Submucosal Cartilage Implantation in Nasal Hyperventilation and Empty Nose Syndrome: Right Inferior Meatus and Lateral Wall Approach
Empty Nose Syndrome (ENS) and nasal hyperventilation are complex clinical conditions that can occur, particularly after inferior turbinate surgeries, and significantly affect the quality of life of patients. Despite having a remarkably wide nasal passage, these patients report feeling unable to breathe. This paradoxical situation is too complex to be explained solely by anatomical changes and is associated with loss of mucosal function, disruption of airflow dynamics, and involvement of neurosensory mechanisms. The faster and more uncontrolled movement of airflow within the nose leads to reduced mucosal contact and consequently inadequate humidification, heating, and filtration functions. This results in dryness, crusting, burning sensations, and especially an uncomfortable feeling of shortness of breath described as "air hunger."Case presentation: A patient who had previously undergone septoplasty + subtotal turbinate resection - RF reduction at a different clinic presented to our clinic with symptoms of nasal hyperventilation - empty nose syndrome (ENS), including a feeling of cold air, dryness, and sticky secretions in the nasal passages, particularly during inhalation from the right nasal cavity. The patient stated that they had been performing a cotton swab test for the right nasal cavity for a long time and that their symptoms had significantly decreased when the nasal air space was reduced by placing cotton swabs. The patient stated that they lived by the sea and regularly performed nasal irrigation with natural seawater, which had partially reduced their symptoms. On examination, it was observed that the right inferior turbinate remnant was quite small, the nasal mucosa was somewhat dry, and there was sticky secretion in the nose. A significant volume loss was observed, especially in the right inferior turbinate head and middle portion. Endoscopic cotton swabs were placed in the inferior meatus and lateral wall region. The patient stated that their symptoms had significantly decreased. He stated that he placed cotton balls in the same area himself for about 2-3 months and that the feeling of cold air and dryness in the nose significantly decreased.
Image Descriptions
- The top image of the three photos shown above and to the side shows the right nasal cavity and abnormally large intranasal air passage before surgery. The middle image shows the area where cotton balls were placed for cartilage implantation (cotton ball placed to nasal floor and inferior meatus to simulate the resistance that an implant will add to the over reduced right inferior turbinate). The bottom image shows the area 3 days after submucosal cartilage implantation in the right inferior meatus and lateral nasal wall. The orange and reddish areas are due to the instillation of rifampicin antibiotic ampoules.
- The top image of the bottom image shows the endoscopic view of the right nasal cavity before surgery. The bottom image shows the right nasal cavity again 3 days after the procedure (before and after implantation of the lateral wall with donor cartilage to reduce the nasal cavity volüme and simulate the function of the missing right inferior turbinate). The dark orange-reddish area is due to the instillation of rifampicin antibiotic into the mucosal incision area. Some of the suture knots from the 5/0 PDS suture materials are visible in the bottom image.
Pathophysiology and Clinical Approach
In normal physiology, the inferior turbinate plays a central role in regulating inspiratory air. However, excessive volumetric reduction or functional deactivation of this structure causes the intranasal airflow to deviate from its laminar nature, becoming irregular and rapid. This change in airflow leads to insufficient stimulation of intranasal receptors and causes patients to experience a feeling of breathlessness. Therefore, the basic approach in the treatment of ENS is not only to narrow the nasal cavity but also to restore the airflow to physiological limits and increase the mucosal contact surface. At this point, the inferior meatus and lateral nasal wall stand out as critical areas in regulating airflow. Generally, in patients, not only volume loss in the turbinates but also their fibrotic coldness and dryness can exacerbate symptoms.
Pre-Surgical Simulation: Cotton Test
One of the most important steps in surgical planning for these patients is the procedure known as the cotton test. In this test, cotton swabs are placed in the lower right meatus and lateral nasal wall area to temporarily reduce intranasal volume, thereby simulating the airflow dynamics targeted after surgery. Cotton is usually applied with a moisturizing ointment to minimize mucosal irritation and provide a more natural experience for the patient. Subjective feedback from the patient during the test is crucial. If the patient reports breathing more easily, more balanced airflow, and reduced dryness after cotton placement, this strongly supports the possibility of beneficial cartilage implantation. This approach is one of the most valuable methods for personalized surgical planning in ENS treatment.
Surgical Technique and Application
Submucosal cartilage implantation is an effective surgical technique applied to reduce intranasal volume in a controlled manner and create turbinate-like resistance. In this procedure, I generally prefer to use natural human tissue in my patients. In this patient, donor cartilage material was used, and the right inferior meatus and lateral nasal wall were selected as the target areas. During surgery, a submucosal pocket is created while preserving mucosal integrity, and the prepared cartilage implant is placed in this area. In this way, the intranasal airway is narrowed without completely closing it, creating physiological resistance. This newly created structure partially takes over the function of the missing or dysfunctional inferior turbinate, slowing and directing airflow and increasing mucosal contact. Thus, both airflow dynamics are regulated, and intranasal humidification and heating functions can be partially regained.
Endoscopic Evaluation Process
Endoscopic images obtained at different time points are crucial for evaluating the effectiveness of this approach. Preoperative images typically show a dilated inferior meatus, a significantly reduced inferior turbinate, and a dried mucosal surface. Our patient's long-term cotton swab test confirms that they tolerate the increased airway resistance resulting from intranasal implantation and that their symptoms have decreased. There is no definitive diagnostic or treatment protocol for this. Patient satisfaction with the cotton swab test indicates that intranasal airflow is uncontrolled, passing through a wide area, and that sufficient mucosal air contact is not achieved. Images obtained after the cotton swab test show a narrowing of the air passage, a redirection of airflow to a more physiological path, and increased mucosal contact. This stage is an important step in visualizing the effect of the surgery beforehand. Endoscopic images obtained three days after cartilage implantation show a significant increase in volume in the implant area, a more regular airway, and early healing signs on the mucosal surface. Even at this early stage, a more balanced intranasal airflow can be observed.
Clinical Outcomes and Expectations
Following submucosal cartilage implantation, patients generally experience a significant improvement in their breathing sensation. Patients report that airflow is more controlled and natural, while dryness and burning sensations decrease. Complaints such as cold sensation and air hunger may also significantly decrease. However, since ENS is a multifactorial condition, the same degree of success should not be expected in every patient. It should be remembered that mucosal healing may take time and some patients may require additional treatments. In this context, combined approaches with PRP injections, fat grafts, or other regenerative treatment methods may provide more successful results.
In conclusion, submucosal cartilage implantation applied to the right inferior meatus and lateral nasal wall is an effective method based on physiological principles in the treatment of nasal hyperventilation and empty nose syndrome. Preoperative cotton swab simulation plays a critical role in accurate patient selection and appropriate surgical planning. This approach, supported by endoscopic findings, can significantly improve the quality of life of patients by reorganizing intranasal airflow. In the future, combining these techniques with regenerative therapies will contribute to achieving more lasting and successful results in ENS treatment.
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Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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