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Almansour YM, Alani A, Wilson CP, Eide JG, Craig JR. Medial Flap Turbinoplasty is Unlikely to Cause Empty Nose Syndrome. Laryngoscope 2025; 135:1622-1627. [PMID: 39673254 DOI: 10.1002/lary.31947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2024] [Revised: 11/16/2024] [Accepted: 11/22/2024] [Indexed: 12/16/2024]
Abstract
BACKGROUND Empty nose syndrome (ENS) is a poorly understood condition that affects a minority of patients who undergo inferior turbinate (IT) surgery. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) was validated to diagnose ENS following IT reduction, with an ENS6Q ≥ 11 being suggestive of ENS. Medial flap turbinoplasty (MFT) involves IT bone removal ± submucosal reduction (SMR) and is highly effective at surgically treating IT hypertrophy. This study's purpose was to determine the incidence of ENS following MFT by comparing ENS6Q scores preoperatively and postoperatively. METHODS A retrospective cohort study was conducted on consecutive patients who underwent bilateral MFT with or without septoplasty to address nasal obstruction. Preoperative and postoperative nasal obstruction and septoplasty effectiveness (NOSE, 0-20) and ENS6Q (0-30) scores were compared at a minimum 12 months postoperatively. RESULTS Of 100 patients, mean age was 48.9 years and 53% were male. Mean follow-up was 25.0 months (range: 12-66 months). Patients underwent MFT with SMR in 70% of cases, whereas 30% had bone removal only, and 79% had septoplasty. NOSE scores decreased significantly postoperatively (mean 9-point reduction, p < 0.0001). Mean preoperative and postoperative ENS6Qs were 8.5 and 3.0, respectively, with a mean 5.6-point decrease postoperatively (p < 0.0001). While some patients developed elevated ENS6Q scores mainly in the first 3 months postoperatively, no patients had ENS6Q scores ≥11 at final follow-up. CONCLUSIONS MFT ± septoplasty led to significant long-term reduction in nasal obstruction, with no patients ultimately developing ENS6Q ≥ 11 postoperatively. Therefore, MFT was unlikely to cause ENS. LEVEL OF EVIDENCE 4 Laryngoscope, 135:1622-1627, 2025.
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Affiliation(s)
| | | | - Carl P Wilson
- Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, U.S.A
| | - Jacob G Eide
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
| | - John R Craig
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, U.S.A
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Rotimi O, Williams I, Rennie C, Okhovat S, Sharma R, Wormald P, Tan NC. Extended Approaches to the Maxillary Sinus are not Associated With an Increased Risk of Empty Nose Syndrome. Int Forum Allergy Rhinol 2025; 15:445-447. [PMID: 39761377 PMCID: PMC11970443 DOI: 10.1002/alr.23513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2024] [Revised: 12/02/2024] [Accepted: 12/13/2024] [Indexed: 04/05/2025]
Affiliation(s)
| | | | - Catherine Rennie
- ENT DepartmentCharing Cross HospitalImperial College NHS TrustLondonUK
| | - Saleh Okhovat
- ENT DepartmentGlasgow Royal Infirmary and Queen Elizabeth University HospitalGlasgowUK
| | | | - Peter‐John Wormald
- Department of Surgery – Otolaryngology Head and Neck SurgeryAdelaide UniversitiesThe Queen Elizabeth HospitalWoodvilleSouth AustraliaAustralia
| | - Neil C.‐W. Tan
- ENT DepartmentRoyal Cornwall HospitalTruroUK
- University of Exeter Medical SchoolRoyal Cornwall HospitalTruroUK
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Odeh A, Wen R, Wu Z, Schneller AR, Root ZT, Hittle B, Wiet GJ, Otto BA, Kelly KM, Zhao K. Does Total Turbinectomy Always Lead to Empty Nose Syndrome? A Computational Virtual Surgery Study. Laryngoscope 2025; 135:562-569. [PMID: 39305211 PMCID: PMC11725719 DOI: 10.1002/lary.31757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 08/16/2024] [Accepted: 08/21/2024] [Indexed: 01/14/2025]
Abstract
INTRODUCTION Computational fluid dynamic (CFD) modeling has previously indicated that distorted nasal airflow patterns may contribute to empty nose syndrome (ENS); however, no data show that aggressive turbinate surgery always leads to ENS. We aim to use virtual surgery planning (VSP) to investigate how a total inferior turbinectomy affects airflow parameters compared with ENS patients. METHODS We retrospectively recruited six nasal obstruction patients who underwent turbinate reduction surgery. We virtually performed total inferior turbinectomy on these patients to compare CFD modeling results to patients' actual surgical outcomes and to that of a previously collected ENS patient cohort (n = 27). RESULTS Patients' actual surgery outcomes were excellent, with Nasal-Obstruction Symptom Evaluation (NOSE) score (pre: 72.5 ± 13.2 vs post-surgery: 10.8 ± 9.8, p < 0.001) and unilateral visual analog scale (VAS) scores of nasal obstruction (pre: 6 ± 2.56 vs post-surgery: 1.2 ± 1, p < 0.001) improved and was statistically significant. The virtual turbinectomy does not create the same distorted nasal airflow patterns as seen in ENS patients, with no statistically significant difference in nasal resistance as compared with post-actual surgery (virtual turbinectomy: 0.10 ± 0.03 Pa/mL*s; actual surgery: 0.12 ± 0.04 Pa/mL*s; ENS: 0.11 ± 0.04, p > 0.05) nor in regional wall shear force distribution, an important indicator of air/mucosa stimulation (inferior turbinate WSF%: virtual 47.3% ± 11.3% vs actual 51.5% ± 15.1%, p > 0.05); however, both are statistically significant higher than that of ENS patients (WSF: 32.2% ± 12.5%, p < 0.001), despite ENS cohort having wider inferior airway cross-sectional area (CSA) than actual surgeries. CONCLUSION Empty nose syndrome is likely a multifactorial disease process that cannot be solely attributed to aggressive turbinate reduction surgery. LEVEL OF EVIDENCE 3 Laryngoscope, 135:562-569, 2025.
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Affiliation(s)
- Ahmad Odeh
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Raymond Wen
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Zhenxing Wu
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Aspen R. Schneller
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Zachary T. Root
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Bradley Hittle
- The Department of Biomedical InformaticsThe Ohio State University Wexner Medical CenterColumbusOhioU.S.A.
| | - Gregory J. Wiet
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
- Department of OtolaryngologyNationwide Children's HospitalColumbusOhioU.S.A.
| | - Bradley A Otto
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Kathleen M Kelly
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
| | - Kai Zhao
- Department of Otolaryngology—Head & Neck SurgeryThe Ohio State UniversityColumbusOhioU.S.A.
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Levi L, Yang A, Tsai EF, Ma Y, Ibrahim N, Dholakia SS, Rao VK, Renteria A, Cao X, Chang MT, Nayak JV. Stepwise Empty Nose Syndrome Evaluation (SENSE) test-A modified cotton test for reduced bias in office diagnosis of empty nose syndrome. Int Forum Allergy Rhinol 2025; 15:149-156. [PMID: 39373717 DOI: 10.1002/alr.23442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 07/25/2024] [Accepted: 08/20/2024] [Indexed: 10/08/2024]
Abstract
INTRODUCTION Diagnosis of empty nose syndrome (ENS) relies on the ENS six-item questionnaire (ENS6Q) with a score of ≥11, followed by a "positive" cotton test yielding seven-point reduction from baseline ENS6Q score via cotton placement to the inferior meatus (IM). Given the intricacies of diagnosing ENS and the propensity for false positives with the standard cotton test, we modified the classic single-step cotton test into a four-part Stepwise Empty Nose Syndrome Evaluation (SENSE) cotton test to reduce bias and evaluate the placebo effect. METHODS Individuals diagnosed with ENS underwent the SENSE test, a single-blinded, four-step, office-based cotton test, without topical anesthesia or decongestants. Conditions included: (1) placebo/no cotton placed; (2) complete cotton-blockade of nasal vestibule; (3) cotton placed medially against the nasal septum; and (4) cotton placed laterally in the IM (site of inferior turbinate tissue loss). With each condition, patients completed an ENS6Q. RESULTS Forty-eight ENS patients were included. Twenty-nine percent demonstrated a placebo effect (p < 0.001), 40.4% had a positive response to complete cotton-blockade (p < 0.001), 64.4% to septum-placed cotton, and 79.1% to IM-placed cotton (p < 0.001), corresponding to a mean ENS6Q reduction of 11.9 points (p < 0.001). Notably, the mean difference in ENS6Q scores between septum and IM placement was 1.7 (p < 0.001). CONCLUSIONS The SENSE test offers further insight into subtleties of nasal breathing experienced by ENS patients. The placebo effect can be prominent and important to consider with individual patients. While most ENS patients prefer any intranasal cotton placement over baseline, blinded testing reveals these patients can accurately discriminate minimal changes in nasal aerodynamics.
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Affiliation(s)
- Lirit Levi
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Otolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel
| | - Angela Yang
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Esmond F Tsai
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Yifei Ma
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nour Ibrahim
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Sachi S Dholakia
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Vidya K Rao
- Divisions of Cardiothoracic Anesthesiology and Critical Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Axel Renteria
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Xueying Cao
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Michael T Chang
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jayakar V Nayak
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
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Hussain S, Hayat J, Almhanedi H, Alherz M, Ebrahim M, Lari A, Thamboo A. A Systematic Review and Meta-Analysis of Management Options for Empty Nose Syndrome: A Proposed Management Algorithm. Otolaryngol Head Neck Surg 2025; 172:1-12. [PMID: 39126290 DOI: 10.1002/ohn.929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 06/27/2024] [Accepted: 07/20/2024] [Indexed: 08/12/2024]
Abstract
OBJECTIVE Empty nose syndrome (ENS) is an acquired condition characterized by paradoxical nasal obstruction and sensation of nasal dryness often accompanied by psychological disorders such as depression or anxiety, typically occurring after the loss of inferior turbinate tissue or volume in the setting of prior sinonasal surgery. This review aims to identify and evaluate the reported management options. DATA SOURCES PubMed, Scopus, and Web of Science. REVIEW METHODS The terms "empty nose syndrome" OR "atrophic rhinitis" were used in a systematic search of original articles since the year 1990, yielding 1432 individual studies. These were screened on the Covidence platform for inclusion if any intervention was reported for the treatment of ENS. A pooled analysis of standardized mean differences (SMDs) combined with a random effects model was employed to report outcomes in Empty Nose 6-Item Questionnaire (ENS6Q), Sino-Nasal Outcome Test (SNOT), anxiety, and depression scores. RESULTS A total of 35 articles were included, comprising 957 individual ENS patients. Surgical interventions mostly in the form of meatus augmentation implants accounted for 26 out of the 36 articles. The remaining ten articles included medical and psychological management options. SMD in SNOT, ENS6Q, anxiety, and depression scores were reported and demonstrated statistically significant improvements in follow-up periods of up to 1 year. All articles reported favorable outcomes following their chosen interventions. CONCLUSION There is a paucity of evidence on the management of ENS and an absence of randomized controlled trials. Surgical intervention appears to be the current mainstay of treatment, but there is a potential role for psychological and medical management.
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Affiliation(s)
- Salman Hussain
- Department of Otolaryngology-Head and Neck Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Jafar Hayat
- Faculty of Medicine, University of Manchester, Manchester, UK
| | - Hamad Almhanedi
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Canada
| | - Mohammad Alherz
- Department of Anatomy, Trinity College Dublin, Dublin, Ireland
| | - Mahmoud Ebrahim
- Department of Otolaryngology-Head and Neck Surgery, McGill University, Montreal, Canada
| | - Ali Lari
- Department of Orthopedic Surgery, Alrazi Hospital, Kuwait
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, St. Paul's Sinus Centre, University of British Columbia, Vancouver, British Columbia, Canada
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Eide JG, Kuan EC, Adappa ND, Chang J, Cho DY, Garg R, Govindaraj S, Grayson J, Im E, Keschner D, Kohanski M, Locke T, Palmer JN, Welch KC, Woodworth BA, Yoo F, Craig JR. Subtotal Middle Turbinate Resection in Patients with Chronic Rhinosinusitis with Nasal Polyps is Unlikely to Cause Empty Nose Syndrome: A Multi-Institutional Prospective Study. Laryngoscope 2025; 135:59-65. [PMID: 39136246 DOI: 10.1002/lary.31694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/03/2024] [Accepted: 07/24/2024] [Indexed: 12/13/2024]
Abstract
BACKGROUND Empty nose syndrome (ENS) is a poorly understood, debilitating condition affecting a minority of patients who underwent nasal airway surgery, most commonly following inferior turbinate surgery. Few publications have demonstrated middle turbinate resection (MTR) causing ENS, but MTR is still considered a potential cause of ENS. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) is validated for ENS diagnosis, with ENS6Q ≥ 11 considered highly suggestive of ENS. The purpose of this multicenter study was to determine the incidence of patients with ENS6Q ≥ 11 following subtotal MTR during endoscopic sinus surgery (ESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) by comparing preoperative and postoperative ENS6Q scores. METHODS A multi-institutional prospective cohort study (8 US institutions) was conducted on patients who underwent bilateral subtotal MTR during ESS for CRSwNP. Preoperative and postoperative ENS6Q scores were compared after at least 12 months of postoperative follow-up. RESULTS Of 110 patients, mean age was 51.6 years and 59.1% were male. Mean follow-up was 14.5 ± 2.5 months (range 12.1-22.3 months). Mean preoperative and postoperative ENS6Q were 7.7 and 2.2, respectively, demonstrating a mean 5.5 point decrease postoperatively (p < 0.0001). At final follow-up, no patient had an ENS6Q ≥ 11. Of note, 20% of patients had preoperative ENS6Q scores ≥11, but all decreased to <11 postoperatively. CONCLUSIONS Based on prospective multicenter data over 1-2 years postoperatively, subtotal MTR for CRSwNP never led to ENS6Q scores ≥11, and patients experienced significant decreases in ENS6Q postoperatively. Subtotal MTR during ESS for CRSwNP was, therefore, unlikely to cause ENS even with long-term follow-up. LEVEL OF EVIDENCE 4 Laryngoscope, 135:59-65, 2025.
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Affiliation(s)
- Jacob G Eide
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California-Irvine, Irvine, CA, USA
| | - Nithin D Adappa
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Do-Yeon Cho
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama, Birmingham, AL, USA
| | - Rohit Garg
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Orange County, Anaheim, CA, USA
| | - Satish Govindaraj
- Department of Otorhinolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jessica Grayson
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Orange County, Anaheim, CA, USA
| | - Eunice Im
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
| | - David Keschner
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Orange County, Anaheim, CA, USA
| | - Michael Kohanski
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Tran Locke
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA
| | - James N Palmer
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin C Welch
- Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bradford A Woodworth
- Department of Otolaryngology-Head and Neck Surgery, University of Alabama, Birmingham, AL, USA
| | - Frederick Yoo
- Department of Otolaryngology-Head and Neck Surgery, Kaiser Permanente Orange County, Anaheim, CA, USA
| | - John R Craig
- Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health, Detroit, Michigan, USA
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Gwak JW, Kim DH, Jang YJ. Application of a Novel 3D-Printed Nasal Plug as a Conservative Treatment for Empty Nose Syndrome. Laryngoscope 2024; 134:3935-3940. [PMID: 38544462 DOI: 10.1002/lary.31414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE Empty nose syndrome (ENS) is commonly treated by surgery, albeit with limited success. Herein, we introduce our experience of applying a newly developed "3D-printed nasal plug" as an alternative conservative treatment modality. METHODS This retrospective study included 20 patients (14 males, 6 females; mean age 46.5 ± 13.5 years) with ENS who underwent the application of the 3D-printed nasal plug at Asan Medical Center between June 2022 and May 2023. Symptom improvement was assessed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) before and after applying the nasal plug. Clinical results, such as duration and frequency of plug use, discomfort, and level of satisfaction, were investigated. RESULTS The mean follow-up duration was 40.3 ± 24.2 weeks. The average duration of nasal plug usage was 10.8 h per day and 5.3 days a week. The ENS6Q scores improved from 19.6 ± 4.6 to 6.8 ± 5.1 (mean reduction 12.8 ± 5.9) after 30 minutes of wearing. Symptom "nose feelings too open" was improved most by a score of 3.0 ± 1.5 (p < 0.001). Thirteen patients (65.0%) reported that the effectiveness of the plug, initially confirmed at the first wearing, was well maintained during the entire follow-up. Four patients (20.0%) wore the nasal plug uninterruptedly throughout the week, whereas nine patients (45.0%) wore it intermittently as needed. Frequently reported complaints with plug usage were 'displacement of the plug' and 'cosmetic concerns' about the visible hook portion. CONCLUSION A 3D-designed nasal plug can be a useful conservative treatment option for ENS patients. LEVEL OF EVIDENCE 4 Laryngoscope, 134:3935-3940, 2024.
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Affiliation(s)
- Jang Wook Gwak
- Department of Otolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Don-Han Kim
- Department of Digital Content, University of Ulsan, Ulsan, Republic of Korea
| | - Yong Ju Jang
- Department of Otolaryngology-Head and Neck Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Huang CC, Sun PH, Wu PW, Huang CC, Chang PH, Fu CH, Lee TJ. Computed Tomographic Evaluations in Patients with Empty Nose Syndrome. Laryngoscope 2024; 134:2105-2110. [PMID: 38009472 DOI: 10.1002/lary.31204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE We aimed to evaluate computed tomography (CT) images of patients with empty nose syndrome (ENS), investigate the impact of reconstruction surgery on sinus inflammation, and identify the optimal airspace diameter after surgery. METHODS We conducted a retrospective case series analysis, identifying and enrolling patients with ENS with perioperative CT findings. The clinical characteristics of the participants were collected, and the modified Lund-Mackay (mLM) CT scores were determined. The anterior airspace diameter was evaluated by measuring the distance between the septum and the lateral nasal wall on the coronal plane at the level of the nasolacrimal duct. RESULTS Twenty patients with ENS and perioperative CT images were enrolled. The mean total mLM CT score and all subsite scores showed no significant changes after surgery. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q) score, Sino-nasal Outcome Test-25 (SNOT-25) score, sleep symptoms domain, psychological domain, and empty nose symptoms domain were significantly associated with anterior airspace diameter in the regression analysis. CONCLUSION There was no significant difference in sinus inflammation between preoperative and postoperative CT evaluations. The anterior airspace diameters were significantly associated with ENS6Q and SNOT-25 scores. LEVEL OF EVIDENCE 4 Laryngoscope, 134:2105-2110, 2024.
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Affiliation(s)
- Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ping Hsueh Sun
- Department of Medical Education, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsiang Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China
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Dholakia SS, Grimm D, Daum R, Bravo DT, Salvi N, Zarabanda D, Overdevest JB, Thamboo A, Nakayama T, Nayak JV. The Serpentine Sign: A Reliable Endoscopic and Radiographic Finding in Empty Nose Syndrome. Laryngoscope 2024; 134:1089-1095. [PMID: 37702458 DOI: 10.1002/lary.30938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/06/2023] [Accepted: 07/19/2023] [Indexed: 09/14/2023]
Abstract
OBJECTIVE Empty nose syndrome (ENS) is a relatively uncommon disease that greatly impacts the quality of life and presents diagnostic challenges. We sought to identify objective clinical findings unique to patients with ENS, and in doing so identified compensatory mucosal hypertrophy in an alternating, undulating swelling on endoscopy and coronal computerized tomography (CT) that we have termed the "Serpentine Sign." Here, we investigated whether this radiographic finding is a reliable manifestation in ENS patients. METHODS Retrospective review was undertaken to identify ENS patients with past turbinoplasty, an ENS6Q score of at least 11/30, and symptomatic improvement with the cotton placement test. Control patients without complaints of ENS symptoms (ENS6Q < 11) were identified for comparison. ENS and control patients had coronal CT imaging available to evaluate for the Serpentine Sign, as well as ENS6Q scores, and histologic analysis of nasal tissue. RESULTS 34 ENS and 74 control patients were evaluated for the presence of the Serpentine Sign. Of the 34 patients with ENS, 18 exhibited this radiographic finding on CT imaging (52.9%) compared to 0 of the 74 control patients (p < 0.0001). Further analysis demonstrated that ENS patients with the Serpentine Sign had lower median scores on ENS6Q than ENS patients without (17.5 vs. 22, p = 0.033). Histology revealed disorganized subepithelium rich in seromucinous glands similar to the nasal septum swell body. CONCLUSION The "Serpentine Sign" is a unique presentation of hypertrophic change to the nasal septum soft tissue that is specific to ENS patients and may serve as a reliable radiographic and endoscopic finding in diagnosis. LEVEL OF EVIDENCE 4 Laryngoscope, 134:1089-1095, 2024.
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Affiliation(s)
- Sachi S Dholakia
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - David Grimm
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Rachel Daum
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Dawn T Bravo
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Nicole Salvi
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - David Zarabanda
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jonathan B Overdevest
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
| | - Andrew Thamboo
- Department of Otolaryngology - Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tsuguhisa Nakayama
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Otolaryngology - Head and Neck Surgery, VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Jayakar V Nayak
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Otolaryngology - Head and Neck Surgery, VA Palo Alto Health Care System, Palo Alto, California, USA
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10
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Zhong Y, Deng Z, Chen H, Qiu Q. Evaluation of sinonasal-related quality of life of 49 patients undergoing endoscopic skull base surgery. Braz J Otorhinolaryngol 2024; 90:101337. [PMID: 37983990 PMCID: PMC10694519 DOI: 10.1016/j.bjorl.2023.101337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 09/06/2023] [Accepted: 09/22/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the sinonasal-related Quality of Life (QoL) in patients undergoing endoscopic skull base surgery. METHODS A retrospective study was performed, including patients with benign and malignant tumors at a single institution. Each patient completed the 22-Item Sino-Nasal Outcome Test (SNOT-22) and the Empty Nose Syndrome 6 Item Questionnaires (ENS6Q) to assess their perceived QoL at least 2-months after treatment. RESULTS Forty-nine patients were enrolled in this study. The average score was 25.1 (Stander Deviation [SD] 14.99) for SNOT-22 and 6.51 (SD=5.58) for ENS6Q. Analysis of the overall results for the SNOT-22 showed that olfactory damage was the most serious syndrome. The most frequently reported high-severity sub-domains in SNOT-22 were nasal symptoms and sleep symptoms. Nasal crusting was the most severe item in ENS6Q according to the report. Nine patients (18.4%) had a score higher than 10.5 which indicates the high risk of Empty Nose Syndrome (ENS). SNOT-22 score was related to the history of radiotherapy (p< 0.05), while the ENS6Q score was not. CONCLUSIONS The possibility of patients suffering from ENS after nasal endoscopic skull base surgery is at a low level, although the nasal cavity structure is damaged to varying degrees. Meanwhile, patients undergoing endoscopic skull base surgery were likely to suffer nasal problems and sleep disorders. Patients who had received radiotherapy have a worse QoL than those without a history of radiotherapy. LEVEL OF EVIDENCE Level 3.
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Affiliation(s)
- Yijie Zhong
- Department of Otorhinolaryngology - Head and Neck Surgery, Guangdong Provincial People's Hospital, Southern Medical University, Guangzhou, China; Department of Otorhinolaryngology, Central People's Hospital of Zhangjiang, Guangdong, China
| | - Zeyi Deng
- Department of Otorhinolaryngology - Head and Neck Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Hailing Chen
- Department of Otorhinolaryngology, Panyu District Hexian Memorial Hospital, Guangzhou, China
| | - Qianhui Qiu
- Department of Otorhinolaryngology - Head and Neck Surgery, Guangdong Provincial People's Hospital, Southern Medical University, Guangzhou, China.
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11
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Wise SK, Damask C, Roland LT, Ebert C, Levy JM, Lin S, Luong A, Rodriguez K, Sedaghat AR, Toskala E, Villwock J, Abdullah B, Akdis C, Alt JA, Ansotegui IJ, Azar A, Baroody F, Benninger MS, Bernstein J, Brook C, Campbell R, Casale T, Chaaban MR, Chew FT, Chambliss J, Cianferoni A, Custovic A, Davis EM, DelGaudio JM, Ellis AK, Flanagan C, Fokkens WJ, Franzese C, Greenhawt M, Gill A, Halderman A, Hohlfeld JM, Incorvaia C, Joe SA, Joshi S, Kuruvilla ME, Kim J, Klein AM, Krouse HJ, Kuan EC, Lang D, Larenas-Linnemann D, Laury AM, Lechner M, Lee SE, Lee VS, Loftus P, Marcus S, Marzouk H, Mattos J, McCoul E, Melen E, Mims JW, Mullol J, Nayak JV, Oppenheimer J, Orlandi RR, Phillips K, Platt M, Ramanathan M, Raymond M, Rhee CS, Reitsma S, Ryan M, Sastre J, Schlosser RJ, Schuman TA, Shaker MS, Sheikh A, Smith KA, Soyka MB, Takashima M, Tang M, Tantilipikorn P, Taw MB, Tversky J, Tyler MA, Veling MC, Wallace D, Wang DY, White A, Zhang L. International consensus statement on allergy and rhinology: Allergic rhinitis - 2023. Int Forum Allergy Rhinol 2023; 13:293-859. [PMID: 36878860 DOI: 10.1002/alr.23090] [Citation(s) in RCA: 160] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/11/2022] [Accepted: 09/13/2022] [Indexed: 03/08/2023]
Abstract
BACKGROUND In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document. METHODS ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. RESULTS ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. CONCLUSION The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.
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Affiliation(s)
- Sarah K Wise
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Cecelia Damask
- Otolaryngology-HNS, Private Practice, University of Central Florida, Lake Mary, Florida, USA
| | - Lauren T Roland
- Otolaryngology-HNS, Washington University, St. Louis, Missouri, USA
| | - Charles Ebert
- Otolaryngology-HNS, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Joshua M Levy
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Sandra Lin
- Otolaryngology-HNS, University of Wisconsin, Madison, Wisconsin, USA
| | - Amber Luong
- Otolaryngology-HNS, McGovern Medical School of the University of Texas, Houston, Texas, USA
| | - Kenneth Rodriguez
- Otolaryngology-HNS, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Ahmad R Sedaghat
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Elina Toskala
- Otolaryngology-HNS, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Baharudin Abdullah
- Otolaryngology-HNS, Universiti Sains Malaysia, Kubang, Kerian, Kelantan, Malaysia
| | - Cezmi Akdis
- Immunology, Infectious Diseases, Swiss Institute of Allergy and Asthma Research, Davos, Switzerland
| | - Jeremiah A Alt
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | | | - Antoine Azar
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Fuad Baroody
- Otolaryngology-HNS, University of Chicago, Chicago, Illinois, USA
| | | | | | - Christopher Brook
- Otolaryngology-HNS, Harvard University, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Raewyn Campbell
- Otolaryngology-HNS, Macquarie University, Sydney, NSW, Australia
| | - Thomas Casale
- Allergy/Immunology, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Mohamad R Chaaban
- Otolaryngology-HNS, Cleveland Clinic, Case Western Reserve University, Cleveland, Ohio, USA
| | - Fook Tim Chew
- Allergy/Immunology, Genetics, National University of Singapore, Singapore, Singapore
| | - Jeffrey Chambliss
- Allergy/Immunology, University of Texas Southwestern, Dallas, Texas, USA
| | - Antonella Cianferoni
- Allergy/Immunology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | | | | | | | - Anne K Ellis
- Allergy/Immunology, Queens University, Kingston, ON, Canada
| | | | - Wytske J Fokkens
- Otorhinolaryngology, Amsterdam University Medical Centres, Amsterdam, Netherlands
| | | | - Matthew Greenhawt
- Allergy/Immunology, Pediatrics, University of Colorado, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Amarbir Gill
- Otolaryngology-HNS, University of Michigan, Ann Arbor, Michigan, USA
| | - Ashleigh Halderman
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Jens M Hohlfeld
- Respiratory Medicine, Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover Medical School, German Center for Lung Research, Hannover, Germany
| | | | - Stephanie A Joe
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Shyam Joshi
- Allergy/Immunology, Oregon Health and Science University, Portland, Oregon, USA
| | | | - Jean Kim
- Otolaryngology-HNS, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adam M Klein
- Otolaryngology-HNS, Emory University, Atlanta, Georgia, USA
| | - Helene J Krouse
- Otorhinolaryngology Nursing, University of Texas Rio Grande Valley, Edinburg, Texas, USA
| | - Edward C Kuan
- Otolaryngology-HNS, University of California Irvine, Orange, California, USA
| | - David Lang
- Allergy/Immunology, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Matt Lechner
- Otolaryngology-HNS, University College London, Barts Health NHS Trust, London, UK
| | - Stella E Lee
- Otolaryngology-HNS, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Victoria S Lee
- Otolaryngology-HNS, University of Illinois Chicago, Chicago, Illinois, USA
| | - Patricia Loftus
- Otolaryngology-HNS, University of California San Francisco, San Francisco, California, USA
| | - Sonya Marcus
- Otolaryngology-HNS, Stony Brook University, Stony Brook, New York, USA
| | - Haidy Marzouk
- Otolaryngology-HNS, State University of New York Upstate, Syracuse, New York, USA
| | - Jose Mattos
- Otolaryngology-HNS, University of Virginia, Charlottesville, Virginia, USA
| | - Edward McCoul
- Otolaryngology-HNS, Ochsner Clinic, New Orleans, Louisiana, USA
| | - Erik Melen
- Pediatric Allergy, Karolinska Institutet, Stockholm, Sweden
| | - James W Mims
- Otolaryngology-HNS, Wake Forest University, Winston Salem, North Carolina, USA
| | - Joaquim Mullol
- Otorhinolaryngology, Hospital Clinic Barcelona, Barcelona, Spain
| | - Jayakar V Nayak
- Otolaryngology-HNS, Stanford University, Palo Alto, California, USA
| | - John Oppenheimer
- Allergy/Immunology, Rutgers, State University of New Jersey, Newark, New Jersey, USA
| | | | - Katie Phillips
- Otolaryngology-HNS, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michael Platt
- Otolaryngology-HNS, Boston University, Boston, Massachusetts, USA
| | | | | | - Chae-Seo Rhee
- Rhinology/Allergy, Seoul National University Hospital and College of Medicine, Seoul, Korea
| | - Sietze Reitsma
- Otolaryngology-HNS, University of Amsterdam, Amsterdam, Netherlands
| | - Matthew Ryan
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Joaquin Sastre
- Allergy, Fundacion Jiminez Diaz, University Autonoma de Madrid, Madrid, Spain
| | - Rodney J Schlosser
- Otolaryngology-HNS, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Theodore A Schuman
- Otolaryngology-HNS, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marcus S Shaker
- Allergy/Immunology, Dartmouth Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Aziz Sheikh
- Primary Care, University of Edinburgh, Edinburgh, Scotland
| | - Kristine A Smith
- Otolaryngology-HNS, University of Utah, Salt Lake City, Utah, USA
| | - Michael B Soyka
- Otolaryngology-HNS, University of Zurich, University Hospital of Zurich, Zurich, Switzerland
| | - Masayoshi Takashima
- Otolaryngology-HNS, Houston Methodist Academic Institute, Houston, Texas, USA
| | - Monica Tang
- Allergy/Immunology, University of California San Francisco, San Francisco, California, USA
| | | | - Malcolm B Taw
- Integrative East-West Medicine, University of California Los Angeles, Westlake Village, California, USA
| | - Jody Tversky
- Allergy/Immunology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew A Tyler
- Otolaryngology-HNS, University of Minnesota, Minneapolis, Minnesota, USA
| | - Maria C Veling
- Otolaryngology-HNS, University of Texas Southwestern, Dallas, Texas, USA
| | - Dana Wallace
- Allergy/Immunology, Nova Southeastern University, Ft. Lauderdale, Florida, USA
| | - De Yun Wang
- Otolaryngology-HNS, National University of Singapore, Singapore, Singapore
| | - Andrew White
- Allergy/Immunology, Scripps Clinic, San Diego, California, USA
| | - Luo Zhang
- Otolaryngology-HNS, Beijing Tongren Hospital, Beijing, China
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12
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Huang CC, Wu PW, Huang CC, Chang PH, Fu CH, Lee TJ. Identifying Residual Psychological Symptoms after Nasal Reconstruction Surgery in Patients with Empty Nose Syndrome. J Clin Med 2023; 12:jcm12072635. [PMID: 37048718 PMCID: PMC10095541 DOI: 10.3390/jcm12072635] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/11/2023] [Accepted: 03/29/2023] [Indexed: 04/05/2023] Open
Abstract
Background: Empty nose syndrome (ENS) is a syndrome of paradoxical nasal obstruction that is thought to be mostly caused by inappropriate turbinate procedures. This study aimed to investigate depression- and anxiety-associated psychological symptoms in patients with ENS before and after surgical reconstruction, and to compare them with those of control subjects. Methods: Patients with ENS were prospectively enrolled. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item questionnaire (ENS6Q), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate the participants before and after reconstruction surgery with submucosal Medpor implantation (Stryker, Kalamazoo, MI), as well as control subjects at enrollment. Results: Forty patients with ENS and forty age- and sex-matched controls were recruited. Patients with ENS experienced significant improvement in SNOT-25, ENS6Q, BDI-II, and BAI scores after surgery, but all were significantly greater than those in the control group. Nine patients with ENS (22.5%) had postoperative residual psychological symptoms. Preoperative BDI-II and BAI scores were significant predictors of postoperative residual psychological symptoms. The optimal cut-off value was BDI-II > 28.5 (sensitivity, 77.8%; specificity, 77.4%) in receiver operating characteristic curve analysis. Conclusions: The nasal and psychological evaluations in patients with ENS significantly improved after nasal reconstruction surgery, but both were significantly greater than those in the control group. Identifying individuals who may experience postoperative residual symptoms and providing a multimodal approach, including surgical reconstruction and psychiatric treatment, are suggested.
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Affiliation(s)
- Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
| | - Chia-Hsiang Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Linkou, Taoyuan City 333, Taiwan
- School of Medicine, Chang Gung University, Taoyuan City 333, Taiwan
- Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen 361000, China
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13
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Huang CC, Lee CC, Wei PW, Chuang CC, Lee YS, Chang PH, Huang CC, Fu CH, Lee TJ. Sleep impairment in patients with empty nose syndrome. Rhinology 2023; 61:47-53. [PMID: 36306524 DOI: 10.4193/rhin22.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Empty nose syndrome (ENS) is characterized by paradoxical nasal obstruction that usually occurs after turbinate surgery. Patients with ENS may also experience significant psychiatric symptoms and sleep dysfunction, which negatively affect the quality of life of affected subjects. This study aimed to evaluate sleep impairment and sleepiness in patients with ENS. METHODS Patients with ENS and control participants were recruited prospectively. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Epworth Sleepiness Scale (EpSS), and modified sleep quality index (MSQI) were used to evaluate the participants before and after nasal surgery. RESULTS Forty-eight patients with ENS and forty-eight age- and sex-matched control subjects were enrolled. The SNOT-25, ENS6Q, EpSS, and MSQI scores in the ENS group were all significantly higher than those in the control group before and after surgery. After surgery, ENS patients all exhibited significant improvements in SNOT-25, ENS6Q, EpSS, and MSQI scores. Regression analysis revealed that SNOT-25 score was a significant predictor of EpSS and MSQI in preoperative evaluations. ENS patients experiencing daytime sleepiness suffered from significantly more "dryness of nose" and "suffocation" than those not experiencing daytime sleepiness. CONCLUSIONS Patients with ENS experienced significantly impaired sleep quality and sleepiness. Nasal reconstruction surgery improved the sleep quality of ENS patients. The severity of sleep dysfunction is associated with the severity of ENS symptoms. Recognizing individuals with significant sleep impairment and sleepiness and providing appropriate management are critical issues for ENS patients.
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Affiliation(s)
- C-C Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-C Lee
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taiwan; Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan
| | - P-W Wei
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology, Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwan
| | - C-C Chuang
- School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou and Chang Gung University, Taiwan
| | - Y-S Lee
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Department of Biotechnology, Ming Chuan University, Taoyuan, Taiwan
| | - P-H Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan
| | - C-C Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - C-H Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - T-J Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan; School of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China
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14
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Lamb M, Bacon DR, Zeatoun A, Onourah P, Thorp BD, Abramowitz J, Ebert CS, Kimple AJ, Senior BA. Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis. Int Forum Allergy Rhinol 2022; 12:1340-1349. [PMID: 35333009 DOI: 10.1002/alr.22997] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 03/15/2022] [Accepted: 03/16/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Empty nose syndrome (ENS) is characterized by the paradoxical perception of nasal obstruction despite patent sinonasal anatomy after surgery. We investigated the relationship between ENS, and anxiety, depression, obsessive-compulsive disorder, and somatic symptom disorder (SSD) compared to individuals with chronic rhinitis (CR) and chronic rhinosinusitis (CRS). METHODS This cross-sectional survey study compared ENS and CR and CRS patients. A total of 116 patients participated: 58 ENS patients from digital support groups, and 58 CRS and CR patients from tertiary rhinology clinics. Study participants completed four validated surveys: (1) Empty Nose Syndrome 6-Item Questionnaire, (2) Rhinosinusitis Disability Index (RSDI), (3) Obsessive Compulsive Inventory - Revised (OCI-R), and (4) PRIME MD Patient Health Questionnaire (PHQ). RESULTS ENS patients exhibited a mean RSDI of 78.6, 95% confidence interval [CI] 72.8-84.5, compared to 25.2, 95% CI 18.6-31.8 for CRS/CR patients (p < 0.0001). This difference was seen across all subdomains. Using the PHQ, 53% of ENS patients met diagnostic thresholds for SSD compared to 14% of CRS patients (p < 0.0001). In relation to obsessive compulsive disorder (OCD), 18.37% of ENS patients compared to 8.62% of CRS/CR patients scored above the diagnostic threshold (>21) on the OCI-R questionnaire (p = 0.159). CONCLUSION ENS patients had diminished sinonasal quality of life and a higher prevalence of comorbid anxiety and depression, compared to CR and CRS. ENS patients were more likely to exceed thresholds for OCD and SSD compared to controls. Future studies are needed to assess the role of SSD in ENS to help optimize treatment for these complex patients.
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Affiliation(s)
- Meredith Lamb
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina, USA
| | - Daniel R Bacon
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Abdullah Zeatoun
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Princess Onourah
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brian D Thorp
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jonathon Abramowitz
- Department of Psychology at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Charles S Ebert
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam J Kimple
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
| | - Brent A Senior
- Department of Otolaryngology-Head & Neck Surgery at the University of North Carolina, Chapel Hill, North Carolina, USA
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Hosokawa Y, Miyawaki T, Omura K, Akutsu T, Kimura R, Ikezono T, Otori N. Surgical Treatment for Empty Nose Syndrome Using Autologous Dermal Fat: Evaluation of Symptomatic Improvement. EAR, NOSE & THROAT JOURNAL 2022:1455613221130885. [PMID: 36174975 DOI: 10.1177/01455613221130885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Empty nose syndrome (ENS) is caused by nasal turbinate surgery. The standard treatment for ENS is an inferior meatus augmentation procedure (IMAP) in which autologous tissue such as auricular cartilage, rib cartilage, or artificial material is transplanted into the nasal cavity. However, some challenges like a very small auricular cartilage are associated with these autologous tissue types. Moreover, since using rib cartilage is a highly invasive technique, the scar on the chest from where the harvesting is done is easily visible, and the artificial material is susceptible to infection. We used autologous dermal fat (ADF) in IMAPs in our study for the following reasons: the quantity of ADF could be increased or reduced as needed, ADF is considered a safer option than rib cartilage because it is harvested from superficial tissue, it is superior in terms of cosmetic appearance to harvested rib cartilage, and it has a lower risk of infection than any artificial material.Objective: The purpose of our study was to investigate the efficacy and safety of IMAPs using ADF.Methods: We included nine patients with ENS who underwent an IMAP using ADF. The patients' backgrounds and responses to the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) were recorded. Changes in each item of the ENS6Q before and after surgery (up to 3 months) were analyzed.Results: The postoperative ENS6Q total score and parameters were significantly better than their preoperative counterparts. Nasal dryness improved slightly less than other symptoms. There were no complications.Conclusions: The IMAP using ADF was effective in improving ENS symptoms; however, some physiological functions were difficult to improve, and dryness persisted. Autologous dermal fat is larger than auricular cartilage, less invasive than rib cartilage, and has a lower risk of infection than artificial material.
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Affiliation(s)
- Yu Hosokawa
- Department of Otorhinolaryngology, Saitama Medical University, Saitama, Japan
- Department of Otorhinolaryngology, the Jikei University School of Medicine, Tokyo, Japan
- Septorhinoplasty Clinic, Jikei University Hospital, Tokyo, Japan
| | - Takeshi Miyawaki
- Septorhinoplasty Clinic, Jikei University Hospital, Tokyo, Japan
- Department of Plastic Surgery, the Jikei University School of Medicine, Tokyo, Japan
| | - Kazuhiro Omura
- Department of Otorhinolaryngology, the Jikei University School of Medicine, Tokyo, Japan
| | - Taisuke Akutsu
- Department of Otorhinolaryngology, the Jikei University School of Medicine, Tokyo, Japan
| | - Ryohei Kimura
- Department of Otorhinolaryngology, the Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuo Ikezono
- Department of Otorhinolaryngology, Saitama Medical University, Saitama, Japan
| | - Nobuyoshi Otori
- Department of Otorhinolaryngology, the Jikei University School of Medicine, Tokyo, Japan
- Septorhinoplasty Clinic, Jikei University Hospital, Tokyo, Japan
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Identifying Obstructive Sleep Apnoea in Patients with Empty Nose Syndrome. Diagnostics (Basel) 2022; 12:diagnostics12071720. [PMID: 35885624 PMCID: PMC9323833 DOI: 10.3390/diagnostics12071720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/01/2022] [Accepted: 07/12/2022] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnoea (OSA) is characterised by repetitive episodes of upper airway collapse and breathing cessation during sleep. Empty nose syndrome (ENS) is a surgically iatrogenic phenomenon of paradoxical nasal obstruction despite an objectively patent nasal airway. This study aimed to investigate sleep quality and the presence of OSA in ENS patients. Forty-eight ENS patients underwent full-night polysomnography. Total nasal resistance (TNR) was determined using anterior rhinomanometry. Symptoms and quality of life were evaluated by the empty nose syndrome 6-item questionnaire (ENS6Q), Sino-Nasal Outcome Test-22 (SNOT-22), and Epworth Sleepiness Scale questionnaires (ESS). Fourteen, twelve, and fourteen patients had mild, moderate, and severe OSA, respectively. The apnoea–hypopnoea index (AHI) and the lowest SpO2 were 23.8 ± 22.4/h and 85.9 ± 11.1%, respectively. N1, N2, N3 and rapid-eye-movement sleep comprised 30.2 ± 16.9%, 47.3 ± 15.5%, 2.1 ± 5.4%, and 20.0 ± 8.1% of the total sleep time. Body mass index, neck circumference, serum total immunoglobulin E, and ENS6Q score were significantly associated with AHI in the regression analysis. The ENS6Q scores correlated positively with AHI, arousal index, and ESS score, but negatively with TNR. ENS patients showed a high OSA prevalence and significant sleep impairment. The extent of OSA was associated with obesity levels and ENS symptom severity. The ENS6Q scores correlated negatively with nasal resistance, and positively with arousal frequency and daytime sleepiness. The recognition of individuals experiencing marked OSA and provision of appropriate intervention is critical to preventing long-term morbidity and mortality, and improving therapeutic outcomes in ENS patients.
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Schmidt N, Behrbohm H, Goubergrits L, Hildebrandt T, Brüning J. Comparison of rhinomanometric and computational fluid dynamic assessment of nasal resistance with respect to measurement accuracy. Int J Comput Assist Radiol Surg 2022; 17:1519-1529. [PMID: 35821562 DOI: 10.1007/s11548-022-02699-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 06/05/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Computational fluid dynamics (CFD)-based calculation of intranasal airflow became an important method in rhinologic research. Current evidence shows weak to moderate correlation as well as a systematic underprediction of nasal resistance by numerical simulations. In this study, we investigate whether these differences can be explained by measurement uncertainties caused by rhinomanometric devices and procedures. Furthermore, preliminary findings regarding the impact of tissue movements are reported. METHODS A retrospective sample of 17 patients, who reported impaired nasal breathing and for which rhinomanometric (RMM) measurements using two different devices as well as computed tomography scans were available, was investigated in this study. Three patients also exhibited a marked collapse of the nasal valve. Agreement between both rhinomanometric measurements as well as between rhinomanometry and CFD-based calculations was assessed using linear correlation and Bland-Altman analyses. These analyses were performed for the volume flow rates measured at trans-nasal pressure differences of 75 and 150 Pa during inspiration and expiration. RESULTS The correlation between volume flow rates measured using both RMM devices was good (R2 > 0.72 for all breathing states), and no relevant differences in measured flow rates was observed (21.6 ml/s and 14.8 ml/s for 75 and 150 Pa, respectively). In contrast, correlation between RMM and CFD was poor (R2 < 0.5) and CFD systematically overpredicted RMM-based flow rate measurements (231.8 ml/s and 328.3 ml/s). No differences between patients with and without nasal valve collapse nor between inspiration and expiration were observed. CONCLUSION Biases introduced during RMM measurements, by either the chosen device, the operator or other aspects as for example the nasal cycle, are not strong enough to explain the gross differences commonly reported between RMM- and CFD-based measurement of nasal resistance. Additionally, tissue movement during breathing is most likely also no sufficient explanation for these differences.
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Affiliation(s)
- Nora Schmidt
- Department of Otorhinolaryngology and Facial Plastic Surgery, Park-Klinik Weissensee, Schönstraße 80, 13086, Berlin, Germany.
| | - Hans Behrbohm
- Department of Otorhinolaryngology and Facial Plastic Surgery, Park-Klinik Weissensee, Schönstraße 80, 13086, Berlin, Germany
| | - Leonid Goubergrits
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Hildebrandt
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jan Brüning
- Institute of Computer-Assisted Cardiovascular Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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18
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Huang C, Wu P, Lee C, Huang C, Fu C, Chang P, Lee T. Comparison of
SNOT
‐25 and
ENS6Q
in evaluating patients with empty nose syndrome. Laryngoscope Investig Otolaryngol 2022; 7:342-348. [PMID: 35434317 PMCID: PMC9008176 DOI: 10.1002/lio2.767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Chien‐Chia Huang
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial HospitalLinkouTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Pei‐Wen Wu
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial HospitalLinkouTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Department of Otolaryngology—Head and Neck SurgeryChang Gung Memorial Hospital and Chang Gung UniversityKeelungTaiwan
| | - Cheng‐Chi Lee
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Department of NeurosurgeryChang Gung Memorial HospitalLinkouTaiwan
- Department of Biomedical EngineeringNational Taiwan UniversityTaipeiTaiwan
| | - Chi‐Che Huang
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial HospitalLinkouTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Chia‐Hsiang Fu
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial HospitalLinkouTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Po‐Hung Chang
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial HospitalLinkouTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Ta‐Jen Lee
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial HospitalLinkouTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Department of OtolaryngologyXiamen Chang Gung HospitalXiamenChina
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19
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Malik J, Otto BA, Zhao K. Computational Fluid Dynamics (CFD) Modeling as an Objective Analytical Tool for Nasal/Upper Airway Breathing. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-021-00387-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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20
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Huang C, Wu P, Lee C, Chang P, Huang C, Lee T. Suicidal thoughts in patients with empty nose syndrome. Laryngoscope Investig Otolaryngol 2022; 7:22-28. [PMID: 35155779 PMCID: PMC8823180 DOI: 10.1002/lio2.730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/15/2021] [Accepted: 12/28/2021] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Patients with empty nose syndrome (ENS) suffer from paradoxical nasal obstruction with a patent objective nasal airway. ENS may result from the excessive surgical reduction of the turbinate tissue. ENS patients also experience significant psychological symptoms such as anxiety and depression. In this study, we aimed to evaluate the prevalence of suicidal thoughts in ENS patients and to characterize these patients for early identification. STUDY DESIGN Prospective case series. METHODS Patients with ENS were prospectively recruited for this study. The Sino-Nasal Outcome Test-25 (SNOT-25), Empty Nose Syndrome 6-item Questionnaire (ENS6Q), Beck Anxiety Inventory (BAI), and Beck Depression Inventory-II (BDI-II) were used to assess ENS patients before and 6 months after nasal reconstruction surgery. RESULTS Sixty-two patients with ENS were enrolled. Suicidal thoughts were identified in 23 ENS patients preoperatively and in four patients postoperatively. ENS patients with suicidal thoughts rated significantly higher in the SNOT-25, ENS6Q, BDI-II, and BAI total scores than those without suicidal thoughts (all P < .05). "Nose feels too open" was the item in ENS6Q that was significantly more severe in ENS patients with suicidal thoughts than those without suicidal thoughts (P < .001). CONCLUSIONS Suicidal thoughts are frequently identified in patients with ENS. ENS patients with suicidal thoughts experienced significantly more severe symptoms, impaired quality of life, and psychological burden than those without suicidal thoughts. Recognizing individuals who may carry suicidal thoughts and provide appropriate psychological interventions is critical to prevent tragedy. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Chien‐Chia Huang
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial Hospital and Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Pei‐Wen Wu
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial Hospital and Chang Gung UniversityTaoyuanTaiwan
- Department of Otolaryngology–Head and Neck SurgeryChang Gung Memorial Hospital and Chang Gung UniversityKeelungTaiwan
| | - Cheng‐Chi Lee
- Department of NeurosurgeryChang Gung Memorial Hospital at LinkouTaoyuanTaiwan
- Department of Biomedical EngineeringNational Taiwan UniversityTaipeiTaiwan
| | - Po‐Hung Chang
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial Hospital and Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Chi‐Che Huang
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial Hospital and Chang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung UniversityTaoyuanTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
| | - Ta‐Jen Lee
- Division of Rhinology, Department of OtolaryngologyChang Gung Memorial Hospital and Chang Gung UniversityTaoyuanTaiwan
- School of Medicine, Chang Gung UniversityTaoyuanTaiwan
- Department of OtolaryngologyXiamen Chang Gung HospitalXiamenChina
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21
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Fu CH, Chen HC, Huang CC, Chang PH, Lee TJ. Serum High-Sensitivity C-Reactive Protein Is Associated with Postoperative Psychiatric Status in Patients with Empty Nose Syndrome. Diagnostics (Basel) 2021; 11:diagnostics11122388. [PMID: 34943627 PMCID: PMC8700485 DOI: 10.3390/diagnostics11122388] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/05/2021] [Accepted: 12/16/2021] [Indexed: 11/30/2022] Open
Abstract
Many patients diagnosed with empty nose syndrome (ENS) later develop mental illness. The literature addressing biomarkers associated with postoperative psychiatric status is limited. This study aimed to assess the association between high-sensitivity C-reactive protein (hs-CRP) and psychiatric status after surgery in ENS. We recruited patients with ENS undergoing endonasal submucosal implantation. Their pre- and postoperative psychiatric status was evaluated using the Beck depression inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI). Serum hs-CRP was analyzed one day before and one year after surgery. Of the 43 patients enrolled, all subjective measurements had improved (symptom scores decreased) significantly by the third month postoperatively and remained plateaued till 12 months. Those with preoperative hs-CRP levels > 2.02 mg/L were likely to remain depressive 1 year postoperatively. The regression model showed that a preoperative hs-CRP level > 2.02 mg/L was significantly correlated with postoperative depression in patients with ENS (odds ratio, 19.9). Hs-CRP level seems to be a feasible predictor of surgical outcome regarding improved depression in patients with ENS. Patients with higher preoperative hs-CRP levels should be monitored closely after surgery.
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Affiliation(s)
- Chia-Hsiang Fu
- Department of Otolaryngology—Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333604, Taiwan; (C.-H.F.); (H.-C.C.); (C.-C.H.); (P.-H.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333604, Taiwan
| | - Hung-Chin Chen
- Department of Otolaryngology—Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333604, Taiwan; (C.-H.F.); (H.-C.C.); (C.-C.H.); (P.-H.C.)
| | - Chi-Che Huang
- Department of Otolaryngology—Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333604, Taiwan; (C.-H.F.); (H.-C.C.); (C.-C.H.); (P.-H.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333604, Taiwan
| | - Po-Hung Chang
- Department of Otolaryngology—Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333604, Taiwan; (C.-H.F.); (H.-C.C.); (C.-C.H.); (P.-H.C.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333604, Taiwan
| | - Ta-Jen Lee
- Department of Otolaryngology—Head and Neck Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan 333604, Taiwan; (C.-H.F.); (H.-C.C.); (C.-C.H.); (P.-H.C.)
- Department of Otolaryngology—Head and Neck Surgery, Xiamen Chang Gung Memorial Hospital, Xiamen 361000, China
- Correspondence:
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22
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Imaging After Sinonasal Surgery. Neuroimaging Clin N Am 2021; 32:55-73. [PMID: 34809844 DOI: 10.1016/j.nic.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Posttreatment imaging evaluation of sinuses encompasses a wide gamut of procedures, ranging from endoscopic procedures for sinonasal inflammatory diseases to markedly radical surgeries for malignant neoplasms (with or without reconstructions), as well as providing access for surgeries involving the anterior and central skull base. Advances in both techniques and devices have expanded the use of endoscopic approaches in managing both benign and malignant lesions, in addition to being the primary surgical method for treating all medically refractive sinonasal inflammatory disorders. Familiarity with the complex anatomy in the sinonasal region and knowledge of the various procedures is indispensable in interpreting these imaging studies.
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23
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Dholakia SS, Yang A, Kim D, Borchard NA, Chang MT, Khanwalkar A, Lechner M, Nayak JV. Long-Term Outcomes of Inferior Meatus Augmentation Procedure to Treat Empty Nose Syndrome. Laryngoscope 2021; 131:E2736-E2741. [PMID: 33991117 DOI: 10.1002/lary.29593] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/12/2021] [Indexed: 02/04/2023]
Abstract
OBJECTIVES/HYPOTHESIS We sought to report the long-term, symptom-focused, prospective outcomes in empty nose syndrome (ENS) patients after undergoing inferior meatus augmentation procedure (IMAP) through use of four validated questionnaires: Empty Nose Syndrome 6-Item Questionnaire (ENS6Q), 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-Item Scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). STUDY DESIGN Prospective case series. METHODS A single-center prospective case series was performed for patients diagnosed with ENS who underwent IMAP between July 2017 and February 2020. Diagnosis of ENS was based on the following criteria: 1) reported discomfort with nasal breathing and/or paradoxical nasal obstruction after inferior turbinate reduction, 2) a positive ENS6Q score of at least 11, and 3) a positive cotton test. Questionnaire responses were recorded prior to surgery as well as 1, 3, 6, and 12 months postoperatively. RESULTS Seventeen eligible patients were included. Mean ENS6Q scores were significantly reduced at all postoperative time points (p < .0001, p < .0001, p < .0001, p = .0003). Of the six ENS6Q subdomains, five (suffocation, dryness, sense of diminished airflow, nasal crusting, and nasal burning) were significantly reduced 1-year postoperatively (p < .0001, p = .0004, p = .0136, p = .0114, p = .0080, respectively). SNOT-22 scores were significantly reduced at all time points (p = .0021, p = .0227, p = .0004, and p = .0025). Of the SNOT-22 subdomains, the sleep subdomain was significantly reduced 1-year postoperatively (p = .0432). Low baseline GAD-7 and PHQ-9 scores were recorded at 7 and 9.4, respectively, and although scores at all postoperative time points were reduced, there was no statistical significance. CONCLUSION IMAP via implant of cadaveric rib cartilage provides significant, long-term improvements in ENS-specific and general sinonasal symptoms. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2736-E2741, 2021.
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Affiliation(s)
- Sachi S Dholakia
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Angela Yang
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Dayoung Kim
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Nicole A Borchard
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Michael T Chang
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Ashoke Khanwalkar
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Matt Lechner
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, California, U.S.A
| | - Jayakar V Nayak
- Department of Otolaryngology - Head and Neck Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, U.S.A
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24
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Kanjanawasee D, Campbell RG, Rimmer J, Alvarado R, Kanjanaumporn J, Snidvongs K, Kalish L, Harvey RJ, Sacks R. Empty Nose Syndrome Pathophysiology: A Systematic Review. Otolaryngol Head Neck Surg 2021; 167:434-451. [PMID: 34665687 DOI: 10.1177/01945998211052919] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The pathophysiology of empty nose syndrome (ENS) remains unclear despite significant research. The pathophysiologic mechanism of ENS was systematically reviewed. DATA SOURCES MEDLINE and Embase. REVIEW METHODS Data were systematically reviewed for studies that provided original data on pathophysiology. RESULTS A total of 2476 studies were screened, and 19 met the inclusion criteria: 13 case-control and 6 cross-sectional. Nine pathophysiologic themes were identified.• Demographics: ENS symptoms had no relationship with climatic factors.• Symptomatology: ENS patients demonstrated high symptom severity.• Mental health: Anxiety and depression including hyperventilation were reported in >50% of ENS patients and correlated with ENS symptom severity.• Anatomic features: Structural changes in response to turbinate surgery were similar between ENS and non-ENS patients.• Airflow analysis: Airflow parameters were similar between ENS and non-ENS patients after turbinate surgery. On computational fluid dynamic analysis, differences were found on multiple outcomes.• Diagnostic testing: The menthol detection test was impaired in ENS, and cotton placement in the airway improved ENS symptoms.• Cognitive function: Functional magnetic resonance imaging showed activation in emotional processing area during breathing.• Olfactory function: Subjective impairment was reported in ENS, but quantitative measures were similar to non-ENS patients.• Mucosal physiology/innate immunity: Turbinate histopathology in ENS showed a tissue-remodeling pattern. Nasal nitric oxide level was lower in ENS patients. CONCLUSION There is evidence of high comorbid mental health disorders in ENS patients. An abnormal trigeminal-thermoreceptor response may be present in some patients. The influence of altered airflow and the evidence of surgery as the cause for ENS are unclear.
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Affiliation(s)
- Dichapong Kanjanawasee
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Parasitology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Raewyn G Campbell
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Otorhinolaryngology-Head and Neck Surgery, Royal Prince Alfred Hospital, Sydney, Australia.,Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Janet Rimmer
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia.,Woolcock Institute, University of Sydney, Sydney, Australia.,Faculty of Medicine, Notre Dame University, Sydney, Australia
| | - Raquel Alvarado
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Jesada Kanjanaumporn
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kornkiat Snidvongs
- Department of Otolaryngology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Larry Kalish
- Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Concord General Hospital, University of Sydney, Australia.,Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Richard J Harvey
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Rhinology and Skull Base Research Group, Applied Medical Research Centre, University of New South Wales, Sydney, Australia
| | - Raymond Sacks
- Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia.,Department of Otolaryngology-Head and Neck Surgery, Concord General Hospital, University of Sydney, Australia
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25
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Gordiienko IM, Gubar OS, Sulik R, Kunakh T, Zlatskiy I, Zlatska A. Empty nose syndrome pathogenesis and cell-based biotechnology products as a new option for treatment. World J Stem Cells 2021; 13:1293-1306. [PMID: 34630863 PMCID: PMC8474723 DOI: 10.4252/wjsc.v13.i9.1293] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/29/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
Empty nose syndrome (ENS) is a rare complication that develops after partial or complete turbinectomy. The main feature of ENS is paradoxical nasal obstruction feeling despite objectively wide nasal airway. ENS pathogenesis is multifactorial and includes changes in laminar physiological airflow, disruption of mucosa functions and deficient neural sensation. This leads to the development of ENS symptomatology such as dyspnea, nasal dryness, nasal burning, nasal obstruction, feeling of suffocation and even comorbid psychiatric disorders that significantly impairs life quality. Specific effective treatment of ENS does not exist up to date. In this review we outline existing biomaterial for surgical reconstitution of nasal anatomy and discuss the perspective of stem cell-based technologies in ENS management. The main focus is directed to justification of rationality application of adult mesenchymal stem cells (MSCs) from different tissues origin and neural crest-derived stem cells (NCSCs) based on their intrinsic biological properties. MSCs transplantation may stimulate mucosa tissue regeneration via trophic factors secretion, direct transdifferentiation into epithelial cells and pronounced immunosuppressive effect. From the other hand, NCSCs based on their high neuroprotective properties may reconstitute nerve structure and functioning leading to normal sensation in ENS patients. We postulate that application of cell-based and tissue-engineered products can help to significantly improve ENS symptomatology only as complex approach aimed at reconstitution of nasal anatomy, recovery the nasal mucosa functionality and neural tissue sensation.
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Affiliation(s)
- Inna M Gordiienko
- Biotechnology Laboratory, Medical Company “Good Cells”, Kyiv 03115, Ukraine
- R.E. Kavetsky Institute of Experimental Pathology, Oncology and Radiobiology NAS of Ukraine, Kyiv 03022, Ukraine
| | - Olga S Gubar
- Institute of Molecular Biology and Genetics NAS of Ukraine, Kyiv 03143, Ukraine
| | - Roman Sulik
- Biotechnology Laboratory, Medical Company “Good Cells”, Kyiv 03115, Ukraine
| | - Taras Kunakh
- Biotechnology Laboratory, Medical Company “Good Cells”, Kyiv 03115, Ukraine
| | - Igor Zlatskiy
- State Institute of Genetic and Regenerative Medicine, National Academy of Medical Sciences of Ukraine, Kyiv 04114, Ukraine
| | - Alona Zlatska
- Biotechnology Laboratory, Medical Company “Good Cells”, Kyiv 03115, Ukraine
- State Institute of Genetic and Regenerative Medicine, National Academy of Medical Sciences of Ukraine, Kyiv 04114, Ukraine
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26
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Outcomes of olfaction in patients with empty nose syndrome after submucosal implantation. Am J Otolaryngol 2021; 42:102989. [PMID: 33676069 DOI: 10.1016/j.amjoto.2021.102989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Olfactory dysfunction, such as hyposmia, is a significant symptom of empty nose syndrome (ENS). The efficacy of surgical intervention in olfaction improvements for ENS has not been investigated extensively. OBJECTIVE The aim of this study was to evaluate changes in olfaction after surgical treatment for ENS. METHODS This prospective cohort study at a tertiary medical center enrolled patients with ENS indicated for surgical treatment between June 2015 and June 2019. The Sniffin' Sticks 12-items odor identification test (SS-12) and subjective olfaction rating were completed by patients before and after surgery to assess olfaction. RESULTS A total of 40 patients completed the survey both before and after surgical treatment. Prior to surgery, 25% of the patients had olfactory dysfunction detected by SS-12, whereas 80% of the patients reported a reduction in olfactory function by subjective rating. The degree of olfactory dysfunction by both assessments significantly improved following surgery. The age was a significant predictor of postoperative improvement. CONCLUSION Surgical treatment is helpful in improving olfaction in patients with ENS who commonly suffer from olfactory dysfunction. Younger patients may benefit more from surgical intervention in aspect of olfaction.
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27
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Law RH, Ahmed AM, Van Harn M, Craig JR. Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively. Am J Otolaryngol 2021; 42:102931. [PMID: 33550027 DOI: 10.1016/j.amjoto.2021.102931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE Empty nose syndrome (ENS) is characterized by nasal dryness, crusting, and paradoxical nasal obstruction most commonly after inferior turbinate resection. ENS has also been reported to occur after middle turbinate resection (MTR), and concern for causing ENS is a possible reason surgeons preserve the MT during endoscopic sinus surgery (ESS). The objective was to determine whether MTR during ESS led to ENS. MATERIALS AND METHODS This was a prospective case series of 95 consecutive patients that underwent bilateral subtotal MTR during ESS with either Draf IIB or Draf III frontal sinusotomies, for chronic rhinosinusitis with or without nasal polyps, and frontal sinus inverted papillomas. Demographic data and postoperative Empty Nose Syndrome 6-item Questionnaire (ENS6Q) scores were obtained. Nasal crusting was also documented on last postoperative nasal endoscopy. RESULTS Pathologies included chronic rhinosinusitis with nasal polyps (69), without nasal polyps (12), and inverted papillomas (14). Fifty-six patients underwent subtotal MTRs during ESS with Draf IIB, and 39 with Draf III. Mean follow-up was 19.4 months (range 12-49). Mean postoperative ENS6Q score was 2.1. Only 2.1% had ENS6Q scores ≥ 11, and 6.3% had nasal crusting at last follow-up. None of the patients with ENS6Q scores ≥ 11 had nasal crusting at last follow-up. There were no significant differences in outcomes between ages, genders, surgery types, or pathologies. CONCLUSIONS Patients who underwent bilateral subtotal MTR during ESS were unlikely to develop ENS by at least 1 year postoperatively, based on patients rarely experiencing ENS6Q scores ≥ 11 or persistent nasal crusting.
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Affiliation(s)
- Richard H Law
- Department of Otolaryngology Head and Neck Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202, USA
| | - Abdelwahab M Ahmed
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, USA
| | - Meredith Van Harn
- Department of Public Health Sciences, Henry Ford Health System, 1 Ford Place, Detroit, MI 48202, USA
| | - John R Craig
- Department of Otolaryngology Head and Neck Surgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI 48202, USA.
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Amanian A, Hari K, Habib AR, Dholakia SS, Nayak J, Thamboo A. The empty nose syndrome 6-item questionnaire (ENS6Q): a diagnostic tool to distinguish empty nose syndrome from primary nasal obstruction. Int Forum Allergy Rhinol 2021; 11:1113-1115. [PMID: 33460303 DOI: 10.1002/alr.22761] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/03/2020] [Accepted: 12/11/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Ameen Amanian
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Kishore Hari
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada
| | - Al-Rahim Habib
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Sachi S Dholakia
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Jayakar Nayak
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Andrew Thamboo
- Division of Otolaryngology, St. Paul's Sinus Centre, University of British Columbia, Vancouver, BC, Canada.,Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
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29
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Malik J, Dholakia S, Spector BM, Yang A, Kim D, Borchard NA, Thamboo A, Zhao K, Nayak JV. Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling. Int Forum Allergy Rhinol 2020; 11:902-909. [PMID: 33249769 DOI: 10.1002/alr.22720] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/29/2020] [Accepted: 10/08/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Empty nose syndrome (ENS) is a controversial upper airway disorder most commonly associated with tissue loss from the inferior turbinates. The inferior meatus augmentation procedure (IMAP) has been shown to effectively reduce ENS symptoms in a durable manner, but the precise mechanisms that may govern this symptomatic improvement remain unknown. METHODS Five patients with ENS who underwent bilateral IMAP via submucosal costal cartilage implant were assessed. Pre-implant and 6 months post-implant computed tomography (CT) imaging for each ENS patient was analyzed in a blinded fashion using computational fluid dynamics (CFD) modeling to investigate intrapatient changes in airflow parameters. RESULTS Following surgery, ENS patients have significantly improved symptoms as indexed by Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) scoring (pre-implant: 14.00 ± 4.06 [mean ± standard deviation]; 95% confidence interval [CI], 10.44 to 17.56; post-implant: 4.8 ± 2.77; 95% CI, 2.37 to 7.23; Cohen's d = 2.64; p = 0.02). Using CFD, a significant shift in nasal airflow patterns was observed, where airflow deviates away from the middle meatus upon hitting the implant (pre-implant: 67.13% ± 11.14%; 95% CI, 60.22% to 74.04%; post-implant: 46.18% ± 12.81%; 95% CI, 38.23% to 54.12%; d = 1.74; p < 0.05) toward the inferior meatus (pre-implant: 30.55% ± 11.29%; 95% CI, 23.55% to 37.55%; post-implant: 42.59% ± 9.60%; 95% CI, 36.63 to 48.54%; d = 1.14; p < 0.05). No significant changes were found in nasal resistance (pre-implant: 0.102 ± 0.015; 95% CI, 0.092 to 0.112 Pa*s/mL; post-implant: 0.105 ± 0.041; 95% CI, 0.081 to 0.130 Pa*s/mL). In addition, the improvement of ENS6Q scoring significantly correlated with percent reduction in aberrant airflow through the middle meatus (R2 = 0.60, p = 0.04). CONCLUSION This study supports our prior working hypothesis that disordered vectors of nasal airflow congregate in the middle meatus contribute to ENS symptoms, not nasal resistance. Moreover, these data illuminate a paradoxical, but consistent, restoration of nasal airflow to the inferior meatus following the replacement of turbinate tissue volume in the inferior meatus via IMAP surgery, potentially due to the Coandă effect.
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Affiliation(s)
- Jennifer Malik
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Sachi Dholakia
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
| | - Barak M Spector
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Angela Yang
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
| | - Dayoung Kim
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
| | - Nicole A Borchard
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
| | - Andrew Thamboo
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
| | - Kai Zhao
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, OH
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA
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30
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Maul X, Thamboo A. The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate-sparing techniques: A prospective self-controlled study. Int Forum Allergy Rhinol 2020; 11:955-956. [PMID: 33151623 DOI: 10.1002/alr.22724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/15/2020] [Accepted: 10/15/2020] [Indexed: 01/12/2023]
Affiliation(s)
- Ximena Maul
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada.,Department of Otolaryngology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Andrew Thamboo
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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Tian P, Hu J, Ma Y, Zhou C, Liu X, Dang H, Zou H. The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate-sparing techniques: a prospective self-controlled study. Int Forum Allergy Rhinol 2020; 11:984-992. [PMID: 33151634 DOI: 10.1002/alr.22726] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 09/29/2020] [Accepted: 10/14/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Individuals affected by empty nose syndrome secondary to turbinate-sparing techniques (ENS-type) experience decreased productivity and lifestyle disruption owing to considerable nasal-associated discomfort. This study aimed to evaluate the effect of psychosomatic intervention on ENS-type. METHODS A prospective self-controlled study was conducted, and 28 patients suffering from ENS-type who met the diagnostic criteria for somatic symptom disorder (SSD) according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) received cognitive and behavioral therapy (CBT) plus antidepressants. Nasal symptom burden was evaluated using the 25-item Sino-Nasal Outcome Test (SNOT-25). Somatic symptom burden, anxiety severity, and depression severity were assessed by the 25-item Patient Health Questionnaire (PHQ-15), the 9-item PHQ (PHQ-9), and the 7-item Generalized Anxiety Disorder (GAD-7) scale, respectively. Patient assessments were completed prior to treatment and 3 and 12 months after the intervention. RESULTS The total scores of the SNOT-25 declined posttreatment, showing a significant difference at the 3-month and 12-month follow-ups compared with the baseline scores (p < 0.001). The severity of the 5 most common subjective symptoms, including "nose is too open," "waking up at night," "lack of a good night's sleep," "difficulty falling asleep," and "reduced concentration," declined significantly at 3 and 12 months posttreatment compared to baseline levels. Statistically significant changes in the PHQ-15, PHQ-9, and GAD-7 scores were observed at 3 and 12 months posttreatment compared to baseline scores (p < 0.001). CONCLUSION This study showed that some patients with ENS-type meeting the diagnostic criteria for SSD might benefit from psychiatric treatment.
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Affiliation(s)
- Peng Tian
- Department of Otorhinolaryngology-Head and Neck Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Junwu Hu
- Department of Psychology, School of Public Health, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Yun Ma
- Department of Otorhinolaryngology-Head and Neck Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Chao Zhou
- Guangzhou Psychiatric Hospital, Guangzhou, Guangdong, People's Republic of China
| | - Xiang Liu
- Department of Otorhinolaryngology-Head and Neck Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Hua Dang
- Department of Otorhinolaryngology-Head and Neck Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
| | - Hua Zou
- Department of Otorhinolaryngology-Head and Neck Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, People's Republic of China
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Huang CC, Wu PW, Fu CH, Huang CC, Chang PH, Lee TJ. Impact of Psychologic Burden on Surgical Outcome in Empty Nose Syndrome. Laryngoscope 2020; 131:E694-E701. [PMID: 32692881 DOI: 10.1002/lary.28845] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/15/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES /HYPOTHESIS Empty nose syndrome (ENS) is a complicated condition currently thought to be caused by excessive surgical resection of turbinate tissue. Patients with ENS experienced significant psychological symptoms, such as depression and anxiety. This study aimed to evaluate the impact of the psychological burden on the surgical outcome of ENS. STUDY DESIGN Prospective case series in a tertiary medical center. METHODS Patients with ENS were prospectively recruited between 2015 and 2018. Validated instruments including the Sinonasal Outcome Test-25 (SNOT-25), Beck Depression Inventory-II (BDI-II), and Beck Anxiety Inventory (BAI) were used to evaluate patients with ENS prior to and 3, 6, and 12 months after nasal reconstruction surgery with submucosal Medpor implantation. RESULTS A total of 54 ENS patients were enrolled during the study period. All three evaluations revealed significant improvement, and symptoms stabilized 3 months after surgery. Six months post-operatively, SNOT-25 scores were significantly associated with the pre-operative BDI-II and BAI scores (β = 0.64 and 0.87; P = .006 and <.001, respectively). Multivariate regression model revealed that only BAI scores were significantly associated with the six-month post-operative SNOT-25 scores (adjusted β = 0.49, P = .036). Moreover, Spearman's correlation found close relationships between the post-operative SNOT-25 and the post-operative BDI-II and BAI scores (rs = 0.751 and 0.884, both P < .001). CONCLUSIONS Psychological evaluation can help predict surgical outcomes and identify patients with residual disease. These findings emphasize the importance of screening for psychological symptoms and structuring care by including psychological therapy in addition to surgery. LEVEL OF EVIDENCE 4. Laryngoscope, 131:E694-E701, 2021.
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Affiliation(s)
- Chien-Chia Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Wen Wu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital and Chang Gung University, Keelung, Taiwan
| | - Chia-Hsiang Fu
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Che Huang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Po-Hung Chang
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ta-Jen Lee
- Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan.,Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China
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Talmadge J, Nayak JV, Yao W, Citardi MJ. Management of Postsurgical Empty Nose Syndrome. Facial Plast Surg Clin North Am 2020; 27:465-475. [PMID: 31587766 DOI: 10.1016/j.fsc.2019.07.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Empty nose syndrome (ENS) is a controversial condition associated with disruption of nasal airflow caused by excessive loss of turbinate tissue. ENS arises after total or near-total inferior turbinate resection. Patients present with intense fixation on the perception of nasal obstruction. Diagnostic tools to assess for empty nose syndrome include a validated patient questionnaire and the office cotton test. Treatment involves topical moisturization, behavioral/psychiatric assessment/treatment, and surgical reconstruction. Current data show promising long-term efficacy after surgical intervention. Postprocedural ENS is best prevented by minimizing inferior and middle turbinate tissue loss.
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Affiliation(s)
- Jason Talmadge
- Department of Otolaryngology, Medical College of Wisconsin, 3400 Market Lane, Kenosha, WI 53144, USA
| | - Jayakar V Nayak
- Department of Otolaryngology, Stanford University School of Medicine, 801 Welch Road, Stanford, CA 94305, USA
| | - William Yao
- Department of Otolaryngology, Medical College of Wisconsin, 3400 Market Lane, Kenosha, WI 53144, USA
| | - Martin J Citardi
- Department of Otorrhinolaryngology, The University of Texas Health Science Center at Houston, McGovern Medical School, 6431 Fannin Street, MSB 5.036, Houston, TX 77030, USA.
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34
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Malik J, Thamboo A, Dholakia S, Borchard NA, McGhee S, Li C, Zhao K, Nayak JV. The cotton test redistributes nasal airflow in patients with empty nose syndrome. Int Forum Allergy Rhinol 2020; 10:539-545. [PMID: 31951101 DOI: 10.1002/alr.22489] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 10/08/2019] [Accepted: 10/11/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Empty nose syndrome (ENS) remains a controversial disease primarily associated with inferior turbinate tissue loss. Cotton placement into the inferior meatus often alleviates ENS symptoms within minutes, but the physiologic explanation for this phenomenon is unknown. Computational fluid dynamics (CFD) was employed to evaluate the mechanisms of altered nasal airflow conferred by cotton testing. METHODS Six ENS patients (12 sides) with pre-existing sinus computed tomography (CT) imaging were enrolled after marked symptomatic improvement (decrease in score on the Empty Nose Syndrome 6-Item Questionnaire [ENS6Q] of >7 points) with office-based cotton testing. The fashioned cotton plug was labeled in situ with iohexol contrast spray, and sinus CT was immediately obtained to detect cotton contouring in the inferior meatus. CT imaging from pre- and post-cotton placement was analyzed using comparative CFD techniques. RESULTS After cotton placement, significant symptomatic improvement and reduced ENS6Q scores (16.8 ± 4.1 to 3.1 ± 2.4; p < 0.001) were recorded. Using CFD, cotton placement produced an expected 21% increase in upper airway resistance (p < 0.05). However, a significant shift in the nasal airflow distribution was also detected, with a transition of airflow vectors away from a middle meatus jetstream (-41%; p < 0.002). CONCLUSION Objective CFD assessment confirmed that the cotton test not only increases nasal resistance, but also restores airflow distribution to the inferior meatus in symptomatic ENS patients. These results highlight the potential efficacy of cotton test in ENS patients and further bolster the utility of this tool in identifying appropriate candidates for the inferior meatus augmentation procedure.
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Affiliation(s)
- Jennifer Malik
- Department of Otolaryngology, Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Andrew Thamboo
- Department of Otolaryngology, Head & Neck Surgery, University of British Columbia, Vancouver, Canada
| | - Sachi Dholakia
- Department of Otolaryngology, Head & Neck Surgery, Stanford University, Stanford, CA
| | - Nicole A Borchard
- Department of Otolaryngology, Head & Neck Surgery, Stanford University, Stanford, CA
| | - Sam McGhee
- Department of Otolaryngology, Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Chengyu Li
- Department of Mechanical Engineering, Villanova University, Villanova, PA
| | - Kai Zhao
- Department of Otolaryngology, Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Jayakar V Nayak
- Department of Otolaryngology, Head & Neck Surgery, Stanford University, Stanford, CA
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Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies. Curr Opin Otolaryngol Head Neck Surg 2020; 27:237-242. [PMID: 31116142 DOI: 10.1097/moo.0000000000000544] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW To discuss the proposed pathophysiology of empty nose syndrome (ENS), summarize and evaluate the role of validated diagnostic tools in the diagnosis of ENS, and review the medical and surgical treatment strategies for patients with ENS. RECENT FINDINGS Historically, ENS has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease. The newly validated empty nose syndrome 6 item questionnaires and Cotton test are steps forward to standardize the diagnosis of ENS. Finally, there has been a marked increase in surgical treatment strategies to reconstitute turbinate volume with various implant materials. SUMMARY The diagnosis of ENS remains controversial but the last several years have seen a rejuvenation of interest in this disease entity. The validated empty nose syndrome 6 item questionnaires and Cotton test provide a standardized and objective means by which to characterize ENS. Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction remains critical in preventing paradoxical nasal obstruction. Nasal humidification, patient education, and treatment of possible concomitant medical conditions (e.g., depression) constitute first lines of treatment. We support the cautious use of these screening tools as adjuncts to clinical decision-making. Although injectable implants to augment turbinate volume show promise as a therapeutic surgical technique, there is insufficient data to fully support their use at this time.
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Gill AS, Said M, Tollefson TT, Strong EB, Nayak JV, Steele TO. Patient-Reported Outcome Measures and Provocative Testing in the Workup of Empty Nose Syndrome-Advances in Diagnosis: A Systematic Review. Am J Rhinol Allergy 2019; 34:134-140. [PMID: 31594386 DOI: 10.1177/1945892419880642] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BackgroundThe last 5 years have seen a surge of both clinical and scientific interest in empty nose syndrome (ENS). Although ENS is still considered a controversial diagnosis plagued by a lack of standardized diagnostic criteria, ENS is increasingly becoming recognized as a legitimate, physiologic disease entity. As such, it is important for clinicians to understand the most up-to-date diagnostic tools to assess ENS, confirm the diagnosis, and create a more standardized means to counsel these complex patients.ObjectiveContemporary literature review to discuss diagnostic modalities in the evaluation of ENS, in order to introduce evidence-based diagnostic criteria.MethodsA systematic review was conducted in PubMed and Embase (2013–2019) using the search term “empty nose syndrome” to identify peer-reviewed articles on the topic of ENS. Articles advancing contemporary methods of ENS diagnosis and testing were included. A quality assessment was conducted using The Rational Clinical Examination Levels of Evidence.ResultsThe novel development of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) offers the clinician a validated patient-reported outcome measure to supplement history and physical examination. The in-office cotton test, performed by placing an endoscopically directed cotton plug in the site of tissue loss, may help to identify patients who may benefit from turbinate augmentation. Tools such as the sinus computed tomography scan, computational fluid dynamics, and intranasal trigeminal nerve function testing currently have insufficient evidence to support routine use in the workup of ENS. Up to 66% of ENS patients present with comorbid anxiety or depression.ConclusionThe ENS6Q and cotton test assist in creating a standardized approach to the evaluation of patients suspected of ENS. These instruments should be used as an adjunct, rather than the sole criteria, on which to ascertain the presumptive diagnosis. Patients suspected of ENS should be screened for comorbid psychological dysfunction.
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Affiliation(s)
- Amarbir S Gill
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California
| | - Mena Said
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California
| | - Travis T Tollefson
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California
| | - E Bradley Strong
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California
| | - Jayakar V Nayak
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, California
| | - Toby O Steele
- Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Davis, California.,Department of Surgery, VA Northern California Healthcare System, Sacramento, California
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Kim CH, Kim J, Song JA, Choi GS, Kwon JH. The Degree of Stress in Patients With Empty Nose Syndrome, Compared With Chronic Rhinosinusitis and Allergic Rhinitis. EAR, NOSE & THROAT JOURNAL 2019; 100:NP87-NP92. [PMID: 31272211 DOI: 10.1177/0145561319858912] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Depression is a mental health disease of growing public health concern because depressive mood affects the sufferer's daily life and is also associated with productivity decline. Depression that is caused by other diseases or substances is referred to as secondary depression, which is an important distinction because curing the underlying cause could subsequently regulate depressive mood. Empty nose syndrome (ENS), also known as "paradoxical obstruction of the nose," is a condition in which the major symptom is difficulty breathing, despite having sufficient breathing space in the nose. Empty nose syndrome has been increasing in prevalence in Korea. We found that patients with this ENS have a tendency toward depressive mood, which can escalate so far as to lead to suicide attempts. Thus, herein, we aimed to investigate the psychological burden on patients with ENS. METHODS We divided patients into 4 groups: ENS (group A), chronic rhinosinusitis with polyp (CRS c polyp, group B), chronic rhinosinusitis without polyp (CRS s polyp, group C), and allergic rhinitis (AR, group D). We estimated and compared Beck Depression Inventory (BDI) scores among the 4 groups, and we investigated the relationship between depression index and nasal cavity area in patients with ENS. RESULTS The ENS group (A) had depression prevalence of 71% with varying severity, which was much higher than group B (19%), group C (15%), and group D (27%). The correlation between nasal cavity volume and BDI score for the ENS group was not statistically significant. CONCLUSION The degree and severity of depression in patients with ENS was higher than in patients with CRS or AR. Furthermore, there was no relationship between depression severity and nasal cavity volume in the patients with ENS. Thus, physicians should be careful not to dismiss the accompanying mental health problems of patients with ENS.
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Affiliation(s)
- Chang Hoi Kim
- Department of Otolaryngology-Head and Neck Surgery, 65366Kosin University College of Medicine, Busan, Korea
| | - Jooyeon Kim
- Department of Otolaryngology-Head and Neck Surgery, 65366Kosin University College of Medicine, Busan, Korea
| | - Ji Ah Song
- Department of Otolaryngology-Head and Neck Surgery, 65366Kosin University College of Medicine, Busan, Korea
| | - Gil Soon Choi
- Department of Internal Medicine, Allergic Division, 65366Kosin University College of Medicine, Busan, Korea
| | - Jae Hwan Kwon
- Department of Otolaryngology-Head and Neck Surgery, 65366Kosin University College of Medicine, Busan, Korea
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Alam ES, Musselman DL, Chyou D, Shukri G, Levine CG, Sanghvi S, Zhang H, Casiano RR. Somatization, Depression, and Anxiety Disorders in a Rhinology Practice. Am J Rhinol Allergy 2019; 33:470-477. [PMID: 30947506 DOI: 10.1177/1945892419841317] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Patients present to rhinology clinics with various complaints. Symptoms may be attributable to objective findings, some remain unexplained. The objective is to investigate the incidence of psychological disorders in a rhinologic practice and evaluate a correlation of these psychiatric diseases with rhinologic symptoms. Methods Patients presenting to a rhinology clinic were administered the Generalized Anxiety Disorder 7 (GAD 7), Patient Health Questionnaire 9 (PHQ 9), and PHQ 15, psychometric instruments that can screen for generalized anxiety, major depression, and somatization disorder, respectively. Patients’ symptoms, endoscopic findings, medication, and psychiatric history were recorded. Multivariable analysis was performed for patients showed moderate-to-severe anxiety, depression, and somatic symptoms via 3 logistic regressions where the outcome was a GAD 7, PHQ 9, or PHQ 15 above 10. Results One hundred ninety-six patients were included for this study. There were 109 females and 87 males with a mean age of 49 years. Overall, 9%, 14%, and 21% exhibited moderate-to-severe anxiety, depressive, and somatization symptoms, respectively. Nasal obstruction was the only statistically significant variable that increased the odds of having moderate-to-severe anxiety symptoms. Similarly, headache, nasal obstruction, and anosmia/hyposmia were associated with increased odds of having depressive symptoms, and female gender, headache, and nasal discharge increased the odds of somatic symptom disorder. Edema was the only objective endoscopic finding, which was associated with depression only. Conclusions Patients should be counseled about the pathophysiology and psychiatric comorbidities affecting their primary rhinologic complaints. The provider needs to set realistic treatment expectations in order to achieve the desired clinical outcomes.
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Affiliation(s)
- Elie S Alam
- 1 Department of Otolaryngology, Head and Neck Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Dominique L Musselman
- 2 Department of Psychiatry, Miller School of Medicine, University of Miami, Miami, Florida
| | - Darius Chyou
- 3 Miller School of Medicine, University of Miami, Miami, Florida
| | - Ghaith Shukri
- 1 Department of Otolaryngology, Head and Neck Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Corinna G Levine
- 1 Department of Otolaryngology, Head and Neck Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Saurin Sanghvi
- 1 Department of Otolaryngology, Head and Neck Surgery, Miller School of Medicine, University of Miami, Miami, Florida
| | - Hang Zhang
- 4 Department of Public Health, Division of Biostatistics, University of Miami, Miami, Florida
| | - Roy R Casiano
- 1 Department of Otolaryngology, Head and Neck Surgery, Miller School of Medicine, University of Miami, Miami, Florida
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Manji J, Patel VS, Nayak JV, Thamboo A. Environmental Triggers Associated With Empty Nose Syndrome Symptoms: A Cross-Sectional Study. Ann Otol Rhinol Laryngol 2019; 128:601-607. [PMID: 30818962 DOI: 10.1177/0003489419833714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Empty nose syndrome (ENS) is thought to have multiple etiologies, one of which is a postsurgical phenomenon resulting from excessive loss of nasal tissues, particularly the inferior turbinate. Given that the inferior turbinate is instrumental in maintaining nasal homeostasis in different environments, it is believed that ENS symptoms arise only in more arid regions of the world. The aim of this study was to recruit an international population of individuals with ENS to investigate the association of local climate factors on the incidence and severity of ENS-specific symptoms. METHODS A cross-sectional study was performed of individuals from an international ENS database. ENS status was determined on the basis of a positive ENS questionnaire score (Empty Nose Syndrome 6-Item Questionnaire) and sinus computed tomographic imaging with supporting medical documentation. Participants completed a survey encompassing demographic, geographic, and symptom indicators. Climate variables were collected from global climate databases. Participant location was classified according to the Köppen-Geiger climate system. Pearson correlation analysis was performed using α = 0.05 to determine significance. RESULTS Fifty-three individuals with ENS were included. Participants were distributed across 5 continents and 15 countries (representing 4 distinct Köppen-Geiger zones). Although local climate factors varied significantly within this cohort, no significant association was found between Empty Nose Syndrome 6-Item Questionnaire symptom severity and these climate factors. However, most study participants reported exacerbation of their ENS symptoms in response to dry air (94%), air conditioning (64%), changes in season and weather (60%), and transitioning between indoors and outdoors (40%). This suggests that everyday local environmental factors may influence the well-being of these patients more than global, climate-level shifts. CONCLUSIONS ENS symptom severity does not appear to be related to climate or geographic factors. These findings deviate from the traditional dogma that ENS is experienced only in arid regions (or precluded in humid regions) and highlight the importance of recognizing this condition independent of geographic location.
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Affiliation(s)
- Jamil Manji
- 1 St. Paul's Sinus Centre, Vancouver, BC, Canada.,2 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA, USA
| | - Vishal S Patel
- 3 Department of Otolaryngology-Head and Neck Surgery, University of California, Los Angeles, CA, USA
| | - Jayakar V Nayak
- 2 Department of Otolaryngology-Head and Neck Surgery, Stanford University, Stanford, CA, USA
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Borchard NA, Dholakia SS, Yan CH, Zarabanda D, Thamboo A, Nayak JV. Use of intranasal submucosal fillers as a transient implant to alter upper airway aerodynamics: implications for the assessment of empty nose syndrome. Int Forum Allergy Rhinol 2019; 9:681-687. [PMID: 30715801 DOI: 10.1002/alr.22299] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 12/04/2018] [Accepted: 01/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Empty nose syndrome (ENS) is a debilitating condition associated with inferior turbinate tissue loss. Surgical augmentation of the inferior meatus has been proposed to treat ENS, although efficacy data with validated, disease-specific questionnaires is limited. Instead we evaluated submucosal injection of a transient, resorbable filler into the inferior meatus to favorably alter nasal aerodynamics in ENS patients. METHODS Patients with a history of inferior turbinate reduction, diagnosed with ENS via Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) and cotton testing, were enrolled and underwent submucosal injection of carboxymethylcellulose/glycerin gel (Prolaryn®) into the inferior meatuses between July 2014 and May 2018. This material likely resorbs over several months. Outcomes included comparisons of preinjection and postinjection symptoms at 1 week, 1 month, and 3 months using the ENS6Q, 22-item Sino-Nasal Outcome Test (SNOT-22), Generalized Anxiety Disorder 7-item scale (GAD-7), and Patient Health Questionnaire-9 (PHQ-9). RESULTS Fourteen patients underwent injections. Mean ENS6Q scores significantly decreased from baseline at 1 week (20.8 vs 10.5; p < 0.0001), and remained reduced but upward-trending at 1 month (13.7, p = 0.002) and 3 months (15.5, p > 0.05) following injections. Mean SNOT-22 scores significantly decreased at 1 week (p = 0.01) and 1 month (p = 0.04), mean GAD-7 at 1 month (p = 0.02) and 3 months (p = 0.02), and mean PHQ-9 at 1 week (p = 0.01) and 1 month (p = 0.004) postinjection. CONCLUSION Transient, focal airway bulking via submucosal filler injection at sites of inferior turbinate tissue loss markedly benefits ENS patients, suggesting that aberrant nasal aerodynamics from inferior turbinate tissue loss contributes to (potentially reversible) ENS symptoms.
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Affiliation(s)
- Nicole A Borchard
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Sachi S Dholakia
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Carol H Yan
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - David Zarabanda
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Andrew Thamboo
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA.,Department of Otolaryngology-Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Jayakar V Nayak
- Division of Rhinology, Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Palo Alto, CA
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Maza G, Li C, Krebs JP, Otto BA, Farag AA, Carrau RL, Zhao K. Computational fluid dynamics after endoscopic endonasal skull base surgery-possible empty nose syndrome in the context of middle turbinate resection. Int Forum Allergy Rhinol 2018; 9:204-211. [PMID: 30488577 DOI: 10.1002/alr.22236] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 08/02/2018] [Accepted: 09/13/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND Empty nose syndrome (ENS) is a rare and debilitating disease with a controversial definition, etiology, and treatment. One puzzling fact is that patients who undergo an endoscopic endonasal approach (EEA) often have resection of multiple anatomic structures, yet seldom develop ENS. In this pilot study, we analyzed and compared the computational fluid dynamics (CFD) and symptoms among post-EEA patients, ENS patients, and healthy subjects. METHODS Computed tomography scans of 4 post-EEA patients were collected and analyzed using CFD techniques. Two patients had significant ENS symptoms based on results of the Empty Nose Syndrome 6-item Questionnaire (score >11), whereas the other 2 were asymptomatic. As a reference, their results were compared with previously published CFD results of 27 non-EEA ENS patients and 42 healthy controls. RESULTS Post-EEA patients with ENS symptoms had a similar nasal airflow pattern as non-EEA ENS patients. This pattern differed significantly from that of EEA patients without ENS symptoms and healthy controls. Overall, groups with ENS symptoms exhibited airflow dominant in the middle meatus region and a significantly lower percentage of airflow in the inferior turbinate region (EEA with ENS, 17.74 ± 4.00% vs EEA without ENS, 51.25 ± 3.33% [t test, p < 0.02]; non-EEA ENS, 25.8 ± 17.6%; healthy subjects, 36.5 ± 15.9%) as well as lower peak wall shear stress (EEA with ENS, 0.30 ± 0.13 Pa vs EEA without ENS, 0.61 ± 0.03 Pa [p = 0.003]; non-EEA ENS, 0.58 ± 0.24 Pa; healthy subjects, 1.18 ± 0.81 Pa). CONCLUSION These results suggest that turbinectomy and/or posterior septectomy may have a varying functional impact and that ENS symptoms go beyond anatomy and correlate with aerodynamic changes. The findings open the door for CFD as a potential objective diagnosis tool for ENS.
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Affiliation(s)
- Guillermo Maza
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Chengyu Li
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH.,Department of Mechanical Engineering, Villanova University, Villanova, PA
| | - Jillian P Krebs
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH
| | - Bradley A Otto
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Alexander A Farag
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Ricardo L Carrau
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH
| | - Kai Zhao
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, OH.,Department of Biomedical Engineering, The Ohio State University, Columbus, OH
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Nasal physiology: improving our understanding in the health and disease. Int Forum Allergy Rhinol 2018; 8:666-667. [DOI: 10.1002/alr.22153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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