Empty nose syndrome
Empty nose syndrome (ENS), also known as secondary atrophic rhinitis, is a condition that is caused when too much inner nasal mucus-producing tissues (the turbinates) are cut out of the nose, leaving the nasal cavities too empty and wide. 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 is when those turbinates get chronically swollen and block too much of the nasal airways. This operation should be performed only after a serious attempt is made to diagnose and treat the initial problem that caused the turbinates to swell in the first place. Among the most common causes for turbinates to swell and over-grow (“turbinate hypertrophy”) 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.
The nose is a very important organ, besides what it’s most famous for, being the major characteristic feature of the human face, and the smelling organ, the nose is also the most important breathing conductor to the lungs. It acts as the guardian of the lungs by heating, humidifying and filtering the inspired air before it enters the lungs. The nose is also in charge of sensing and smelling the inspired airflow and enriches our lives with a whole range of sensations which are crucial for maintaining healthy patterns of emotional, cognitive and sexual brain functions and behaviors. A crippled nose can have a huge impact on a person's quality of life, and it can cause depression, slow down and impair cognitive processes and inhibit sexual and social activities. It can also cause a person to feel weak and depleted of energy.
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 include:
- Shortness of breath (dyspnea)
- Hyperventilation
- Extreme nasal dryness
- Nasal pain
- Sinusitis
- Nasal emptiness and lack of airflow sensation
- 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
- Dry eyes
- Ear pressure and/or fluids in ear
- Facial pain
- High Blood pressure
- Crusting of nasal mucosa
- Foul smell from nose (Ozaena)
Psychological symptoms include:
- Anxiety
- Depression
- Anger
- Hopelessness
- Emotionless
- Feelings of impending doom
- Inferiority
- Inability to concentrate
- Feeling overwhelmed
- Avoidance of social situations
Certain sleep problems are also symptoms:
- Unable to sleep through the night.
- Not feeling rested in the morning.
- Nightmares or night terrors.
- Sleep disordered breathing and sometimes full apnea.
Turbinates
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Their roles in the nose
The turbinates (also known as nasal Conchae) are long, narrow and curled bone shelves (shaped like elongated sea-shells) which are covered with a thick, very vascular and erectable, glandular tissue layer. They are located laterally in the nasal cavities, curling medially and downwards into the nasal airway. There are a three pairs of turbinates, each divided by the septum. The inferior turbinate is the largest, about as long as an index finger. The middle turbinate is as long as a pinky, and the superior turbinate is even smaller. The turbinates harbor most of the functional breathing and mucosal tissue of the nose. They have a very rich net of blood and nerve supply, which has tremendous erectable capabilities (very much like the male’s penis) of congesting and decongesting, in response to the climatic conditions and the ever-changing needs of the body. For example, when a person has to suddenly run for his life, the turbinates will automatically shrink, thus allowing a larger intake of air with every breath. On the other hand, when a person is trying to rest in a cold and dry environment, the turbinates will swell to provide a larger "tissue to air" mucosal surface, to ensure that all the air that is sucked in by the nose passes over those tissues and gets properly heated (to fit body temperature), humidified (up to 98% water saturation) and filtered. The filterization is achieved by a thin layer called respiratory epithelium, which covers the erectile tissue of the turbinates (called the “endothelial” layer, or the “Lamina-Propria”). It is made of goblet cells which secrete the mucus that covers the nasal cavities, and allows passages for secretion of lymphatic serum which carries anti-viral and anti-bacterial agents and which play a major role in the body’s first line of respiratory defense. All air-borne particles larger than 2 to 3 micrometres get trapped in the mucus and neutralized by the lymphatic serum. All the produced mucus with the debris gets rhythmically propelled towards the back of the nose until it gets swallowed into the throat at the naso-pharynx (the nasal-throat region). The mucus is propelled to the throat by the top layer of the respiratory epithelium, known as “cilia”. The cilia layer is like a blanket of millions of microscopic hairs that trap the airborne irritants and propel them towards the naso-pharynx in a wave like motion. A normal person is unaware that they are costatantly swallowing mucus and as long as the mucus is properly diluted, and the nose is not too dry, this will remain the case. A normal healthy person swallows about 0.65 liters of mucus in 24 hours. If the cilia is damaged or paralyzed, like in the case of a serious nasal infection, the mucus will build up in the nose and throat and will become thick and sticky. In cases of extreme dryness, the mucus will dry up in the nose, and form painful crusts.
The turbinates divide the nasal airway into three groove-like air passages: the inferior, middle and superior meatuses, thus forcing the air to flow in a steady regular pattern around the largest possible surface of cilia and climate controlling tissue. The turbinates are essentially like the radiator and engine of the nose. Without them, the airflow will be tooturbulent, causing nasal obstruction (known as “paradoxical obstruction”), where air will not flow alongside enough mucosal tissue, and therefore will not get cleaned, heated, or humidified. This means that the throat and lungs will get overwhelmed with cold, dirty, and dry air. The turbinates are also rich in airflow sensing nerve receptors (linked to the “trigeminal” nerve route, the fifth cranial nerve). These receptors sense pressure and temperature, and also aid in a way that is still not fully understood, to the activation of the smelling receptors of the higher regions of the nose. The inferior turbinates are the main humidifying, heating, filtering and airflow directing tissues of the nose. Most of the inhaled airflow travels in the middle meatus between the inferior turbinates and the middle ones. The middle ones are smaller and project downwards from the ethmoid sinuses. They harbor over the openings to the maxilla and ethmoid sinuses, and act as air buffers to protect the sinuses from coming in direct contact with the pressurized nasal airflow. The superior turbinates protect the olfactory bulb, and are also innervated with many smell nerve-endings, which extend somewhat into the middle turbinates too.
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 obstructed. The Empty Nose Syndrome patient feels a constant shortness of breath, his sleep becomes very shallow and many develop sleep apnea too. ENS sufferers tend to be depressed and anxious, which may cause them to avoid social interactions. Sinus pain is sometimes an issue. 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. It is often accompanied by foul smelling secretions (known as “Ozaena”), nosebleeds and crusts. 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.
Treatments
Non-surgical treatment
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 CPAP (Continuous Positive Air Pressure) machine with a built-in humidifier can be used.
Surgical treatment
If a significant portion of a turbinate remains, it can be augmented with acellular dermis ("alloderm") or SIS, two known natural biomaterials. Once either of these materials are implanted in the desired area, the local tissue slowly incorperates into the material, and the end result is partially fuctional, partially scared tissue. These materials can help with redirecting the airflow back to a more or less “laminar” (steady) state, and improve nasal humidity, with varying degrees of success. Somtimes these augmentations can be difficult and demand much skill and expertise. Some biomaterials can be reabsorbed by the body to a large extent, and with synthetic materials there is always a chance of rejection. The probability of success lies in how much of the original turbinate(s) remains, the condition of the remaining inner nasal tissues, the overall state of health of the patient, and of-course the expertise of the surgeon who must also be highly qualified in understanding the complexities of nasal physiology and especially its aerodynamics. In cases where too much turbinate tissue has been removed, and the surgeon estimates that the turbinate can't be augmented successfully, there are still things that can be attempted surgically, which might improve symptoms. For example - augmenting the septum opposite of the resected turbinate, and other tricks that an ENS educated surgeon might know.
There aren't any official statistics on longtime success rates of these transplantations. Some patients seem to benefit a lot while others complain that it didn't help them or that it increased their nasal dryness. Two known American surgeons, who have gained some expertise with turbinate augmentations, are Dr. Dale Rice and Dr. Steven Houser (see links for Dr. Houser's web-site and ENS tutorial). Hopefully, as doctors are becoming more aware of ENS, they will reach a better understanding of the long-term effects which ENS has on the quality of life of ENS patients. This will hopefully encourage more and more surgeons to develop the expertise and needed therapies for reconstructing resected nasal turbinates.
Quotations
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.)
References
1. The turbinates in nasal and sinus surgery: A consensus statement. Rice DH et al', Ear Nose & Throat Journal, Feb' 2003. (warns specifically against ENS and secondary Atrophic Rhinitis).
2. The combination of acoustic rhinometry, rhinoresistometry and flow simulation in noses before and after turbinate surgery: A model study. Grutzenmacher S, Lang C and Mlynski G.; ORL (Journal) volume 65, 2003, pp 341-347. (explains the change of airflow patterns and their effect on nasal physiology, in ENS).
3. The normal inferior turbinate: Histomorphometric analysis and clinical implications. By Berger G, Balum-Azim M, and Ophir D. In Laryngoscope (volume 113), July 2003. (mentions ENS and Rhinitis Sicca as known outcomes of removing too much turbinate tissue).
4. Treatment of hypertrophy of the inferior turbinate: Long-term results in 382 patient randomly assigned to therapy. by Passali D, et al'. in Ann' Otol' Rhinol' Laryngol', volume 108, 1999. (Warns against Secondary Atrophic Rhinitis and claims that of all the different techniques of turbinate reduction - turbinectomy, and total turbinectomy, causes the most negative side effects, and lists them).
5. Tailored nasal surgery for normalization of nasal resistance. by Sulsenti G, and Palma P. in Journal of Facial Plastic Surgery, volume 12, number 4, October 1996. (warns against cutting too much turbinate tissue and warrants such operation as highly destructive and disruptive to nasal and pulmonary physiology).
6. Surgical treatment of the inferior turbinate: new techniques: Chang and Ries W. in Current Opinion in Otolaryngology & Head and Neck Surgery, volume 12, 2004 (pp 53-57). (warns specifically against ENS and Secondary Atrophic Rhinitis as well known side effects of turbinectomies).
7. Septoplasty and turbinate surgery. by Becker D. in Aesthetic Surgery Journal, September/October 2003, volume 23, number 5. (warns against Secondary Atrophic Rhinitis as well known side effects of turbinectomies).
8. Rebuilding the inferior turbinate with hydroxyapatite cement. by Rice DH. in ENT- Ear Nose & Throat Journal. April 2000. (describes a method of transplant for alleviating symptoms of ENS, caused by too much turbinate resection).
9. Extended follow-up of total inferior turbinate resection for relief of chronic nasal obstruction. by Moore GF, Freeman TJ, Yonkers AJ, and Ogren FP. in Laryngoscope, volume 95, September 1985. (strongly condemns the procedure of inferior turbinectomy because of its long term negative side effects).
10. Erasorama surgery. by May M, and Schaitkin BM. in Current Opinion in Otolaryngology & Head and Neck Surgery, 2002, volume 10, pp: 19-21. (Warns against the development of ENS and Secondary Atrophic Rhinitis because of too much Turbinate and other nasal tissues resection, and also explains the inside dynamics and politics of the ENT world in regards to why do many surgeons still ignore those warnings).
11. Complications following bilateral turbinectomy. by Oburra HO, in East African Medical Journal, volume 72, number 2, February 1995. (Condemns inferior turbinectomy as a cause of Secondary Atrophic Rhinitis).
12. Chronic Sinusitis: A sequela of Inferior Turbinectomy. by Berenholz L, et al'. in American Journal of Rhinology, July-August 1998, volume 12, number 4. (warns that inferior turbinectomy may cause Chronic Sinusitis and Secondary Atrophic Rhinitis).
13. Atrophic rhinitis: A review of 242 cases. by Moore EJ, and Kern EB. In American Journal of Rhinology. November- December 2001, volume 15, number 6. (the landmark paper on ENS and Secondary Atrophic Rhinitis proving strong and significant statistical links between turbinectomies and the late development of Secondary Atrophic Rhinits and ENS in 242 documented cases).