What is Empty Nose Syndrome?

ENS can occur as a complication of nasal surgery and is most commonly associated with turbinate reduction. The condition of ENS is characterized by damage to nasal nerves and impaired nasal aerodynamics.

ENS can occur within weeks, months or years following turbinate surgery. It describes a nose crippled by excessive resection or damage to the inferior and/or middle nasal turbinates.

Nasal turbinates are organ of the nose within the nasal cavity. When turbinates are excessively resected (partially/ totally removed) or are significantly damaged (despite ‘adequate’ tissue remaining), normal nasal physiology is lost. When this happens, some nasal functions such as warming & humidifying air, filtering, immunologic defense, and smell are damaged.

With the destruction or loss of nasal mucosa, the nose is left in a chronic state of painful dryness, lacking necessary or correct nasal aerodynamic features, without the ability to sense air, motion, and temperature.

Breathing difficulties are central to this condition with feelings of suffocation and shortness of breath often leading to difficulty sleeping and trouble concentrating. Many have little or no sense of smell. It is not known how much turbinate tissue can be removed or damaged before it destroys the physiology of the nose, resulting in ENS.

This debilitating condition is associated with a severe reduction in quality of life.

What is Turbinate surgery?

Turbinate surgery is often proposed to correct the problem of nasal obstruction. It is thought by reducing the turbinate size, thereby decreasing airway resistance while preserving the natural function of the turbinates, breathing may be improved. However, there are serious risks associated with this surgery that are not often communicated to the patient.

There are many ways to shrink the size of the turbinates. Many of the procedures rely on cutting and scarring the tissue. Surgery can be performed either in the office or in the operating room. Turbinate reduction is commonly performed in conjunction with septoplasty or as part of sinus surgery. You may hear of many different terms being used to describe a turbinate reduction procedure. Examples of these terms are turbinectomy, cauterization, coblation, radiofrequency reduction, microdebrider resection, laser and partial resection. These all refer to different methods of reducing the size of the turbinates.

Here you can find a review of different turbinate surgeries.

What is the relation between Turbinate surgery and ENS?

Turbinate surgeries have enormous risks and can sometimes have devastating side-effects, as they can permanently damage turbinates. While careful and judicial conservative reductions of a turbinate’s volume can be sometimes beneficial to the patient, ENS-type like symptoms develop even after what seems to be conservative reductions of the turbinates, especially if they include the anterior portion of the inferior turbinates, which are essentially a vital part of the inner nasal valve.

Empty Nose Syndrome is a direct result of turbinate reduction surgery. It can happen even from so-called “conservative” procedures — the whole inferior turbinate need not be removed. The goal of turbinate reduction is to “shrink” the turbinates by removing tissue and damaging the blood supply & mucous glands. For some noses, the turbinates are “shrunk” too much. Nasal mucosal function becomes impaired and severe dryness and breathing problems result.

A sensation of suffocation known as “paradoxical obstruction” develops from weak, turbulent airflow, decreased nasal resistance & lack of air sensation. Over time the condition can progress to atrophy.

There is no way to predict if ENS will be the outcome of a turbinate procedure. Severe physical and psychological effects of this condition disable many ENS sufferers.

What is ENS? Podcasts by Dr. Steven Houser

Steven Houser, MD, is one of the world’s foremost experts on ENS.

“Introduction to ENS”  – a podcast by Dr. Houser describing the condition and its diagnosis.

‘Form versus Function’ – a podcast by Dr. Houser describing his clinical experience diagnosing patients with ENS.

What is a Turbinate?

In anatomy, a turbinate (or nasal concha) is a long, narrow and curled bone shelf with a thick, vascular, and erectile glandular tissue layer that protrudes into the breathing passage of the nose.

The turbinates divide the nasal airway into four groove-like air passages, and are responsible for forcing inhaled air to flow in a steady, regular pattern around the largest possible surface of cilia and climate-controlling tissue.

The inferior turbinates are the largest turbinates, can be as long as the index finger in humans, and are responsible for the majority of airflow direction, humidification, heating, and filtering of air inhaled through the nose.

The middle turbinates are smaller. They are usually as long as the little finger. Most inhaled airflow travels between the inferior turbinate and the middle meatus.

The superior turbinates are smaller structures, connected to the middle turbinates by nerve-endings, and serve to protect the olfactory bulb.

Please find below a complete description of Internal Nose and Paranasal Sinuses by the Official Journal of the International Rhinologic Society.

Nose and Paranasal Sinuses

How is breathing for ENS sufferers?

During inspiration, the air is heated, humidified, and cleaned. The so-called “airconditioning” within the nasal airways should guarantee an undisturbed alveolar gas exchange.” (Lindemann & Keck, 2011). However, in ENS case, patient’s “airconditioning” is severely impaired, affecting alveolar gas exchange.

Analogy is simple: in order to blow up a balloon when it is in its shrunk stage if the air hole is too big the balloon will not blow up below it; if the air hole is small then the balloon will have enough resistancy to blow itself up. Given that ENS sufferer’s turbinates have been resected and there’s a lot of air going through the nose without proper level of resistance it’s like a large hole at the end of a small balloon trying to expand itself it will only open partially and then stop. The absence of needed nasal resistance is what is causing the paradox obstruction because there’s too much air: the balloon quote lungs nose nozzle is too big.

How many people have ENS?

World-wide, there are many thousands of people who undergo turbinate surgeries. For example, in France more than 12,000 people undergo turbinate surgery every year. The exact percentage of people who develop Empty Nose Syndrome is unknown.

Thousands of people are suffering from Empty Nose Syndrome everywhere in the world.

Dr. Eugene Kern’s Lecture on Empty Nose Syndrome

Transcription here