2016 Section 5 Green Book

clinicians (and ultimately patients) with a realistic view- point on contemporary surgical outcomes and also recom- mend a minimum dataset for reporting of outcomes.

TABLE I. The Sino-Nasal Outcome Test-25 for the Assessment of Empty Nose Syndrome. 6,7

1

Need to blow nose

2

Sneezing

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. 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 RESULTS Literature Search

3 4

Runny nose

Cough

5

Postnasal discharge

6 7

Thick nasal discharge

Ear fullness

8

Dizziness

9

Ear pain

10

Facial pain/pressure

11

Difficulty falling asleep

12 13

Waking up at night

Lack of good night’s sleep

14

Waking up tired

15 16

Fatigue

Reduced productivity

17

Reduced concentration

18 19

Frustration/restlessness/irritability

Sadness

20

Embarrassment

ENS-specific symptoms 21

Dryness

22

Difficulty with nasal breathing

23 24

Suffocation

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.

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

Fig. 1. Flow chart of literature search strategy. MeSH 5 medical subject heading.

Laryngoscope 125: July 2015

Leong: Surgical Interventions for Empty Nose Syndrome

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