The Paradox Between Turbinate Volume and Complaint Severity in Patients with "Empty Nose Syndrome - ENS"

The Discrepancy Between Turbinate Size and Patient Complaints in Empty Nose Syndrome

Above are CT scan images of two patients with symptoms of empty nose syndrome (ENS). You can read more about this below.

Turbinate Volume May Be Large, but Functionally Decreased 

In patients with turbinate hypertrophy, the turbinate tissue may be altered by heat damage during therapeutic radiofrequency, laser, and other procedures. Even if it doesn't significantly reduce in volume, it can become swollen, dry, and fibrotic. Adverse changes in the turbinate mucosa may also contribute to this condition. Following excessive radiofrequency or surgical interventions, the turbinate mucosa may lose its function. In this case, symptoms and complaints in patients with empty nose syndrome may vary depending on the health of the turbinate remnant. In the image above, "Patient 1" on the right underwent a near-total turbinate resection and has an "S-shaped nasal septum deviation". While the patient in image "patient 2" did not have many symptoms of ENS, following turbinate radiofrequency reduction performed 3 months ago, the patient in image 2 has numerous symptoms of ENS, including a feeling of dry and cold air in the nose and a feeling of air hunger. This could be due to increased nasal resistance due to the patient in image 1's deviated septum, slowing down the inflow of inhaled air into the nose, or the remaining turbinate remnants being healthier. Although the turbinate size in image 2 doesn't appear to have decreased significantly, the excessive radiofrequency energy applied to the remaining turbinates may have caused them to become cold, dry, and fibrotic, leading to a decrease in function. This patient was advised to regularly perform nasal irrigations with ocean water, drink plenty of water, avoid salty foods, avoid strong tea and coffee, follow a high-hydrate diet of vegetables and Mediterranean.

Symptoms of Empty Nose Syndrome (ENS) - Early Symptoms and Advanced Symptoms

The table below shows the early and later symptoms of empty nose syndrome. It's difficult to tell which patient may be experiencing which of these numerous symptoms simply by examination.

The Volume and Shape Observed on Examination Do Not Provide Complete Information About Function!

Even if the turbinate appears normal in size, its airflow-regulating function may be weakened. The turbinates are structures whose volume can change throughout the day, and their shape can change depending on airflow, hormonal status, allergies, and infection. In patients who have previously undergone various nasal surgeries and turbinate reduction procedures, the remaining turbinate tissue is called "remnant turbinate." The closer this "remaining tissue" is to normal in both shape and structure, the less likely it is to experience symptoms of empty nose syndrome or nasal hyperventilation.

Differences Between Older, Inexpensive Radiofrequency Devices and Modern RF Devices

Old devices that applied radiofrequency to tissue between the positive and negative poles, resulting in tissue shrinkage, operated entirely on the principle of "continuous energy delivery" as long as the surgeon pressed a button. Current radiofrequency devices have features at the tip of their probes that measure tissue resistance, prevent charring the tissue, and minimize mucosal damage. Thanks to their features that alert the surgeon and automatically cut off the energy during the procedure, patients experience minimal post-procedural dryness and crusting, while also minimizing the changes that may occur due to burn damage to the turbinates. In other words, the remnant turbinate mucosa is less damaged, and permanent fibrotic changes within the remnant turbinate are minimized. These devices are generally more expensive than traditional radiofrequency devices. Turbinate resection, turbinoplasty, and turbinate reduction with laser also involve direct turbinate damage and volume loss.

Mucosal Health of Remnant Turbinates Plays a Critical Role in Empty Nose Complaints

The health of the outer mucosa of the turbinates is crucial. Surgical and medical treatments for turbinate hypertrophy can lead to adverse changes in the turbinate mucosa. Furthermore, living in cold and dry mountainous terrain and regularly inserting objects such as napkins or cotton swabs into the nose, which can cause moisture loss and mechanical trauma to the mucosa, can also cause the turbinate mucosa to become dry and unhealthy. The resulting loss of moisturizing, filtering, and airflow-directing functions exacerbates patient complaints. After turbinate radiofrequency reduction, irrigation of the nasal cavity with natural seawater or ocean water, avoiding mechanical trauma, ensuring the patient drinks plenty of water, and maintaining a moist environment are crucial for normalizing the mucosal health of the turbinate remnants. The workload of the remaining turbinate, which has already been reduced in size, logically increases. In this case, the information I've written here is crucial for preserving nasal health and the remaining turbinate. Similarly, smoking or prolonged exposure to polluted air after the procedure can also cause adverse changes in the turbinate mucosa.

Why Do Some Patients Experience More Complaints?

This beautiful and elusive question is not easy to answer. While the turbinates may appear adequately anatomically during examination, functional losses and mucosal dryness can increase the severity of symptoms. Patients who undergo repeated turbinate reductions likely experience increased complaints not only because of the turbinate volume reduction but also because a more fibrotic, drier, and colder "remnant turbinate" emerges. Normally, the turbinate tissue has a fairly extensive blood circulation network, meaning it should have some "warm tissue". An outer layer of warm mucus, containing ciliated epithelium, exists. This mucus layer, when inhaled, hits the air, which is slowed by rotation due to the shape of the turbinate, and traps foreign particles and microorganisms in the ambient air, becoming a "dirty mucus layer". During this process, the cilia push the old mucus backwards, and we swallow it through our nasal passages, sending the particulate mucus layer into our stomach. All microorganisms are eliminated in the gastric juices. In short, the following problems can arise when reducing the turbinates with radiofrequency or laser:

- If the turbinates are reduced too much, incoming airflow accelerates, changing the rotational airflow in the nose to linear and rapid (nasal hyperventilation), making it very difficult to warm, purify, humidify, and pressurize this air.

- If excessive thermal energy is applied to the turbinates, burn damage and structural changes occur in both the outer mucosa and the inner tissue. Dry, cold, and fibrotic remnant turbinates cannot perform the nasal functions mentioned above, and ENS symptoms may occur.

Functional Assessment: Not Just Volume, But Dynamic Effect Is Important

Intranasal airflow, mucosal sensors, and humidification mechanisms should be evaluated together. During endoscopic examination, when the air space between the turbinate remnant and the septum is examined, pink and moist turbinate and septum mucosa is a positive and encouraging finding in patients with a larger than normal "air gap." However, when dry, red mucosa is observed, along with reddened, dry mucosa in the anterior part of the middle turbinate, it can be interpreted as rapid airflow into the nose. However, it is crucial that the shape, internal structure, and external mucosa of the turbinate remnants are as close to normal as possible.

The More the Nasal Anatomy Changes, the More the Complaints May Be!

Above is a CT image of a patient who had previously undergone functional endoscopic sinus surgery and turbinectomy at a different clinic. It shows a near-complete resection of the right middle turbinate, a relatively extensive maxillary antrostomy with partial resection of the medial wall of the right maxillary sinus, very small remnants of both inferior turbinates, and a "paradoxical middle turbinate" anomaly in the left middle turbinate. In this patient, resection of both the inferior turbinates, the right middle turbinate, and the medial wall of the maxillary sinus increase intranasal airflow. Increased secretions may be evident due to the presence of contaminated and particulate air entering the maxillary sinus. In other words, not only changes in turbinate volume and structure, but also resection or alteration of other anatomic structures may alter or exacerbate the symptoms associated with empty nose syndrome. "Complaint increases with anatomy change" is the primary concern in these patients.

Why Don't I Perform Turbinate Cartilage Implantation?

I perform intraturbinate gel filler and PRP injections in patients who have previously undergone various turbinate reduction procedures and who have symptoms of nasal hyperventilation or an empty nose. Because these procedures do not cause significant damage to the turbinate tissue, I can also perform these procedures as temporary treatments. However, I generally perform intranasal cartilage implants using either inferior meatal cartilage implantation (IMAP procedure) or lateral cartilage implants. The main reasons I don't perform turbinate implants are:

1. To minimize surgical trauma to the already damaged turbinates, preserving both the mucosa and internal structure.

2. I believe that sufficient volume growth cannot be achieved with cartilage implantation alone in turbinates that have been rendered fibrotic and scarred by radiofrequency.

ENS patients already spend money on repeated PRP, stem cell injections, and examination and test fees. When I compared the pre- and post-operative turbinate volumes of several patients who had previously undergone turbinate cartilage implantation at other clinics, I observed that neither the volume increase was significant nor did the patient's complaints decrease significantly. Of course, the recommendations of the ENT specialist examining you would be the most appropriate.

Mucosal Health in the Entire Nasal Cavity is Also Crucial! 

It's crucial for patients with empty nose syndrome or Nazar hyperventilation to maintain healthy and moist nasal mucosa. If additional factors exacerbate nasal mucosal dryness, such as diuretic use, allergy medication use, prolonged exposure to cold and dry ambient air, consuming unhealthy and salty foods, or drinking insufficient water, the remaining remnant turbinate may be small and not unhealthy, but the patient may experience significant symptoms. Regardless of the structure and volume of the remnant turbinate, the overall health of the mucosa in the nasal cavity can influence the severity of symptoms in patients with empty nose syndrome. A mucosa that is already dry is unlikely to moisten the air that hits it.

The above photos show intranasal endoscopic examinations of two different patients with ENS symptoms. The patient in Patient 3's photo shows a very unhealthy, dry, and hyperemic nasal mucosa. The patient does not have a septal perforation, and the turbinate remnant is larger than in Patient 4. Despite this, the sensation of dryness and nasal congestion is more pronounced. The patient in Patient 4's photo has both a septal perforation and a much smaller turbinate remnant. The patient's entire nasal cavity mucosa is moist and covered with secretions. Allergic rhinitis or active allergen exposure may have kept the mucosa healthy, but despite the larger nasal passage and nasal septal perforation, his complaints are less severe than in Patient 3.

The image above shows a nasal endoscopic examination of a patient who had previously undergone a total near-turbinate resection at a different clinic. The mucosa in almost the entire left nasal cavity appears red and unhealthy. The area indicated by the yellow arrows is the dry and unhealthy mucosa on the anterior surface of the middle turbinate due to rapid air contact. Because air does not normally impact the middle turbinate so rapidly, such an appearance is not expected. There is bleeding and dry mucosa over the left inferior turbinate remnant (red arrows). The naso-pharyngeal mucosa is reddened, and purulent discharge is present, as indicated by the green arrows.

Empty nose syndrome (ENS) is a condition that can occur especially after turbinate surgery, profoundly impacting patients' quality of life, and can sometimes be difficult for physicians to understand. A striking aspect of this syndrome is that despite the surgical expansion of the nasal cavity, patients often feel unable to breathe, complaining of a stuffy nose, and experience numerous other complaints. The experiences of patients diagnosed with or followed with suspicion of ENS often differ from the typical examination findings of physicians. In other words, despite the nose appearing wide and open, patients may present with rather dramatic complaints such as shortness of breath, air hunger, and a feeling of suffocation.

In light of all this information, you are expected to provide a detailed discussion of the complaints associated with empty nose syndrome, the physiological and psychological basis of these complaints, the difficulties they create in patient-physician communication, and treatment options. You are expected to focus specifically on the following:

• What mechanisms might explain the feeling of "can't breathe" in ENS patients?
• How do nasal physiology deterioration, sensory perception loss, and psychological factors play a role in complaints?
• How should the discrepancy between objective examination findings and patients' subjective experiences be addressed in clinical practice?
• What are the effectiveness and limitations of the methods used in the treatment of ENS?
• What ethical and professional responsibilities does the impact of this syndrome on patients' quality of life entail for physicians?

The basis of nasal physiology is not only the free inflow and outflow of air, but also its proper direction, humidification, warming, and perception through the nasal mucosa. After the turbinates are reduced or completely removed, aerodynamic flow within the nose is disrupted, normal neural feedback mechanisms are affected, and the patient cannot adequately sense the air passing through the nose. This leads to a paradoxical situation: a physically wide but functionally inadequate nose. Patients' complaints are not limited to "breathlessness"; It can span a wide spectrum, including chronic dryness, crusting, a burning sensation, a feeling of being stuck in the throat, loss of smell, sleep problems, anxiety, and even depression.

One of the points that must be emphasized when discussing ENS is the difficulty in objectively measuring patient complaints. While many standard tests—such as rhinomanometry or endoscopic examination—show a clear nose, the patient claims the opposite. This situation not only creates conflicts in patient-physician communication but also complicates the physician's development of a treatment plan. A patient who feels "suffocated" only to be confronted with a "perfectly clear nose" during examination calls into question the classical causal relationship in medicine.

However, it should be emphasized that ENS is not solely a mechanical problem related to surgery. Some studies suggest that decreased sensory perception in the trigeminal nerve fibers or disruption of neural feedback mechanisms may also play a role in these complaints. Furthermore, chronic inflammation, mucosal healing problems, and psychological factors can exacerbate the condition. Therefore, ENS is considered a complex syndrome requiring not only a comprehensive otolaryngology (ENT) practice but also a multidisciplinary approach.

Treating patients with ENS is at least as challenging as diagnosing it. Humectant sprays, oil-based drops, gel formulations, and various surgical reconstruction techniques aimed at improving airflow are being tried (I advise my patients not to use nasal moisturizers containing oils such as Vaseline, olive oil, or sesame oil. Instead, I recommend rinsing with natural ocean water or seawater. Some patients also benefit from nasal moisturizers containing hyaluronic acid). However, treatment results may not always be satisfactory. While even minimal improvements can make a significant difference in quality of life for some patients, others may report no benefit from treatment. ENS is often described as a syndrome "known to those who experience it," and this requires considerable patience and empathy from both patient and physician.

Search result link where you can find articles about empty nose prepared by Dr. Murat Enöz and published on this website (you can also access previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=empty+nose

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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