Overimplantation and Nasal Congestion in Patinets With ENS

A Discussion on the Size and Location of the Graft at Implantation in Empty Nose Syndrome

In the CT image above, the lateral meatal implantation on the side indicated by the red arrows in the left image shows the placed graft. In the same image, the adhesion (synechiae) between the turbinate remnant and the septum is seen in the contralateral nasal cavity, shown by the yellow arrow. In the image above right, the synechiae between the turbinate remnant and the septum is seen by the yellow arrow. The abnormally wide intranasal air space on the same side is shown by the green arrow. Due to the near-complete excision of the inferior turbinate tissue, nasal hyperventilation has caused edematous nasal mucosa on this side. Similar mucosal changes can occur in all respiratory tracts exposed to fast, dirty, cold, moist, and unpressurized air. The color, moistness, and health of the nasal mucosa can be assessed by endoscopic examination rather than CT.

In patients with empty nose syndrome or nasal hyperventilation, it is crucial to accurately determine the site of intranasal cartilage implantation and the size of the implant to be placed. I generally recommend that my patients insert a cylindrical cotton ball, 6-8 mm x 3 cm, coated with Vaseline or eye ointment. After a few weeks, I question the "reduction in symptoms" observed with the cotton test. Of course, a lost or excessively reduced turbinate cannot be replaced with cotton, but if slowing down the existing accelerated airflow is beneficial, it is best to perform this procedure in the most accurate and appropriate way. The nasal anatomy should be "normalized" as much as possible. Lateral or inferior nasal implants can be performed in the area where the turbinates are located. Lateral nasal implants are highly beneficial in patients whose turbinates have been nearly completely removed. Cartilage, fascia, or collagen matrix can be used for this purpose. I particularly recommend using soft, well-circulated nasal tissue. I prefer to use a cartilage graft along with the fascia, which is a tissue. I don't like to use implants inside the turbinate because I don't want turbinates that have already been reduced with radiofrequency and have developed scar tissue within them to be injured by additional surgical trauma, causing further scarring and fibrosis. I've also observed that in patients I've tried this method before, there was no significant increase in turbinate volume. Below, I share CT images of a patient who underwent the procedure at different clinics.

In the CT image above, the nasal passage on the side indicated by the red arrow is extremely open and wide, with a near-total inferior turbinectomy (turbinate remnant is not visible). On the other side, the passage is already narrow due to nasal septum deviation, and the turbinate remnant is of sufficient size. The passage on that side is significantly narrowed due to the implant or synechia (yellow arrow). In other words, one nasal passage appears excessively and abnormally wide, while the other appears narrow and closed.

In the CT image above, the lateral meatal implantation on the side indicated by the red arrow shows the placed graft. On the other side, the yellow arrow shows the adhesion (synechia) between the turbinate remnant and the septum. A significant air gap is observed on the same side due to the nearly complete excision of the inferior tubulin. In the area marked by the green arrow, the nasal mucosa is edematous due to nasal hyperventilation (easily identifiable when comparing the mucosa of the inferior meatus with the contralateral side).

In the tomography image above, the lateral and inferior meatal implantation on the side indicated by the red arrows and the placed graft are shown, and on the other side, the adhesion (synechia) between the turbinate remnant and septum is seen with the yellow arrow.

You May Experience More Nasal Congestion Than Normal in the First Weeks After Proper Implantation!

Patients with empty nose syndrome who undergo intranasal submucosal cartilage implantation may experience increased nasal congestion and a greater-than-expected sensation of nasal constriction, particularly during the first three days, due to nasal edema, bleeding, and clot accumulation. This typically resolves within a few weeks.

When Can a Decision Be Made for a Second Implant After Intranasal Cartilage Implantation? 

There are no definitive treatment guidelines on this topic. However, I advise that these patients may need to wait 8-12 months after the procedure to fully assess the surgical outcome. I previously thought a wait of only 6 months would be appropriate, but I am recommending this timeframe because my patients with ENS who underwent submucosal nasal cartilage implantation with inferior and lateral meatal augmentation emphasize that intranasal changes can last up to 12 months. This is because when the nasal air passage is narrowed, the nasal mucosa, previously dry and unhealthy due to increased airflow, requires a long wait for positive changes to occur and for it to become healthier and more moist. The severity of symptoms in patients with ENS can vary depending on the condition of the entire nasal cavity, and the healthier and more moist the nasal mucosa, the greater the reduction in symptoms. I advise my patients to wait longer than six months before considering a second implantation, to retest with cotton or sponge, and to notify their doctor if they are satisfied.

Submucosal Costal Cartilage Implantation (Inferior Meatus Augmentation Procedure (IMAP))
In the image above, a preoperative photograph taken during a nasal endoscopic examination, a patient who had undergone a turbinate resection shows an abnormally large nasal airway, a direct view of the nasopharynx, and a red and dry area. The lower photograph was taken after the "Submucosal Costal Cartilage Implantation (Inferior Meatus Augmentation Procedure (IMAP))" procedure, and the narrowing of the nasal airway is evident. Purple self-dissolving sutures were used for the mucosal incision sutures. The patient's cotton swab test results were evaluated before the procedure, and a decrease in symptoms was observed afterward.

A Patient with Empty Nose Syndrome Symptoms Despite Lateral Nasal Wall Implantation! 

The adjacent image shows intranasal endoscopic images of a patient who previously had symptoms of ENS after a right inferior turbinate resection and presented to another clinic a few months ago after a lateral nasal implantation because, although symptoms had diminished, these symptoms persisted. Image 1 shows the slightly dry intranasal mucosa. Image 2 shows the cartilage graft site placed for lateral nasal wall implantation, marked with a yellow dotted line. The patient reported that her symptoms had improved after a long period of cotton swabs, and in response to the question of which area could be reimplanted, the square red-lined area in image 3 (nasal floor augmentation/inferior meatus augmentation) was marked. In fact, it is best to narrow the airway, which is the area of ​​greatest width, at the point where it is most dilated. This area was also marked based on the information provided by the patient during the cotton swab placement. In patients undergoing total or near-total turbinate resection, implantation of the anterior nasal cavity into the lateral nasal wall to narrow the air passage and placement of large-sized grafts are beneficial. In patients undergoing partial turbinectomy or radiofrequency-assisted turbinate reduction, augmentation to the largest visible area and inferior meatal may be beneficial, after confirmation with a cotton swab test. This patient was advised to wait approximately six months or longer, drink plenty of water, avoid cold and dry environments, avoid salty foods, and avoid mechanical trauma to the nasal cavity. It was emphasized that long-term outcomes would be the sole basis for decision-making.

Submucosal Temporalis Fascia Implantation (Inferior Meatus Augmentation  Procedure - Nasal Floor Implantation and Lateral Nasal Wall Temporalis Fascia Implantation

The image above shows an intranasal endoscopic examination of a patient who presented with complaints of a feeling of cold air, crusting, dryness, and bleeding within the nose after a previous rhinoplasty performed at a different clinic. The patient's left inferior turbinate was completely resected, and this area was significantly enlarged. A dry and red area is visible in the anterior portion of the middle turbinate due to rapid air exposure (green arrow). The nasal mucosa is unhealthy, bleeding, and crusty. The patient's left nasal cavity became abnormally wide. A temporalis fascia graft, taken from the temporal region on both sides, was placed submucosally in several layers to the left nasal floor (yellow arrow) and the lateral nasal wall (blue arrow). A silicone splint was removed after a week of use. Even after just one week, the nasal mucosa appeared healthier and pinker, the dry, reddened area in the middle turbinate mucosa had completely disappeared, and the nasal passage was narrowed.

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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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