Paradoxical Nasal Obstruction Research Articles

A Systematic Review and Meta-Analysis of Management Options for Empty Nose Syndrome: A Proposed Management Algorithm.

Empty nose syndrome (ENS) is an acquired condition characterized by paradoxical nasal obstruction and sensation of nasal dryness often accompanied by psychological disorders such as depression or anxiety, typically occurring after the loss of inferior turbinate tissue or volume in the setting of prior sinonasal surgery. This review aims to identify and evaluate the reported management options. PubMed, Scopus, and Web of Science. The terms "empty nose syndrome" OR "atrophic rhinitis" were used in a systematic search of original articles since the year 1990, yielding 1432 individual studies. These were screened on the Covidence platform for inclusion if any intervention was reported for the treatment of ENS. A pooled analysis of standardized mean differences (SMDs) combined with a random effects model was employed to report outcomes in Empty Nose 6-Item Questionnaire (ENS6Q), Sino-Nasal Outcome Test (SNOT), anxiety, and depression scores. A total of 35 articles were included, comprising 957 individual ENS patients. Surgical interventions mostly in the form of meatus augmentation implants accounted for 26 out of the 36 articles. The remaining ten articles included medical and psychological management options. SMD in SNOT, ENS6Q, anxiety, and depression scores were reported and demonstrated statistically significant improvements in follow-up periods of up to 1 year. All articles reported favorable outcomes following their chosen interventions. There is a paucity of evidence on the management of ENS and an absence of randomized controlled trials. Surgical intervention appears to be the current mainstay of treatment, but there is a potential role for psychological and medical management.

Characterization of nasal aerodynamics and air conditioning ability using CFD and its application to improve the empty nose syndrome (ENS) submucosal floor implant surgery–Part II virtual surgery

BackgroundInformative virtual surgeries provide useful insights for surgical options to patients. In the case of evaluating surgical treatments for the empty nose syndrome (ENS), reliable CFD virtual surgery is a predictive tool for symptom improvement. MethodsFive submucosal implant surgeries with two different implant volumes and three different implant sites were performed on the diseased side of an ENS patient. In each case, a post-surgery nasal cavity was created based on ENS patient's computed tomography images. The airflow and air-conditioning abilities of these nasal surgery models were computed to examine the effects of implant size and site on the surgical outcomes. Significant findingsThe largest improvements were achieved with the larger submucosal implant size at the lateral site. Airflow was redistributed into the inferior and superior meatuses, enhancing air interactions with the nasal mucus. The increased wall shear stress enhanced mucus secretion and sensation of airflow. The reduced vortex size alleviated the paradoxical nasal obstruction feeling. The results suggested that larger implant sizes and the lateral implant site would be advisable for submucosal implant surgeries on ENS patients. Inferior implant with a smaller size being a second advisable approach in terms of heating and humidification efficiencies.

The digestive Enzyme-Based nasal dysbiosis in Empty nose Syndrome: A theory

Empty nose syndrome (ENS) is described as an empty space in the region of the inferior and middle turbinates of patients who underwent inferior and middle turbinectomy. Patients commonly complained of dry nose, paradoxical nasal obstruction, and crust. Symptoms significantly worsen the quality of life of patients. The pathophysiology of ENS is poorly understood. Several abnormalities in the nasal airflow dynamics, air humidification and warming, mucociliary clearance, and trigeminal-related sensory function were reported but it is misunderstood why some patients with anatomical turbinate defects developed ENS, while others do not experience symptoms with similar anatomy. This paper proposes a theory associating the development of ENS with the presence of laryngopharyngeal reflux disease (LPRD). LPRD is associated with the deposit of gastroduodenal enzymes into the upper aerodigestive tract mucosa, which lead to a decrease of the defense mechanisms of mucosa (mucus hydration, bicarbonate secretion, growth factor production) and an increase of mucosa injuries. In ENS patients, the deposit of digestive enzymes into the nasal mucosa may lead to concurrent injuries of the nasal cells involved in air humidification, warming, or sensory function, and modifications of the nasal microbiome that cannot heal the injured mucosa.

Auricular conchal cartilage for treatment of empty nose syndrome

Empty nose syndrome is an uncommon complication of turbinoplasty and other nasal operations. It presents with various manifestations, with the most common symptom being paradoxical nasal obstruction. Here, we report the case of a 67-year-old male patient diagnosed with empty nose syndrome 20 years after turbinoplasty. Autologous auricular conchal cartilage was harvested and implanted into the lateral wall of the inferior turbinate to reduce nasal volume. The patient experienced significant relief from subjective nasal obstruction symptoms immediately after surgery. Over a 23-month follow-up period, no side effects or symptom recurrence was reported.

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.

Autologous Costal Cartilage Augmentation Technique for Treatment of Empty Nose Syndrome

Empty nose syndrome is a rare complication caused by excessive removal of normal tissues after nose surgery. The main symptoms of empty nose syndrome are paradoxical nasal obstruction, dryness, crust and dyspnea. Medical treatments such as irrigation, humidification, and ointment are not very effective, so surgical treatments to reconstruct the normal nasal cavity using implant materials are often considered. If the implant is not properly inserted, the symptoms persist and the implant must be removed again, resulting in the only donor site complications. Therefore, it is essential to treat the implant well and insert it precisely. Here we describe a surgical procedure to manage implant materials using autologous costal cartilage in the form of block, diced, and crushed cartilage for augmentation technique.

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.

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

A Case of Empty Nose Syndrome Developed After Septal Spur Removal

Empty nose syndrome (ENS) is a rare complication of turbinate surgery, in which patients suffer from symptoms such as paradoxical nasal obstruction, nasal dryness, facial pain and feeling excessive nasal openness. Its occurrence is generally attributed to excessive turbinate reductive procedures. However, theoretically, any procedure which can cause increased nasal airflow and decreased nasal resistance may have a risk of causing ENS. We recently experienced a case of ENS developed after septal spur removal without turbinate reduction, which has not previously been reported in the literature. Here we present the case history of this unusual occurrence.

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

Sublabial bioactive glass implantation for the management of primary atrophic rhinitis and empty nose syndrome: Operative technique.

ObjectivesAtrophic rhinitis (AR) and empty nose syndrome (ENS) are chronic diseases characterized by a paradoxical nasal obstruction. These rare syndromes tend to occur after nasal surgery of the inferior turbinates in ENS and can be idiopathic in AR. Medical treatments alone are often insufficient. Surgical options are challenging and numerous resorbable and nonresorbable implants have been described in small series, with as many surgical techniques described. Whereas current surgical procedures are for risk of extrusions, graft rejections or poor lasting results, the use of GlassBONE™ (Sodimed®, Avignon, France), a bioactive glass, for a vestibular approach in AR and ENS has never been reported for this indication.MethodsWe described an original technique of nasal submucoperiosteal bilateral ceramic glass implantation in two patients with AR and ENS.ResultsThe two cases presented a postoperative satisfying endoscopic and sinus CT‐scan results with filling of the nasal cavities, with less crusts and a complete wound healing. They had no short‐term complications.ConclusionThis innovative approach is easily feasible and could be an option considered for the surgical management of AR and ENS. Level of evidence: 4.

Empty nose syndrome pathogenesis and cell-based biotechnology products as a new option for treatment.

Empty nose syndrome (ENS) is a rare complication that develops after partial or complete turbinectomy. The main feature of ENS is paradoxical nasal obstruction feeling despite objectively wide nasal airway. ENS pathogenesis is multifactorial and includes changes in laminar physiological airflow, disruption of mucosa functions and deficient neural sensation. This leads to the development of ENS symptomatology such as dyspnea, nasal dryness, nasal burning, nasal obstruction, feeling of suffocation and even comorbid psychiatric disorders that significantly impairs life quality. Specific effective treatment of ENS does not exist up to date. In this review we outline existing biomaterial for surgical reconstitution of nasal anatomy and discuss the perspective of stem cell-based technologies in ENS management. The main focus is directed to justification of rationality application of adult mesenchymal stem cells (MSCs) from different tissues origin and neural crest-derived stem cells (NCSCs) based on their intrinsic biological properties. MSCs transplantation may stimulate mucosa tissue regeneration via trophic factors secretion, direct transdifferentiation into epithelial cells and pronounced immunosuppressive effect. From the other hand, NCSCs based on their high neuroprotective properties may reconstitute nerve structure and functioning leading to normal sensation in ENS patients. We postulate that application of cell-based and tissue-engineered products can help to significantly improve ENS symptomatology only as complex approach aimed at reconstitution of nasal anatomy, recovery the nasal mucosa functionality and neural tissue sensation.

Using platelet-rich fibrin scaffolds with diced cartilage graft in the treatment of empty nose syndrome.

Empty nose syndrome (ENS) is a rare entity in patients who undergo sinonasal surgery due to over-resection of the turbinate. This syndrome leads to debilitating symptoms that include dry nose, painful nasal breathing, paradoxical nasal obstruction, crusting, and sleep disorder. The goal of surgical treatment is to reestablish the volume of the turbinates to rehabilitate the nasal resistance. Endonasal microplasty with cartilage implants on the lateral wall of the nasal cavity is useful for creating the neoturbinate. Here, we present 2 cases that describe the management of empty nose syndrome by endonasal microplasty using platelet-rich fibrin (PRF) scaffolds embedded with a diced cartilage graft. The integration of the PRF scaffolds with diced cartilage efficiently facilitated the reestablishment of the neoturbinate. This autologous biomaterial is suitable for the treatment of ENS.

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.

Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively

PurposeEmpty nose syndrome (ENS) is characterized by nasal dryness, crusting, and paradoxical nasal obstruction most commonly after inferior turbinate resection. ENS has also been reported to occur after middle turbinate resection (MTR), and concern for causing ENS is a possible reason surgeons preserve the MT during endoscopic sinus surgery (ESS). The objective was to determine whether MTR during ESS led to ENS. Materials and methodsThis was a prospective case series of 95 consecutive patients that underwent bilateral subtotal MTR during ESS with either Draf IIB or Draf III frontal sinusotomies, for chronic rhinosinusitis with or without nasal polyps, and frontal sinus inverted papillomas. Demographic data and postoperative Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores were obtained. Nasal crusting was also documented on last postoperative nasal endoscopy. ResultsPathologies included chronic rhinosinusitis with nasal polyps (69), without nasal polyps (12), and inverted papillomas (14). Fifty-six patients underwent subtotal MTRs during ESS with Draf IIB, and 39 with Draf III. Mean follow-up was 19.4 months (range 12–49). Mean postoperative ENS6Q score was 2.1. Only 2.1% had ENS6Q scores ≥ 11, and 6.3% had nasal crusting at last follow-up. None of the patients with ENS6Q scores ≥ 11 had nasal crusting at last follow-up. There were no significant differences in outcomes between ages, genders, surgery types, or pathologies. ConclusionsPatients who underwent bilateral subtotal MTR during ESS were unlikely to develop ENS by at least 1 year postoperatively, based on patients rarely experiencing ENS6Q scores ≥ 11 or persistent nasal crusting.

What drives depression in empty nose syndrome? A Sinonasal Outcome Test-25 subdomain analysis.

Empty nose syndrome (ENS) is a debilitating disorder characterised by paradoxical nasal obstruction after excessive surgical excision of nasal tissues. ENS negatively impacts the quality of life (QOL) and psychological status of patients. This study aimed to determine the associations among disease-specific QOL impairments and the severity of anxiety and depression before and after surgery in ENS patients. A total of 68 ENS patients were prospectively recruited and underwent submucosal Medpor implantation. QOL impairments and the severity of anxiety and depression were evaluated using the Sinonasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) 1 day before and 6 months after surgery. The BDI-II and BAI scores were significantly associated with the total score and ear/facial symptoms, psychological dysfunction, sleep dysfunction, and empty nose symptoms domains of the SNOT-25. Surgery improved disease-specific and psychological symptoms. Post-operative changes in the BDI-II score were correlated with changes in the total score and sleep dysfunction and empty nose symptoms domains of the SNOT-25. A SNOT-25 total score of greater than 60, sleep dysfunction domain score of greater than 18, and empty nose symptoms domain score of greater than 14 were good predictors of moderate-to-severe depression. ENS symptoms are associated with psychological burden and could be good predictors of moderate-to-severe depression. Targeted symptom improvement could reduce the psychological burden.

Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies.

To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS. Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials. The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.