoperatively.

METHODS

A retrospective cohort study was conducted on consecutive patients who underwent bilateral MFT with or without septoplasty to address nasal obstruction. Preoperative and postoperative nasal obstruction and septoplasty effectiveness (NOSE, 0-20) and ENS6Q (0-30) scores were compared at a minimum 12 months postoperatively.

RESULTS

Of 100 patients, mean age was 48.9 years and 53% were male. Mean follow-up was 25.0 months (range: 12-66 months). Patients underwent MFT with SMR in 70% of cases, whereas 30% had bone removal only, and 79% had septoplasty. NOSE scores decreased significantly postoperatively (mean 9-point reduction, p < 0.0001). Mean preoperative and postoperative ENS6Qs were 8.5 and 3.0, respectively, with a mean 5.6-point decrease postoperatively (p < 0.0001). While some patients developed elevated ENS6Q scores mainly in the first 3 months postoperatively, no patients had ENS6Q scores ≥11 at final follow-up.

CONCLUSIONS

MFT ± septoplasty led to significant long-term reduction in nasal obstruction, with no patients ultimately developing ENS6Q ≥ 11 postoperatively. Therefore, MFT was unlikely to cause ENS.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:1622-1627, 2025.

Subtotal Middle Turbinate Resection in Patients with Chronic Rhinosinusitis with Nasal Polyps is Unlikely to Cause Empty Nose Syndrome: A Multi-Institutional Prospective Study

BACKGROUND

Empty nose syndrome (ENS) is a poorly understood, debilitating condition affecting a minority of patients who underwent nasal airway surgery, most commonly following inferior turbinate surgery. Few publications have demonstrated middle turbinate resection (MTR) causing ENS, but MTR is still considered a potential cause of ENS. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) is validated for ENS diagnosis, with ENS6Q ≥ 11 considered highly suggestive of ENS. The purpose of this multicenter study was to determine the incidence of patients with ENS6Q ≥ 11 following subtotal MTR during endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) by comparing preoperative and postoperative ENS6Q scores.

METHODS

A multi-institutional prospective cohort study (8 US institutions) was conducted on patients who underwent bilateral subtotal MTR during ESS for CRSwNP. Preoperative and postoperative ENS6Q scores were compared after at least 12 months of postoperative follow-up.

RESULTS

Of 110 patients, mean age was 51.6 years and 59.1% were male. Mean follow-up was 14.5 ± 2.5 months (range 12.1-22.3 months). Mean preoperative and postoperative ENS6Q were 7.7 and 2.2, respectively, demonstrating a mean 5.5 point decrease postoperatively (p < 0.0001). At final follow-up, no patient had an ENS6Q ≥ 11. Of note, 20% of patients had preoperative ENS6Q scores ≥11, but all decreased to <11 postoperatively.

CONCLUSIONS

Based on prospective multicenter data over 1-2 years postoperatively, subtotal MTR for CRSwNP never led to ENS6Q scores ≥11, and patients experienced significant decreases in ENS6Q postoperatively. Subtotal MTR during ESS for CRSwNP was, therefore, unlikely to cause ENS even with long-term follow-up.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:59-65, 2025.

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

KEY POINTS

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

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.

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.