Distinct Histopathology Characteristics in Empty Nose Syndrome

Surgical and Regenerative Treatment Options for Empty Nose Syndrome: A Systematic Review

OBJECTIVES

Patients with empty nose syndrome typically experience paradoxical nasal congestion, nasal dryness, epistaxis, and suffocation. Conservative management is generally preferred for empty nose syndrome. However, some patients continue to experience persistent symptoms. When symptoms do not resolve, surgical options are considered. Therefore, we reviewed the surgical and regenerative treatment options for empty nose syndrome.

METHODS

PubMed, Embase, Scopus, Cochrane Register of Controlled Trials, and Google Scholar were searched from the earliest date provided in the database until December 2022. This review included studies that assessed treatment outcomes using patient symptom scores, including the Sino-Nasal Outcome Test (SNOT-20, -22, and -25) and the Empty Nose Syndrome 6-Item Questionnaire, supplemented by various clinical examinations.

RESULTS

Twenty-eight studies were analyzed. Various materials were utilized, including submucosal injectable materials, allografts/xenografts/cadaveric implants, autologous implants, and synthetic implants. The polyethylene implant was the most commonly used (23.3%), followed by autologous, homologous, or cadaveric costal cartilage (20%). The anterior-inferior lateral nasal wall was the most frequent site of administration. Most studies indicated that surgical intervention led to significant improvements in clinical outcomes, as evidenced by endoscopic exams, acoustic rhinometry, and computed tomography scans, along with patient-reported enhancements in nasal symptoms, psychological well-being, and overall health-related quality of life. However, several studies found no improvement in certain psychological-related questionnaires or saccharin transit times. The average follow-up duration was 12.0 months (range, 2.0-27.6 months). Only two studies reported postoperative adverse effects.

CONCLUSION

Several surgical options and recent tissue regeneration techniques have demonstrated efficacy in treating empty nose syndrome. However, more detailed investigations involving a larger number of participants and a randomized control study are necessary to establish a standardized treatment protocol for patients with empty nose syndrome.

Computed Tomographic Evaluations in Patients with Empty Nose Syndrome

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2105-2110, 2024.

An Updated Review on Atrophic Rhinitis and Empty Nose Syndrome

Objective: Atrophic rhinitis (AR) is a rare clinical condition affecting the nasal mucosa. It is characterized by progressive nasal congestion and thick, bothersome nasal secretions. In this narrative review, pathogenesis, differences between the 2 types of AR, new management modalities, and the impact of management on lifestyle have been highlighted. Materials and Methods: An extensive literature search was conducted using PubMed, Web of Science, Google Scholar, and Saudi Digital Library databases. The articles were investigated to extract information on the pathogenesis, types, new treatment modalities, and the impact of management on lifestyle. Results: AR has primary and secondary types that affect different populations and have specific clinical presentations. Primary AR is common in women and countries with long, warm seasons. Secondary AR is the most common disease in the industrialized world. It is more common among adults who have systemic disease, have undergone extensive nasal surgery, and have experienced nasal trauma. Certain infections, autoimmune disorders, chronic sinusitis, hormonal imbalance, poor nutritional condition, and iron deficiency anemia have been suggested as etiological factors. Conservative treatment is safe, inexpensive, and effective. Hygiene, a well-balanced diet, smoking cessation, and early detection and treatment of nasal pathology can help prevent AR. Some interventions shown to improve quality of life was explained in detail. Conclusions: This paper reviewed published relevant literature on AR related to pathogenesis, types, new treatment modalities, and the impact of treatment on lifestyle, thus, providing a comprehensive view of the management and prevention of AR.

Sleep impairment in patients with empty nose syndrome

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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.

Sublabial bioactive glass implantation for the management of primary atrophic rhinitis and empty nose syndrome: Operative technique

OBJECTIVES

Atrophic rhinitis (AR) and empty nose syndrome (ENS) are chronic diseases characterized by a paradoxical nasal obstruction. These rare syndromes tend to occur after nasal surgery of the inferior turbinates in ENS and can be idiopathic in AR. Medical treatments alone are often insufficient. Surgical options are challenging and numerous resorbable and nonresorbable implants have been described in small series, with as many surgical techniques described. Whereas current surgical procedures are for risk of extrusions, graft rejections or poor lasting results, the use of GlassBONE™ (Sodimed®, Avignon, France), a bioactive glass, for a vestibular approach in AR and ENS has never been reported for this indication.

METHODS

We described an original technique of nasal submucoperiosteal bilateral ceramic glass implantation in two patients with AR and ENS.

RESULTS

The two cases presented a postoperative satisfying endoscopic and sinus CT-scan results with filling of the nasal cavities, with less crusts and a complete wound healing. They had no short-term complications.

CONCLUSION

This innovative approach is easily feasible and could be an option considered for the surgical management of AR and ENS. 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.

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

OBJECTIVES/HYPOTHESIS

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

STUDY DESIGN

Prospective case series.

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2736-E2741, 2021.

A TRiP Through the Roles of Transient Receptor Potential Cation Channels in Type 2 Upper Airway Inflammation

PURPOSE OF REVIEW

Despite their high prevalence, the pathophysiology of allergic rhinitis (AR) and chronic rhinosinusitis (CRS) remains unclear. Recently, transient receptor potential (TRP) cation channels emerged as important players in type 2 upper airway inflammatory disorders. In this review, we aim to discuss known and yet to be explored roles of TRP channels in the pathophysiology of AR and CRS with nasal polyps.

RECENT FINDINGS

TRP channels participate in a plethora of cellular functions and are expressed on T cells, mast cells, respiratory epithelial cells, and sensory neurons of the upper airways. In chronic upper airway inflammation, TRP vanilloid 1 is mostly studied in relation to nasal hyperreactivity. Several other TRP channels such as TRP vanilloid 4, TRP ankyrin 1, TRP melastatin channels, and TRP canonical channels also have important functions, rendering them potential targets for therapy. The role of TRP channels in type 2 inflammatory upper airway diseases is steadily being uncovered and increasingly recognized. Modulation of TRP channels may offer therapeutic perspectives.

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.