Serious Complications of a Simple Nasal Surgical Procedures: Empty Nose

Turbinate Resection With Septum Perforation Resulting In Nasal Hyperventilation And Empty Nose Syndrome

 I wanted to share with you a few patient examination photos that show the importance of the inferior turbinate. The patient, who had undergone septoplasty, radiofrequency and turbinate resection twice in another clinic, applied to our clinic with the following complaints:

- sticky and solid discharge from the nasal passages

- dry and crusty discharge in the nose

- nose bleeding

- not enough air taken from the nose

- feeling of cold and dry air in your nose

- dry nose, painful areas, thick viscous discharge, more on the right side

- decreased sleep quality (turbinates may affect lying position and nasal cycle changes may also occur after turbinate procedures)

Tomography and nasal examination sections of the patient who developed nasal septum perforation, nasal hyperventilation, and empty nose syndrome on the right after two separate nasal surgeries performed in a different clinic. In the right nasal cavity of the patient, due to the almost complete inferior turbinate resection, nasal mucosal crusting, inflammation, and areas with inflammatory discharge are observed. In the left nasal cavity, despite nasal septum perforation; since there is a healthy and sufficient size of infeor turbinate, the mucosa is dry only in some limited areas; mucosal color is normal.
There are also mucosal thickenings and signs of chronic sinusitis in the sinuses. Due to the rapid, dirty, dry and cold air hitting the sinus cavities and the mucosal areas in the nose, these negative changes can occur much more easily over time.

In the endoscopic nasal examination of the patient, there was a 2x1 cm nasal septum perforation and the right inferior turbinate was resected almost completely (there is only a very small turbinate tissue in the posterior part), the nasal mucosa on the right was dry and hyperemic, and the nasal mucosa on the right was inflammatory. It was observed that there were areas of dryness on the left side, only a small amount of nasal mucosa.

The reasons that are mainly responsible for so many complaints of the patient are "nasal septal perforation" and "turbinate resection".

Why Is The Nasal Mucosa So Different In The Right And Left Nasal Cavities?

In the perforation of the nasal septum, which divides the nasal cavity into two, due to the entry of air escaping from the septal hole into the nose, drying of the mucosa, crusting of the mucosa and nasal hyperventilation may occur. In addition, when turbinate resection is performed, since the diameter of the intranasal airway increases, the speed of the airflow entering the nose increases gradually, the patient's nasal mucosa may become dry and crusted, and the dry, cold and unfiltered air moves backwards and towards the lower respiratory tract. In this patient, although nasal septum perforation was present; Since there is a healthy and normal sized inferior turbinate on the left side, a limited amount of dry areas are seen in the nasal mucosa and the color of the mucosa is seen as healthy and close to pink. In the right nasal cavity, since the inferior turbinate was surgically removed; Since the accelerated air flow velocity due to septum perforation accelerates even more in a large space, and the volume of turbinate tissue that warms and purifies the air is very small, drying, crusting, hyperemic inflammation areas and inflammatory areas appear in the right nasal cavity. That is, when the turbinates are healthy and of sufficient size, even if there is a perforation in the nose; They are organs that can enlarge their own volume, increase their volume as it dries and rise, and perform the tasks of heating, purifying, humidifying and pressurizing the intranasal air. Turbinates are unique. No technology can produce a healthy turbinate tissue. They are tissues covered with a network of blood vessels inside and warm, covered with a layer of ciliated epithelium and mucus on the outside.

On the tomography image, the right nasal cavity is abnormally large, the right inferior turbinate is not observed, nasal septum perforation and mucosal thickenings in the sinuses are seen. On the right side, there are prominent empty nose syndrome and nasal hyperventilation symptoms.

In the photograph of the endoscopic examination of the right nasal cavity, the perforation area in the nasal septum, the abnormally wide right nasal cavity, a small amount of inferior turbinate tissue at the back, and a prominent hyperemic dry mucosal area over that section (it happens because of the rapid nasal airflow hitting the last remaining inferior turbinate), dry in the nasal cavity mucosal areas, red, covered with inflammatory discharge are seen. You can watch for signs of empty nose syndrome. Because of both nasal septal hole and turbinate resection, the consequences of altered nasal anatomy are easily discernible. In the photo above, the absence of the right inferior turbinate caused the symptoms to be more pronounced. Despite the presence of septum perforation in the nasal endoscopic examination photograph below, showing the left nasal cavity; due to the presence of the left inferior turbinate, the nasal mucosa appears to be much healthier.
Turbinate removal is a surgical procedure that can cause permanent loss of nasal function, resulting in an organ loss.

The tomography image above shows that the right nasal cavity is abnormally wide due to the removal of the inferior turbinate, there is limited adhesion (synechiae) between the left inferior turbinate and the nasal septum, and mucosal thickening and fullness in almost all sinuses.

In the left endoscopic nasal examination photograph above, the left inferior turbinate is of normal size, the left nasal mucosa is almost healthy, only a small amount of dry mucosal area in the anterior part (maybe due to finger picking). Although there is a posterior septum perforation; viewed from the front, it is seen as a healthy-looking nasal cavity. That's how important the inferior turbinate is. In the same patient, almost all the symptoms of empty nose syndrome were present on the right side where the inferior turbinate was almost completely resected; In the left nasal cavity, where the inferior turbinate is complete and healthy, it looks like a healthy nasal cavity, right to the septum perforation. Inferior turbinate, when in contact with cold and dry air for a long time, has an autonomous structure that can grow itself and regulates the intranasal airflow.

In the tomography image above, nasal septum perforation, thickening of the nasal mucosa, almost complete excision of the right inferior turbinate, abnormal enlargement of the right nasal cavity, and mucosal thickening that almost completely fills both maxillary sinuses (chronic sinusitis) are seen. These changes, caused by the abnormally accelerated airflow, are easily noticeable in both examination photographs and CT images.>

In the endoscopic exam image showing the posterior side of the left nasal cavity above, despite the septal hole, due to the normal size of the left inferior turbinate; It can be seen that the nasal mucosa is close to normal and pink in color. Inflammatory discharge, hyperemic areas can be seen on the nasopharynx (not very clear area at the back). Unfortunately, this occurs due to chronic contact with abnormally accelerated, cold, polluted, dry air on the right side, due to both septal perforation and turbinate removal. Nasal hyperventilation or empty nose syndrome may occur after any surgical operation that permanently changes the turbinate structure, volume, and vascular network within it, no matter what it is called turbinate removal, turbinectomy, or turbinate resection.

In the tomography image above, nasal septum perforation, soft tissue density that almost completely fills the right maxillary sinus (maxillary sinus retention cyst, mucosal thickening), retantion cyst and inflammatory secretion image in the left macular sinus, mucosal thickening in the ethmoid sinuses and inferoir tubinate only in the right nasal cavity. it is seen that a very small piece of bone remains from inferior turbinate, and the nasal cavity is larger than normal. The contralateral inferior tubinate (left inferior turbinate) appears to hypertrophy towards the perforation to close the septal hole and to reduce rapid airflow. In other words, even the presence of unilateral turbinate tissue can be understood how important it is in balancing the nasal physiology.

Above, endoscopic examination photograph showing the left nasal cavity, showing nasal septum perforation and left inferior tubinate slightly enlarged towards the perforation. Unlike the right side, the left nasal mucosa appears quite healthy and moist (due to the normal size and structure of the turbinate, much less mucosal drying despite the accelerated airflow due to the septal hole).

In the tomography image above, it is seen that the nasal septal hole, wide right nasal cavity, mucosal thickening in the nasal cavity in general, and the right inferior turbinate have been almost completely excised.

Above, the endoscopic examination photograph showing the right nasal cavity shows dry and hyperemic nasal mucosa, areas covered with inflammatory secretions, abnormally wide nasal cavity and septal perforation. It can be seen that only a small part of the right inferior turbinate remains at the back and the mucosa in this part is much redder and drier (since the part remaining as the turbinate part is the part that is exposed to the most airflow; it does not adequately perform the tasks of humidification, heating, purification and slowing the air flow).

In the tomography image above, the right nasal cavity is abnormally large, the inferior turbinate is almost completely resected, the nasal septum perforation and the inferior turbinate trying to close the hole by enlarging itself towards this perforation area on the opposite side are seen. Retention cyst originating from the anterior wall in the left maxillary sinus, and mucosal thickening in the right maxillary sinus are seen.

Unilateral Chronic Sinusitis and Mucosal Thickening Occurred After Unilateral Turbinate Removal!

The patient, who had undergone an operation for turbinate hypertrophy 9 months ago in a different clinic, applied with various symptoms such as unilateral dark sticky secretion in the nose, a feeling of fullness in the nose, a feeling of sticky secretion in the nasal passages, and not enough breathing from the nose. tomography sections (one shared above and the other below) are shown. It is observed that the left inferior turbinate is almost completely resected (green arrow), the mucosa in the left nasal cavity is thickened, and the right maxillary sinus mucosa is thickened and transformed into a cyst on the upper side (red arrow). Looking at these tomography images, mucosal thickening caused by cold, dirty, dry air in the nasal mucosa and sinuses can be easily noticed after turbinate resection. Empty nose syndrome and nasal hyperventilation can cause chronic mucosal changes in the nose in the long term.

The photograph below shows a tomography image of a patient whose right inferior turbinate was nearly completely resected. A retention cyst in the right maxillary sinus and a very small right inferior turbinate remnant are seen.

Video: Diagnosis of Empty Nose Syndrome (ENS) and Atrophic Rhinitis with Endoscopic Examination: A Close Look at the Case

Applications made with complaints of nasal congestion are among the most frequently encountered conditions in ENT practice today. However, complications that may develop after some surgical interventions can seriously affect the quality of life of patients. In this article, I share the endoscopic examination findings of a patient whose inferior turbinates were surgically cut and removed almost completely and who developed empty nose syndrome (ENS) and atrophic rhinitis symptoms within a few years.

Case Summary

Our patient had undergone intranasal surgery in different clinics in the past due to chronic nasal obstruction. During the procedure, the inferior turbinates were almost completely resected. Although symptomatic relief was initially achieved, a few years after the surgery, the patient developed symptoms of ENS and atrophic rhinitis, especially in the right nasal cavity.

Symptoms of this patient

• A feeling of nasal obstruction despite taking in air
• Nasal dryness and crusting
• A feeling of fullness and pressure in the nasal region
• Chronic postnasal drip
• Olfactory disorders
• Psychological disorders (such as anxiety, depression)

These symptoms are typical symptoms of ENS. The most striking aspect of this syndrome is that the patient does not feel the air flow and describes this situation as "I can't breathe".

Endoscopic Examination Findings

During the endoscopic evaluation, it was observed that the right nasal cavity was enlarged, and the mucosal surface was thinned and dry. More pronounced on the right side; loss of brightness, crusting and accumulation of inflammatory dry secretion in the mucosa were remarkable. The disruption of the anatomical integrity of the inferior turbinate caused the loss of airflow balance. Mucosal atrophy reflected the typical findings of atrophic rhinitis.

Similar findings were present in the left nasal cavity, although less, and it was observed that the mucosa was dry and reddened and direct contact with air negatively affected the integrity of the mucosa. Although a very small portion of the inferior turbinate remained in the left nasal cavity; it may have provided a partially healthier nasal mucosa compared to the other side.

The Relationship Between Empty Nose Syndrome and Atrophic Rhinitis

Empty nose syndrome is a condition that often develops as a result of excessive surgical intervention. Excessive removal of turbinate tissue disrupts the balance of intranasal airflow and causes mucosal receptors to lose their function. This situation causes the brain to perceive obstruction even when there is no actual obstruction in the body (a feeling of air hunger).

Atrophic rhinitis is a progressive disease that usually progresses with dry mucosa and susceptibility to infections. When seen with ENS, the severity of symptoms increases and the treatment process becomes more complicated. Endoscopic examination is a very valuable method in the diagnosis of ENS and atrophic rhinitis. Early diagnosis of these complications, especially in patients who have had aggressive turbinate surgery in the past, is critical in terms of improving quality of life and preventing progressive damage.

Treatment Approach

The treatment of ENS and atrophic rhinitis requires a multidisciplinary approach. Nasal moisturizers, saline irrigations, topical antibiotics and mucosal protective agents are usually used as the first step. However, in advanced cases, surgical interventions such as intranasal tissue volume-reducing implant applications or tissue transfer may be considered.

Similar links >> Nasal Septum Perforation - Definition, Causes, Symptoms, Diagnosis and Treatment / Turbinate Reduction Procedures / Overreduction of Turbinate - Nasal Hyperventilation / Why Turbinates Are Important? - Empty Nose Syndrome / Cool, Small, Dry Turbinate: Empty Nose Syndrome

Source links >> Empty nose syndrome - PubMed / Surgical Treatment for Empty Nose Syndrome | Facial Plastic Surgery - JAMA Network / Anatomy, Head and Neck, Nasal Concha - StatPearls - NCBI Bookshelf

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

Private Office:

Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52

E-Mail: muratenoz@gmail.com 
Mobile phone: +90 533 6550199

Fax: +90 212 542 74 47