32 / 236
candidates was undertaken in three studies.
18,21,23
Most
patients had been suffering with ENS for many years
(up to 29.7 years
12
), and there was general consensus
that ENS surgery was deferred for at least 1 year after
turbinectomy. Although all studies reported on patients
who had inferior turbinectomy, the degree of turbinate
resection (partial, total) was not consistently reported.
Surgical Technique
The most common surgical technique involved a
transnasal approach, with implant material secured
within a submucosal pocket. The amount and thickness of
implant material was arbitrarily decided based on how
much inferior turbinate reconstruction was necessary at
the time of the operation. Multiple implant sites in the
lateral nasal wall, remnant of the inferior turbinate or
septal area adjacent to the resected turbinate, were nor-
mally performed to narrow the nasal valve region. Com-
mon implant material used in the studies included
noncellular dermis (AlloDerm) and porous high-density
polyethylene (Medpor, Porex Surgical, Inc., GA). These
materials were used in 47% of cases, whereas autologous
(septal, conchal) and homologous (Tutoplast-processed cos-
tal cartilage; Tutogen Medical GmbH, Neunkirchen am
Brand, Germany) cartilage was utilized in 38% of cases.
In three cases, small aliquots (0.3–0.4 mL) of hyaluronic
acid gel (Juvederm; Allergan, Inc., CA) was injected into
the remnant of the head of inferior turbinate, and adja-
cent septum after the nasal mucosa was perforated with a
CO2 laser.
25
One study involving five patients embedded
nonporous
b
-tricalcium phosphate (SINUS UP; Kasios,
Launaguet, France) via a gingival incision within a sub-
mucoperiosteal pocket in the lateral nasal wall.
12
Clinical Outcomes
The follow-up period varied widely (range 6–48
months). Most studies reported postintervention data based
on an aggregated follow-up period, although two presented
results at 3-, 6-, and 12-month follow-up.
12,18
Of the eight
studies, seven assessed clinical efficacy with a patient-
reported outcome tool (Table II). Five studies utilized the
SNOT, totaling 103 patients. The weighted mean preopera-
tive SNOT-20 and SNOT-25 scores were 48.3 and 65.9
respectively. At the latest follow-up, these scores improved
significantly (
P
<
0.05) to 24.4 and 33.3, respectively.
Averaged scores of individual SNOT questions were
available from 64 patients, which enabled the analysis of
SNOT subdomains.
12,18,22
High SNOT scores were attrib-
uted to issues of reduced productivity, poor concentra-
tion, and feeling frustrated. Although all SNOT
subdomains improved subsequent to surgery, the largest
improvement was observed in ENS symptoms and
TABLE II.
Summary of Evaluated Studies Included in This Review in Chronological Order.
First Author
(year of publication)
Number of
Patients
Age
(years)
Gender Distribution
(male:female)
Implant
Material
Surgical
Approach
Outcome
Measures
Follow-up
(months)
Jiang (2014)
24
18–64
18:6
Medpor
Transnasal SNOT-25
3,6,12
Tam (2014)
16
31–68
10:6
Medpor
Transnasal SNOT-22
12
Jung (2013)
31 Mean 43.5
22:9
Conchal, costal
cartilage
Transnasal SNOT-25
6
Bastier (2013)
5 49.2–54.7
3:2
Nonporous
b
-tricalcium
phosphate
Transoral
NOSE,
RhinolQoL
Mean 13.5, Range 8.2–21
Saafan (2013)
24 Mean 27
11:13
12
3
AlloDerm,
12
3
Silastic
Transnasal SNOT-25
Mean 18, Range 9–24
Modrzynski (2011)
3
48–64
2:1
Hyaluronic
acid gel
Transnasal Subjective,
acoustic
rhinometry
12
Jang (2011)
17
20–66
11:6
Cartilage
(autologous,
homologous)
Transnasal 10-point visual
analogue scale
Mean 11.8, Range 6 - 27
Houser (2007)
8
18–45
7:1
AlloDerm
Transnasal SNOT-20
Range 6–48
NOSE
5
Nasal Obstruction Symptom Evaluation; RhinolQOL
5
Rhinosinusitis Quality of Life; SNOT
5
Sino-Nasal Outcome Test.
Fig. 2. Changes in average pre- and postoperative Sino-Nasal
Outcome Test subdomain scores, based on data obtained from
Jiang et al.,
17
Tam et al.,
18
Jung et al.,
19
and Saafan et al.
22
The
maximum score column represents the maximum possible score
for that particular subdomain. ENS
5
empty nose syndrome.
[Color figure can be viewed in the online issue, which is available
at
www.laryngoscope.com.]
Laryngoscope 125: July 2015
Leong: Surgical Interventions for Empty Nose Syndrome
10