2016 Section 5 Green Book

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

The Laryngoscope V C 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) 2 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 1 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. 2 Simi- lar sentiments against radical turbinate surgery were 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

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’.” 3 For many years, ENS was thought to be a form of secondary atrophic rhinitis. 4 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. 5 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. 9 Recommended conservative management does not differ significantly from atrophic rhinitis, which includes nasal lavage, lubricant drops, and topical corticosteroids. 10 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

DOI: 10.1002/lary.25170

Laryngoscope 125: July 2015

Leong: Surgical Interventions for Empty Nose Syndrome

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