Empty nose syndrome (ENS) is an iatrogenic nasal disorder that occurs when too much of the nasal turbinates are resected. The turbinates have many important roles in the respiratory system. They offer protection of heat exchange, humidification and filtration to the nose the pharynx, larynx, trachea and lungs, and help to preserve the body from dehydration, by cooling down and trapping most of the water vapor that is retrieved from the lungs upon exhalation, and there is even evidence that they help to keep the brain from over heating.[1]

They also create an adequate level of nasal resistance that is crucial for deep pulmonary breathing. In addition they direct most of the airflow to flow through the middle meatus (the passage between the inferior and middle turbinate) and provide a heavily innervated surface area of pressure receptors to inform the brain that air is traversing the nose in a sufficient volume to sustain life.[2][3]

When an inferior nasal turbinate, or a middle turbinate, are over resected the nose and the pharynx usually become chronically dry and irritated (perhaps even inflamed) and the lungs suffer from poorer quality of ventilation and gas exchange, in addition to a more shallow pattern of breathing that emerges. In addition, nasal airflow sensation is severely reduced and the patients feel as if their nose is not traversing enough air although it is wide open. This sensation is known as 'paradoxical obstruction'. This sensation varies in it's intensity between patients, but generally speaking it causes a chronic and debilitating breathing difficulty which significantly reduces the quality of life and sense of well-being.[4][5][6][7][8]

ENS usually occurs after radical inferior turbinectomy, as the inferior turbinate is the largest nasal turbinate and processes most of the inspired airflow. The inferior turbinate is also responsible for deflecting most of the air to flow through the middle meatus (the passage between the middle and inferior turbinates). The middle meatus is the area of mucosa most sensitive to airflow sensation in the inner nose. If not enough air gets deflected into it, or if the air flows too slowly through it - 'paradoxical obstruction' sensation occurs. When ENS occurs because of inferior turbinate resection it is termed ENS-IT.

The middle turbinate plays a less important role than the inferior turbinates do, in all aspects of airflow conditioning and nasal aerodynamics. However it is crucial for protecting the superior olfactory regions of the nose and the sinus openings and harbors some olfactory nerve endings in it too. It's resection can shock these very sensitive superior areas of the nose and cause them to be chronically dry, and this in itself can cause ENS symptoms to emerge. ENS following middle turbinate resection is termed ENS-MT.[9] When ENS appears after both types of turbinates have been over resected, it is termed ENS-both.

The main symptoms of ENS are:

Nose feels too empty/hollow/absent.
Extreme sensation of dryness of the nasal cavities, with or without crusting.
Hardly any moisture production.
Dryness of the pharynx, soft palate and back of the tongue.
Feeling of needing more nasal resistance (or membrane responsiveness) to breathe.
Difficulty breathing in deep.
Nasal cavities and sinuses over sensitive to cold air.
Increased pulmonary sensitivity to air-borne irritants and cold air.
Breathing difficulties due to: nasal dryness and/or pharyngeal dryness and/or over taxation of bronchi with cold and dry air.
Diminished nasal airflow sensation feedback ('paradoxical obstruction').
Phantom limb sensations (which some experience as actual pain).
Increased hypersensitivity to different volatile scents like - smoke, perfume, gasoline, which cause gagging and feeling sick, but at the same time a marked reduction in the ability to smell casually during relaxed breathing or eating.
Difficulty projecting or resonating speech.
Feeling weak and depleted of energy.
Poor quality of sleep.
Difficulty concentrating ('aprosexia nasalis').
Marked reduction in sense of self and very crippled sense of well-being, coupled with very irritated and/or depressed mood, avoidance of social interactions, anxieties, difficulty making simple every day decisions, and often clinical depression.

Other charateristic symptoms that many ENS patients may develop:

Thick constant drainage at the back of the nose and throat.
Chronic sinusitis.
Dry eyes.
Worsening of pre surgical nasal symptoms, such as allergic rhinitis, etc'.
Epitaxis.
Hardly any mucus production, or the opposite - unstopable rhinoreah.
Foul smell from nasal cavities.

Terminology

The term "empty nose syndrome" was originally coined in the early 1990s by Dr. E.B. Kern (MD.) 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 who had undergone aggressive resections of their inferior or middle turbinates seemed to develop symptoms of nasal obstruction and shortness of breath even though their noses appeared to be wide open, following partial or total turbinectomies. Other hallmark symptoms were chronic nasal dryness, difficulty concentrating, and often clinical depression. They found that all these symptoms and more, in all the patients examined, developed only after their inferior or middle turbinate were over aggressively resected.

All the patients had CT scans that showed abnormally wide and empty looking nasal cavities, thus they called it - "Empty Nose Syndrome".[10]

ENS is often referred to also as 'secondary atrophic rhinitis', because it is believed that the over exposed and wide cavities may become atrophic over time ('secondary'= caused by surgery or other medical intervention, or direct trauma to the nose, as opposed to 'primary' which develops because of systemic illnesses). However, developing an atrophic mucosa on top of ENS is not a prerequisite for diagnosing a post-turbinectomy patient with ENS.

In ENS the mucosa in the over exposed cavities, where the turbinates were over resected, becomes chronically dry and in some cases even atrophic. But, unlike in atrophic rhinitis, this dryness or atrophy is caused directly by the direct impact of over turbulent and dry airflow and not because of chronic inflammation of the mucosa that occurs in atrophic rhinitis. So, perhaps a more accurate description, when comparing the two, would be to say that ENS symptoms can appear do be similar to those of atrophic rhinitis, but unlike the latter the dryness or atrophy in ENS is not of a progressive inflammatory kind.

Treatment options

Non-surgical treatment options are meant to maintain and slightly improve the health of the remaining nasal mucosa in the ENS nose, by keeping it moist and free as possible from irritation and infection.

Surgical treatment is meant to try to permanently improve the severity of the symptoms.

Non-surgical treatment

Non-surgical treatments will not cure ENS, because it cannot restore the missing turbinates, but it can help control some of the symptoms and make the suffering more tolerable:

ü Daily nasal irrigations of regular saline are always recommended. Many patients prefer to use Ringer Lactate solution instead, as they find it's easier on the mucosa than regular saline, and there are some empirical studies that back up that claim.

ü Saline, Ringer Lactate, or hyaluronic acid based - nasal mist sprays, or gels, are always helpful when proper irrigation is not possible.

ü Sesame oil can help in cases of extreme dryness and crusts.

ü Sleeping with a cool mist humidifier.

ü Sleeping with a CPAP machine that has a built-in humidifier.

ü Some patients respond well to orally taken vitamin A and D.

ü Acupuncture and shiatsu meant to improve nasal blood supply and nerve function.

ü Dressing warm, drinking plenty of water and sleeping in a warm environment.

ü Regular physical activity and a healthy life style are most important too.

Surgical treatment

The underlying rational of surgery is to restore the inner nasal geometrical structure of the nasal passages of air (the inferior, middle and superior meatuses).

Turbinate tissue is unique and there are no potential donor sites in the body to harvest similar tissue from. However, in the nose, Form = Function. It is therefore possible to restore some function by restoring the natural contours and proportions of the nasal passages: It is possible to create an artificial look alike structure of a turbinate in the nasal cavities, and thus - to regain some of the nose's capabilities to adequately pressurize, streamline, heat, humidify, filter and sense the airflow.

By implanting different grafts and material underneath the patients' submucosa at the right places - the surgeon hopes to create a look alike turbinal structure which will do four things:[11]

a) To restrict the amount of airflow, just enough to allow the nasal mucosa to cope better, while still allowing enough air to pass through for all needs of breathing. This is referred to as normalizing the nasal rates of resistance.

b) To restore close to normal rates of nasal mucosal heat and humidity, as the implant projections trap the heat and moisture in the air returning from the lungs.

c) To normalize the post surgical disrupted airflow patterns of the nose and make sure that the vast majority of airflow is redirected into the middle meatus of the nose.

d) To increase the mucosal surface in the nose that comes in contact with the airflow. This increases airflow sensation, amongst all the other things that are mentioned above that help improve the sensation too.

The following is a short video demonstrating Alloderm implantation to create a septal neo-inferior-turbinate in a cavity where the original IT was completely resected and of augmenting a partially reduced inferior turbinate in the other cavity with adding some Alloderm strips to it. Preformed by Dr Steven Houser:

Dr. Houser's Alloderm implant procedure

Implant Materials

The bulking up of the sub-mucosa and mucosa to create a neo-turbinate structure can be achieved through implanting some supporting material between the bone/cartilage and the submucosal layer. Many materials have been tried over the past 100 years. In most cases this operation was used to restore heat and humidity to atrophic noses.

Generally speaking - the implant materials can be divided into 3 groups:

autografts: bone, cartilage, fat, etc' from one site to another in the same patient. The problems here are relative shortage of tissue, and long term studies have shown high absorption rates in the nose.

foreign materials: such as - hydroxyapatite, fibrin glue, Teflon, gortex, and plastipore, which solve the shortage problem of autografts, are easy to shape and don't tend to get absorbed. However they have a high extrusion rate, and sometimes cause infection.

allografts: In the last decade scientists have been able to harvest and remove away genetic markers of some basic human tissues (like skin dermis) from donors, and thus supplying a human natural implant material which will not stimulate the immune system to reject it. A good example for such material is acellular dermis (brand named - "Alloderm"). It does not get resected and in most areas retains most of it's volume over long periods.

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 cannot fully cure ENS but can help alleviate much of the suffering, with various degrees of success, depending on the individual condition of each patient. Dr. Steven Houser from Cleveland is an American ENT surgeon who has gained probably the most extensive experience to date in surgically treating ENS.

The ideal implant material, other than real original turbinate tissue (which is still an impossibility at this time and age), should be something with low extrusion and rejection rates, minimal infection risk, and very importantly - that will provide a strong and endurable enough structure and at the same time allow good permeability for blood vessel incorporation, which seems to be the key against long term absorption.

Additional Citations

"The symptom that most often indicates ENS is paradoxical obstruction: subjects may have an impressively large nasal airway because they lack turbinate tissue, yet they state they feel they cannot breathe well. There is no clear way to describe the breathing sensation that patients with ENS experience. Some patients may state that their nose feels “stuffy,” for lack of a better word, whereas others state their nose feels too open, yet they cannot seem to properly inflate the lungs; they feel they need some resistance to do so. Patients with ENS do not sense the airflow passing through their nasal cavities, whereas their distal structures (pharynx, lungs) do detect inspiration; the patients’ central nervous systems receive conflicting information. These patients seem to be in a constant state of dyspnea and may describe the sensation of suffocating. The constant abnormal breathing sensations cause these patients to be consistently preoccupied with their breathing and nasal sensations, and this often leads to the inability to concentrate (aprosexia nasalis), chronic fatigue, frustration, irritability, anger, anxiety, and depression."

(Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863).

"… 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.”

(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.)

"Empty nose syndrome: Some patients who have had excision of the inferior and/or middle turbinates may report increased symptoms thereafter. They may report a reduction in nasal mucus, nasal dryness or sensation of nasal obstruction or blockage and a general reduction in their sense of well-being.

Out of concern for this problem, many surgeons are now reluctant to perform any significant amount of surgical turbinectomy. As a result, preservation of as much turbinate tissue as is possible is now considered by many to be an important part of surgical management. Many surgeons will only remove a very small portion of the middle turbinate if absolutely necessary in order to achieve adequate visualization or to remove devitalized tissue. Operative descriptions of the extent of resection may be variable, and the endoscopist should make an independent assessment of the amount of resection performed. Radiofrequency ablation of the turbinates (e.g. Somnoplasty) has not caused the same problems as surgical turbinate reduction."

(Wellington S. Tichenor, MD; Allen Adinoff, MD; Brian Smart, MD; and Daniel Hamilos, MD. The American Academy of Allergy Asthma Immunology Work Group Report: Nasal and Sinus Endoscopy for Medical Management of Resistant Rhinosinusitis, Including Post-surgical Patients November, 2006. Prepared by an Ad Hoc Committee of the Rhinosinusitis Committee.)

“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: "Otolaryngology – Head and Neck Surgery", Page 496, chapter 23. Chapter written by Dr. Kern. Book by Dr. Meyyerhoff and Dr. Rice, published by the W.B. Saunders Company, 1992).

“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).

"...Resistance to air currents on inspiration and during expiration is necessary to maintain elasticity of the lungs."

(Cottle MH. Nasal Breathing Pressures and Cardio-Pulmonary Illness. The Eye, Ear Nose and throat Monthly. Volume 51, September 1972.)

References

Willem J. Hillenius. The Evolution of Nasal Turbinates and Mammalian Endothermy. Paleobiology, Vol. 18, No. 1. (Winter, 1992), pp. 17-29.
Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863
Elad D, Naftali S, Rosenfeld M, Wolf M. Physical stresses at the air-wall interface of the human nasal cavity during breathing. J Appl Physiol. 2006 Mar;100(3):1003-10.
Rice, Kern, Mabry, Friedman. The turbinates in nasal and sinus surgery: A consensus statement. Ear Nose & Throat Journal, Feb' 2003.
Grutzenmacher S, Lang C and Mlynski G. The combination of acoustic rhinometry, rhinoresistometry and flow simulation in noses before and after turbinate surgery: A model study. ORL (Journal) volume 65, 2003, pp 341-347.
Kern E.B. & Moore E.J. Atrophic rhinitis: A review of 242 cases. American Journal of Rhinology, 15(6),(2001)
Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863.
Thomson St. C. & Negus VE. Inflammatory diseases. Chronic Rhinitis. Diseases of the nose and throat, 6th edition. London: Cassel & Co. Lmt. 1955; 124-145
Houser SM. Empty nose syndrome associated with middle turbinate resection. Otolaryngol Head Neck Surg. 2006 Dec;135(6):972-3.
Moore, E.J. & Kern, E.B. (2001). Atrophic rhinitis: A review of 242 cases. American Journal of Rhinology, 15(6)
Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863.