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Careful analysis of turbinectomy studies show that small
numbers of patients continue to complain of nasal
obstruction despite having turbinate resection, whereas
others suffer with crusting and foul-smelling secretions.
Whether these patients have ENS is unknown given
that the existence of this condition has been contentious
and will perhaps remain so. Because there is no empiri-
cal evidence to support the diagnosis of ENS at present,
it is argued that many otolaryngologists remain skepti-
cal about its existence and are not willing acknowledge
the diagnosis and offer treatment. Nevertheless, Houser
makes a compelling argument that ENS should be
regarded as a condition that is distinct from atropic rhi-
nitis, and that greater effort should be made to under-
stand this clinical entity so that clinicians can be
enabled to provide relief to those who have already been
afflicted by it.7,8,23
Surgical implantation of biocompatible material to
reconstruct a pseudoturbinate or to narrow the nasal
valve region appears to result in improved patient-
reported sinonasal symptoms, regardless of implant
material used. There was insufficient evidence from this
review to favor any particular implant material,
although it was observed that Silastic had higher extru-
sion rate and that hyaluronic acid gel was resorbed
within 12 months.
The magnitude of patient reported improvement
varied widely and according to Houser6 may be due to
poor regeneration of sensory nerves to the resected area.
Moore and Kern1 postulated that the “wear and tear’’ on
the mucosa under the circumstances of altered airflow
leads to a disruption and degeneration of the mucosal
nerve fibres, resulting in a decreased ability to sense air-
flow. This may explain why 21% (10 out of 48 patients)
had less than 10 SNOT points improvement after sur-
gery.18,22,23 Furthermore, the bulk of nasal airflow
streams predominate at the floor of the nasal cavity fol-
lowing radical turbinectomy.26 In addition, it should be
remembered that none of the patients in studies were
blinded to surgical intervention; therefore, a degree of
positive reporting bias may be expected.
The baseline total SNOT scores of ENS patients
were higher than those suffering with nasal polyps or
chronic rhinosinusitis.27 This observation may repre-
sent greater functional and psychological burden, akin
to patients suffering with nonsinogenic facial pain.28
The modified SNOT questionnaire, which incorporates
five additional questions specific to ENS, should form
the baseline of future clinical reports. Psychometric val-
idation of this modified questionnaire would be ideal,
but challenging, given the relatively small number of
ENS patients seen by individual otolaryngologists.
Objective measures of nasal airflow such as rhinoman-
ometry are an important adjunct to substantiate the
results of ENS surgery. A total nasal airway resistance
of 0.3 Pa/cm 3/s (3.0 cm H2O/l/s) is generally accepted
as the upper limit of normal.29 Jiang et al.22 reported
that the mean nasal airway resistance improved from
1.03 cm H2O/l/min to 1.9 cm H2O/l/min at 12 months
follow-up. Computational fluid dynamic studies of nasal
aerodynamics may have a role in ENS to plan place-
ment and quantity of implants in order to predict neo-
nasal airflow.30
The utility of the cotton test remains to be validated.
This test is performed by placing cotton moistened with
isotonic sodium chloride solution within the nonanaesthe-
tized nasal cavity in a region where an implant would be
feasible.6 The patient is then asked to breathe comfort-
ably with this in place for approximately 30 minutes and
to gauge any change in sensation or symptoms. Patients
who report a definite subjective improvement from the
cotton test were, in some studies, offered implanta-
tion.18,22,23 However, Bastier et al.20 argued that it would
stimulate trigeminal sensitivity and affect the patient’s
subjective assessment of their sinonasal symptoms.
CONCLUSION
Empty nose syndrome is a challenging condition to
treat, compounded by the lack of objective tests to facili-
tate diagnosis. Nevertheless, a realistic but empathetic
approach is required taking into account the current evi-
dence (grade of recommendation C) for surgical interven-
tion. Clinical response varies between patients; up to
21% may report only marginal improvement. Authors
should be encouraged to consider long-term follow-up (>
12 months) of patients using both subjective (SNOT-25)
and objective (rhinomanometry) measures of clinical
outcome.
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