Empty Nose Syndrome

Empty nose syndrome (ENS) was originally described by Dr. Eugene Kern in the 1990s to describe symptoms suffered by some patients who had received a partial and/or total middle and/or inferior turbinate reductions or resections. Turbinates serve as radiator fins in the nose that project off the side of the nose to help filter and humidify the air. Turbinate reduction or resection has been a common procedure that is practiced throughout the world. In the absolute great majority, the surgery provides improvedment in nasal airflow. Those patients that benefit from turbinate reduction surgery routinely require less use of medications and report better breathing on nasal and sinus surveys. Surgical benefits of turbinate reduction include: improvements in nasal breathing, decreased use of nasal medications, and improvements in validated quality of life survey instruments. Despite excellent results in most patients, there is a small subset of patients who have reported nasal crusting/dryness, poor nasal airflow and significant impact on sleep and quality of life measures after over aggressive turbinate surgery.

Empty nose syndrome patients mainly complain of obstructed nasal passages and not being able to get a full breath in through the nose despite having wide open nasal passages. Other less reported symptoms include nasal crusting, inhaling too much cold air and suffocation symptoms that affect sleep. In severe cases, patients can develop physcological or psychiatric conditions such as anxiety about their lack of nasal airflow, depression and sleep disorders.

How can resection of turbinates lead to worse congestion?

Recent research suggests that the feeling of nasal congestion is likely related to the body sensing different levels of pressure and/or temperature in each nasal cavity. These pressure and temperature receptors are likely located on the turbinate structures themselves, typically within the surface mucosal layer. With over-aggressive resection (surgically removing) of these turbinate structures, particularly with resection of the mucosal layer of the turbinates, people with ENS lose the ability to feel their nasal breathing.

How do we treat empty nose syndrome?
Empty nose syndrome can be treated with topical therapies that attempt to moisturize the nose and plump up the lining.   Humidifiers are helpful and living in a warm, humid climate, such as close to the beach. Antibiotic nasal irrigations are often necessary in advanced forms of ENS to kill and deter growth of harmful bacteria such as Klebsiella species. Certain creams and oral therapies have been tried as well to hypertrophy (increase the size) of any remaining turbinate tissue. These include estrogen creams (turbinates enlarge during pregnancy).

What treatments are available for empty nose syndrome?

Surgery for ENS has typically involved using implants or bulking materials to increase the size of any remaining turbinate tissue, or to increase nasal resistance by implanting materials to recreate a nasal turbinate. These implants have been partially successful in reducing the turbulence of nasal airflow that occurs. However, these implants do not reproduce the humidification or immune protection aspects of the original turbinate mucosa.  Implanted materials include cartilage, bone, fat and acelluar dermis.  We also have considerable experience with platelet-rich plasma combined with acellular extracellular matrix implants for the therapy of ENS.

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