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.
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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