Research articles

Research articles 2017-08-30T17:22:09+00:00
The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review

Objective: To evaluate the outcomes of surgical intervention for empty nose syndrome (ENS).

Cochrane Collaboration database, U.S National Institutes of Health database (ClinicalTrials), U.S National Library of Medicine (PubMed).
Structured search using medical subject-heading terms: nose, turbinate, surgery, atrophic rhinitis, and empty nose syndrome.
A total of 128 patients were collated from eight studies with an age range of 18 to 64 years. Most patients had been suffering with ENS for many years, up to 29.7 years. The most common surgical technique involved a transnasal approach with implant material secured within a submucosal pocket. Common implant material used in the studies included biosynthetic, and autologous cartilage. The weighted mean preoperative Sino-Nasal Outcome Test (SNOT)-20 and SNOT-25 scores were 48.3 and 65.9, respectively. At latest follow-up, these scores improved significantly to 24.4 and 33.3, respectively. Although all SNOT subdomains improved following surgery, the highest improvement was observed in ENS symptoms and psychological issues. SNOT scores improved by 3 months postsurgery and this trend continued over time, although available data was limited to only 12 months follow-up. Nevertheless, 10 patients had less than 10 points improvement, including three patients who had no change in SNOT scores. Extrusion of the implant occurred in six cases, and one developed chronic rhinosinusitis.
Surgical intervention for ENS appears to result in clinical improvement, although not all patients derived benefit. Long-term follow-up should be considered utilizing using both subjective (SNOT-25) and objective (rhinomanometry) measures of clinical outcome. Laryngoscope, 2015.
Pathophysiology of Empty Nose Syndrome

Objective: To review current knowledge on nasal airflow sensation in relation to empty nose syndrome (ENS).

PubMed searches.
Current literature pertaining to measurement of nasal patency, mechanism of sensory perception of nasal airflow, and ENS.
A reliance on pure anatomical analysis of the anatomy in ENS falls short of explaining the disorder. Our understanding of subjective nasal sensation has advanced, as has our understanding of the flow of air through the nose. Neural healing following a surgical insult may not result in a return to a normal physiologic state. Aberrations in neurosensory systems from improper healing may play a major role in the abnormal sensations ENS patients experience.
An evidence-based hypothesis for the development and symptoms of ENS is offered.
Sozansky J, Houser SM.
Empty Nose Syndrome

Objective: Review of empty nose syndrome (ENS).

Empty nose syndrome (ENS) is a rare, late complication of turbinate surgery. The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea. Little is known about the pathogenesis of ENS, though it is speculated that anatomical changes leading to alterations in local environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms are strongly implicated. The diagnosis is clinical, though often difficult to make due to the poor correlation between subjective and objective findings. Medical therapies include mucosal humidification, irrigations, and emollients. Surgical therapy should be reserved for refractory cases and may involve turbinate reconstruction, most commonly using implantable biomaterials. Ultimately, prevention of this feared complication through turbinate-sparing techniques is essential.
Kuan EC, Suh JD, Wang MB
Assessment of surgical results in patients with empty nose syndrome using the 25-item Sino-Nasal Outcome Test Evaluation

Objective: To evaluate the effectiveness of the Medpor implant (Porex Surgical Inc) to improve the disease-specific quality of life in patients with ENS and to validate the 25-Item SNOT (SNOT-25) as an assessment tool in patients with ENS.

IMPORTANCE Empty nose syndrome (ENS) is an iatrogenic disorder, which severely affects the normal nasal breathing function. People affected by ENS may experience decreased productivity and lifestyle disruption. The 20-Item Sino-Nasal Outcome Test (SNOT-20) is a validated quality-of-life measurement and can be used to compare before and after intervention outcomes. OBJECTIVES To evaluate the effectiveness of the Medpor implant (Porex Surgical Inc) to improve the disease-specific quality of life in patients with ENS and to validate the 25-Item SNOT (SNOT-25) as an assessment tool in patients with ENS. DESIGN, SETTING, AND PARTICIPANTS We prospectively enrolled 24 patients from our hospital who received inferior turbinate reconstruction surgery after drug therapy failed to improve their symptoms. INTERVENTIONS All the patients underwent submucosal Medpor implant surgery to reconstruct their inferior turbinate. MAIN OUTCOMES AND MEASURES Patient assessments were based on the SNOT-25 questionnaire prior to surgery and at 3, 6, and 12 months after surgery. RESULTS The total scores of the SNOT-25 declined postoperatively, showing a significant difference at 3, 6, and 12 months after surgery compared with their initial visit (P = .045, P < .001, and P < .001, respectively). The 5 items most frequently reported by patients as important at their initial visit were “fatigue,” “reduced concentration,” “sadness,” “dryness,” and “nose is too open.” The mean overall scores for these 5 important items also declined, showing statistically significant decreases compared with their initial visit (P < .05) and indicating that the items patients believed were important had improved. CONCLUSIONS AND RELEVANCE Medpor implant surgery in patients with ENS is associated with statistically significant improvements in disease-specific quality of life measures. The modified version of SNOT-20 Health Survey Scales, the SNOT-25,may be a useful measurement tool in patients with ENS.
Clinical analysis of submucosal Medpor implantation for empty nose syndrome

Objective: To analyse clinical outcomes of submucosal Medpor® implantation for ENS.

Empty nose syndrome (ENS) describes symptomatology and radiographic findings after surgeries on turbinates. The treatment of ENS is still debatable.
A total of 18 patients underwent submucosal Medpor® implantation from 2006 to 2011. We applied SNOT-22 (SinoNasalOutcome Test) for statistical survey of the patients’ symptoms before and after surgery.
Two patients were lost to follow up after the surgery. Most of the patients developed ENS-related symptoms gradually within 2 years to 16 years after the previous nasal surgery or treatment. The sites of submucosal implantation are mainly septum and nasal floor, unilaterally or bilaterally. There is a significant improvement of SNOT-22 pre-operatively to one year post-operatively.
The symptomatolgy remains the most important point when dealing with patients with ENS. Submucosal implantation of Medpor® is a feasible surgical treatment to ENS. A positive cotton test is suggested for the surgical indication and planning.
Numerical simulation of airflow fields in two typical nasal structures of empty nose syndrome: a computational fluid dynamics study

Objective: To investigate the nasal aerodynamic features of ENS and to explore the role of aerodynamic changes on the pathogenesis of ENS.

The pathogenesis of empty nose syndrome (ENS) has not been elucidated so far. Though postulated, there remains a lack of experimental evidence about the roles of nasal aerodynamics on the development of ENS.
Seven sinonasal models were numerically constructed, based on the high resolution computed tomography images of seven healthy male adults. Bilateral radical inferior/middle turbinectomy were numerically performed to mimic the typical nasal structures of ENS-inferior turbinate (ENS-IT) and ENS-middle turbinate (ENS-MT). A steady laminar model was applied in calculation. Velocity, pressure, streamlines, air flux and wall shear stress were numerically investigated. Each parameter of normal structures was compared with those of the corresponding pathological models of ENS-IT and ENS-MT, respectively.
ENS-MT: Streamlines, air flux distribution, and wall shear stress distribution were generally similar to those of the normal structures; nasal resistances decreased. Velocities decreased locally, while increased around the sphenopalatine ganglion by 0.20 ± 0.17 m/s and 0.22 ± 0.10 m/s during inspiration and expiration, respectively. ENS-IT: Streamlines were less organized with new vortexes shown near the bottom wall. The airflow rates passing through the nasal olfactory area decreased by 26.27% ± 8.68% and 13.18% ± 7.59% during inspiration and expiration, respectively. Wall shear stresses, nasal resistances and local velocities all decreased.
Our CFD simulation study suggests that the changes in nasal aerodynamics may play an essential role in the pathogenesis of ENS. An increased velocity around the sphenopalatine ganglion in the ENS-MT models could be responsible for headache in patients with ENS-MT. However, these results need to be validated in further studies with a larger sample size and more complicated calculating models.
Costal cartilage is a superior implant material than conchal cartilage in the treatment of empty nose syndrome

Objective: The objective of this study was to evaluate the outcomes of endonasal microplasty in treating empty nose syndrome by comparing the use of costal and conchal cartilage implants to construct neoturbinates.

Case series with chart review.
Tertiary referral center.
A total of 31 patients who were diagnosed with empty nose syndrome and underwent endonasal microplasty with conchal cartilage (n = 17) or costal cartilage implants (n = 14) were included. Each patient’s clinico-demographic profile was reviewed to compare the conchal cartilage group and the costal cartilage groups. Pre- and postoperative Sino-Nasal Outcome Test (SNOT-25) scores were also compared.
Both groups showed a significant improvement in SNOT-25 scores following surgery (P < .05). The group who received costal cartilage implants demonstrated more significant improvements than the conchal cartilage group in terms of the mean difference between pre- and postoperative SNOT-25 scores (P = .023). Symptom outcomes related to depression demonstrated significant improvements in the conchal cartilage group (P < .05), while in the costal cartilage group, in addition to these 3 variables, 7 items related to functional problems also demonstrated significant improvements (P < .05).
Costal cartilage is a more useful material than conchal cartilage as implants for the treatment of empty nose syndrome patients.
Empty Nose Syndrome

Objective: To investigate the nasal aerodynamic features of ENS and to explore the role of aerodynamic changes on the pathogenesis of ENS.

Empty nose syndrome (ENS) is a clinical entity without consensual definition; it is a rare complication of nose or sinus surgery, and of inferior turbinectomy in particular. Physiopathology remains unclear, but probably involves disorder caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and conditioning functions. Neuropsychological involvement is suspected. Symptomatology is variable and changeable, the most common sign being paradoxical nasal obstruction. Diagnosis is founded on: (1) a range of symptoms that need to be precisely collated; (2) broad post-surgical nasal permeability. Management is problematic, deploying the full range of simple nasal cavity hygiene and humidification techniques, with surgery reserved for the most severe cases; whatever the technique, surgery aims at partial filling of the nasal airway. Prevention is the most important strategy, and seeks (1) to check, before any surgery is envisaged, the reality of nasal dyspermeability resistant to medical treatment; and (2) to prefer the most conservative surgical techniques.
Reconstruction of functional nasal tissue

Objective: The expansion of autologous adipose‑derived stem cells in vitro for the functional reconstruction of nasal mucosal tissue.

It is established that adipose-derived stem cells (ADSCs) produce and secrete cytokines/growth factors that antagonize mucosal injury. However, the exact molecular basis underlying the treatment effects exerted by ADSCs is ill understood, and whether ADSCs cooperate with adipose tissue particles to improve mucosal function in patients with empty nose syndrome (ENS) has not been explored. We investigated the impact of ADSCs on nasal mucosa, the associated mechanisms, and their use in the treatment of patients with ENS.
Xiao Xu, Liang Li, Cheng Wang, Yang Liu, Chong Chen, Junling Yan, Hong Ding and Su‑yang Tang
New regenerative approach to atrophic rhinitis

Objective: New regenerative approach to atrophic rhinitis using autologous lipoaspirate transfer and platelet-rich plasma in five patients: Our Experience.

Atrophic rhinitis (AR) is a debilitating chronic nasalmucosal disease of unknown aetiology. The condition is characterised by progressive nasal mucosal atrophy, atrophy of the underlying bone of the turbinate, abnormal widening of the nasal cavities with paradoxical nasal obstruction and formation of viscid secretions and dried crusts leading to a characteristic fetor (ozaena).1 Atrophic Rhinitis was first described by Fraenkel in 1876, but the aetiology of the disease is still a matter of dispute. Various methods of treatment, both medical and surgical, have been tried without much success. However, clinical features of the disease can be attributed to the destruction of the normal respiratory epithelium and metaplasia to a nonciliated squamous epithelium and loss of mucociliary clearance. Thus the curative treatment of AR should address the reversal of this basic pathologic alteration in its microanatomy. Promotion of regeneration of normal nasal mucosa must be the aim of any treatment for long-lasting success. The aim of this article is to present a new regenerative approach to reverse atrophy of nasal mucosa by grafting autologous of lipoaspirate.

Friji, M.T., Gopalakrishnan, S., Verma, S.K., Parida, P.K. & Mohapatra, D.P.

Inferior turbinate augmentation with auricular cartilage for the treatment of empty nose syndrome.

Objective: Inferior turbinate augmentation with auricular cartilage for the treatment of empty nose syndrome.

Empty nose syndrome (ENS) is a potential complication of excessive resection of turbinate tissue. Patients with ENS complain of nasal obstruction despite a widely patent nasal cavity. Various implants, including autologous bone and biomaterials, have been used to reduce the width of the nasal cavity. Implantation of these grafts, however, has been limited by extrusion, infection, and resorption. We introduce a novel surgical technique that uses autologous auricular cartilage to augment the turbinate and to restore the natural airflow patterns of the nasal cavity. We present a representative case of ENS caused by excessive inferior turbinate reduction that was improved by turbinate augmentation with autologous auricular cartilage.

Chang AA, Watson D.

Correlation between remnant inferior turbinate volume and symptom severity of empty nose syndrome

Objective: The aim of this study was to evaluate the effects of remnant inferior turbinate volume on symptom severity.

Empty nose syndrome (ENS) is an iatrogenic disorder caused by turbinate reduction procedures, which results in considerable nasal dysfunction and severely impaired quality of life. However, there is a lack of data that explains the relationship between the degree of turbinate reduction and subjective symptoms. The aim of this study was to evaluate the effects of remnant inferior turbinate volume on symptom severity.

Hye Ran Hong MD andYong Ju Jang MD, PhD*

Correlation between remnant inferior turbinate volume and symptom severity of empty nose syndrome

Objective: The aim of this study was to evaluate the effects of remnant inferior turbinate volume on symptom severity.

Empty nose syndrome (ENS) is an iatrogenic disorder caused by turbinate reduction procedures, which results in considerable nasal dysfunction and severely impaired quality of life. However, there is a lack of data that explains the relationship between the degree of turbinate reduction and subjective symptoms. The aim of this study was to evaluate the effects of remnant inferior turbinate volume on symptom severity.

Hye Ran Hong MD andYong Ju Jang MD, PhD*

Evaluation of depression and anxiety in empty nose syndrome after surgical treatment

Objective: The aim of this study was to evaluate the change in depression and anxiety before and after surgical treatment for ENS.

Empty nose syndrome (ENS) is often associated with psychological symptoms. With the absence of psychiatric instruments utilized in the current literature, the assessment of psychological disorder is limited, and the effectiveness of surgical intervention in improving such disorders in ENS are not well understood. The aim of this study was to evaluate the change in depression and anxiety before and after surgical treatment for ENS.

Ta-Jen Lee MD1,†,*, Chia-Hsiang Fu MD1,2,†, Ching-Lung Wu MD1, Yuan-Yun Tam MD3, Chi-Che Huang MD1,2, Po-Hung Chang MD1,2, Yi-Wei Chen MD1 andMeng-Hsiu Wu MD4