Empty nose syndrome

Empty nose syndrome (ENS) is a medical condition that is caused when too much inner nasal mucus-producing tissue (the turbinates) are cut out of the nose, leaving the nasal cavities too empty, too wide and too dry, with severely diminished capabilities to perform their functions of conducting, filtering and humidifying the inhaled air to the lungs and with severely impaired capabilities to preserve themselves and regenerate.

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Explanation

These operations, known as 'turbinate resections', 'turbinectomies', or nasal 'conchotomies', are performed by ear nose and throat surgeons or by plastic surgeons for different reasons.

The most common reason to operate is chronic hypertrophy (over-enlargement) of the turbinates, which can block too much of the air passage in nasal airways. Among the most common causes for this condition are allergies, hormonal imbalance, too much exposure to dust, smoke and other airborne irritants, nasal structural deformities like a deviated septum and prolonged use of nasal decongesting medications.

Terminology

  The term "empty nose syndrome" was originally coined in the 1990's by Dr. E.B. Kern who was at the time head of the otolaryngology ward in the Mayo Clinic in Rochester, Minnesota, USA. He and his colleagues began to notice that more and more patients that underwent turbinectomies seemed to develop symptoms of nasal obstruction and shortness of breath even though their noses appeared to be wide open. Other symptoms were nasal dryness, dryness in mouth and throat, eye dryness, shallow unrested sleep, diminished sense of smell, difficulty concentrating, and quite often clinical depression. All the patients' CT scans showed that they had very wide and almost totally empty nasal cavities, thus they called it the "Empty Nose Syndrome". Dr. Kern then went on to give a series of lectures on ENS, and later summarized his findings in a medical article.^[1]

Effects

The nose has many functions, besides it being the most prominent feature that shapes our face: Breathing, smelling, humidifying, heat regulating and filtering the inspired air to meet the requirements of the lungs for optimal rate of function and gas-exchange, supplying the lungs with just the right amount of respiratory resistance. It's no wonder, then, that an 'empty nose' can have a huge negative impact on a person's general physical health and quality of life, and it can also cause depression, slow down and impair cognitive processes and inhibit sexual and social activities.

What happens when ENS occurs

When too much of the turbinates are resected, the nose loses its capacities to properly pressurize, direct, temperature regulate, humidify, filter, smell and sense the inspired airflow. The natural synchronization of breathing between the nose, the mouth and the lungs is also interfered, and the result is an empty, dry and crippled nose, which feels too empty and at the same time non-functional. People suffering from Empty Nose Syndrome feel a constant confusing of inability to breathe in a satisfying deep breath through their nose, their sleep becomes very shallow and many also develop sleep apnea. ENS sufferers tend to be depressed and anxious, which may cause them to avoid social interactions. Some experience problems such as Sinus pressure, nasal or facial pain.

The main problem in ENS - paradoxical obstruction:

ENS is physically characterized by grossly and abnormally enlarged airways, due to loss of the inferior or middle turbinates. This has a dramatic impact on the quality and features of the inhaled air through the nose, which results in significant breathing difficulty known as "paradoxical obstruction". This obstruction is caused by a multiple of pathological factors that occur when the turbinates are removed:

a) The airflow becomes too turbulent, hence less air gets conducted efficiently through the nose to the lungs.

b) The trigeminal airflow motion and temperature sensing receptors, embedded in the nasal mucosal layers, do not get stimulated enough, and this registers in the brain's breathing centers as a breathing obstruction.

c) The dramatic loss of humidifying, filtering and heat-transfer tissues of the turbinates reduce the quality of the air that does reach the lungs, and this results in less efficient gas exchange at the alveoli of the lungs.

d) Nasal resistance to the lungs drops below the optimal level and this weakens the elasticity of the lungs thus decreasing lung expansion resulting in a less efficient gas exchange.

e) The nasopulmonary neuro-vacular reflex is disrupted. This reflex connects the sensation of airflow in the nose to all activities of the lungs - lung excitation, pulmonary blood flow, rate of expansion, rate of contraction, which all eventually affect the efficacy of the gas exchange process.

f) The altered aerodynamics of the air-flow, causes the flow to converge too much into the lower empty cavities of the airway, which in-turn prevents proper ventilation of the upper cavities resulting in diminished sense of smell. This further diminishes the sense of airflow motion through the nose, because of synergic interactive influences between the olfactory nervous pathways and the trigeminal ones.

g) The constant state of dryness and sub-atrophy of the nasal mucosa induces rhinitis sicca which is a state of reduced blood supply to the mucosa, reduced ciliary activity and mucus secretion, resulting in more dryness and poor waste disposal which accumulates in the nasal passages and throat, which continues to impair and deteriorate all nasal functions, not to mention sensation and reflexes such as the nasopulmonary relefex (mentioned earlier), sneeze reflex, etc'.

ENS does not necessarily begin as Atrophic Rhinitis but can develop into it:

The main danger with prolonged Empty Nose Syndrome is developing Atrophic Rhinitis, which is an inflammatory, degenerating disease of the nasal cavities and sinuses, characterized by degeneration of nasal bone and soft tissue, enlarged nasal cavities and totally dysfunctional remaining nasal mucosa, which may or may not be accompanied by foul smelling secretions (known as “Ozaena”), nosebleeds and crusts.

For many years, people with ENS have been automatically labeled as suffering from Secondary Atrophic Rhinitis. "Secondary" - to imply that the chronic state of nasal atrophy was caused by surgery, as opposed to "Primary" in which the atrophy occurs from other reasons that are not induced by medical intervention. ENS is an iatrogenic condition too ("iatrogenic" = caused by medical procedure or therapy), but does not begin as full blown Atrophic Rhinitis, although very similar in some of its symptoms (mainly the breathing difficulties and the over enlarged nasal cavities). Nevertheless even in early stages of ENS there is some degree of nasal dryness present, perhaps more similar to sub-atrophic tissues or to rhinitis-sicca (a chronically dry nose) than to atrophic rhinitis. Still, it should remain a bleak warning that ENS can develop into full blown atrophic rhinitis.

The main features in ENS are the paradoxical breathing difficulties, sensation of nasal emptiness, and the sensation of an unduly patent current of too cold and too dry air impeding the remaining nasal structures and nasopharynx. to the naked eye - the remaining mucosal tissues usually seem reasonably normal and not grossly atrophic (besides the fact that a large portion of the nasal mucosa's has been lost in the turbinectomy). Over the years, due to ill health or simply initial loss of too much nasal mucosa and blood supply, the remaining mucosa can become drier and drier, and there is a danger that it will go through metaplasia and become grossly atrophic. But this seems to be more of a rarity in western societies today. The reasons for that might be the abundance of protein, fresh fruit and vegetables, clean drinking water and improved conditions of hygiene. The mechanism of how exactly atrophic rhinitis begins when it still unknown.

Symptoms

ENS can cause a wide variety of symptoms, some directly relating to the nose and others relating to other parts of the body. All symptoms listed can significantly affect a person's quality of life.

Physical symptoms may include:

• Paradoxical Obstruction: Dyspnea: Shortness of breath: feeling that although enough (and even too much air is coming in) but nevertheless one still feels short of air.
• Tend to start hyperventilation at the slightest appearance of pressure (physical or mental).
• Feeling of lack of resistance to the lungs when inhaling or exhaling through the nose: difficulty inflating the lungs properly when breathing through the nose.
• Feeling difficulty in controlling one's breath.
• Difficulty to breathe through nose calmly and slowly.
• Too much nasal air-intake when inhaling strongly through nose.
• Nasal airflow feels too dry and cold.
• Nasal membranes feel dry.
• Either too little mucus production, or constant un-stopable rhinorhea.
• Nasal pain (feels similar to a tooth-ache).
• Annoying feeling of Nasal emptiness. Whole sections of the nose, in particularly in-front, feel missing - amputated.
• Lack of nasal airflow sensation.
• Feeling that the nose is not ventilated enough.
• Diminished sense of smell and/or taste together with over-sensitivity to highly volatile compounds such as: synthetic paint, perfume, cleaning detergents, gasoline.
• Speech problems (Patients report a sensation of too much air escaping their noses or as if their noses were numb and can't sense the air as it travles through when speech is performed. Therefore they sense difficulty in controlling speech and punctuating some words, especially which involve words that are made of soft sounds like: a vowel +"n", for example- "lent", or - "safe", etc'). Sometimes the voice sounds as if the nose is obstructed.
• Thick post nasal drip or dry sticky phlegm building up in pharynx and throat.
• Hyper pulmonary sensitivity to cold and dry air, to airborne irritants and odors (such as smoke, dust, gasoline and paint fumes, etc'). Not uncommon to develop asthma and chronic bronchitis.
• Dryness in the larynx, back of the mouth, palette, tongue.
• Dry eyes.
• Sinus pressures and pain (even without clinical symptoms of sinusitis)
• Headaches
• Elevated or unstable blood pressure
• Crusts in nasal airway.
• Occasional bleeding.
• Foul smell in or from nose.
• Bad breath
• Lethargic/apathetic behaviour or affect caused by lack of oxygen and/or sinus and superior nasal regions pressure.

Certain sleep problems are also symptoms:

• Unable to sleep through the night.
• Poor quality sleep: Not feeling rested in the morning.
• Nightmares or night terrors.
• Sleep disordered breathing and sometimes full apnea.

Psychological symptoms:

• Depression.
• Anxieties.
• Social phobia (constantly avoiding social interaction)
• Loss of self esteem.
• Panic in the slightest presence of stress.
• high irratibility.
• Acute stress disorders.

Cognitive symptoms:

• Difficulty concentrating. ("aprosexia-nasalis")

Treatments

Once too much of a turbinate is resected it cannot recover, grow back, or be replaced. There are no donor sites in the human body with a similar kind of tissue. The turbinates and nasal mucosa are unique.

Non-surgical treatment

Daily irrigation and a healthy life style can slow down the progression of atrophy in-case of rhinitis sicca and atrophic rhinitis, and can help cope with the symptoms of ENS.

There are different types of treatment available for ENS. Saline (physiological salt water, 0.9% sodium-chloride) can be used to rinse out the dry mucus and moisten the nasal cavity, this could also prevent infection. Some people find relief by increasing nasal secretions by consuming large amounts of dairy products. Vitamin A and D might help with mucus production. Humidifiers can be used to help with the dryness, and in cases of sleep disordered breathing a continuous positive airway pressure (CPAP) machine with a built-in humidifier can be used. Nasal salves sooth the anterior aspects of the nasal cavity and help to reduce disease susceptablity. Acupuncture, shiatsu, inversion therapy, regular physical exercise - all these will improve the blood circulation to the nose and help preserve the remaining nasal mucosa.

All the above non-surgical treatments will help improve dryness conditions, and sustain the health of the remaining membranes, but they will not restore the lost functions or the nose and normal nasal sensations.

Surgical treatment

ENS, can be improved to varying degrees of success, though not fully cured, by trying to fabricate the structure and quality of the missing turbinates, with implants made of all sorts of materials from self donated living tissues such as bone and cartilage fragments, followed by artificial materials like - plastipore and hydroxyapatite cement and recently also biomaterials such as Alloderm and/or SIS.

If a significant portion of a turbinate remains, it can be augmented with bio-materials such as acellular dermis ("Alloderm") and SIS, two known natural biomaterials with low absorption and rejection rates. Once either of these materials is implanted in the desired area, the implants incorporate into the surrounding tissue and adopt many of the host tissue's qualities. Even if the turbinates are totally resected there is still much that can be achieved by narrowing the nasal airway at key-strategic locations with submucosal implants that will normalize airway resistance, trap moisture and increase humidifcation, and will deflect the airflow to flow more calmly and steadily. The implants help to normalize the nasal pressures and aerodynamics of airflow, restore normal nasal sensations, and improve nasal humidity. Common places for effective implantation, other than to the turbinates, is opposite the resected turbinates, inno the septum or nasal floor (see example in pictures below). The nasal lateral wall can be augmented to. Other materials can be used as implants, but none have shown the same level of success as Alloderm. Today there is also a new approved form of micronized Alloderm, brand-named Cymetra, that can be injected in liquid form. Once it is in place it solidifies and becomes like regular Alloderm. It is difficult or virtually impossible to use Cymetra on its own to achieve a large volume implant, but it can be used successfully to further augment prior Alloderm implants, thus perfecting the initial result achieved with regular Alloderm.

Alloderm implants have already been implanted successfully for a few years now in a small but growing number of ENS patients. At four years follow-up, results seem stable and encouraging. It seems that Alloderm implants can't fully cure ENS but can help alleviate the symptoms with various degrees of success, depending on the individual condition of each patient.

Dr. Steven Houser from Cleveland is a well-known American ENT surgeon who has gained quite a lot of experience with reconstructive implant surgery for ENS. He has a keen scientific interest in researching, understanding and treating ENS patients.

Hopefully, as doctors become more aware of ENS, they will reach a better understanding of its long-term effects on its sufferers' quality of life. This will hopefully encourage more surgeons to develop better ways of reconstructing resected nasal turbinates and to normalize the contours and function of the inner nasal airway anatomy and physiology.

Citations

This is what a panel of top American rhinology experts from the American Rhinological Society had to say about Empty Nose Syndrome:

"… The excess removal of turbinate tissue might lead to empty-nose syndrome. Excess resection can lead to crusting, bleeding, breathing difficulty (often the paradoxical sensation of obstruction), recurrent infections, nasal odor, pain, and often clinical depression. In one study, the mean onset of symptoms occurred more than 8 years following the turbinectomies.”

(cited from: “The turbinates in nasal and sinus surgery: A consensus statement.” By D. H. Rice, E. B. Kern, B. F. Marple, R. L. Mabry, W. H. Friedman. ENT – Ear, Nose & Throat Journal, February 2003, pp. 82-83.)

This is what Dr. E.B. Kern (former president of the American and of the International Rhinological Societies) has to say about radical turbinectomies:

“Removal of an entire inferior turbinate for benign disease is strongly discouraged because removal of an inferior turbinate can produce nasal atrophy and a miserable person. Such people unfortunately are still seen in the author’s offices; these people are nasal cripples.”

(from page 496 of chapter 23, “Nasal Obstruction”, written by Dr. E Kern, Of the book: Otolaryngology – Head and Neck Surgery, by Dr. Meyyerhoff and Dr. Rice, published by the W.B. Saunders Company, 1992).

When reexamining groups of patients who had undergone total inferior turbinectomies, and were expected by their surgeons to be well in the long run, Moore et al’ found that that was not to be the case at all, as the grim reality of those post inferior turbinectomied patients revealed itself:

“Total inferior turbinectomy has been proposed as a treatment for chronic nasal airway obstruction refractory to other, more conservative, methods of treatment. Traditionally, it has been criticized because of its adverse effects on nasophysiology. In this study, patients who had previously undergone total inferior turbinectomy were evaluated with the use of an extensive questionnaire. It confirms that total inferior turbinectomy carries significant morbidity and should be condemned.”

(from – “Extended Follow-Up Of Total Inferior Turbinate Resection For Relief Of Chronic Nasal Obstruction”, G. F. Moore, T. J. Freeman, F. P. Ogren & A. J. Yonkers., Laryngoscope, September 1985, pp. 1095-1099.)

"... The inferior turbinal should never be entirely removed... Excessive removal allows a jet of inspired ventilation, the mucus evaporates and becomes so viscid as to impede ciliary action... In some cases where the inferior turbinal has been too freely removed, the loss of valvular action and undue patency of the nostril produce the discomfort of dry pharyngitis and laryngitis, with difficulty in expelling stagnant secretion from the nose. The loss of the turbinal may lead to a condition simulating atrophic rhinitis or even ozaena."

(Thomson St. C & Negus VE. Inflammatory diseases. Chronic Rhinitis. Diseases of the nose and throat, 6th edition. London: Cassel & Co. Lmt. 1955; 124-145).

References

1. ^ Moore, E.J. & Kern, E.B. (2001). Atrophic rhinitis: A review of 242 cases. American Journal of Rhinology, 15(6)

External links

• Dr. Houser's tutorial pages on ENS
• Dr. Grossan's ear, nose and throat pages
• Listen to Dr. Kern's lecture on Empty Nose Syndrome
• Interactive Forum for ENS Patients
• The ENS book