2016 Section 5 Green Book

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 Houser 6 may be due to poor regeneration of sensory nerves to the resected area. Moore and Kern 1 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. BIBLIOGRAPHY 1. Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol 2001;15:355–361. 2. Empty Nose Syndrome. Available at: http://www.emptynosesyndrome.org/ what-is-ens/ Accessed June 30, 2014. 3. Huizing EH, De Groot J. Functional Reconstructive Nasal Surgery . New York, NY: Thieme; 2003: 286. 4. Hildenbrand T, Weber RK, Brehmer D. Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature. Eur Arch Otorhinolaryngol 2011;268:17–26. 5. Payne SC. Empty nose syndrome: what are we really talking about? Oto- laryngol Clin North Am 2009;42:331–337. 6. Houser SM. Surgical treatment for empty nose syndrome. Arch Otolaryn- gol Head Neck Surg 2007;133:858–8 63. 7. Chhabra N, Houser SM. The diagnosis and management of empty nose syndrome. Otolaryngol Clin North Am 2009;42:311–330. 8. Sozansky J, Houser SM. Pathophysiology of empty nose syndrome. Laryn- goscope 2015;125:70–74. doi: 10.1002/lary.24813. Epub 2014. 9. Mishra A, Kawatra R, Gola M. Interventions for atrophic rhinitis. Cochrane Database Syst Rev 2012;2:CD008280. 10. Coste A, Dessi P, Serrano E. Empty nose syndrome. Eur Ann Otorhinolar- yngol Head Neck Dis 2012;129:93–97. 11. Browne JP, Hopkins C, Slack R, Cano SJ. The Sino-Nasal Outcome Test (SNOT): can we make it more clinically meaningful? Otolaryngol Head Neck Surg 2007;136:736–41. 12. Freund W, Wunderlich AP, Stocker T, Schmitz BL, Scheithauer MO. Empty nose syndrome: limbic system activation observed by functional magnetic resonance imaging. Laryngoscope 2011;121:2019–2025. 13. Christmas DA, Mirante JP, Yanagisawa E. Endoscopic view of an "empty nose". Ear Nose Throat J 2013;92:58. 14. Iqbal FR, Gendeh BS. Empty nose syndrome post radical turbinate sur- gery. Med J Malaysia 2007;62:341–342. 15. Houser SM. Empty nose syndrome associated with middle turbinate resec- tion. Otolaryngol Head Neck Surg 2006;135:972–973. 16. Rice DH. Rebuilding the inferior turbinate with hydroxyapatite cement. Ear Nose Throat J 2000;79:276–277. 17. Jiang C, Wong F, Chen K, Shi R. Assessment of surgical results in patients with empty nose syndrome using the 25-item sino-nasal out- come test evaluation. JAMA Otolaryngol Head Neck Surg 2014;140:453– 458. 18. Tam YY, Lee TJ, Wu CC, et al. Clinical analysis of submucosal Medpor implantation for empty nose syndrome. Rhinology 2014;52:35–40. 19. Jung JH, Baguindali MA, Park JT, Jang YJ. Costal cartilage is a superior implant material than conchal cartilage in the treatment of empty nose syndrome. Otolaryngol Head Neck Surg 2013;149:500–505.

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