Empty Nose Syndrome 6-Item Questionnaire Research Articles

Association between empty nose syndrome and laryngopharyngeal reflux disease: a preliminary cohort study.

To investigate the association between laryngopharyngeal reflux disease (LPRD) and Empty Nose Syndrome (ENS). Nasal and laryngopharyngeal reflux symptoms were investigated in patients with ENS. Symptoms were evaluated with reflux symptom score-12 (RSS-12), nasal obstruction symptom evaluation (NOSE), empty nose syndrome 6-item questionnaire (ENS6Q), empty nose syndrome index (ENSI), and sinonasal outcome tool-22 (SNOT-22). The anxiety and depression were assessed with the general anxiety disorder-7 (GAD-7), and patient health questionnaire-9 (PHQ-9). A study of association was conducted between demographics and patient-reported outcome questionnaires. Forty-one ENS patients were included (20 females (48.8%)). The control groups included 27 patients with rhinitis/rhinosinusitis and 36 asymptomatic individuals. The ENSI and ENS6Q detected ENS in 97.6% and 90.2% of cases, respectively. The mean scores of ENSI, ENS6Q, RSS-12, NOSE, and SNOT-22 were significantly higher in the ENS group compared to controls. The prevalence of suspected LPRD was 90.2% in the ENS group, which was significantly higher compared to controls. The prevalence of mild, moderate, moderately severe, and severe depression in ENS patients was 7.3% (n = 3), 4.9% (n = 2), 39.0% (n = 16), and 46.3% (n = 19), respectively. RSS-12 reported significant and high associations with the ENS6Q (rs=0.939; p = .001) and ENSI (rs=0.699; p = .001). LPRD symptoms and prevalence were significantly higher in ENS patients compared to controls. Future controlled studies are needed to investigate the prevalence of LPRD in ENS patients through objective approaches (impedance-pH monitoring, nasal digestive enzyme measurements).

Topical intranasal anesthesia impairs trigeminal function and airflow perception

Background: Impairment of airflow perception by the intranasal trigeminal system may explain chronic nasal obstruction (CNO), especially in cases where no major deformity or mucosal inflammation can explain reduced airflow. We aim to characterize the effect of topical intranasal anesthesia on intranasal trigeminal sensitivity and consequently the sensation of nasal obstruction. Methodology: We performed a crossover study of 16 healthy subjects, randomised for either treatment (topical intranasal anesthesia with 10% Xylocaine) or placebo (saline solution). We used the Trigeminal Lateralization Task (TLT) with eucalyptol to assess trigeminal sensitivity. We measured nasal patency objectively with Peak Nasal Inspiratory Flow (PNIF), and subjectively with a Visual Analog Scale (VAS), the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), and the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. Results: Topical intranasal anesthesia significantly reduced intranasal trigeminal sensitivity. Further, after topical intranasal anesthesia, reduced trigeminal sensitivity was associated with the subjectively reduced nasal patency, as highlighted by ENS6Q and NOSE scores. Conclusions: Topical intranasal anesthesia reduces intranasal trigeminal function resulting in subjectively reduced nasal patency. In future studies, the relation of reduced intranasal trigeminal function and subjective nasal obstruction needs to be addressed to open an avenue for potential interventions for an important portion of ENT patients.

Surgical and regenerative treatment options for empty nose syndrome: A systematic review.

Patients with empty nose syndrome usually suffer from paradoxical nasal congestion, nasal dryness, epistaxis and suffocation. Conservative management is general option for the empty nose syndrome. However, there are several patients who continually complain of symptoms. If symptoms persist, surgical options are considered. Therefore, we reviewed surgical and regenerative treatment options of empty nose syndrome. PubMed, Embase, Scopus, Cochrane Register of Controlled Trials, and Google Scholar were searched from the earliest date provided in the database until December 2022. In the studies, treatment outcomes were measured by patient symptom scores such as Sino-Nasal Outcome Test (SNOT-20, 22, and 25), and Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) along with various clinical examiniations. Twenty-eight studies were analyzed. Submucosal injectable materials, allografts/xenografts/cadaveric implants, autologous implants, and synthetic implants were used. Among them, polyethylene implant was most commonly used (23.3%), followed by autologous, homologous, or cadaveric costal cartilage (20%). The most common administration site was the anterior-inferior lateral nasal wall. Most of the studies showed that surgical intervention brought significant improvements in clinical findings including endoscopic exam, acoustic rhinometry, and CT, as well as patients reporting nasal symptom-, psychological-, or overall health-related quality of life questionnaires. However, several studies did not confirm improvement effects in some psychological-related questionnaires or saccharin transit time. The average follow-up duration was 12.0 (2.0-27.6) months. Postoperative adverse effects were reported in only two studies. Several surgical options and recent tissue regeneration techniques have shown its positive efficacy in treating empty nose syndrome. However more detailed investigations with a larger number and a randomized control study are needed to establish a standardized protocol in treating empty nose syndrome patients.

Application of a Novel 3D-Printed Nasal Plug as a Conservative Treatment for Empty Nose Syndrome.

Empty nose syndrome (ENS) is commonly treated by surgery, albeit with limited success. Herein, we introduce our experience of applying a newly developed "3D-printed nasal plug" as an alternative conservative treatment modality. This retrospective study included 20 patients (14 males, 6 females; mean age 46.5 ± 13.5 years) with ENS who underwent the application of the 3D-printed nasal plug at Asan Medical Center between June 2022 and May 2023. Symptom improvement was assessed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) before and after applying the nasal plug. Clinical results, such as duration and frequency of plug use, discomfort, and level of satisfaction, were investigated. The mean follow-up duration was 40.3 ± 24.2 weeks. The average duration of nasal plug usage was 10.8 h per day and 5.3 days a week. The ENS6Q scores improved from 19.6 ± 4.6 to 6.8 ± 5.1 (mean reduction 12.8 ± 5.9) after 30 minutes of wearing. Symptom "nose feelings too open" was improved most by a score of 3.0 ± 1.5 (p < 0.001). Thirteen patients (65.0%) reported that the effectiveness of the plug, initially confirmed at the first wearing, was well maintained during the entire follow-up. Four patients (20.0%) wore the nasal plug uninterruptedly throughout the week, whereas nine patients (45.0%) wore it intermittently as needed. Frequently reported complaints with plug usage were 'displacement of the plug' and 'cosmetic concerns' about the visible hook portion. A 3D-designed nasal plug can be a useful conservative treatment option for ENS patients. 4 Laryngoscope, 134:3935-3940, 2024.

Morphology, Not Only Volume: A Study on Empty Nose Syndrome and Inferior Turbinates.

Empty nose syndrome (ENS) is an underdiagnosed but burdensome clinical condition. Studies that have addressed the impact of remnant inferior turbinate volume (ITV) on ENS are scarce. We aimed to evaluate the impact of ITV and phenotyping on the severity and presentation of ENS. All the enrolled patients underwent the following subjective assessments: the ENS 6-Item Questionnaire (ENS6Q), Sino-Nasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI). The ITV was obtained from finely cut (1-mm-thick slices) sino-nasal computed tomography scan images and analyzed using ImageJ. The correlation between ITV, subjective measurements, and morphology of inferior turbinates was evaluated. ENS was categorized as torpedo type (balanced tissue volume) or pistol type (posterior dominance) based on the morphology. Overall, 54 patients met the inclusion criteria. The ITV was positively correlated with the ENS6Q score and domain of ENS symptoms in SNOT-25. Neither BDI-II nor BAI scores had a significant correlation with ITV. Based on their morphological classification, the torpedo type exhibited diverse manifestations in the SNOT-25 analysis in response to changes in ITV, while the pistol type demonstrated an elevated rhinologic symptom burden and ENS-specific symptoms as their ITV increased. Nasal resistance did not correlate with the ITV in either type of ENS. Symptoms were paradoxically worse in ENS patients with greater remnant ITV, and distinct morphological phenotypes in the nasal cavities may result in different presentations. Further investigation into the correlation between remnant inferior turbinates and nerve function is warranted. 3 Laryngoscope, 134:3060-3066, 2024.

Empty nose syndrome

Empty nose syndrome (ENS) is an iatrogenic condition that results from traumatic injury, often overresection, of the turbinates during sinonasal surgery. The underlying etiology is not entirely understood but is thought to have multifactorial contributions including alterations in the native nasal airway anatomy, abnormal mucosal and neural healing, and decreased trigeminal sensitivity, among other possibilities and contributors. Patients typically present with an intense fixation on their sensations of nasal obstruction and congestion despite an anatomically patent airway on examination. Because many patients with ENS have been shown to have significant psychiatric comorbidities, multidisciplinary specialist care including psychiatry and pain services is essential. Diagnosis is often difficult due to the variability of presentation and severity of symptoms, but standard assessments exist including the empty nose syndrome 6-item questionnaire (ENS6Q) and cotton test. Patients can be initially managed with conservative measures through humidification, moisturization, and psychiatric testing/referral. Procedural approaches to improve the nasal airway include submucosal implantation of temporary, semi-permanent, and permanent materials. A realistic and empathetic approach to patient communication is necessary in order to help manage patients with ENS, and all plastic surgeons performing septorhinoplasty should be aware of the risk and treatment options of the disease.

Autologous fat injection for empty-nose syndrome

AimsInferior meatus augmentation by injection or implants is one of the treatments for empty-nose syndrome (ENS), but levels of evidence of efficacy are low. We present the technique and evaluate our experience. The primary objective was to analyze changes in Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores after treating patients with ENS by autologous fat injection. Secondary objectives were the analysis of the evolution of each of the six ENS6Q items and identification of complications. Eleven patients underwent a minimally invasive approach to limit nasal airflow using fat injection between March 2021 and December 2022. ResultsTen of the 11 patients showed a decrease in overall ENS6Q score (P=0.0058); 6 had a final ENS6Q score<11. Ten were satisfied with the procedure, but remained symptomatic. The procedure did not result in any complications. ConclusionThese encouraging results confirm the data in the literature suggesting that fat injection improves symptomatology in empty nose syndrome. However, like other minimally invasive approaches to limit nasal airflow, it does not eliminate all symptoms. These results need to be confirmed by studies on larger cohorts with longer follow-up, preferably in a multicenter setting.

Evaluation of Post-Intervention Outcomes in Patients with Empty Nose Syndrome.

To conduct a systematic review and meta-analysis of published articles to assess the impact of inferior turbinate/meatus augmentation in patients diagnosed with empty nose syndrome (ENS). PubMed, Cochrane database, Embase, Web of Science, SCOPUS, and Google Scholar. Six databases were searched to December 2022. We retrieved studies evaluating improvements in refractory ENS-related symptoms based on various patient-reported outcome measures after inferior turbinate/meatus augmentation. As a result of meta-analysis, Sinonasal Outcome Test, Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), and depression scores were measured at 1 week; 1, 3, and 6 months; and later than 12 months after intervention for patients with ENS. All scores revealed significant symptom improvement. By reference to the minimal clinically important difference of the ENS6Q (6.25), inferior turbinate/meatus augmentation relieved the nasal symptoms of ENS in the long term. Although the improvements in anxiety scores at 1 week (0.4133 [-0.3366; 1.1633], 0.00, I2 = NA) and 1 month (0.4525 [-0.0529; 0.9579], I2 = 0.0%) were not statistically significant, the scores differed significantly at 3 months (0.7351 [0.4143; 1.0559], I2 = 28.4%), 6 months (0.8297 [0.6256; 1.0337], I2 = 37.2%), and longer than 12 months (0.7969 [0.4768; 1.1170], I2 = 0.0%). These data and analysis suggest that performing inferior turbinate/meatus augmentation on ENS patients may improve not only nasal symptom scores but also accompanying psychological problems such as anxiety and depression. Laryngoscope, 134:2005-2011, 2024.

Impact of sinonasal anatomic changes after endoscopic anterior skull base surgery on nasal airflow and air conditioning: a computational fluid dynamics study

Objective: To analyze the impact of the sinonasal anatomic changes after endonasal endoscopic anterior skull base surgery on the nasal airflow and heating and humidification by computational fluid dynamics (CFD), and to explore the correlation between the postoperative CFD parameters and the subjective symptoms of the patients. Methods: The clinical data in the Rhinology Department of the First Affiliated Hospital of Zhengzhou University from 2016 to 2021 were retrospectively analyzed. The patients received the endoscopic resection of the anterior skull base tumor were selected as the case group, and the adults whose CT scans had no sinonasal abnormalities were chosen as the control group. The CFD simulation was performed on the sinonasal models after reconstructed from the patients' sinus CT images during the post-surgical follow-up. All the patients were asked to complete the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) to assess the subjective symptoms. The comparison between two independent groups and the correlation analysis were carried out by using the Mann-Whitney U test and the Spearman correlation test in the SPSS 26.0 software. Results: Nineteen patients (including 8 males and 11 females, from 22 to 67 years old) in the case group and 2 patients (a male of 38 years old and a female of 45 years old) in the control group were enrolled in this study. After the anterior skull base surgery, the high-speed airflow moved to the upper part of the nasal cavity, and the lowest temperature shifted upwards on the choana. Comparing with the control group, the ratio of nasal mucosal surface area to nasal ventilation volume in the case group decreased [0.41 (0.40, 0.41) mm-1 vs 0.32 (0.30, 0.38) mm-1; Z=-2.04, P=0.041], the air flow in the upper and middle part of the nasal cavity increased [61.14 (59.78, 62.51)% vs 78.07 (76.22, 94.43)%; Z=-2.28, P=0.023], the nasal resistance decreased [0.024 (0.022, 0.026) Pa·s/ml vs 0.016 (0.009, 0.018) Pa·s/ml; Z=-2.29, P=0.022], the lowest temperature in the middle of the nasal cavity decreased [28.29 (27.23, 29.35)℃ vs 25.06 (24.07, 25.50)℃; Z=-2.28, P=0.023], the nasal heating efficiency decreased [98.74 (97.95, 99.52)% vs 82.16 (80.24, 86.91)%; Z=-2.28, P=0.023], the lowest relative humidity decreased [(79.62 (76.55, 82.69)% vs 73.28 (71.27, 75.05)%; Z=-2.28, P=0.023], and the nasal humidification efficiency decreased [99.50 (97.69, 101.30)% vs 86.09 (79.33, 87.16)%; Z=-2.28, P=0.023]. The ENS6Q total scores of all patients in the case group were less than 11 points. There was a moderate negative correlation between the proportion of the inferior airflow in the post-surgical nasal cavity negatively and the ENS6Q total scores (rs=-0.50, P=0.029). Conclusions: The sinonasal anatomic changes after the endoscopic anterior skull base surgery alter the nasal airflow patterns, reducing the efficiency of nasal heating and humidification. However, the post-surgical occurrence tendency of the empty nose syndrome is weak.

Identifying Residual Psychological Symptoms after Nasal Reconstruction Surgery in Patients with Empty Nose Syndrome.

Empty nose syndrome (ENS) is a syndrome of paradoxical nasal obstruction that is thought to be mostly caused by inappropriate turbinate procedures. This study aimed to investigate depression- and anxiety-associated psychological symptoms in patients with ENS before and after surgical reconstruction, and to compare them with those of control subjects. Patients with ENS were prospectively enrolled. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item questionnaire (ENS6Q), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate the participants before and after reconstruction surgery with submucosal Medpor implantation (Stryker, Kalamazoo, MI), as well as control subjects at enrollment. Forty patients with ENS and forty age- and sex-matched controls were recruited. Patients with ENS experienced significant improvement in SNOT-25, ENS6Q, BDI-II, and BAI scores after surgery, but all were significantly greater than those in the control group. Nine patients with ENS (22.5%) had postoperative residual psychological symptoms. Preoperative BDI-II and BAI scores were significant predictors of postoperative residual psychological symptoms. The optimal cut-off value was BDI-II > 28.5 (sensitivity, 77.8%; specificity, 77.4%) in receiver operating characteristic curve analysis. The nasal and psychological evaluations in patients with ENS significantly improved after nasal reconstruction surgery, but both were significantly greater than those in the control group. Identifying individuals who may experience postoperative residual symptoms and providing a multimodal approach, including surgical reconstruction and psychiatric treatment, are suggested.

Utility of Serum Interleukine-6 Level in Empty Nose Syndrome.

Objectives: Empty nose syndrome (ENS), a complication resulting from surgical procedures on turbinate tissue, is characterized by paradoxical nasal obstruction with wide nasal airways. Patients with ENS often also experience psychiatric symptoms, and psychiatric disorder detection remains dependent on subjective evaluation. Objective biomarkers for mental status assessment in patients with ENS are unestablished. This study aimed to evaluate the role of serum interleukin-6 (IL-6) levels in the mental status of patients with ENS. Methods: Overall, 35 patients with ENS who underwent endonasal submucosal implantation surgery were prospectively included in the study. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II) were used to assess the physical and psychiatric symptoms of these patients preoperatively, and 3, 6, and 12 months postoperatively. Serum IL-6 levels were analyzed 1 day before surgery. Results: All subjective assessments significantly improved 3 months after surgery and plateaued at 12 months. Patients with higher serum preoperative IL-6 levels tended to experience more severe depression. Regression analysis showed that a preoperative serum IL-6 level > 1.985 pg/mL was significantly correlated with severe depression status in patients with ENS (odds ratio = 9.76, p = 0.020). Conclusions: ENS patients with higher preoperative serum IL-6 levels were more likely to have severe depressive burden. Since more suicidal thoughts or attempts were noted in these patients, timely treatment plan for patients with high levels of serum IL-6 is crucial and may consider psychotherapy after surgical treatment.

Sleep impairment in patients with empty nose syndrome.

Empty nose syndrome (ENS) is characterized by paradoxical nasal obstruction that usually occurs after turbinate surgery. Patients with ENS may also experience significant psychiatric symptoms and sleep dysfunction, which negatively affect the quality of life of affected subjects. This study aimed to evaluate sleep impairment and sleepiness in patients with ENS. Patients with ENS and control participants were recruited prospectively. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Epworth Sleepiness Scale (EpSS), and modified sleep quality index (MSQI) were used to evaluate the participants before and after nasal surgery. Forty-eight patients with ENS and forty-eight age- and sex-matched control subjects were enrolled. The SNOT-25, ENS6Q, EpSS, and MSQI scores in the ENS group were all significantly higher than those in the control group before and after surgery. After surgery, ENS patients all exhibited significant improvements in SNOT-25, ENS6Q, EpSS, and MSQI scores. Regression analysis revealed that SNOT-25 score was a significant predictor of EpSS and MSQI in preoperative evaluations. ENS patients experiencing daytime sleepiness suffered from significantly more "dryness of nose" and "suffocation" than those not experiencing daytime sleepiness. Patients with ENS experienced significantly impaired sleep quality and sleepiness. Nasal reconstruction surgery improved the sleep quality of ENS patients. The severity of sleep dysfunction is associated with the severity of ENS symptoms. Recognizing individuals with significant sleep impairment and sleepiness and providing appropriate management are critical issues for ENS patients.

Surgical Treatment for Empty Nose Syndrome Using Autologous Dermal Fat: Evaluation of Symptomatic Improvement.

Background: Empty nose syndrome (ENS) is caused by nasal turbinate surgery. The standard treatment for ENS is an inferior meatus augmentation procedure (IMAP) in which autologous tissue such as auricular cartilage, rib cartilage, or artificial material is transplanted into the nasal cavity. However, some challenges like a very small auricular cartilage are associated with these autologous tissue types. Moreover, since using rib cartilage is a highly invasive technique, the scar on the chest from where the harvesting is done is easily visible, and the artificial material is susceptible to infection. We used autologous dermal fat (ADF) in IMAPs in our study for the following reasons: the quantity of ADF could be increased or reduced as needed, ADF is considered a safer option than rib cartilage because it is harvested from superficial tissue, it is superior in terms of cosmetic appearance to harvested rib cartilage, and it has a lower risk of infection than any artificial material.Objective: The purpose of our study was to investigate the efficacy and safety of IMAPs using ADF.Methods: We included nine patients with ENS who underwent an IMAP using ADF. The patients' backgrounds and responses to the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) were recorded. Changes in each item of the ENS6Q before and after surgery (up to 3 months) were analyzed.Results: The postoperative ENS6Q total score and parameters were significantly better than their preoperative counterparts. Nasal dryness improved slightly less than other symptoms. There were no complications.Conclusions: The IMAP using ADF was effective in improving ENS symptoms; however, some physiological functions were difficult to improve, and dryness persisted. Autologous dermal fat is larger than auricular cartilage, less invasive than rib cartilage, and has a lower risk of infection than artificial material.

Identifying Obstructive Sleep Apnoea in Patients with Empty Nose Syndrome.

Obstructive sleep apnoea (OSA) is characterised by repetitive episodes of upper airway collapse and breathing cessation during sleep. Empty nose syndrome (ENS) is a surgically iatrogenic phenomenon of paradoxical nasal obstruction despite an objectively patent nasal airway. This study aimed to investigate sleep quality and the presence of OSA in ENS patients. Forty-eight ENS patients underwent full-night polysomnography. Total nasal resistance (TNR) was determined using anterior rhinomanometry. Symptoms and quality of life were evaluated by the empty nose syndrome 6-item questionnaire (ENS6Q), Sino-Nasal Outcome Test-22 (SNOT-22), and Epworth Sleepiness Scale questionnaires (ESS). Fourteen, twelve, and fourteen patients had mild, moderate, and severe OSA, respectively. The apnoea–hypopnoea index (AHI) and the lowest SpO2 were 23.8 ± 22.4/h and 85.9 ± 11.1%, respectively. N1, N2, N3 and rapid-eye-movement sleep comprised 30.2 ± 16.9%, 47.3 ± 15.5%, 2.1 ± 5.4%, and 20.0 ± 8.1% of the total sleep time. Body mass index, neck circumference, serum total immunoglobulin E, and ENS6Q score were significantly associated with AHI in the regression analysis. The ENS6Q scores correlated positively with AHI, arousal index, and ESS score, but negatively with TNR. ENS patients showed a high OSA prevalence and significant sleep impairment. The extent of OSA was associated with obesity levels and ENS symptom severity. The ENS6Q scores correlated negatively with nasal resistance, and positively with arousal frequency and daytime sleepiness. The recognition of individuals experiencing marked OSA and provision of appropriate intervention is critical to preventing long-term morbidity and mortality, and improving therapeutic outcomes in ENS patients.

Impact of sleep dysfunction on psychological burden in patients with empty nose syndrome.

Background Empty nose syndrome (ENS) is a paradoxical nasal obstruction that occurs after turbinate surgery. This study aimed to evaluate the impact of sleep dysfunction on the psychological burden in patients with ENS by simultaneously measuring sleep quality and psychological symptoms using validated questionnaire instruments. Methods Patients with ENS were prospectively enrolled over 5 years. The Empty Nose Syndrome 6-item questionnaire (ENS6Q), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), Epworth Sleepiness Scale (EpSS), and modified sleep quality index (MSQI) were used to evaluate the participants before and after reconstruction surgery with submucosal Medpor implantation. Results Forty-six patients with ENS were included in this study. The BDI-II and BAI depression and anxiety scores were significantly associated with the MSQI and EpSS sleep scores in preoperative evaluations and perioperative changes. Multivariable regression models revealed that the preoperative EpSS score (coefficient=0.76, p=0.046) was a significant predictor of preoperative BDI-II scores. The receiver operating characteristic (ROC) curves of EpSS (p=0.003) and MSQI (p<0.001) scores had an area under the ROC curve that was significantly greater than 0.5 in detecting moderate-to-severe depression. The optimal cut-off values for these variables were EpSS >13 (sensitivity, 52.6%; specificity, 85.2%) and MSQI >28 (sensitivity, 78.9%; specificity, 81.5%). Conclusions There is a close association between the evaluation of sleep dysfunction and psychological symptoms in ENS patients. Recognizing individuals with significant sleep impairment and providing appropriate management to improve sleep quality and diminish their psychological burden are crucial issues for ENS patients. This article is protected by copyright. All rights reserved

Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis.

Empty nose syndrome (ENS) is characterized by the paradoxical perception of nasal obstruction despite patent sinonasal anatomy after surgery. We investigated the relationship between ENS, and anxiety, depression, obsessive-compulsive disorder, and somatic symptom disorder (SSD) compared to individuals with chronic rhinitis (CR) and chronic rhinosinusitis (CRS). This cross-sectional survey study compared ENS and CR and CRS patients. A total of 116 patients participated: 58 ENS patients from digital support groups, and 58 CRS and CR patients from tertiary rhinology clinics. Study participants completed four validated surveys: (1) Empty Nose Syndrome 6-Item Questionnaire, (2) Rhinosinusitis Disability Index (RSDI), (3) Obsessive Compulsive Inventory - Revised (OCI-R), and (4) PRIME MD Patient Health Questionnaire (PHQ). ENS patients exhibited a mean RSDI of 78.6, 95% confidence interval [CI] 72.8-84.5, compared to 25.2, 95% CI 18.6-31.8 for CRS/CR patients (p<0.0001). This difference was seen across all subdomains. Using the PHQ, 53% of ENS patients met diagnostic thresholds for SSD compared to 14% of CRS patients (p<0.0001). In relation to obsessive compulsive disorder (OCD), 18.37% of ENS patients compared to 8.62% of CRS/CR patients scored above the diagnostic threshold (>21) on the OCI-R questionnaire (p=0.159). ENS patients had diminished sinonasal quality of life and a higher prevalence of comorbid anxiety and depression, compared to CR and CRS. ENS patients were more likely to exceed thresholds for OCD and SSD compared to controls. Future studies are needed to assess the role of SSD in ENS to help optimize treatment for these complex patients.

Effects of orthognathic surgery with maxillary impaction plus septoplasty and total turbinectomy on breathing

Complete removal of hypertrophied inferior nasal turbinates may favour the occurrence of the empty nose syndrome (ENS). Some surgeons recommend partial turbinectomy in order to minimize the occurrence of ENS. However, little is known about whether total removal of the inferior nasal turbinate is associated with ENS. The aim of the present study was to evaluate the effects of total turbinectomy and septoplasty on the breathing of individuals undergoing orthognathic surgery with maxillary impaction. A total of 20 individuals participated in this cross-sectional study, in which the relationship between exposure (maxillary orthognathic surgery) and outcome (nasal respiratory function) was investigated. The Empty Nose Syndrome 6-Item questionnaire and Nasal Obstruction Symptom evaluation scale were applied to investigate the ENS. A three-dimensional assessment of the piriform opening was performed pre- and postoperatively by computed tomography in order to measure the volume of the nasal cavities using the Dolphin Imaging software. ENS was detected in 35% of patients, while 13 reported improved breathing. Symptoms of ENS such as dryness, suffocation, nose feels too open and nasal crusting were mentioned. The mean nasal cavity volume was 7477.15 mm³ greater in the initial evaluation (p&lt;0.05). In summary, the occurrence of ENS does not constitute an absolute contraindication of total turbinectomy, a procedure that contributed to the improvement of airway permeability.

Comparison of SNOT-25 and ENS6Q in evaluating patients with empty nose syndrome.

ObjectivesPatients with empty nose syndrome (ENS) experience paradoxical nasal obstruction and various psychological burdens. This study aimed to compare ENS‐specific questionnaires of sino‐nasal outcome test‐25 (SNOT‐25) and empty nose syndrome 6‐item questionnaire (ENS6Q) in the peri‐operative evaluation of ENS.MethodsThis was a prospective case series study. Patients with ENS were recruited and evaluated with the SNOT‐25, ENS6Q, beck depression inventory‐II (BDI‐II), and beck anxiety inventory (BAI) before and 6 months after nasal reconstruction surgery.ResultsSeventy‐four ENS patients were enrolled during the study period. All four evaluations revealed significant improvements after surgery. Pre‐operative SNOT‐25 scores exhibited a significant correlation with pre‐operative ENS6Q (r = 0.682), BDI‐II (r = 0.485), and BAI scores (r = 0.608) (p < 0.001), as well as a weak correlation with post‐operative SNOT‐25 (r = 0.336), BDI‐II (r = 0.266), and BAI scores (r = 0.235) (p < 0.05). Additionally, pre‐operative ENS6Q scores were significantly correlated with pre‐operative BDI‐II (r = 0.434), BAI (r = 0.521) (p < 0.001), and post‐operative ENS6Q scores (r = 0.262, p < 0.05). However, there was no correlation between pre‐operative ENS6Q scores and post‐operative BDI‐II and BAI scores.ConclusionsBoth SNOT‐25 and ENS6Q were helpful in evaluating peri‐operative symptoms for patients with ENS. Although the ENS6Q score had a good correlation with the BDI‐II and BAI scores preoperatively, it was not associated with post‐operative BDI‐II and BAI scores. Hence, a simultaneous psychological assessment is necessary when evaluating patients using the ENS6Q.Level of Evidence: 2c

Suicidal thoughts in patients with empty nose syndrome.

ObjectivesPatients with empty nose syndrome (ENS) suffer from paradoxical nasal obstruction with a patent objective nasal airway. ENS may result from the excessive surgical reduction of the turbinate tissue. ENS patients also experience significant psychological symptoms such as anxiety and depression. In this study, we aimed to evaluate the prevalence of suicidal thoughts in ENS patients and to characterize these patients for early identification.Study DesignProspective case series.MethodsPatients with ENS were prospectively recruited for this study. The Sino‐Nasal Outcome Test‐25 (SNOT‐25), Empty Nose Syndrome 6‐item Questionnaire (ENS6Q), Beck Anxiety Inventory (BAI), and Beck Depression Inventory‐II (BDI‐II) were used to assess ENS patients before and 6 months after nasal reconstruction surgery.ResultsSixty‐two patients with ENS were enrolled. Suicidal thoughts were identified in 23 ENS patients preoperatively and in four patients postoperatively. ENS patients with suicidal thoughts rated significantly higher in the SNOT‐25, ENS6Q, BDI‐II, and BAI total scores than those without suicidal thoughts (all P < .05). “Nose feels too open” was the item in ENS6Q that was significantly more severe in ENS patients with suicidal thoughts than those without suicidal thoughts (P < .001).ConclusionsSuicidal thoughts are frequently identified in patients with ENS. ENS patients with suicidal thoughts experienced significantly more severe symptoms, impaired quality of life, and psychological burden than those without suicidal thoughts. Recognizing individuals who may carry suicidal thoughts and provide appropriate psychological interventions is critical to prevent tragedy.Level of Evidence4

Long-Term Outcomes of Inferior Meatus Augmentation Procedure to Treat Empty Nose Syndrome.

We sought to report the long-term, symptom-focused, prospective outcomes in empty nose syndrome (ENS) patients after undergoing inferior meatus augmentation procedure (IMAP) through use of four validated questionnaires: Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-Item Scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). Prospective case series. A single-center prospective case series was performed for patients diagnosed with ENS who underwent IMAP between July 2017 and February 2020. Diagnosis of ENS was based on the following criteria: 1) reported discomfort with nasal breathing and/or paradoxical nasal obstruction after inferior turbinate reduction, 2) a positive ENS6Q score of at least 11, and 3) a positive cotton test. Questionnaire responses were recorded prior to surgery as well as 1, 3, 6, and 12 months postoperatively. Seventeen eligible patients were included. Mean ENS6Q scores were significantly reduced at all postoperative time points (p < .0001, p < .0001, p < .0001, p=.0003). Of the six ENS6Q subdomains, five (suffocation, dryness, sense of diminished airflow, nasal crusting, and nasal burning) were significantly reduced 1-year postoperatively (p < .0001, p=.0004, p=.0136, p=.0114, p=.0080, respectively). SNOT-22 scores were significantly reduced at all time points (p=.0021, p=.0227, p=.0004, and p=.0025). Of the SNOT-22 subdomains, the sleep subdomain was significantly reduced 1-year postoperatively (p=.0432). Low baseline GAD-7 and PHQ-9 scores were recorded at 7 and 9.4, respectively, and although scores at all postoperative time points were reduced, there was no statistical significance. IMAP via implant of cadaveric rib cartilage provides significant, long-term improvements in ENS-specific and general sinonasal symptoms. 4 Laryngoscope, 131:E2736-E2741, 2021.