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clinicians (and ultimately patients) with a realistic view-
point on contemporary surgical outcomes and also recom-
mend a minimum dataset for reporting of outcomes.
METHODS
A structured search of the Cochrane Collaboration database,
U.S National Institutes of Health database (ClinicalTrials), and
U.S National Library of Medicine (PubMed) was undertaken
using a combination of medical subject-heading (MeSH) terms:
nose, turbinate, surgery, atrophic rhinitis, and empty nose syn-
drome. The review period was restricted from January 1, 2000, to
June 30, 2014, and limited to the English language. The
abstracts were appraised for relevance, and full-text articles were
obtained as appropriate. The bibliography of each article was
reviewed to identify any other potentially relevant study. The
full-text version was then reviewed for patient demographics,
surgical intervention, complications, and outcome. If single units
had reported on more than one case series with overlapping
review periods, the earlier study was excluded unless it contained
more comprehensive data for analysis than the latter report.
Finally, the studies were assessed according to criteria defined by
the Oxford Centre for Evidence-Based Medicine (Oxford, UK).
For studies that utilized similar clinical outcome tools
such as the Sino-Nasal Outcome Test (SNOT), data were col-
lated according to individual patients and domain scores.
Browne et al.
11
described four distinct subdomains within the
SNOT-20: 1) rhinologic symptoms, 2) ear and facial symptoms,
3) sleep function, and 4) psychological issues. Houser proposed
an additional five ENS-specific questions to aid with the assess-
ment of ENS patients
7
(Table I).
Statistical analysis was performed using SigmaPlot ver-
sion 12 (Systat Software, Inc., CA). A normality test (Shapiro-
Wilk) was undertaken; as appropriate, the Student
t
test or
Mann–Whitney U test was used to assess the difference
between pre- and postsurgery SNOT scores. A
P
value of 0.05
was deemed to be statistically significant.
RESULTS
Literature Search
Fourteen studies were identified from the PubMed
literature search. Five were excluded due to insufficient
outcome data, including one that was exclusively man-
aged medically.
12–16
The remaining nine were potentially
suitable for review.
17–25
One other clinical trial was iden-
tified from the U.S National Institutes of Health elec-
tronic database, but this trial was terminated when the
lead investigator left the sponsoring institution. Of the
nine potentially suitable studies, one was excluded
because a more recent report from the same institution
yielded more data.
21
The remaining eight studies were
eligible for inclusion (Fig. 1). Seven studies were graded
as level 4 evidence base, whereas one study randomized
patients to either the Silastic (Dow Corning, Midland,
MI) or AlloDerm (LifeCell Corporation, NJ) implant group
(level 2b).
22
The overall grade of recommendation was C.
Patient Demographics
A total of 128 patients (84 males) were collated
from the eight studies, with an age range of 18 to 64
years (Table II). A diagnosis of ENS in all cases was
achieved from clinical history and examination. Two
studies undertook preoperative rhinomanometry and/or
acoustic rhinometry, although the measurements did not
influence a diagnosis or indication for ENS surgery.
22,25
The use of the cotton wool test to select suitable surgical
TABLE I.
The Sino-Nasal Outcome Test-25 for the Assessment of Empty
Nose Syndrome.
6,7
1
Need to blow nose
2
Sneezing
3
Runny nose
4
Cough
5
Postnasal discharge
6
Thick nasal discharge
7
Ear fullness
8
Dizziness
9
Ear pain
10
Facial pain/pressure
11
Difficulty falling asleep
12
Waking up at night
13
Lack of good night’s sleep
14
Waking up tired
15
Fatigue
16
Reduced productivity
17
Reduced concentration
18
Frustration/restlessness/irritability
19
Sadness
20
Embarrassment
ENS-specific symptoms
21
Dryness
22
Difficulty with nasal breathing
23
Suffocation
24
Nose is too open
25
Nasal crusting
Each question is evaluated on a Likert scale of 0 to 5, with 5 being
most severe.
ENS
5
empty nose syndrome.
Fig. 1. Flow chart of literature search strategy.
MeSH
5
medical subject heading.
Laryngoscope 125: July 2015
Leong: Surgical Interventions for Empty Nose Syndrome
9