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psychological issues (Fig. 2). Total and subdomain scores
improved by 3 months postsurgery, and this trend con-
tinued to improve over time, although available data
was limited to only 12 months follow-up (Fig. 3).
Total pre- and postoperative SNOT scores were avail-
able from 48 patients derived from three studies.18,22,23
The average total SNOT score improved significantly
(P < 0.001) after surgery, with an average improvement of
29.0 (standard deviation, 15.9) points. At least 50% of
patients reported an improvement of 30 SNOT points or
more (Fig. 4). Nevertheless, 10 patients had less than 10
points improvement, including three patients who had no
change in SNOT scores. Alloderm, Medpor, and Silastic
were implanted in 20, 16, and 12 patients, respectively.
ANOVA analysis of the pre- and postoperative scores was
not possible due to the mix of SNOT-22 and 225 scores
reported in these cohorts. Nevertheless, statistically sig-
nificant improvements in mean postoperative SNOT
scores were observed in all three implanted materials.
Instead of the SNOT, Bastier et al.20 reported out-
comes using the Nasal Obstruction Symptom Evaluation
(NOSE) and Rhinosinusitis Quality of Life (RhinolQoL)
questionnaires. All five patients in this study reported
statistically significant improvement in NOSE and Rhi-
nolQoL scores. RhinoQOL symptom frequency, bother-
someness, and impact subscales improved after surgery.
The case series reported by Jang et al.24 utilized a
10-point visual analogue scale for subjective symptoms
such as excessive airflow, nasal obstruction, nasal/facial
pain, rhinorrhoea/postnasal drip, and headache. Nine
patients were satisfied with ENS surgery and reported
significant improvement in excessive airflow, nasal
obstruction, and nasal/facial pain.
Although two studies reported on nasal physiological
parameters, only one had informative data. Modrzynski25
merely reported that “acoustic rhinometry performed 7
days, and 3 and 6 months after surgery confirmed that
the positive outcome of surgery was maintained”; how-
ever, follow-up examination performed after 12 months
showed that the original effects of the surgery remained
in only one of their patients."25 In the earlier report by
Jiang et al.,21 Medpor implants resulted in a significant
increase in the mean nasal resistance, nasal volume, and
nasal minimum cross-sectional area at 12 months follow-
up. There was an upward trend in the mean mucociliary
clearance time, although the differences between pre- and
postimplant did not achieve statistical significance.
Complications, Failure, and Extrusion of
Implant
No intraoperative complications were reported in
any of the studies. One patient was described to have
developed postoperative chronic rhinosinusitis attributed
to overcorrection of the nasal valve region.18 In another
study, two patients had under correction requiring fur-
ther augmentation.24 Of the three patients who had
hyaluronic acid gel injections, the augmentation was
found to be completely resorbed in two patients at the
12-month follow-up; one of who had further treatment.25
Three patients reported no change in their SNOT score
and another seven had < 10 SNOT points change after
surgery, although it was unclear if these patients had
revision surgery.18,23 Extrusion of the implant occurred
in six cases (1 b-tricalcium phosphate; 1 Medpor; 4 Silas-
tic) however, because multiple layers of the implant
were used, no adverse impact on final outcome was
reported. 18,20,22
DISCUSSION
The actual number of patients suffering with ENS
is unknown. The relatively small cohort identified in
this literature review undoubtedly belies the true figure,
and it is unfortunate that many patients suffer without
recourse to potentially effective surgical treatment.
Fig. 3. Comparison of pre- and postoperative total and subdomain
SNOT scores over time, based on data obtained from Jiang
et al.17 and Tam et al.18
ENS 5 empty nose syndrome; SNOT 5 Sino-Nasal Outcome Test.
[Color figure can be viewed in the online issue, which is available
at .]
Fig. 4. Column bar graph demonstrating the percentage of
patients based on the difference between pre- and postoperative
total SNOT scores. SNOT 5 Sino-Nasal Outcome Test. [Color fig-
ure can be viewed in the online issue, which is available at
]
Laryngoscope 125: July 2015 Leong: Surgical Interventions for Empty Nose Syndrome
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