2016 Section 5 Green Book

The Laryngoscope

2015 The American Laryngological,

Rhinological and Otological Society, Inc.

Contemporary Review

The Clinical Efficacy of Surgical Interventions for Empty Nose

Syndrome: A Systematic Review

Samuel C. Leong, MPhil, FRCSEd (ORL-HNS)

Objective:

To evaluate the outcomes of surgical intervention for empty nose syndrome (ENS).

Data Source:

Cochrane Collaboration database, U.S National Institutes of Health database (ClinicalTrials), U.S National

Library of Medicine (PubMed).

Review Methods:

Structured search using medical subject-heading terms: nose, turbinate, surgery, atrophic rhinitis, and

empty nose syndrome.

Results:

A total of 128 patients were collated from eight studies with an age range of 18 to 64 years. Most patients had

been suffering with ENS for many years, up to 29.7 years. The most common surgical technique involved a transnasal

approach with implant material secured within a submucosal pocket. Common implant material used in the studies included

biosynthetic, and autologous cartilage. The weighted mean preoperative Sino-Nasal Outcome Test (SNOT)

20 and SNOT-25

scores were 48.3 and 65.9, respectively. At latest follow-up, these scores improved significantly to 24.4 and 33.3, respectively.

Although all SNOT subdomains improved following surgery, the highest improvement was observed in ENS symptoms and

psychological issues. SNOT scores improved by 3 months postsurgery and this trend continued over time, although available

data was limited to only 12 months follow-up. Nevertheless, 10 patients had less than 10 points improvement, including

three patients who had no change in SNOT scores. Extrusion of the implant occurred in six cases, and one developed chronic

rhinosinusitis.

Conclusion:

Surgical intervention for ENS appears to result in clinical improvement, although not all patients derived

benefit. Long-term follow-up should be considered utilizing using both subjective (SNOT-25) and objective (rhinomanometry)

measures of clinical outcome.

Key Words:

Atrophic rhinitis, turbinate, paranasal sinus, surgery, empty nose syndrome.

Laryngoscope

, 125:1557–1562, 2015

INTRODUCTION

Empty nose syndrome (ENS) is a poorly recognized

but undoubtedly devastating clinical entity. In their

2001 article on atrophic rhinitis, Moore and Kern

stated

in reference to those suffering from this affliction that,

‘‘the absence of normal nasal structures is universal in

these patients, and the symptoms of atrophic rhinitis

coupled with a cavernous nasal airway lacking identifia-

ble turbinate tissue has been termed the empty nose

syndrome.’’ Both clinical cases presented Kern at the

American Rhinologic Society meeting committed suicide

as a result of their disabling sinonasal symptoms.

Simi-

lar sentiments against radical turbinate surgery were

echoed by Huizing and De Groot, who stated that “a

wide nasal cavity syndrome due to reduction of the infe-

rior turbinate (and/or middle turbinate) is still fre-

quently seen. In our opinion, it is a ‘nasal crime’.”

For many years, ENS was thought to be a form of

secondary atrophic rhinitis.

The existence of ENS has

been hotly debated, and it remains to be answered why

some patients develop ENS following turbinate surgery.

The inability to diagnose ENS objectively has fuelled fur-

ther speculation that it could be either a form of nasal

neuropathy or rhinitis hystericus.

After years of careful

assessment and follow-up of ENS patients, Houser pro-

posed that ENS should be redefined as a symptom com-

plex that includes a paradoxical sense of obstruction in

spite of partial or complete turbinate resection.

6–8

The management of ENS is challenging and the evi-

dence base for most treatment modalities remains low.

Recommended conservative management does not differ

significantly from atrophic rhinitis, which includes nasal

lavage, lubricant drops, and topical corticosteroids.

Sur-

gical intervention for ENS aims to increase nasal airway

resistance by narrowing the nasal valve region or recon-

structing a pseudoturbinate. The purpose of this review

was to evaluate the efficacy of surgical treatments for

ENS. It is envisaged that the results would provide

From the Division of Rhinology and Anterior Skull Base Surgery,

Department of Otorhinolaryngology–Head and Neck Surgery, University

Hospital Aintree, Liverpool, United Kingdom

Editor’s Note: This Manuscript was accepted for publication

December 18, 2014.

The author has no funding, financial relationships, or conflicts of

interest to disclose.

Send correspondence to Mr. Samuel C. Leong, MPhil FRCSEd

(ORL-HNS), Department of Otorhinolaryngology–Head and Neck Sur-

gery, University Hospital Aintree, Liverpool L9 7AL, United Kingdom.

E-mail:

lcheel@doctors.org.uk

DOI: 10.1002/lary.25170

Laryngoscope 125: July 2015

Leong: Surgical Interventions for Empty Nose Syndrome

Reprinted by permission of Laryngoscope. 2015; 125(7):1557-1562.