A Contentious Method Used to Address Empty Nose Syndrome: Medialisation of Remaining Part of Inferior Turbinates

Medial Repositioning of The Inferior Turbinate

In the examination of the patient, who had septoplasty and turbinate reduction procedures in different clinics before, and had symptoms of empty nose syndrome and nasal hyperventilation, the remaining part of the inferior turbinate in the left nasal cavity was quite small (image "1" in the upper photo), the intranasal air passage was larger than normal, It was observed that the nasal mucosa was dry, especially in the nasal region, dry mucosa and sticky secretion. The patient was advised to try breathing in this way for a few hours a day by narrowing the nose. For this, a 1 cm diameter cotton ball impregnated with eye ointment was used. Techniques such as inferior metatus augmentation (with cartilage implantation), modified Young's operation, gel filler injection and turbinate augmentation were suggested to the patient and discussed. I would like to point out here that most patients with empty nose syndrome have a limited amount of inferior turbinate tissue. Since the bone fragments of the turbinates are usually excreted, changes in turbinate position do not have a lasting effect. At the patient's special request, the remaining part of the left inferior turbinate was medialized under local anesthesia. Nasal examination photograph immediately after the procedure is available in image "2", image number "3" 2 hours after the procedure, and image number "4" 1.5 days after the procedure. Here, although there is a medialized view of the inferior turbinate; it actually appears to consist of soft tissue trauma and temporary tissue swelling. In patients with healthy turbinate tissue, lateral repositioning of the inferior turbinate is an effective application that provides simple and limited anatomical changes; It is not an easy and logical practice to move the fibrous turbinate residues, whose volume and bone tissue have been reduced, back to the nasal cavity. Patients with empty nose syndrome and avoiding a serious nose surgery can apply with the request of "turbinate position change", "inferior turbinate medialization". Permanent narrowing in the nose cannot be expected with simple and blunt trauma in patients with less and replaced inferior turbinate tissue. Turbinate repositioning is a technique that can be used, especially for middle turbinate and inferior turbinate. In empty nose syndrome, it is an application that may take a few weeks, just like in PRP and stem cell injection.

Although it is seen in the image numbered "4" above that the inferior turbinate both increases in volume and medializes, it cannot guarantee that the turbinates will remain in this position and volume in the long run.

The cotton test is a diagnostic procedure used for empty nose patients. It involves inserting a small piece of cotton into the nasal cavity to assess nasal airflow and sensation. The cotton test is a practical and effective technique for patient selection for inferior meatus augmentation. You can take a look at the source article at the bottom of the article.

Inferior Meatus Augmentation or Turbinate Augmentation?

Turbinate augmentation is a procedure aimed at treating conditions like Empty Nose Syndrome. It involves adding materials, such as cartilage, filler or synthetic implants, to the nasal turbinates to restore normal airflow and improve nasal function. The goal is to increase the size and volume of the turbinates to alleviate symptoms like nasal congestion and breathing difficulties. Turbinate augmentation is a specialized technique performed by qualified ENT surgeons and is tailored to each patient's specific needs. Turbinate augmentation is very difficult and sometimes near impossible in patients with a limited amount of inferior tubinate tissue. Instead, it is more reasonable to perform the Inferior Meatus Augmentation Procedure (IMAP) with submucosal cartilage implantation in the inferior meatus. Inferior meatus augmentation involves augmenting the inferior meatus, which is the lower portion of the nasal passage, to improve airflow and alleviate symptoms such as nasal congestion and difficulty breathing. This procedure can be performed using various materials, such as synthetic implants or autologous tissue grafts, to increase the size and patency of the inferior meatus. Inferior meatus augmentation is a specialized procedure performed by ENT surgeons to restore nasal function and enhance overall patient well-being. I generally prefer to use cartilage grafts rather than synthetic materials.

1 Week After Left Inferior Turbinate Medialization - Completely Returned to Its Old Position and Volume

One week after the left inferior turbinate medialization, the patient came for control. Endoscopic examination (photo 5 above) revealed that the turbinate had become almost the same position and volume as it was 1 week ago (photo 1 above). When you compare photos 1 and 5 above, it can be seen that there is almost no change. The reason for this is that the remaining part of the turbinate is small and it will only provide temporary edema and shape change with the pressure in the form of mechanical pushing or pulling on the remaining fibrotic tissue. In fact, the effect here is soft tissue trauma and the resulting temporary tissue edema. The patient stated that the air passage in the nose was normalized for only a few days after the procedure, and then the old symptoms started again. In the future, inferior meatal augmentation with submucosal cartilage implantation can be planned after repeated gel filler injection or cotton test.

Turbinate Augmentation Was Performed With Hyaluronic Acid Gel Filler Injection In Office Conditions!

As seen in image 6 above, 1 ml gel filler was injected into the lower anterior and lateral parts of the patient's left inferior turbinate. The treatment was planned according to the patient's satisfaction.

Before and after 1 ml filler injection to augment the remnant inferior turbinate photo (image 7):

In the collage above, it can be seen that the nasopharynx is easily seen when viewed from the front in the upper image, and in the lower image, the volume of the turbinate anterior portion has increased and re-narrowed the inside of the nose.

As seen in the image above, the volume increase in the anterior part of the turbinate is seen with the injection of hyaluronic acid-containing elephants into the inferior turbinate remnant. Bleeding is caused by the holes where the needle used during the injection enters (usually, 2 or 3 needle holes are sufficient at most).

Left inferior turbinate after second injection of 1 ml filler -  1 week later

The image above was obtained in the endoscopic examination through the nose and after the first filler injection and turbinate augmentation, the complaints in the nose decreased and on the satisfaction; 1 ml filler was injected once again and the above photo was obtained. It can be noticed that the left inferior turbinate is very close to the nasal septum and the passage is narrowed, and the mucosa is more moist.

Link group where you can read the articles I have prepared before on nasal hyperventilation on this website >> https://www.ent-istanbul.com/search?q=Nasal+Hyperventilation

Source links >>

• IJERPH | Free Full-Text | Surgical Interventions for Inferior Turbinate Hypertrophy: A Comprehensive Review of Current Techniques and Technologies (mdpi.com)
• Management of Postsurgical Empty Nose Syndrome - PubMed (nih.gov)
• The cotton test redistributes nasal airflow in patients with empty nose syndrome - Malik - 2020 - International Forum of Allergy & Rhinology - Wiley Online Library

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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