Empty Nose Syndrome

Introduction

Empty Nose Syndrome (ENS) is caused when too much turbinate mucosal tissue is removed from a person's nasal cavity. Turbinate surgery, which is most commonly performed by Ear Nose and Throat specialists (ENT's), is performed when a patient has persistent nasal obstruction which does not respond to common therapies, such as decongestants and nasal steroids. The most common operation is a Inferior Turbinectomy, which decreases the size of the inferior turbinates. A partial turbinectomy removes around two thirds of the turbinate's mucosa and bone. A total turbinectomy is a complete resection of the entire turbinate.

There is no standard, however, of how much turbinate tissue can be removed before it causes damage to the physiology of the nose, thus resulting in ENS.

Please read the Turbinate tutorial to learn more about the turbinates and their functions.

Fig 1: Right lateral wall of the nasal cavity with all right side turbinates and right side olfactory bulb.	Fig 2: Front mid-section of both sides of nasal cavities presenting all three pairs of turbinates.

Over resection of the turbinates ruins the nose’s ability to function:

The turbinates make up most of the inner nose’s functional tissue. The nose has three major roles, all vital for keeping the lungs fully functional and healthy. Those roles are: supplying 50% of lung resistance, adjusting the inspired air to body temperature, filtering the inspired air and humidifying it before it reaches the delicate tissues of the lungs.

The key to understanding how the turbinates enable the nose to perform those functions so well is in understanding the impact of the unique form and location of the turbinates in the nasal airway.

The turbinates receive the inspired air as a turbulent current and they deflect it to stream through narrow groove like passages (known as meatuses). This form of organized air streaming, is called – “Laminar” airflow. It causes the air to come in contact and utilize the maximum amount of nasal mucosa for effective temperature regulation, filtration, humidification and sensing (airflow and olfaction) the inspired air before it enters the lungs.

Resecting too much of the turbinates, alters their form, thus upsetting the laminar airflow and causing it to be more turbulent. This reduces the ability of the nose to function and perform it’s roles:

Fig 3: Optimal function of the turbinates in the right nasal airway: Directing and deflecting the airflow to stream in a laminar fashion through the meatuses (under and above the turbinates, heating, humidifying, filtring and sensing the inspired air.	Fig 4: The front head of the inferior turbinate, at the site of the internal nasal valve.

Three major problems associated with removal of significant turbinate tissue:

1. Nasal Resistance

The nasal airway creates 50% of the total respiratory resistance to the lungs. This resistance is caused by the turbinates forcing the inspired air to be sucked in by the lungs through very narrow passages. This is vital for maintaining the needed amount of negative pressure (vacuum force) to the lungs, so that they can maintain a strong enough suction power, which is crucial for proper inflation of the lungs and full exploitation of their alveoli surface capacity (where the gas exchange of the breathing process occurs).

When the turbinates are radically reduced, this proper nasal resistance is diminished and this decreases the suction power of the lungs, forcing the patient to breathe in much harder to receive normal amounts of oxygen. This phenomena manifests its self as chronic shortness of breath, and is known as “paradoxical obstruction.” The paradox being the fact that although the nose is wide open – the end result is obstruction.

2. Heating and Humidification by the Nose

When significant portions of the turbinates are removed, this significantly decreases the mucosal surface area. This decrease in mucosal tissue diminishes much of the nose’s capacity to condition the air before it reaches the lungs A normal nose will adjust the inspired air to body temperature and humidify it to about 98% humidity. With major turbinate tissue removed, the nose can’t provide this essential heat and humidity to the lungs, which, in turn, can cause pulmonary dysfunction.

3. Neural Functions of the Nose

Because turbinate tissue contains much of the nose’s innervated nasal tissue, when a substantial amount of tissue is removed, it compromises many nerve related functions of the nose.

When the inferior or middle turbinates are resected the nose loses much of its Trigeminal nerve supply, which means the remaining tissue can’t properly sense airflow, temperature, and nasal humidity.

Compromising the Trigeminal nerves can also interfere with the lower respiratory airway’s constriction and expansion responses (known as naso-pulmonary reflex). The loss of the nose’s ability to sense inspired air can cause a sensation known as “paradoxical obstruction” which causes constant shortness of breath.

The olfactory nerves are compromised as well. The turbulent airflow does not allow much air to pass over the olfactory nerves, which reduces one’s abilities to smell and to taste.

Fig 5: Before surgery.	Fig 6: After Bilateral Total Inferior Turbinectomy.

Fig 7: Before surgery (CT).	Fig 8: After Bilateral Total Inferior Turbinectomy(CT).Now the nose is an "Empty Nose".

ENS Symptoms

All of these symptoms, particularly the breathing and psychological symptoms, have been reported by ENS sufferers using our registration page on the ENS Association website. According to our research, a person with ENS suffers from a majority of the symptoms listed below.

Breathing Symptoms

• Shortness of breath (dyspnea)
• Chest tightness
• Breathing troubles while exercising
• Abnormal heart rate when exercising
• Unable to control breathing

Psychological Symptoms

• Anxiety
• Depression
• Hopelessness
• Feelings of impending doom
• Inability to concentrate
• Emotionless
• Anger
• Feeling overwhelmed
• Avoidance of social situations

Physical Symptoms

• Fatigue
• Extreme nasal dryness
• Nasal pain
• Sinusitis
• Nasal emptiness and lack of airflow sensation
• Constant headaches
• Diminished or loss of smell and taste
• Speech problems
• Thick post nasal drip
• Coughing attacks due to dry sticky phlegm
• Dryness in throat, palette, tongue
• Ear pressure and/or fluids in ear
• Facial pain
• High Blood pressure
• Crusting of nasal mucosa
• Nasal bleeding
• Foul smell from nose (Ozaena)

Sleep problems

• Unable to sleep though the night
• Not feeling rested in the morning.
• Nightmares or night terrors

Fig 9: Low pressurized turbulent air flow after inferior turbinectomy, mainly flowing in the inferior meatus, and hardly reaching the middle and superior meatuses. This nose will suffer from poor sense of smell and paradoxical obstruction due to poor conduct of airflow.Poor perfomances of heating and humidifying too.	Fig 10: Low pressurized turbulent air flow after inferior turbinectomy causing paradoxical obstruction during sleep, and forcing mouth brathing, resulting in oral airway semi-obstruction, snoring and sleep disturbances.

The Number One Symptom

The most common and debilitating symptom reported by ENS sufferers is a constant shortness of breath. Another name for this symptom is dyspnea. Dyspnea is very disruptive to every day life because it can cause all of the psychological symptoms that ENS suffers complain about.

In a famous article exploring how turbinectomies cause ENS and Secondary Atrophic Rhinitis, Professor Kern, who coined the name "Empty Nose Syndrome," reported that more than 50% of the ENS patients he examined had become clinically depressed since the onset of their symptoms (Atrophic rhinitis: A review of 242 cases. Moore, EJ and EB Kern. (2001). Atrophic Rhinitis: A review of 242 cases. American Journal of Rhinology, 15, 6.

ENS patients complain they can't properly breathe through their noses, even though the nasal cavity is wide open. We believe this paradoxical nasal obstruction is caused by the three major problems we described at the top of the page.

Long Term Effects

Long term effects of ENS symptoms have been shown to cause Atrophic Rhinitis, an extreme nasal dryness that causes the remaining nasal tissue to atrophy. There is also a high risk of cardiovascular and metabolic disease due to prolonged stress, breathing difficulties and sleep disorders.

Since the turbinate tissue doesn't regenerate, people with ENS have to suffer with these symptoms until doctors find a way to replace the turbinate tissue that was carelessly removed.