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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 2 25 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. Modrzynski 25

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. 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. 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 www. laryngoscope.com.] Complications, Failure, and Extrusion of Implant

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 www.laryngoscope.com.]

Laryngoscope 125: July 2015

Leong: Surgical Interventions for Empty Nose Syndrome

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