This chapter presents the introduction and overview of the empty nose syndrome (ENS), highlighting subjects we will consider in detail with corresponding citations from the literature (included in the broad bibliography of 376 references), besides providing complete commentary regarding the fundamental features of ENS along with a review of pertinent nasal physiology, a comprehensive differential diagnosis and an analysis of the various medical, surgical, and psychological treatment options for these desperately distraught patients, some of whom have committed suicide because of their horrific torment. ENS was initially recognized and formally presented to the profession by the Mayo Clinic team in 1994. With over a quarter of a century experience treating hundreds of patients devastated by ENS, we reexamined the existing thinking concerning the etiology, differential diagnosis, diagnosis, treatment, and ultimately preventing this crippling disorder.

This chapter presents the review, finishing touches, and closing thoughts regarding the empty nose syndrome (ENS). Following our literature review, apparently other observers also agree with us that while the ENS is a relatively uncommon clinical entity, nonetheless, it is a strikingly important postturbinate treatment condition because of the profound physical suffering that patients experience especially with breathing difficulties and a surprisingly high incidence of disabling emotional anguish, including suicidal ideation, experienced by so many of these patients. We journey through and beyond the “empty nose syndrome,” appropriately so, as we contemporaneously, almost up to the very minute, offer an overview as to where we are and where we, as a profession, need to go first by protecting patients by preventing ENS when we manage the turbinates and when needed, treating those patients plagued with “empty nose syndrome.” The landmark randomized turbinate study of Passali et al. who followed their 382 patients, carefully collecting objective breathing and other physiologic data, at 4 and 6 years after treatment, recommended: “…submucosal resection combined with lateral displacement as the first-choice technique for the treatment of nasal obstruction due to hypertrophy of the inferior turbinates.” Presently, this study has the longest follow-up period to date and demonstrates that submucosal resection provides the greatest improvement in long-term nasal airway breathing capacity, while reestablishing mucociliary clearance and normalizing IgA production. The addition of out-fracture (lateralization) to the submucosal resection improved longstanding 6-year outcomes. Notwithstanding these conclusions, this study was omitted from the Cochrane (2010) review due to failure to use stringent criteria for patient selection.

This chapter presents the treatment options for empty nose syndrome (ENS). Unfortunately, currently there are no curative or even restorative therapies for ENS. Realistic management is obliged to provide emotional support by compassionate attentive listening along with controlling and relieving as many of the patient’s debilitating symptoms as feasible. Available treatments range from conservative medical measures to surgical interventions, although nothing that we know of today can renew, restore, or recreate the damaged, impaired, or resected nasal mucosa. Short of stem cell rejuvenation, the question remains, how do you create a new and functional nasal turbinate? Hope nonetheless exists that research in the realms of stem cell and tissue engineering will deliver potential future possibilities for our patients. Prevention is always the most prudent choice, of course. Psychological support with a compassionate respectful referral to a psychiatrist or other interested mental health professionals has been valuable in managing the anxiety and depression experienced by a sizable share (over 50%) of these patients.

This chapter presents the pathophysiology of empty nose syndrome. Although scientific research regarding nasal physiology, the essence of nasal function, has increased considerably, there are, according to the literature, still insufficient preoperative objective studies to guide surgical practice. Often the nasal surgeon determines the functional capacity of the nasal “organ” by observation and subjective patient reporting alone, as evidenced by the ample and abundant absence of objective testing data in the majority of papers in the literature dealing with almost any aspect of nasal surgery. The justification of this “observational” practice stems from a number of factors. Although some objective nasal functional tests are available, few are routinely used by practicing surgeons. In addition, there is an associated absence of medical, legal, or patient community pressure demanding functional testing prior to any nasal surgery including rhinoplasty.

Who was behind the concept of evidence-based medicine (EBM)? David Sackett, MD, is considered the “father” of EBM. EBM is primarily about discovery of the best medical scientific evidence, as opposed to the best expert opinion for crafting clinical choices in the best interest of the patient. The major goal of EBM practice is finding the highest level of evidence to resolve a clinical problem. According to Thoma and Eaves, the British Medical Journal conducted an online poll of its readers in January 2007 finding that EBM was ranked seventh among the 15 most momentous milestones molding modern medicine. Some of these major milestones included sanitation (germ theory of disease), immunization (vaccines), antibiotics, and anesthesia along with imaging (radiology) noting that a Google search today (in 2015) regarding anything to do with EBM would be in the millions.Practicing EBM means incorporating three fundamental requirements:1.Primarily, harvesting the “best scientific” research from the literature.2.That best research evidence must be combined with the physician's unique clinical expertise.3.Integrating the patient’s values, desires, and specific situation into the decision-making process.

This chapter presents how to find the best reduction method for inferior turbinate enlargement (“hypertrophy”) reduction. It also discusses some specific critical confounding questions regarding the same. As we all know too well, when medical therapy fails to reduce an enlarged inferior turbinate, a “surgical” reduction is advocated. To strictly and decisively answer the question of what is the “best method,” a well-designed and well-performed randomized controlled trial is needed to confirm or contradict the randomized trial of Passali et al.211,216211216

This chapter presents the scope of the empty nose syndrome (ENS). The term “empty nose syndrome” was coined by the Mayo Clinic team (Stenkvist and Kern) in 1994 when Dr. Monika Stenkvist, visiting surgeon and scientist, observed the noticeably and conspicuously empty nasal cavities on computerized tomography scans of patients missing almost all identifiable inferior and middle turbinate mucosal structures secondary to surgical resection of the turbinates followed by a multiple symptom complex arising months to years after their initial surgery (performed at sites other than Mayo Clinic). By definition, ENS is primarily an iatrogenic condition, a secondary atrophic rhinitis, secondary to turbinate trauma, in which a surgical resection removes various amounts of functioning nasal turbinate mucosal and submucosal (lamina propria, stroma) tissue. All of the various fluctuating symptoms seen in ENS are considered along with differentiating between primary and secondary atrophic rhinitis. The differential diagnosis of nasal atrophy and the diagnostic workup of these patients is presented. The history of surgical and nonsurgical turbinate reduction procedures is presented. Today, some authors consider ENS as a legitimate “physiologic disease entity” as do we.

This chapter presents the management of the turbinates. The debate regarding middle turbinate preservation has a heated history of disagreement raging for more than a century, the rhinologic equivalent of the Hundred Years’ War, 1337–1453, in the blossom of the Middle Ages. Middle turbinate “resectors” are surgeons who remorselessly rationalize resection of the middle turbinate to forestall formation of synechia in the region of the middle meatus. Proponents on the other side of the divide champion respecting not resecting the middle turbinate for its importance as a critical anatomical landmark and as an independent functional organ system. In the absence of certainty from RTCs, we champion saving the middle turbinate for both physiologic function and as a critical anatomic landmark, especially for potential revision surgery in patients with CRS harboring recurrent polypoid disease. It was Passali et al. in 1999 and 2003, respectively, (n = 382) who confirmed (at four and six years follow-up) that turbinoplasty accompanied with an out-fracture (lateralization) is an effective approach to inferior turbinate enlargement (“hypertrophy”) when compared to electrocautery, cryotherapy, laser cautery, turbinectomy, and submucosal resection without an out-fracture (lateral displacement). Their work confirmed the superiority of turbinoplasty with an out-fracture (lateralization) over all other methods studied.211,216211216

This chapter presents the inferior turbinate reduction in children. Principally, this book is about the empty nose syndrome and inferior turbinate management in adults and not about the pediatric population with enlarged inferior turbinates. However, because of the enormity of a possible lifespan of the surgical consequences in children, we think some cosmic frame of reference is vital to the childhood turbinate debate; therefore, a very succinct overview concerning children and inferior turbinate reduction is warranted; we are speaking about our children and a possible lifetime handicap! Since there is no guidance from any randomized controlled trial in children, microdebrider submucosal inferior turbinoplasty (without bony resection) with additional out-fracture (lateralization) of an inferior turbinate makes the most sense at this time for children who fail the obligatory three month trial of intense medical therapy. We think that these children must be followed into adulthood.

This chapter presents judging the quality of the editors, the peer reviewers, plus the issue of plagiarism in medical journals. Journals can be and often are extremely influential voices in setting standards of accepting and adjudicating submitted research to accurately and unbiasedly update and inform the profession. We depend upon the editors and their legions of peer reviewers for supreme sagacity with soaring standards of integrity when reviewing the submitted texts of thinking and data-rich experimental findings. Our unwritten covenant with the peer reviewers and their editors is they all act in the best interest of the profession, ultimately that is translated into, for the best interest of the patient. Recently, in the year 2019, there was comprehensive assessment of peer review reports searching for tools for determining the quality of peer reviewers and their submissions. Those authors plan to continue the quest for new validated quality assessment tools for peer review reports in biomedical research. Numerous critics of the review process asked questions such as the following:1.Is peer review: a flawed process at the heart of science and journals?2.Who reviews the reviewers?3.Editorial peer reviewers’ recommendations at a general medical journal: are they reliable and do editors care?4.Rereviewing peer review.5.Peer review for biomedical publications: we can improve the system.6.Make peer review scientific.7.Custodians of high-quality science: are editors and peer reviewers good enough?