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

Exploring postoperative nasal airflow dynamics and impact on crust formation and mucosal healing after endoscopic tumor resection using computational fluid dynamics analysis

BACKGROUND

Postoperative observations in patients undergoing radical endoscopic resection surgery for sinonasal tumors have frequently noted the occurrence of mucosal crusts or bleeding on the nasal epithelial surface. This study employs computational fluid dynamics (CFD) techniques to elucidate the critical fluidic factors associated with these postoperative morbidities.

METHODS

Three-dimensional models of the postoperative nasal cavities were constructed using thin-section computed tomography data from nine patients who underwent radical resection surgery for sinonasal tumors, encompassing endoscopic medial maxillectomy (N = 3), endoscopic craniofacial resection (N = 3), and endoscopic resection with septectomy (N = 3). Simulations of inspiratory airflow, assuming turbulent flow, were conducted to analyze airflow and air conditioning characteristics at sites where crust formation occurred.

RESULTS

Frequent sites of crusting or bleeding were associated with the maxillary or sphenoidal sinuses (five out of nine subjects), where the ostia were substantially enlarged due to the surgery. Two distinct fluid dynamic features contributing to crust formation were identified. In five cases, crusts formed where local wall shear stress was elevated, while in four cases, crusts were observed in regions characterized by stagnant flow. Additionally, the relative humidity in the nasopharynx decreased to an unsatisfactory range (83.8‒85.7%).

CONCLUSION

This study demonstrated that two distinct fluid dynamic environments conducive to postoperative crust formation are possible, indicating that the wall shear stress level alone is insufficient for crust formation. Additionally, impaired humidification function observed following the surgery underscores the necessity of providing adequate moisturization for post-surgical care.

Use of bovine-derived collagen matrix in the surgical treatment of empty nose syndrome

KEY POINTS

Bovine-derived collagen matrix (BDCM) is a safe augmentation material in patients with empty nose syndrome. BDCM augmentation results in clinically and statistically significant improvement in nasal symptoms. Improvements in nasal symptoms with BDCM augmentation may be durable and can be seen up to 2 years postoperative.

Stepwise Empty Nose Syndrome Evaluation (SENSE) test-A modified cotton test for reduced bias in office diagnosis of empty nose syndrome

INTRODUCTION

Diagnosis of empty nose syndrome (ENS) relies on the ENS six-item questionnaire (ENS6Q) with a score of ≥11, followed by a "positive" cotton test yielding seven-point reduction from baseline ENS6Q score via cotton placement to the inferior meatus (IM). Given the intricacies of diagnosing ENS and the propensity for false positives with the standard cotton test, we modified the classic single-step cotton test into a four-part Stepwise Empty Nose Syndrome Evaluation (SENSE) cotton test to reduce bias and evaluate the placebo effect.

METHODS

Individuals diagnosed with ENS underwent the SENSE test, a single-blinded, four-step, office-based cotton test, without topical anesthesia or decongestants. Conditions included: (1) placebo/no cotton placed; (2) complete cotton-blockade of nasal vestibule; (3) cotton placed medially against the nasal septum; and (4) cotton placed laterally in the IM (site of inferior turbinate tissue loss). With each condition, patients completed an ENS6Q.

RESULTS

Forty-eight ENS patients were included. Twenty-nine percent demonstrated a placebo effect (p < 0.001), 40.4% had a positive response to complete cotton-blockade (p < 0.001), 64.4% to septum-placed cotton, and 79.1% to IM-placed cotton (p < 0.001), corresponding to a mean ENS6Q reduction of 11.9 points (p < 0.001). Notably, the mean difference in ENS6Q scores between septum and IM placement was 1.7 (p < 0.001).

CONCLUSIONS

The SENSE test offers further insight into subtleties of nasal breathing experienced by ENS patients. The placebo effect can be prominent and important to consider with individual patients. While most ENS patients prefer any intranasal cotton placement over baseline, blinded testing reveals these patients can accurately discriminate minimal changes in nasal aerodynamics.

Application of a Novel 3D-Printed Nasal Plug as a Conservative Treatment for Empty Nose Syndrome

OBJECTIVE

Empty nose syndrome (ENS) is commonly treated by surgery, albeit with limited success. Herein, we introduce our experience of applying a newly developed "3D-printed nasal plug" as an alternative conservative treatment modality.

METHODS

This retrospective study included 20 patients (14 males, 6 females; mean age 46.5 ± 13.5 years) with ENS who underwent the application of the 3D-printed nasal plug at Asan Medical Center between June 2022 and May 2023. Symptom improvement was assessed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) before and after applying the nasal plug. Clinical results, such as duration and frequency of plug use, discomfort, and level of satisfaction, were investigated.

RESULTS

The mean follow-up duration was 40.3 ± 24.2 weeks. The average duration of nasal plug usage was 10.8 h per day and 5.3 days a week. The ENS6Q scores improved from 19.6 ± 4.6 to 6.8 ± 5.1 (mean reduction 12.8 ± 5.9) after 30 minutes of wearing. Symptom "nose feelings too open" was improved most by a score of 3.0 ± 1.5 (p < 0.001). Thirteen patients (65.0%) reported that the effectiveness of the plug, initially confirmed at the first wearing, was well maintained during the entire follow-up. Four patients (20.0%) wore the nasal plug uninterruptedly throughout the week, whereas nine patients (45.0%) wore it intermittently as needed. Frequently reported complaints with plug usage were 'displacement of the plug' and 'cosmetic concerns' about the visible hook portion.

CONCLUSION

A 3D-designed nasal plug can be a useful conservative treatment option for ENS patients.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:3935-3940, 2024.

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.

Autologous fat injection for empty-nose syndrome

AIMS

Inferior meatus augmentation by injection or implants is one of the treatments for empty-nose syndrome (ENS), but levels of evidence of efficacy are low. We present the technique and evaluate our experience. The primary objective was to analyze changes in Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores after treating patients with ENS by autologous fat injection. Secondary objectives were the analysis of the evolution of each of the six ENS6Q items and identification of complications. Eleven patients underwent a minimally invasive approach to limit nasal airflow using fat injection between March 2021 and December 2022.

RESULTS

Ten of the 11 patients showed a decrease in overall ENS6Q score (P=0.0058); 6 had a final ENS6Q score<11. Ten were satisfied with the procedure, but remained symptomatic. The procedure did not result in any complications.

CONCLUSION

These encouraging results confirm the data in the literature suggesting that fat injection improves symptomatology in empty nose syndrome. However, like other minimally invasive approaches to limit nasal airflow, it does not eliminate all symptoms. These results need to be confirmed by studies on larger cohorts with longer follow-up, preferably in a multicenter setting.

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.

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.

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.

The Serpentine Sign: A Reliable Endoscopic and Radiographic Finding in Empty Nose Syndrome

OBJECTIVE

Empty nose syndrome (ENS) is a relatively uncommon disease that greatly impacts the quality of life and presents diagnostic challenges. We sought to identify objective clinical findings unique to patients with ENS, and in doing so identified compensatory mucosal hypertrophy in an alternating, undulating swelling on endoscopy and coronal computerized tomography (CT) that we have termed the "Serpentine Sign." Here, we investigated whether this radiographic finding is a reliable manifestation in ENS patients.

METHODS

Retrospective review was undertaken to identify ENS patients with past turbinoplasty, an ENS6Q score of at least 11/30, and symptomatic improvement with the cotton placement test. Control patients without complaints of ENS symptoms (ENS6Q < 11) were identified for comparison. ENS and control patients had coronal CT imaging available to evaluate for the Serpentine Sign, as well as ENS6Q scores, and histologic analysis of nasal tissue.

RESULTS

34 ENS and 74 control patients were evaluated for the presence of the Serpentine Sign. Of the 34 patients with ENS, 18 exhibited this radiographic finding on CT imaging (52.9%) compared to 0 of the 74 control patients (p < 0.0001). Further analysis demonstrated that ENS patients with the Serpentine Sign had lower median scores on ENS6Q than ENS patients without (17.5 vs. 22, p = 0.033). Histology revealed disorganized subepithelium rich in seromucinous glands similar to the nasal septum swell body.

CONCLUSION

The "Serpentine Sign" is a unique presentation of hypertrophic change to the nasal septum soft tissue that is specific to ENS patients and may serve as a reliable radiographic and endoscopic finding in diagnosis.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1089-1095, 2024.

Facial Pain Triggered by Inferior Turbinate Partial Resection in a Patient with a Previous History of Inferior Meatal Antrostomy: A Case Report

OBJECTIVES

Inferior meatal antrostomy (IMA) is regarded as a safe method, with minimal complications, for managing various lesions in the maxillary sinus. However, in patients with persisting IMA window, resection of the inferior turbinate may result in direct airflow into the antrum, irritating the antral mucosa.

METHODS

Case report and review of literature.

RESULTS/CASE

The present report describes a 29-year-old man who previously underwent unilateral IMA for the excision of a dentigerous cyst. The patient did not report any facial pain following the excision of the cyst. One year later, this patient underwent partial resection of the inferior turbinate for the resolution of nasal stuffiness by another surgeon. Soon after surgery, the patient developed severe facial and ocular pain on the side of the IMA, with the pain being especially aggravated upon inhalation. Endoscopy and computed tomography (CT) revealed a persisting IMA window. The patient's severe discomfort was thought to result from direct airflow into the maxillary sinus, as the resected turbinate may have altered normal nasal airflow. A unilateral inferior meatal augmentation procedure (IMAP) with an autologous ear cartilage implant was performed, resulting in complete relief of pain and discomfort.

CONCLUSIONS

Although IMA alone is a relatively safe surgical procedure, care should be taken when performing inferior turbinoplasty in patients with persistent IMA opening.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

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.

Optimizing Quality of Life and Minimizing Morbidity through Nasal Preservation in Endoscopic Skull Base Surgery: A Contemporary Review

Introduction  Endoscopic endonasal approaches (EEAs) are increasingly utilized for intracranial pathology. As opposed to sinonasal tumors, the nasal cavity is being used as a corridor to access these intracranial tumors but is not the site of primary surgical intent. Accordingly, there has been recent interest in preserving intranasal structures not directly involved by tumor and improving postoperative sinonasal quality of life (QOL). Objectives  The aim of the study is to highlight recent advances in EEA techniques focused on improving sinonasal QOL including turbinate preservation, reducing the morbidity of reconstructive techniques, and the development of alternative minimally invasive EEA corridors. Methods  The method of the study involves contemporary literature review and summary of implications for clinical practice. Results  Nasoseptal flap (NSF) harvest is associated with significant morbidity including septal perforation, prolonged nasal crusting, and external nasal deformities. Various grafting and local rotational flaps have demonstrated the ability to significantly limit donor site morbidity. Free mucosal grafts have re-emerged as a reliable reconstructive option for sellar defects with an excellent sinonasal morbidity profile. Middle turbinate preservation is achievable in most EEA cases and has not been shown to cause postoperative obstructive sinusitis. Recently developed minimally invasive EEA techniques such as the superior ethmoidal approach have been described to better preserve intranasal structures while allowing intracranial access to resect skull base tumors and have shown promising sinonasal QOL results. Conclusion  This contemporary review discusses balancing effective skull base reconstructive techniques with associated morbidity, the role of turbinate preservation in EEA, and the development of unique EEA techniques that allow for increased nasal structure preservation.

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.

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.