Empty nose syndrome
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226123056
2008-07-16T22:32:11Z
Moesau
5919556
[[Image:Samples-of-ENS-CT's.jpg|right|CT pictures of different classifications of ENS following inferior and/or middle turbinectomy|Frame]]
'''Empty nose syndrome''' (ENS), also known in research as "the wide nasal cavity syndrome", is a medical term used to describe a [[nose]] crippled by over resection of the inferior and/or middle [[turbinates]] of the nose.<ref>Rice, Kern, Mabry, Friedman. The turbinates in nasal and sinus surgery: A consensus statement. Ear Nose & Throat Journal, Feb' 2003.</ref>
Empty nose syndrome is an [[iatrogenic]] condition that can and should be completely avoided, except for the rare cases of cancerous tumours in the nasal cavity, in which radical resection of nasal structures may be mandatory.<ref> Meyyerhoff & Rice. Otolaryngology – Head and Neck Surgery. Page 496, chapter 23. Chapter Written by EB Kern. Published by the W.B. Saunders Company, 1992.</ref><ref>Huizing & de-Groot. Functional Reconstructive Nasal Surgery. Pages 285 - 288: Surgery of the Wide Nasal Cavity. Published by Thieme. 2003.</ref>
Over resection of the inferior or middle turbinates leaves the nose in a chronic state of dryness (lack of mucus/moisture production) and incapable of streamlining, sensing (motion and temperature wise) and processing the inhaled air in a satisfactory manner. <ref>Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863.</ref>
The main symptoms are - chronic dryness of the nose and pharynx, shortness of breath, upsetting nasal sensations switching between over openness or congestion of the remaining mucosa, difficulty sleeping, difficulty concentrating and a generally depressed and irritated mood.
The patients feel confusing sensations of too much air entering their nose and pharynx, yet at the same time they feel that they need more nasal resistance to breathe-in satisfactorily. Patients may report that their nose feels un-responsive, too empty and at the same time stuffy, or that although they can sense plenty of air passing through their noses towards their lungs, they feel as if they can't catch their breath and as if their lungs are constantly starved for air.
Paradoxically their shortness of breath improves when their nasal mucosa becomes swollen and their nasal resistance increases, like when their nose becomes infected or after drinking a lot of alcohol.
ENS is a physically, cognitively and emotionally debilitating condition as good nasal functions are crucial for proper lung functions and breathing, cognitive functions, and sense of well-being.
==Symptoms==
===Physical symptoms===
* Nose feels too empty/hollow/absent.
* Diminished nasal airflow sensation feedback ('paradoxical obstruction').
* Extreme sensation of dryness of the nasal cavities, with or without crusting.
* Not enough moisture/mucus production.
* Dryness of the pharynx, [[soft palate]] and back of the [[tongue]] ("dry pharyngitis" and "dry laryngitis"<ref>Thomson St. C & Negus VE. Inflammatory diseases. Chronic Rhinitis. Diseases of the nose and throat, 6th edition. London: Cassel & Co. Lmt. 1955; 124-145</ref>).
* Feeling of needing more nasal resistance (or nasal membrane responsiveness) to breathe.
* Increased pulmonary sensitivity to air-borne irritants, strong scents and cold air. Causes much uneasiness in breathing and sometimes even long-periods (can last hours) of severe shortness of breath, depending on the degree of exposure.
* Diminished sense of smell and/or taste. Can be confusing - because although there is diminished sense of smell there is also hyper-responsiveness to light and volatile airborne chemicals, fumes and irritants.
* Difficulty projecting or resonating [[speech]]. The voice seems weak and requires some straining to sound loud and articulate well, which causes uneasiness in speech.
* Feeling weak and depleted of [[energy]].
* Very poor quality of [[sleep]]. Not necessarily full sleep apnea, but shallow and dry breathing, which often switches entirely to mouth breathing only, waking up a lot very dry, with headaches, severe dizziness and very little [[REM]] sleep.
* Relatively dry skin and eyes.
===Cognitive symptoms===
* Difficulty concentrating ('aprosexia nasalis').
* Difficulty performing mental tasks.
===Emotional symptoms===
* Marked reduction in sense of self and very crippled sense of [[well-being]].
* Irritated and/or depressed mood. Often [[clinical depression]].
* Anxieties.
* Avoidance of social interactions.
===Other characteristic physical symptoms that many ENS patients develop===
* irritating sensation of thick stagnant mucus stuck at the back of the throat. Because of the dryness of the mucosa the mucus propelled to the throat (on the way to the stomach - the nasal mucociliary clearance that occurs in all humans) simply becomes too dry and sticks to the sides of the throat instead of sliding smoothly unfelt.
* Chronic [[sinusitis]].
* Worsening of pre surgical nasal symptoms, such as [[allergic rhinitis]], etc'.
* [[Epistaxis]].
* Hardly any [[mucus]] production, or the opposite – episodes of excessive rhinoreah.
* Foul smell from nasal cavities.
* Gastroesophageal reflux ([[GERD]]).
* Elevated levels of blood pressure.
* Hormonal and metabolic imbalances.
* Significant weight gain.
==Etiology==
===The roles of the turbinates and how their absence causes symptoms of ENS===
The nasal turbinates are elongated bony structures, covered with nasal mucosa, that project off the nasal side walls and stretch across the entire nasal airway. In adults - the inferior turbinate is about the size of an index finger and the middle turbinate is about the size of the small finger. They are the most important mucosal and moisture secreting structures of the nose and they serve to heat regulate (to body temperature), humidify (to 98% humidity), to filter, to pressurize, elevate and streamline the air that flows through the nose. They provide most of the nasal mucosa for the air to flow over and by doing so they act as the radiators, the humidifiers and filters of the nose. The unique air-conditioning and processing conditions that the turbinates supply are not important only for proper lung function but also for keeping the health, function and integrity of the rest of the nasal mucosa, which is essentially the organ-system of the nose, as it covers all the inner nasal chambers and sinus cavities. The turbinates, in particularly the inferior ones, also play a crucial role in protecting the pharynx and larynx from the effect of direct insult of airflow and dryness.
The turbinates are also heavily innervated with pressure sensing receptors (of the trigeminal cranial nerve) that sense the airflow and thus notify the brain that enough air is traversing the nose to sustain life. If too much of these receptors are gone nasal breathing becomes unsatisfying, even though there is no structural blockage. This is called 'paradoxical obstruction' and is very common in ENS. This lack of airflow sensation causes much distress and morbidity to the sense of well being.<ref>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.</ref>
The turbinates, especially the inferior ones, also provide most of the nasal resistance to the lungs. The lungs need some resistance to allow them to reach their proper inflation and deflation rates during inhalation and exhalation. The nose supplies 50% of the entire resistance to the lungs. The turbinates supply most of these 50%. The function of nasal resistance is poorly researched and understood. It is well known from clinical observation that too little nasal resistance can cause similar pulmonary breathing difficulties and shortness of breath as too much resistance. Healthy nasal breathing is essential for maintaining all aspects of physical and mental health.<ref>Swift AC, Campbell IT, Mckown TM. Oronasal Obstruction, Lung Volumes, And Arterial Oxygenaytion. The Lancet. January 1988, pages 72-75.</ref><ref> Cottle MH. Nasal Breathing Pressures and Cardio-Pulmonary Illness. The Eye, Ear Nose and throat Monthly. Volume 51, September 1972.</ref>
The turbinates also trap more than 75% of the water vapor returning from the lungs upon exhalation and thus help protect the body from [[dehydration]].
The poorly understood [[naso-pulmonary reflex]] may also play a role in causing pulmonary restriction in ENS patients.<ref>Milicić D, Mladina R, Djanić D, Prgomet D, Leović D. Influence of Nasal Fontanel Receptors on the Regulation of Tracheobronchal Vagal Tone. Croat Med J. 1998 Dec;39(4):426-9.</ref>
===The implication of turbinectomies in causing ENS===
Sometimes the turbinates become chronically swollen in such a way which causes too much nasal obstruction. ENT and plastic surgeons can decrease their volume using the surgical procedure known as a turbinectomy. However this is a wide code-name that might mean anything from minimal reduction to complete resection of an entire turbinate.
While careful and judicial conservative reductions of a turbinate's volume can be beneficial to the patient, an aggressive turbinectomy, in which most or all of the main turbinal body is resected, can be a devastating procedure that causes ENS.<ref>Berenholz L, et al'. Chronic Sinusitis: A sequela of Inferior Turbinectomy. American Journal of Rhinology, July-August 1998, volume 12, number 4.</ref> <ref>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.</ref> <ref>Passali D, et al'. Treatment of hypertrophy of the inferior turbinate: Long-term results in 382 patient randomly assigned to therapy. by in Ann' Otol' Rhinol' Laryngol', volume 108, 1999.</ref> <ref>Chang and Ries W. Surgical treatment of the inferior turbinate: new techniques: in Current Opinion in Otolaryngology & Head and Neck Surgery, volume 12, 2004 (pp 53-57).</ref> <ref> Moore GF, Freeman TJ, Yonkers AJ, Ogren FP. Extended follow-up of total inferior turbinate resection for relief of chronic nasal obstruction. by in Laryngoscope, volume 95, September 1985.</ref> <ref>Oburra HO. Complications following bilateral turbinectomy. East African Medical Journal, volume 72, number 2, February 1995.</ref> <ref>Houser SM. Empty nose syndrome associated with middle turbinate resection. Otolaryngol Head Neck Surg. 2006 Dec;135(6):972-3.</ref> <ref>May M, Schaitkin BM. Erasorama surgery. Current Opinion in Otolaryngology & Head and Neck Surgery, 2002, volume 10, pp: 19-21.</ref><ref>Wang Y, Liu T, Qu Y, Dong Z, Yang Z. Empty nose syndrome. Zhonghua Er Bi Yan Hou Ke Za Zhi. 2001 Jun;36(3):203-5.</ref>
In many patients, ENS-type like symptoms develop even after what seems to be conservative reductions of the turbinates, especially if they include the anterior portion of the inferior turbinates, which are essentially a vital part of the inner nasal valve. However these symptoms will not be as severe as in over aggressive reductions of the turbinates.
When taking nasal anatomy and physiology into account it is very easy to see how over resection of nasal inferior and/or middle turbinates (also known as 'conchae') will cause the nasal chambers to be too empty, too wide and too dry, resulting in a marked decline of all nasal functions and sensations and this has a profound effect on the sufferer's quality of life and sense of well-being.
==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|Rochester]], [[Minnesota]], [[United States|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".<ref>Moore, E.J. & Kern, E.B. (2001). Atrophic rhinitis: A review of 242 cases. ''American Journal of Rhinology, 15(6)</ref>
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 sort.
From a histological point of view the clinical picture in ENS tends to resemble a form of [[rhinitis sicca]] with perhaps some limited areas of atrophic mucosa, usually at the front of the nose, rather than full blown atrophic rhinitis.
Of course, atrophic rhinitis in itself, or ozena, can both result in ENS too.
==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:
* Daily [[nasal irrigation]]s of regular [[saline (medicine)|saline]] are always recommended. Many patients prefer to use [[Ringer's 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.
* Saline, Ringer's Lactate, or [[hyaluronan|hyaluronic acid]] based - nasal mist sprays, or gels, are always helpful when proper irrigation is not possible.
* [[Sesame oil]] can help in cases of extreme dryness and crusts.
* Drinking lots of hot soups and beverages. Caffeine is best avoided.
* Sleeping with a cool mist humidifier.
* Sleeping with a [[Positive airway pressure|CPAP machine]] that has a built-in humidifier.
* [[Acupuncture]] and [[shiatsu]] meant to improve nasal blood supply and nerve function.
* Dressing warmly and sleeping in a warm environment.
* 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:<ref>Houser SM. Surgical Treatment for Empty Nose Syndrome. Archives of Otolaryngology Head & Neck Surgery\ Vol 133 (No.9) Sep' 2007: 858-863.</ref>
a) 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) 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) 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) 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.
----
'''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 rejected and in most areas retains most of its 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.
The ideal implant material, other than real original turbinate tissue 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.
===What lies ahead===
A cure will only be available if and when the situation is reversed and the actual real tissues of the resected turbinates are regenerated or returned to the nose through means of [[regenerative medicine]] and/or [[tissue-engineering]].
The technology and know-how knowledge of how to do so exist. The application, like in so many other physical disorders, is another matter altogether.
Hopefully tissue engineering and regenerative scientists will begin to take more interest in functional inner nasal reconstruction, as the complication rates of functional nasal surgery are amongst the highest rates compared to most other types of elective surgery.
== Citations from the medical literature==
:'''''"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.)
:'''''"Turbinate Reduction and Resection:'''''
'''''Unfortunately, a wide nasal cavity syndrome due to reduction or resection of the inferior turbinate (and/or middle turbinate) is still frequently seen. When caused by (subtotal) turbinectomy, it can hardly be considered a complication. In our opinion, it is a "nasal crime". This iatrogenic condition can easily be avoided by reducing a hypertrophic turbinate using one of the intraturbinal function-preserving techniques."'''''
(From: "Functional Reconstructive Nasal Surgery". By Egbert H. Huizing, John De Groot. Hard-cover publication by Thieme, 2003. page 285).
:'''''"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.)
==Additional images==
<gallery>
Image:Anterior-nasal-endoscopy.jpg|Internal view of the front inferior part of the nasal airways, after total inferior turbinectomy.
Image:Empty-nose-after-80per-cent-partial-bilateral-turbinectomy.jpeg|Empty Nose Syndrome after partial inferior turbinectomy. Many doctors might think that there is enough inferior turbinates remaining here, but the degree of resection is certainly radical enough to cause ENS.
Image:Illu nose nasal cavities.jpg |All turbinates removed - Right lateral wall view.
Image:Gray153.png | Anatomy of the nasal cavity
Image:Gray994.png|Sagittal section of nose mouth, pharynx, and larynx.
</gallery>
==References==
{{reflist}}
==External links==
*[http://www.ent-consult.com/emptynose.html Dr. Grossan's ear, nose and throat pages on ENS]
[[Category:Head and neck]]
[[es:Síndrome de la nariz vacía]]
[[fr:Syndrome du nez vide]]
[[he:סינדרום האף הריק]]