Anatomical and Functional Losses Associated with Turbinectomy in Empty Nose Syndrome
The inferior turbinates are critical anatomical structures for regulating airflow within the nose, humidifying, filtering, and warming the air. Specifically, the inferior turbinates increase air contact with the mucosal surface by creating turbulence during inspiration. Therefore, excessive reduction or complete removal of the turbinates can lead to significant functional losses, not just anatomical ones.
Empty Nose Syndrome (ENS) is a chronic clinical condition that severely impairs quality of life and often occurs after aggressive turbinate surgeries. Patients frequently describe a feeling of "inability to breathe," nasal dryness, burning, paradoxical nasal congestion, crusting, anxiety, and sleep disturbances. In this case, the advanced ENS findings following total turbinectomy are evaluated in conjunction with radiological images and the patient's preserved turbinate tissue.
What is Empty Nose Syndrome?
Empty Nose Syndrome (ENS) is a chronic nasal dysfunction that often occurs after aggressive turbinate surgeries and can lead to significant loss of quality of life in patients. Patients may describe symptoms such as paradoxical nasal congestion, a feeling of breathlessness, nasal dryness, burning, air hunger, and anxiety. Although the nasal passage appears anatomically wide, the patient does not feel adequate airflow.
Nasal turbinates are not only structures that obstruct airflow. These tissues play a critical role in filtering, humidifying, warming the air, and regulating laminar airflow. Complete removal of the turbinates can disrupt nasal aerodynamics and lead to significant losses in mucosal sensory receptors.
In this case, the findings of Empty Nose Syndrome that developed after total turbinectomy are evaluated using both clinical symptoms and computed tomography images.
What is Total Turbinectomy?
Total turbinectomy is a surgical procedure in which a large portion or all of the inferior turbinates are removed. While it was more frequently performed in the past to treat chronic nasal congestion, it is not recommended in most centers today due to the risk of serious complications.
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| The image above shows the intranasal tissues removed after a septoplasty + total turbinate resection (turbinectomy) operation performed on a patient at another clinic. The images show cartilage fragments removed after septoplasty, and unfortunately, almost all of both inferior turbinates were resected and removed. |
In the modern functional rhinoplasty approach, the goal is not to completely remove the turbinates, but to reduce volume while preserving the mucosa. This is because the turbinate mucosa is essential for the continuation of nasal physiology. Therefore, total resections can lead to long-term functional losses that are difficult to reverse.
Anatomical Changes Following Total Turbinectomy
A dramatic increase in nasal cavity volume can be observed after total turbinectomy. Computed tomography scans may reveal complete absence of the inferior turbinates, enlarged inferior meatus areas, and abnormal patency in the airway.
While preoperative CT scans show the normal anatomical placement of the inferior turbinates, postoperative images reveal complete removal of both inferior turbinates. These changes can lead to severe disruption of nasal physiology.
Increased turbulence in nasal airflow, mucosal dryness, and loss of physiological airflow contact points may play a significant role in the development of ENS.
Visual Presence of Removed Concha Tissues After Surgery
One of the striking findings in this case is the physical preservation of the two inferior concha tissues removed from the patient after surgery. The images of the concha tissues recovered after surgery clearly demonstrate the extent of the resection performed.
Total removal of the inferior conchae can be considered a rather aggressive approach according to the principles of modern conservative rhinoplasty. Today, the primary goal in concha surgeries is to regulate the airway passage while preserving the mucosa and concha functions as much as possible.
Preoperative and Postoperative CT Scans
Preoperative paranasal sinus CT scans show the presence of the natural anatomical structures of the inferior turbinates. Postoperative images, however, reveal a significant absence of both inferior turbinates and excessive widening of the nasal cavity.
Postoperative CT scans clearly show increased width of the lower nasal passages, increased air space, and loss of anatomical structures that ensure normal nasal aerodynamics. These radiological changes are important objective findings supporting the diagnosis of Empty Nose Syndrome.
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| The image above also shows preoperative CT scans of the patient. Both maxillary sinuses show mucosal thickening and a cystic appearance in places. Both inferior turbinates appear slightly hypertrophic. A limited degree of nasal septum deviation is also observed. |
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| The image above shows a patient who underwent septoplasty + total turbinectomy surgery at another clinic. The image shows an abnormal, nearly cylindrical airway cavity formed inside the nose. Unfortunately, this type of anomalous airway dilation and changes/acceleration in airflow curves are unavoidable. |
Patient's Preservation of Inferior Concha Tissues
One of the remarkable aspects of this case is that the patient preserved two inferior concha tissues removed during surgery. The images clearly show the distinct mucosal and submucosal structures of the inferior conchae.
The physical presence of the surgically removed tissues reveals the scope of the procedure performed. Furthermore, this can be considered one of the rare clinical examples that visually supports the anatomical basis of the symptoms experienced by the patient.
Images of Fragments of Cartilage Removed or Detached After Septoplasty
The patient also has images of septal cartilage fragments that were removed or detached after septoplasty. Excessive removal of septal support structures can affect nasal airflow dynamics and cause functional problems in the internal nasal valve area.
The nasal septum is not only a structure separating the midline; it also plays a significant role in nasal support and airflow direction. Excessive cartilage resection can disrupt nasal resistance mechanisms.
In this case, both turbinate loss and septal structure changes can be considered together to address the multifactorial mechanisms in the development of Empty Nose Syndrome.
Symptoms of Empty Nose Syndrome (ENS)
Patients with ENS often describe their symptoms as "I can't breathe, but my nose is clear." This paradoxical situation is one of the most characteristic features of the disease. Although the nasal passage appears wide, the patient does not perceive sufficient airflow.
Common symptoms may include:
- Paradoxical nasal congestion
- Excessive dryness in the nose
- Burning sensation
- Crusting
- Feeling of air hunger
- Sleep disturbances
- Panic attacks and anxiety
- Feeling of suffocation
Some patients may also develop depression and serious psychological effects. Therefore, ENS is a complex syndrome with not only anatomical but also neurosensory and psychological aspects.
Diagnosis of Empty Nose Syndrome (ENS)
ENS is usually diagnosed by evaluating the patient's complaints, endoscopic examination, and radiological findings together. An excessively wide nasal cavity is a significant clue.
The cotton test can be used in some patients to temporarily mimic the missing turbinate volume. Improvement in the patient's symptoms during this test may support the idea that volume deficiency contributes to the symptoms.
Empty Nose Syndrome (ENS) is not a simple diagnosis that can be made solely based on nasal CT scans or physical examinations. Evaluation requires a comprehensive assessment of the patient's symptoms, history of previous surgery, endoscopic examination findings, imaging techniques, and functional tests. This is because, despite the anatomically large nasal cavity present in ENS, the patient may experience severe nasal congestion and a feeling of inability to breathe.
One of the most important aspects of ENS diagnosis is that the patient's complaints differ from those of classic nasal obstruction patients. Patients often use expressions such as "my nose is completely open but I can't breathe," "air isn't hitting my nose," "I've lost my sense of breath," or "I feel like I'm suffocating." This paradoxical presentation is one of the characteristic features of the syndrome.
Detailed Patient History and Surgical History
A detailed anamnesis forms the basis of the diagnosis. A large proportion of patients developing ENS have a history of previous turbinate surgery. The risk may increase, especially after the following procedures:
- Total inferior turbinectomy
- Submucosal turbinate resection
- Excessive volume loss after radiofrequency ablation
- Aggressive turbinate reduction with laser or cautery
- Multiple revision rhinoplasty
- Extensive resections performed in conjunction with septoplasty
The relationship between the patient's nasal function before surgery and the time of symptoms developing after surgery should be carefully evaluated. In many ENS patients, complaints may become apparent weeks or months after surgery.
While some patients initially experience a feeling of "too much nasal opening," dryness, shortness of breath, and difficulty breathing may develop later.
Typical Clinical Signs in ENS
Symptoms are very important in the diagnosis of ENS. The most common symptoms are:
- Paradoxical nasal congestion
- Feeling of excessive openness in the nose
- Inability to feel airflow
- Feeling of air hunger
- Need to take deep breaths
- Nasal dryness
- Crusting
- Burning sensation
- Pain or irritation in the nose
- Sleep disturbances
- Panic attack-like episodes
- Difficulty concentrating
- Depressive symptoms
The feeling of "air hunger" is particularly characteristic of ENS patients. Patients may feel they cannot breathe enough even though their oxygen levels are normal.
This condition is based not only on anatomical changes but also on mucosal mechanoreceptor loss and physiological disturbances in nasal airflow.
Endoscopic Examination Findings
Nasal endoscopic examination plays an important role in the evaluation of ENS. The following findings may be observed during examination:
- Complete or partial absence of the inferior turbinates
- Enlarged inferior meatus
- Excessively wide nasal cavity
- Dry and pale mucosa
- Areas of crusting
- Atrophic changes
- Air spaces creating turbulence
While mucosal atrophy may be quite pronounced in some patients, in others, serious symptoms may be present despite a relatively normal anatomical appearance. Therefore, ENS cannot be ruled out solely by looking at the image.
Computed Tomography (CT) Findings
Paranasal sinus tomography can provide important information in the evaluation of ENS. Comparison of pre- and post-operative images is particularly valuable.
The main findings that can be seen on tomography are:
- Total or subtotal absence of inferior turbinates
- Wide nasal air column
- Significant increase in inferior meatus volume
- Excessive opening in the middle meatus and nasal cavity
- Loss of septal support
- Postoperative anatomical irregularities
However, it should be remembered that ENS cannot be diagnosed solely with tomography. While some patients may have no symptoms despite significant turbinate loss, others may develop a severe clinical picture even with more limited resections.
Therefore, imaging findings must be evaluated together with clinical symptoms.
Empty Nose Syndrome Treatment Options
The treatment approach varies depending on the severity of the patient's symptoms. Conservative treatment options include moisturizing treatments, nasal irrigation, mucosal protective applications, and psychological support.
In advanced cases, submucosal implant applications, cartilage grafts, or biomaterial injections may be used to restore nasal volume. The aim is to reduce the patient's symptoms by improving airflow to a more physiological level.
Total turbinectomy, while widening the nasal passage in the short term, can cause serious functional problems in the long term. In this case, the findings of Empty Nose Syndrome that developed after surgery are quite striking when evaluated together with the tomography images, the removed turbinate tissue, and septal cartilage fragments.
The fundamental approach in modern nasal surgery is to achieve functional improvement while preserving nasal anatomy as much as possible. The preference for mucosa-sparing techniques instead of complete turbinate removal is of great importance in reducing the risk of Empty Nose Syndrome.
Cotton Test
The Cotton Test is one of the most important functional assessment methods used in the diagnosis of ENS (Endoscopic Nerve Suppression Disorder). During the test, small pieces of moist cotton are placed in areas of the nasal cavity thought to be deficient.
Cotton is usually applied to the following areas:
- Inferior meatus
- Lateral nasal wall
- Inferior turbinate region
After the cotton is placed, the patient's breath sensation is evaluated. If the patient reports:
- That they are breathing more easily,
- That they feel better airflow,
- That the feeling of suffocation is reduced,
the test can be considered positive.
The logic of the Cotton Test is to temporarily mimic the missing turbinate volume. Therefore, it can also guide surgical reconstruction planning.
ENS6Q Questionnaire
One of the validated patient questionnaires used in ENS assessment is the ENS6Q scoring system. This questionnaire evaluates the following symptoms in the patient:
- Dryness
- Air hunger
- Feeling of suffocation
- Feeling of nasal congestion
- Crusting
- Burning sensation
High scores may be supportive of ENS. The ENS6Q can be particularly useful in objectively monitoring patient symptoms before and after treatment.
Differential Diagnosis
Before diagnosing ENS, other diseases that may cause similar symptoms must be ruled out:
- Chronic rhinitis
- Atrophic rhinitis
- Nasal valve insufficiency
- Chronic sinusitis
- Septal perforation
- Psychogenic dyspnea
- Obstructive sleep apnea
- Anxiety disorders
In some ENS patients, psychological symptoms may be prominent. However, this does not mean that the disease is "psychological." Impairment of nasal neurosensory mechanisms can create serious autonomic and psychological effects.
Multidisciplinary Approach in ENS Diagnosis
Empty Nose Syndrome is a complex and multifactorial disease. Therefore, the evaluation process should consider not only anatomical losses; A holistic approach is needed, considering airflow physiology, mucosal functions, neurosensory changes, and the patient's quality of life.
Especially in cases developing after total turbinectomy, comparing pre- and post-operative CT images, documenting the removed turbinate tissue, and Cotton test results can provide valuable diagnostic information.
Why Is the Inferior Turbinate Not Just a Simple "Fleshy Growth" Inside the Nose?
The inferior turbinate is a dynamic structure located on the lateral wall of the nasal cavity that plays a vital role in respiratory physiology. Its primary function is not merely to narrow the nasal airway; thanks to its mucosa and underlying vascular tissue, it contributes to warming, humidifying, and filtering inhaled air, as well as regulating airflow.
Turbinate tissue also influences the speed and direction of airflow through the nose. Therefore, when reducing turbinate volume to relieve nasal congestion, the critical factors are not only the amount of tissue removed but also which tissue is preserved and the extent to which the remaining turbinate can maintain its function.
Today, the primary goal of inferior turbinate surgery is to widen the airway sufficiently while preserving as much functional mucosa and supportive tissue as possible. Medical literature emphasizes that the fundamental objective of modern turbinate surgery is to alleviate obstruction while maintaining the turbinate's physiological functions.
The History of Turbinectomy: Why Were Turbinates Removed More Radically in the Past?
The history of inferior turbinate surgery dates back to the early days of surgical treatment for nasal congestion. Particularly during the 19th and early 20th centuries, more radical resection methods were employed to widen the nasal passage.
During this period, the prevailing view was that "excess tissue" was the root cause of nasal congestion. Therefore, widening the airway as much as possible was viewed as a logical surgical goal. However, long-term follow-ups revealed that the complete or extensive removal of the turbinate did not merely relieve nasal obstruction; in some patients, it led to serious functional problems such as atrophic rhinitis, crusting, dryness, and foul-smelling nasal discharge.
This historical experience is one of the primary reasons behind the modern understanding that "more resection does not always mean better breathing."
What Is Total Turbinectomy?
Total turbinectomy involves the removal of the vast majority or the entirety of the inferior turbinate by detaching it from its base on the lateral nasal wall. It is considered one of the most radical forms of turbinate surgery.
This method can create a very significant widening of the nasal airway. Although this may appear advantageous at first glance, it must be remembered that the turbinate is not merely an "obstruction that narrows the airway." It is also a structure that directs airflow and contributes to nasal mucosal functions.
For this reason, many surgeons today prefer conservative, mucosa-sparing turbinoplasty techniques over total resection.
Why Did Total Turbinectomy Fall Out of Favor?
One of the most significant turning points in the history of total turbinectomy was the recognition of complications that could arise in the long term following the surgery.
The literature reports that total turbinectomy has been associated with serious conditions such as atrophic rhinitis and ozena. Although the method regained popularity in the 1970s and 1980s due to studies reporting high short- and medium-term success rates, interest in more conservative approaches has resurged as the functions of the turbinates have become better understood.
The fundamental issue here is that the fact a surgery relieves nasal obstruction does not mean it is optimal in terms of nasal physiology. Symptomatic success and physiological success are not the same concept.
Why Is Total Turbinectomy Considered an Excessively Aggressive Approach Today?
The guiding principle in modern inferior turbinate surgery is to reduce volume only as much as necessary and to preserve as much functional mucosa as possible, rather than simply removing as much tissue as possible.
Total turbinectomy can result in significant tissue loss involving both bone and mucosa. In some patients, this can lead to postoperative issues such as crusting, bleeding, dryness, pain, a prolonged healing process, and impaired nasal physiology.
A comprehensive 2021 review classified turbinate surgery techniques into mucosa-sparing and non-sparing methods; it noted that total and partial turbinectomies—due to excessive tissue loss—may be associated with complications such as bleeding, crusting, pain, and prolonged healing.
How Can Total Turbinectomy Lead to Empty Nose Syndrome?
Empty Nose Syndrome (ENS) is a complex clinical condition that can arise, particularly following the excessive resection of inferior turbinate tissue. A characteristic feature is that, despite the patient's nasal airway being objectively open, they paradoxically experience nasal congestion, an inability to breathe, air hunger, or a sensation of suffocation.
The substantial loss of turbinate tissue can alter the distribution of airflow within the nose. In particular, the failure of normal turbinate structures to regulate high-velocity and intense airflow can cause the air current to concentrate in non-physiological areas.
Therefore, explaining ENS simply by stating that "the nose has become too wide" is insufficient. Factors such as airflow velocity, direction, and distribution, as well as mucosal sensory mechanisms and the patient's perception of breathing, must all be considered together.
An Interesting Paradox: Why Might a Patient Say "My Nose Is Blocked" When It Is Actually Open?
This is one of the most striking features of ENS. In a patient who has undergone excessive turbinate tissue removal, endoscopy may reveal a wide nasal cavity. Despite this, the patient may report an inability to breathe adequately through the nose.
This situation demonstrates that airway patency and the sensation of breathing are not the same thing. Sensory receptors within the nose and the interaction of airflow with the mucosa play a role in the perception of breathing. The fact that airflow becomes more concentrated and turbulent in the middle meatus region—particularly following the loss of inferior turbinate tissue—may contribute to the sensation of paradoxical breathing in some patients.
How Does Airflow Change After Total Turbinectomy?
Turbinate tissue contributes to the regulation of airflow within the nose. When a large portion of the turbinate is removed, the distribution and local velocities of the airflow may change, rather than the total volume of airflow itself.
Computational Fluid Dynamics (CFD) studies have demonstrated that airflow in patients with ENS differs from normal anatomy and that intense jet-like airflow patterns can develop in certain regions.
Therefore, the goal of surgery for ENS is not merely to narrow the airway but to restore physiological airflow patterns as much as possible.
What Symptoms May Arise After Total Turbinectomy?
Symptoms in ENS patients can vary from person to person. The most frequently reported complaints include paradoxical nasal obstruction, a sensation of being unable to breathe adequately through the nose, air hunger, a feeling of suffocation, nasal dryness, crusting, and a burning sensation inside the nose.
Some patients report difficulty breathing, particularly at night, or a constant urge to take deeper breaths. For some individuals, this condition can significantly impact sleep quality and daily life.
However, it is incorrect to attribute these symptoms solely to a prior turbinectomy. In the assessment of ENS, the patient's surgical history, endoscopic findings, and symptoms should be considered alongside validated assessment tools such as the ENS6Q when necessary.
What Is Minimally Traumatic Turbinate Reduction?
The primary goal of minimally traumatic turbinate surgery is to reduce turbinate volume while preserving the mucosa and as much functional tissue as possible.
In this approach, reducing submucosal tissues or a limited amount of the bony component is preferred over removing the entire turbinate. This allows for the expansion of the nasal airway while preserving the turbinate's superficial mucosa which regulates airflow to the greatest extent possible.
In modern literature, the fundamental principle of this approach can be summarized as "tissue-sparing, mucosa-preserving turbinate reduction."
Submucosal Turbinate Resection: A Classic Technique That Minimizes Tissue Loss
Submucosal turbinectomy is based on the principle of reducing the deeper soft tissue and/or bony components while preserving the turbinate mucosa.
A significant advantage of this technique is the preservation of the functional mucosa on the outer surface as much as possible. Submucosal turbinectomy—redefined by Howard House in the 1950s—has historically been one of the methods aimed at reducing turbinate volume while preserving the mucosa.
Long-term studies have reported that the combined application of submucosal resection and lateralization yields positive results regarding nasal breathing and mucociliary function.
Microdebrider-Assisted Turbinoplasty: Controlled Submucosal Volume Reduction
Microdebrider-assisted inferior turbinoplasty is a technique that allows for the controlled reduction of the submucosal soft tissue volume of the turbinate.
The goal of this method is to reduce the underlying hypertrophic tissue while preserving the outer surface of the turbinate as much as possible. The high level of microsurgical control offered by this technique can be advantageous, particularly in patients requiring the removal of only a limited amount of tissue.
Systematic reviews have shown that the microdebrider technique is effective in reducing nasal obstruction caused by inferior turbinate hypertrophy; however, while some studies report better subjective nasal obstruction scores compared to radiofrequency, objective results do not always align with these findings.
Radiofrequency Turbinate Reduction: Volume Reduction Without Extensive External Resection
In radiofrequency procedures, the aim is to induce volume reduction in the submucosal tissue of the turbinate using controlled energy. Preserving the superficial mucosa as much as possible is a key feature of this method.
Therefore, radiofrequency is a minimally invasive option worth considering, especially for patients in whom the soft tissue component of the turbinate is predominant.
A 2022 systematic review evaluated 62 studies and demonstrated that various inferior turbinate reduction techniques can alleviate nasal obstruction. It was reported that both radiofrequency and microdebrider-assisted turbinoplasty are effective according to both subjective and physiological measurements.
Coblation, Laser, and Other Energy-Based Techniques
In addition to radiofrequency, various energy-based technologies such as coblation, laser, electrocautery, and plasma-based methods have been used for turbinate reduction.
The common goal of these methods is to achieve controlled volume reduction, particularly within the submucosal component of the turbinate. However, the fact that an energy-based technique is "minimally invasive" does not automatically mean it is risk-free. If the depth and intensity of the energy are not properly controlled, complications such as mucosal damage, crusting, and healing issues may arise.
Therefore, the depth of application, the amount of energy used, the anatomical target, and the preservation of the mucosa are just as important as the technology itself.
Is Turbinate Lateralization Sufficient on Its Own?
Lateralization or the "outfracture" procedure of the inferior turbinate aims to widen the airway by moving the turbinate toward the lateral nasal wall.
However, lateralization alone may not provide a permanent solution for every patient. A systematic review indicated that there is insufficient evidence to support outfracture as an effective long-term treatment for inferior turbinate hypertrophy on its own, suggesting instead that combining it with another tissue-volume-reducing technique when necessary may be more appropriate.
For this reason, "breaking and displacing the turbinate outward" and "reducing the turbinate's volume in a controlled manner" are not the same surgical procedure.
Why Is Preserving the Mucosa So Important in Turbinate Reduction?
The turbinate mucosa is not merely an epithelial lining covering the inner surface of the nasal cavity; the underlying vascular structure and the mucosal surface itself contribute to the conditioning of inspired air.
Therefore, the success of turbinate surgery should not be evaluated solely by the question, "How open is the nose?" postoperatively. The question, "How well is the nose functioning?" is equally important.
This highlights the fundamental difference between the modern turbinoplasty approach and total turbinectomy: the goal is not to completely eliminate the turbinate's function, but rather to reduce the excess volume causing obstruction while preserving a functional turbinate.
The Major Surgical Challenge in Turbinate Reduction: "How Much Reduction Is Sufficient?"
In inferior turbinate surgery, perhaps the most critical question is, "How much tissue should be removed?"
If too little tissue is resected, nasal obstruction may persist. If too much is resected, the physiological functions of the turbinate may be compromised, potentially leading to long-term issues such as dryness, crusting, or symptoms resembling Empty Nose Syndrome (ENS).
Consequently, success in modern turbinate surgery is defined not by maximal resection, but by establishing an adequate airway with minimal necessary tissue loss.
A 2014 review also emphasizes that, given the inferior turbinate's vital role in nasal physiology, current surgical approaches must strike a balance between sufficient tissue reduction and the preservation of functional tissue.
What Are the Risks of Total Turbinectomy?
Total or extensive inferior turbinectomy can lead to both early and late-stage complications. Early complications may include bleeding, pain, crusting, and a prolonged healing process.
In the long term, more complex issues such as mucosal dryness, crusting, atrophic rhinitis, and in some patients paradoxical nasal obstruction may arise.
It is not always easy to directly attribute symptoms that appear years later to the surgery itself, particularly in patients who have lost a significant amount of turbinate tissue. Therefore, a detailed evaluation of the surgical history is important.
How Is Surgical Treatment Planned for Empty Nose Syndrome?
Modern treatment for ENS aims not only to alleviate symptoms but also to restore lost anatomical volume and re-establish proper airflow.
Surgical planning may involve the use of the ENS6Q questionnaire, nasal endoscopy, a review of the patient's surgical history and remaining turbinate tissue, and imaging studies when necessary. In some patients, the cotton test can help determine which area requires volume augmentation to alleviate symptoms.
A 2024 systematic review reported the use of submucosal injection materials, autologous or homologous cartilage, synthetic implants, and various reconstructive techniques in the treatment of ENS. One of the most common sites for implantation is the anterior-inferior lateral nasal wall.
Turbinate Reconstruction in ENS Treatment: Restoring Lost Tissue
Medication or humidification therapies alone may not suffice for patients who have experienced significant turbinate loss. In such cases, various reconstructive methods can be employed to restore the lost volume.
In submucosal implantation techniques, cartilage, synthetic materials, or various biological materials can be placed in the inferior meatus or lateral nasal wall region. The goal is not to completely occlude the nose, but rather to bring the excessively wide airway closer to a more physiological geometry.
Systematic reviews on surgical treatments for ENS indicate that while improvements in symptom scores have been reported with various implant materials, the studies are heterogeneous, and there is currently no single standardized reconstruction technique applicable to all patients.
Can a “Neoturbinate” Be Created via Submucosal Cartilage Implantation?
Submucosal placement of cartilage grafts is one of the approaches used in ENS reconstruction. The concept involves the controlled restoration of previously lost turbinate volume.
This technique may be particularly beneficial for patients identified—via the cotton test—as likely to gain relief from increased volume in a specific area. However, an implant that is too large could create a new mechanical obstruction, whereas one that is insufficient might result in the persistence of symptoms. Therefore, the surgical goal is not to "place the largest implant," but rather to determine the appropriate volume and anatomical site that will improve the patient's physiological airflow.
Why Is the "Mucosa-Sparing" Approach in Turbinate Surgery the Standard of Today, Not Just the Future?
Although numerous techniques exist for inferior turbinate surgery today, the prevailing trend favors methods that preserve the mucosa and reduce volume only to the extent necessary.
Microdebrider-assisted turbinoplasty, submucosal resection, radiofrequency, coblation, and other techniques can be performed based on this principle. The choice of method depends on factors such as the size of the turbinate's bony and soft-tissue components, mucosal characteristics, the presence of comorbidities like allergic or vasomotor rhinitis, and the surgeon's experience.
A 2022 systematic review examined 62 studies and demonstrated that various techniques are capable of alleviating nasal obstruction. This finding supports the importance of selecting a technique tailored to the specific patient and anatomical issue, rather than adhering to the notion that there is a single "ideal" turbinate surgery.
Which Minimally Traumatic Techniques Can Be Preferred Over Total Turbinectomy?
Today, more conservative options that can be considered for suitable patients include submucosal turbinoplasty, microdebrider-assisted turbinoplasty, radiofrequency submucosal reduction, coblation, limited bone resection, conservative anterior turbinoplasty, and when necessary lateralization.
The common goal here is to sufficiently widen the airway and preserve the functional mucosa of the turbinate, rather than completely removing the inferior turbinate.
However, no single technique is automatically the "best" for every patient. For instance, while radiofrequency alone might be insufficient for a turbinate with a significant bony component, a more limited submucosal approach might suffice for a patient whose condition is primarily due to soft tissue hypertrophy.
Is Empty Nose Syndrome (ENS) Inevitable After Total Turbinectomy?
Although total or extensive turbinate resection is considered a significant risk factor for ENS, it cannot be said that every patient undergoing total turbinectomy will develop the condition.
Factors other than the mere amount of tissue removed such as the shape of the remaining anatomical structures, characteristics of the lateral nasal wall, the condition of the septum, mucosal function, airflow dynamics, and individual sensory mechanisms can also play a role in the development of ENS.
Therefore, a mathematical equation equating "total turbinectomy" with "guaranteed ENS" is incorrect. Nevertheless, avoiding unnecessary or excessive turbinate resection is one of the fundamental principles of functional nasal surgery today.
The Golden Rule in Turbinate Surgery: Preserving Nasal Physiology While Treating Nasal Obstruction
The historical evolution of inferior turbinate surgery illustrates an important lesson in surgical medicine. While the primary goal in the past was to create the widest possible nasal passage, the preservation of functional anatomy has gained far greater importance today.
The aim in treating nasal obstruction is not to eliminate the turbinate itself, but to enable the patient to breathe comfortably by reducing its hypertrophic or pathological volume.
Therefore, the modern approach can be summarized as follows:
“Not more turbinate resection, but turbinate reduction that is tailored to needs and preserves the mucosa.”
Historical experiences with total turbinectomy and current literature regarding Empty Nose Syndrome (ENS) clearly demonstrate why this principle is important.
The Goal of Turbinate Surgery Is a Functional Nose, Not an “Empty Nose”
Total turbinectomy is a radical surgical procedure that can reduce nasal obstruction but largely eliminates the physiological functions of the inferior turbinate. The historical occurrence of complications such as atrophic rhinitis and ozena has contributed to the understanding of the importance of preserving turbinate tissue. The currently preferred approach involves the controlled reduction of turbinate volume and the preservation of the mucosa, aiming to establish an adequate airway while maintaining nasal physiology to the greatest extent possible. Submucosal resection, microdebrider-assisted turbinoplasty, radiofrequency, coblation, and other mucosa-sparing techniques represent various applications of this principle.
Empty Nose Syndrome (ENS) should be considered, particularly in patients who have previously undergone turbinate surgery and subsequently developed paradoxical nasal obstruction, a sensation of air hunger, dryness, and crusting. Current literature on ENS indicates that while surgical treatments can lead to significant improvements in quality of life and symptoms for some patients, the complexity of the condition necessitates personalized treatment and high-quality long-term studies.
Therefore, the fundamental approach to functional nasal surgery can be summarized not as "widening the nasal passage as much as possible," but rather as "widening it only to the extent required by the patient while preserving nasal physiology."
To read other articles about empty nose syndrome prepared by Dr. Murat Enoz and published on this website, you can click on the search result link (you can access other articles by clicking on "more posts" at the bottom of the opened link) >> https://www.ent-istanbul.com/search?q=empty+nose
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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