Empty Nose Syndrome
Empty nose syndrome (ENS) is a rare, late complication of turbinate surgery. The most common clinical symptoms are paradoxically nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea. Little is known about the pathogenesis of ENS, though it is speculated that anatomical changes leading to alterations in the nasal environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms are strongly implicated. Medical therapies include mucosal humidification, irrigations, and emollients. Surgical therapy is reserved for refractory cases and may involve turbinate reconstruction, most commonly using implantable biomaterials.
Empty nose syndrome is a controversial condition not formally recognized by the medical community. That’s because most septoplasty and turbinate reduction surgeries are considered successful.
Many doctors consider it counterintuitive that a surgery used to open up a person’s nasal passages would actually worsen their ability to breathe.
In the early 2000s, ear, nose, and throat (ENT) specialists began addressing this condition as they noticed the pattern in people presenting “empty nose syndrome” symptoms.
Some people were so distraught by their inability to breathe properly that they attempted or committed suicide. Since then, a growing group of ENT specialists has started to recognize, study, and treat the condition.
The defining symptom of empty nose syndrome is a nose that feels “stuffy” or “clogged” despite a person’s nasal passages being wide open. Time and increased drying out of the nasal passages appears to worsen this sensation and other empty nose syndrome symptoms.
Symptoms of Empty Nose Syndrome
Most people with ENS feel like they can’t inhale a full breath through their nose. Other empty nose syndrome symptoms include:
- Nasal congestion, even though your passageways are clear.
- Nosebleeds.
- A sensation that the air you inhale is too cold or dry.
- Dizziness.
- Reduced mucus production.
- Severe nasal dryness.
- Reduced sensation of breathing.
- Headaches.
- Sensation of drowning.
- Post-nasal drip.
- Pain.
- Inflammation.
- Problems with taste (ageusia) or smell (anosmia).
- Insomnia.
- Tiredness.
Symptoms are different for each person. They may develop weeks, months or even years after nasal surgery. Because empty nose syndrome symptoms can be distracting, many people have difficulty focusing on routine tasks. People with ENS may also develop anxiety and depression as a result of their condition.
Causes of Empty Nose Syndrome
Experts don’t know why empty nose syndrome affects some people who’ve had nasal surgery but not others. Research is ongoing in this area to find out how to prevent or reduce the risk of this condition. Studies are looking at these possible empty nose syndrome causes:
- Levels of nasal pressure: Your body might be able to sense when there are different levels of pressure or temperature inside each of your nasal cavities. As a result, you may not be able to fully feel when you’re breathing.
- Disruption of nasal receptors: Receptors that sense pressure or temperature changes may be located on your turbinates (bony structures inside of your nose). Surgery may interfere with these receptors. As a result, you might lose your sense of nasal breathing.
- Increase in harmful bacteria: When you have nasal surgery, it might eliminate some of your mucus, which helps regulate healthy bacteria inside of your nose. This reduction in mucus could increase your risk for harmful bacteria, which can make empty nose syndrome symptoms worse.
Diagnostics of Empty Nose Syndrome
Because ENS isn’t well understood, diagnosing it can be tricky. Currently, there aren’t any standard tests or assessments that can tell you if you have the disorder. That being said, your doctor can make a diagnosis once they rule out other conditions that cause similar symptoms. To do this, they may look inside of your nose with an endoscope (a flexible tube with a tiny camera and light at the end).
Empty nose syndrome is not officially recognized as a medical condition, and doctors have only begun studying it. Routine, reliable tests have not yet been developed to diagnose empty nose syndrome.
Some ENT specialists will diagnose it based on a person’s symptoms and by checking turbinate damage on a CT scan. A person’s nasal passage airflow may also be tested. The specialist may find that a person’s nose is too open, causing a low rate of airflow.
But a low airflow rate can be caused by other conditions. A person’s total respiratory health should be evaluated before a doctor arrives at an empty nose syndrome diagnosis.
Complications of Empty Nose Syndrome
ENS is rare problem that is a complication of poor surgical technique. In the vast majority of patients, resection of the turbinates by any means, including older techniques which simply resected turbinate structures with surgical scissors, was effective in improving symptoms of nasal obstruction. Many otolaryngologists who utilize these older techniques are unaware of ENS and have had good surgical outcomes for most patients. As a result, when patients complain of persistent nasal obstruction after an overly-aggressive turbinate resection, it was oft
en incorrectly assumed that the patient’s nasal airflow was significantly improved and that the symptoms were psychosomatic. Otolaryngologists are the experts in nasal airflow, so primary care physicians would often defer to their judgment. As a result, many patients with ENS suffer the double victimization of having an iatrogenic problem created by over-aggressive surgery and then being told that their symptoms “do not make sense” and can be cured with behavioral therapy.
ENS patients usually experience psychiatric problems, including chronic fatigue, frustration, irritability, anger, anxiety, and depression. As a result, a significant negative impact on the quality of life and increased risk of mental health disorders are frequently reported. In severe cases, patients may struggle to maintain relationships, employment, and daily activities. Their focus is centered on their nasal and suffocation symptoms. Cognitive behavioral therapy or counseling may be helpful for anxiety and depression. Medications can also be useful.
Treatment of Empty Nose Syndrome
The goal of any surgical procedure is to bring the air flows in the nose back into balance so as to restore largely natural nasal breathing. The missing nasal turbinates are reconstructed using implants. This is possible with modern implant technology.
Our hospitals use state-of-the-art technical tools to assist in making a decision as to where an implant should be placed, relying on video nasopharyngoscopy as well as data from Rhino-Sys flowmetry and 3D reconstruction with DVT.
Nasal turbinate tissue is unique and irreplaceable. New implant materials like acellular collagen matrix can reduce symptoms. They are placed underneath the nasal mucosa of the septum and/or the lateral wall of the nose, and are meant to restore normal air flows, so that the typical ENS symptoms like dry nose can subside.
If only a little of the inferior nasal turbinate has been removed, the structure of the turbinate can also be improved by an injection of Cymetra (liquid Alloderm). The advantage of this new “Alloderm implant” is that it is not rejected by the body, and also retains its form and volume in most locations in long-term studies.
