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BackTable / ENT / Article
Empty Nose Syndrome: Symptoms, Diagnosis & Solutions
Melissa Malena • Aug 7, 2023 • 2k hits
Empty Nose Syndrome is a condition associated with turbinate reduction surgery complications. Empty Nose Syndrome (ENS) is characterized by a unique set of unpleasant symptoms such as feelings of suffocation and nose burning. ENS diagnosis criteria consist of the Cotton Test, ENS6Q questionnaire and patient history. Expert ENT Dr. Jayakar Nayak highlights the importance of physicians accepting Empty Nose Syndrome as a valid condition, rather than a trivial complaint of dissatisfied patients. In order to reduce risk of Empty Nose Syndrome, Dr. Nayak recommends careful handling of the turbinates and avoidance of full turbinate excision.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Empty Nose Syndrome is a term coined a few decades ago, highlighting the abnormal spaciousness in the nasal cavity due to the removal or reduction of nasal structures, particularly the turbinates.
• Empty Nose Syndrome symptoms are: suffocation, restricted airflow, nasal crusting, nose burning, sense of an overly open nose, and diminished airflow. These symptoms are documented in the ENS6Q questionnaire, and scoring above 11 (on a scale from 0-30) indicates potential Empty Nose Syndrome.
• The Cotton Test is a diagnostic tool for Empty Nose Syndrome and functions by placing a piece of cotton in the area of the reduced turbinate. If this makes the patient more comfortable and decreases their symptoms, they are a positive test.
• Dr. Nayak's technique involves making an incision in the anterior head of the turbinate, raising a medial flap, and carefully removing the central part of the turbinate bone. He uses a pediatric microdebrider to create channels in the submucosal tunnel, aiming to reduce the thickness of the medial flap while leaving the lateral flap untouched in an attempt to avoid Empty Nose Syndrome.
Table of Contents
(1) What is Empty Nose Syndrome?
(2) Empty Nose Syndrome Symptoms
(3) Empty Nose Syndrome Diagnosis with The Cotton Test
(4) Turbinate Reduction Surgical Techniques to Reduce Risk of Empty Nose Syndrome
What is Empty Nose Syndrome?
Empty Nose Syndrome is characterized by an excessive emptiness in the nasal cavity due to the removal of important structures called turbinates, particularly after turbinate reduction surgery. Interestingly, other tissue-removing nasal surgeries, such as sinus surgery and septoplasty, do not seem to be associated with the development of Empty Nose Syndrome. Empty Nose Syndrome symptoms can vary as a result from these procedures, offering a crucial perspective on the potential negative impacts of certain nasal procedures.
[Dr. Jayakar Nayak]
I don't know how it happened, but it just turned into it. I don't know if I want to talk about empty nose syndrome first.
[Dr. Gopi Shah]
Yes. Maybe that would be good to just set the stage so that listeners who may not be familiar, can understand what that's about.
[Dr. Jayakar Nayak]:
Sure. Okay. Empty nose syndrome is a term coined only a few decades ago with the idea being that when doctors, Eugene Kern, and others looked in the nose, they said, "Wow, there's a lot of empty space here." The nasal cavity instead of having the same structures that you're used to seeing, the two inferior turbinates, especially sometimes the two middle turbinates, wow, there's an expansive empty space here like a cavern. That's, I think, where the term came from.
Empty nose syndrome has grown to be a constellation of symptoms that seem to be very commonly associated with, especially turbinate reduction surgery. Many patients there will have and have had all types of nasal procedures, for example, sinus surgery, septoplasty, and things like that. Those two surgeries do not seem to be linked to empty nose syndrome.
I just have numbers of patients who, in my own practice, and just from the data that's out there from the publications that exist, it's just never linked to those two surgeries even though those are tissue-removing surgeries as well. We make windows into the sinuses to do the sinus surgery. We remove cartilage and bone and straighten out a septum to correct a deviated crooked septum. Those procedures are not linked but turbinates themselves, those tubular pendant structures in the nose, especially the lower third of the nose, when those are overly reduced, some patients have these symptoms of empty nose syndrome.
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Empty Nose Syndrome Symptoms
Empty Nose Syndrome has many intricate and counterintuitive characteristics. Dr. Nayak introduces the specific set of Empty Nose Syndrome symptoms, documented in the ENS6Q questionnaire. Empty Nose Syndrome symptoms are feelings of suffocation, restricted airflow, nasal crusting, nose burning, and a sense of the nose being too open. Each patient may describe what empty nose syndrome feels like differently based on their symptoms. There are a variety of turbinate surgeries that lack standardization, which can lead to Empty Nose Syndrome. Despite these potentially detrimental outcomes, it's notable that not all patients are affected similarly post-surgery, leading to a controversial discourse on the topic. Many patients experience relief and satisfaction after turbinate surgery, making Empty Nose Syndrome a somewhat elusive and complex condition to understand and diagnose.
[Dr. Jayakar Nayak]
What are the empty nose syndrome symptoms and what does it feel like? We were able to codify and invalidate six symptoms that are really strongly associated with empty nose syndrome. There's a metric that we have in our field called the SNOT-22, which is the Sino-nasal Outcome Test, that's 22 questions. Each of them, you rate from zero to five, and that's very closely linked to your symptom and your subjective well-being, your sense of your own well-being for sinusitis. If you have a certain number, you're more likely to have very debilitating symptoms associated with chronic rhinosinusitis, CRS.
Now, instead of making a SNOT-28, we found that there are 6 symptoms that are much more strongly and regularly associated with empty nose syndrome, and we validated that in a publication that we put out in 2016. We call it the ENS6Q, the ENS, empty nose syndrome six-item questionnaire. Those six symptoms seem to be very strongly associated with empty nose syndrome, and that is the sense of suffocation, the feeling that you have almost a pillow over your nose, you can't get in a full breath.
There are some subjective sense that airflow is restricted in a very uncomfortable way. Nasal crusting. The vent of your nose is just making too many little scabs and little boogers and things that you didn't have before. Nasal burning. A sense that airflow through your nose is painful. Some people will describe a razor blade sensation, some people will just describe a freezing sensation. It's very uncomfortable. Sometimes they'll even say things like dental pain, some eye pain, things like that. You have to try to sort those things out. A sense of "My nose feeling too open." Many patients with this empty nose issue will say that "Air is rushing through my nose, I don't feel a peak, I don't feel a trough. I feel just this open cavity where air is rushing in. I feel like it's hitting my throat and it's very uncomfortable."
Actually, then there's also a sense of diminished airflow that I do feel congested. It's funny, sometimes patients will say on a zero to five scale, five being terrible and zero being no symptoms, they'll often score four or five for both. Sense of my nose feels too open, i.e. there's a rushing of air in through my nose, and I feel congested, which sounds like too little airflow, not too much airflow. They'll say, "Yes, I just don't feel like the air is properly going into my lungs, so that's why I feel congested." They have this very complex new nasal problem that they didn't have before.
The main thing that they will say though is "Before the surgery, I never had any of these things." Some of them will directly admit. There's a whole thing about whether empty nose syndrome is psychiatric and neurologic and all these things. I agree, I've a very different opinion on some of those things, or maybe, I think a reasonable opinion on some of those things, but the point is that I think that those symptoms are not easy to make up.
It's very interesting how patients from all over the world and multiple states all say the same relative thing and they don't know each other. [chuckles] Their description is so detailed and so specific that it's hard to describe razor blades going into your nose and a sense of disturbing crusting and whatever. "I feel like there's a cage around my lungs because I kept suffocating."
Other patients describe that. You don't describe that for a standard nasal obstruction from turbinate hypertrophy of adenoid hypertrophy before surgery.
I have no sinus surgery patients ever describing anything like that and no septoplasty patients saying that, so that's the idea of empty nose syndrome. Oh, and it's associated with not just turbinate surgery because I've done over 3,000 turbinate reductions and I've only had maybe 3 patients describe something like that on one side, by the way, after my surgery. Let's say, my rate of empty nose syndrome is about one in a thousand.
Let's just say that's the case, but the fact is that, that I think the goal of turbinate surgery if you fail medical management and the things we talked about before, should be to-- And this is what I tell all my residents, and what I tell all my fellows and those who work with me and follow and rooted with us and visiting scholars from other countries to Stanford, is that the goal of turbinate surgery is to reduce the size and caliber of the turbinate from, let's say, thumb-like structures, these swollen torpedoes that look like thumbs, to maybe the fourth finger or a pinky, that structure, but it's still a recognizable tubular finger-like structure. You should keep the contour of the turbinate as this tubular structure. Just reduce its size so that there's more of an airway between the septum and the turbinate. That's it.
The thing with empty nose syndrome patients is that there's a vast variety of patients out there, but it's initially described as this massively open nasal cavity where the turbinates have been resected but in practice, and we're publishing all of these things that, there's a wide variety of turbinate tissue loss. Sometimes you can just have a turbinate trim where a scissor was taken to the bottom half of the turbinate. Now, some of the top half of the turbinate is still present so you still have that pendant structure in the center of the nose, but the bottom half is missing. There are 30% turbinate trims, 70% turbinate trims.
There are some patients of empty nose syndrome or a variant of empty nose syndrome where they're the cookie bite deformity of that, I call it there, or a straight through cut instrument or a curve scissor was taken in just lop-off the head of the turbinate. I've had colleagues and mentors in my training do that and patients initially seem very happy, but then later you find out that some of the patients were unhappy with certain aspects of their breathing, and things like that.
It's hard to know which ones are associated with empty nose syndrome because there's no standardization of the procedure of turbinate reduction. First, I would just say that I think it's just empty nose syndrome with a wide variety of symptoms. Some people just have suffocation, some people have suffocation with nose burning, some people just have "My nose feels too open."
It doesn't have to have all of those things but most people have a few of those six symptoms and that's in the ENS6Q questionnaire. Usually, they have a score above 11. That's our standard for the metric, for determining if you have any ENS. 11 to 30 on that scale because control patients, when we've done this for that paper, control patients score 0 to 5. They'll have maybe ones for each of those symptoms and zeros. Then if you're ENS, you have threes, fours, and fives for those symptoms.
You think about it like my two hosts, I don't think you've ever had nasal burning. It's very hard to have that. You'll score a zero to one on that, so you'll be a control patient. That's what we're looking for in that symptom.
In terms of the symptoms and then I look in their nose and I see a wide variety. I sometimes even see just a very good turbinate reduction that anyone would say, "Okay, I think objectively, those are crooked septum and large turbinates before surgery." You know what? After surgery, I see the CAT scan, it's a pretty straight septum and a pretty nicely reduced turbinate, looks pretty good. Unfortunately, some of those patients still say the same things concerning complaints.
Again, I don't necessarily think they're making it up, but I test them then and that's the next step of what I am happy to talk about. How I test them for empty nose syndrome, that's one aspect of this. The two is then it has to be said is that some patients with the same findings I just described, loss of the inferior turbinate, complete resection of the inferior turbinate, partial resection of the inferior turbinate, cookie-bite deformity of inferior turbinate.
The majority of patients actually are happy. They know that they were breathing poorly before, they know how they had sleep apnea before, they feel that their airway's better and they're very content patients. Sometimes they're content for their lives, sometimes they're content for a few years and then they might develop new symptoms, things like that.
Unfortunately, that's the paradox of empty nose syndrome is that not everyone-- Like the heart, like I said, if you damage the valve, you're going to get symptoms every time, because I think it's a tightly regulated structure for so many, in size, in shape and valve quality and all these things. The nose, because those are subject to differences in size, nostril size, shape, airflow differences, lung differences, I think, everyone's going to experience this.
If you have the same surgery in 2,000 people and only a small percentage of those patients will have empty nose syndrome because again, I think, some of these dynamics of the nose, receptor differences in the nose, nerve input, and sensitivity differences in the nose, things like that. That's why empty nose syndrome has turned into a controversial topic, I think because understandably, not all patients who have the same postsurgical outcome of tissue loss to the turbinate have the same symptoms.
It's not a one-to-one thing for us and it doesn't always happen immediately after surgery. The symptoms of empty nose syndrome and then therefore we say like, "Wait a second, you were happy before. I saw you two years ago after your surgery, you were totally happy, now you're not?" Things like that come into play. I think doctors tend to say, "Well, it can't be me, it can't be my surgery. I have all these other patients who're really happy with that surgery so there might be something wrong with how you're perceiving things. Maybe I have more anxiety or depression, maybe other things that I didn't know about before."
It turns into a cyclical issue where then they're seeing other doctors and they're not necessarily even getting acknowledgment of their experience, much less any direction as to what to do because they seem to be unhappy with their nasal breathing, whether it's immediately after surgery or sometime after surgery.
That's the idea of empty nose syndrome though, is that the dissatisfaction of the nasal breathing and the breathing experience and these new symptoms that are very disturbing, again, related to turbinate surgery.
Empty Nose Syndrome Diagnosis with The Cotton Test
While there is no definite mechanism associated with the development of empty nose syndrome, Dr. Nayak most commonly sees complaints of empty nose syndrome after direct usage of scissors in turbinate reduction surgery. For Empty Nose Syndrome diagnosis, Dr. Nayak has developed an in-office procedure called the cotton test. After patients have completed the ENS6Q questionnaire, they are blindfolded and a forcep is simply tapped on each side of the nose. Although nothing has been placed into the nose, the patient is unaware of this and asked how their breathing feels. Their nose is then completely blocked with cotton as a positive control and they once again rate their breathing. Cotton is then placed only in the areas of turbinate loss. Patients with Empty Nose Syndrome will often score much lower on the ENS6Q questionnaire and express an increase in comfort from the direct turbinate cotton placement. This result is indicative of empty nose syndrome, while other results from the cotton test could guide symptom origin towards anxiety or neurological causes.
[Dr. Jayakar Nayak]
Sure. We've published on some of this when patients come to see me-- And this has been now a labor of love or interest or both, for at least since 2013. Now I've seen over 350 patients, referred to me for empty nose syndrome evaluation.
Just trying to give you my summary of some of my experiences in this podcast, but the idea is to answer previous questions about coblator versus not, so I've seen all of those procedures. Even submucosal reduction in my hands lead to some empty nose syndrome complaints, but the most common I've seen for empty nose syndrome is direct use of scissors to clip off the turbinate.
Then I think that there are so many examples of cautery being fine that it's hard to know if that's directly related to empty nose syndrome, but patients will say on these empty nose syndrome forums that exist out there in Facebook and other places, that "They over-cauterized the turbinates, and they burned off my nose, and burned off the nerves of my turbinates," and things like that. I'm just saying that there are probably hundreds of others who had the same surgery and that same procedure and didn't have that experience. I've seen that every single technique that is out there for reducing a turbinate can lead to empty nose syndrome because any of those things can lead to excessive tissue loss.
I don't think there's one mechanism for it, but I think scissors because scissors will directly change the contour and the shape of a turbinate from a rounded cylinder, a rounded finger, to a truncated finger, or a truncated cylinder. Therefore, that's the one that's most commonly associated with distorted nasal breathing and distorted experience of satisfying nasal airflow.
Then when patients develop-- And we've also published on this, that there are some patients that come immediately after surgery, "I knew right after they took out those Doyle splints, I just couldn't breathe. It was just a rush of air, it was cold, it was uncomfortable. It was not what I was expecting. It was much worse, it was much different than I had before surgery." Some of them are immediate, but I think the majority are between six months to five years. I think they're just giving you time. They are recovering, it's just okay. "I don't love it, but it's okay," or "it really is okay. I really did feel good."
Then something happened. They had a cold, they moved, they went to visit Las Vegas. Now it's drier. I don't know, "Something happened, I just couldn't breathe. It was totally different for me." It's hard to know what to make of that. It's honestly just hard to know what to make of it because maybe there's a change in the mucosa, change in just the lung capacity. I don't really know why suddenly something turns and switches.
That is the hardest thing about empty nose syndrome is that, because I think that makes it harder to accept, and doctors naturally feel sometimes that they're under attack. "Oh, well, I'm doing the surgery that later is now being ascribed to empty nose syndrome and patients can blame me at any time for something that happened 5 years ago, 10 years ago."
I don't think anyone's blaming anybody. I just think that just the experience is there. It turns out that replacing some of the turbinate tissue with various means that we'll talk about, I'm sure, restores and removes those symptoms. It was related in some way to the loss of turbinate tissue and regaining turbinate tissue, removing those symptoms, which is great. At least it's remediable, but I think just acknowledging that it can happen and it can happen in a delayed fashion is important.
A patient just again saw me yesterday with a concern of empty nose syndrome and came in from another state. For everybody, I just listen to the story, I look at the imaging. In her case, she had a very nice surgery in general. She had septoplasty turbinate reduction and limited sinus surgery. Unfortunately, she feels that she has some ongoing sinus infections so that's a problem. Also, just these things that she says about her breathing, "I'd never had this before, but now my nose burns when I breathe. It's just air is rushing, flowing through my nose when it didn't do this before. It's very uncomfortable for me," these things.
I didn't press her, I didn't ask her, she's just naturally saying these things. Then I add or fill out my ENS6Q, six-item questionnaire, and she has a score of 25. I'm like, "Okay, that's way above 11." Okay, so let's see. Then what I do is a blind contest. They don't know what I'm doing. They're blindfolded when I'm doing this evaluation. It takes time to do all of this. I put things in their nose or I don't put things in their nose, and I test them again, answer six questions again.
The first thing I do is have them close their eyes, and I put nothing in their nose. I put a little Blakesley forcep in there, touch the left side, touch the right side. They don't know that I'm not doing anything. They think I'm doing something, I think. I just have them open their eyes, "Breath through your nose." I just want to document the placebo effect. We're going to publish this soon. We've done this on over 100 patients, because you can really lead patients with anything you do, and they're sometimes so desperate, they want to say, "Yes, I'm breathing better." Since they don't know what I'm doing, and it's double-blinded, I don't know what they're scoring, they don't know what I'm doing.
Then I found out that her score was a 22. Basically, she had no placebo effect. She went from 25 to 22, which is great. All right. It sounds like you didn't immediately rush to say "I improved." Some people have done that, by the way. I don't know what that means. That means it might actually be in your head, or you're very anxious about being in my office. I'm not sure exactly.
In any case, then I completely block up their nose with cotton. That's a positive control, so I have a negative control or a placebo control. Then I do a totally plugged-up their nose. They don't like that either, which is good. That means that they want some airflow. Too little airflow, complete blockade is not good for them. Then we document that.
Then I put cotton where tissue is missing. In her case, she was missing some tissue in the medial aspects of both in inferior turbinates. Almost they'd look like a little cavity in the central aspect of the interior turbinate, almost like what you'd want. For most patients, that's what they exactly want.
As soon as I put the cotton there, in her case, she dropped 12 points in the ENS6Q. We published before that if you ever have a drop of 7 points or more, then you likely able to have empty nose syndrome treatment. It was actually reassuring for her. She didn't know what I was doing, again, and she just said, "I don't know. Whatever you just did, I like it better. It's better than when I walked in."
I just restored a little bit of volume now with a piece of cotton, half the same piece of cotton on both sides. She liked it more, she said, "There's less airflow rushing through my nose, I feel more resistance. The air even feels warmer. It feels more comfortable to me." Great, so at least we have some idea. I'm not sure yet. I'm just meeting you for the first time, but we have some suggestions, you have empty nose syndrome or symptoms of it.
Again, I can tell you that this is not anything that anyone would have predicted, "Your surgery looks great. I've had this outcome and patients were really happy. Just letting you know that." This is something that might resolve over time because turbinate tissue tends to hypertrophy again over time, which I think we mentioned before. This is something that might resolve over the next one or two years. We'll see.
Sometimes you might need help with this symptom, but we can deal with that. Unfortunately, she had the sinusitis issue, so we had to deal with that first. That's how I try to fair through and sort out if you have empty nose syndrome or not. I do it in a blinded fashion.
When I first started doing this stuff here because there was a cotton test out there, I just put cotton in the nose and said, "Hey, you feel better?" Universally, everyone said, yes. I thought I was doing a great job. Then I realized that a lot of those patients I would take their surgery and I would put these implants in their nose to restore volume.
Honestly, some patients weren't better. A good majority were, but some weren't. I think that they just were going to say, yes, to anything I said. Anything I did, they were going to say, "Yes, I'm better." I realized that I had to be better than that. Then I started doing this sequential, graded, time-consuming, empty nose syndrome cotton test. Also, I do that all without any anesthesia. There's no top-of-the-line anesthesia. This is all native testing, so there's no other variables in the equation. I hope that helps explain how we do the cotton test.
Some patients totally fail the cotton test. They're like, "I don't like that. I don't like it when cotton's in where tissue is missing. I don't like when cotton's in the nose. It all just feels terrible to me." I'm not sure what to do with that. I typically put them on budesonide rinses. I'll see them again in three months, I'll reevaluate.
Some patients just can't be figured out right then and there. Some patients need a second visit. Some patients just are very anxious about being there. They're still very upset about whatever the symptoms are. After surgery, they thought they'd feel better, now they feel worse, and things like that. It might be something else that we need to figure out with them but not everyone is figure-out-able on the first visit.
[Dr. Gopi Shah]
It can be really complicated with these patients. It's very interesting to hear that step-by-step process to nail down what's going on. Is there any last parting words of wisdom that you'd want to leave our listeners with to just put a bow on this?
[Dr. Jayakar Nayak]
Let's see. In terms of the bow, I think that these issues can exist for empty nose syndrome after turbinate surgery. Turbinate surgery is a surgery that helps thousands and thousands of patients every year. It's not something to be maligned. I just think that because it can be associated with excessive tissue loss, aggressive aspects along. Even the length of the turbinate can lead to scarring and lead to little change in the contour.
We just have to be respectful of the procedure and the fact that we're guests in people's noses. We're guests in people's noses for a few hours, and they have to live with what we do for their life or for a long time. Conservative and small changes can lead to massive benefits for patients. Again, reducing but not resecting tissue I think, is important as much as we can do it, at least for the turbinates.
I think for the sinuses it might be totally different. I make large openings for the sinuses. I make large openings that I think are better for the sinuses, but that's a different topic altogether.
If patients have these issues, I think, it's important to acknowledge them rather than dismiss them. Now that it might be the case, and that there are these published criteria out there like these empty nose syndrome ENS6Q, it's out, it's for public availability. It's something you can test patients on. Anyone can do a cotton test, that's all published as to how to do that and where to place the cotton. You've heard maybe how you can do it, you can do it in a sequential fashion so that you're not biasing yourself and biasing the patient per se.
Then a simple thing that can be done by anybody, also published by us and others now, is gel filler injections. One can just actually put an inert gel filler like Prolaryn gel, there's Renú gel. Other ones that are used in facial plastics, for example, Restylane can be injected in with numbing up the tissues of the nose and injected into the sidewalls where the turbinate tissue is missing and plumping up the turbinate tissue in that area.
That can really assist with "Okay," then that lasts two or three months and then you can have the patient, rather than forcing answers in your office in half an hour, you have two to three months where you can just test this out. You can fly home or go home and you can test it out day and night for one season and, "Do you like this or not?" If that's the case, then great. Then we have an even better answer as to whether increasing tissue volume, replacing tissue volume in your turbinate area will assist you.
Then sometimes patients can get repeat gel injections, and that really helps them and that's all they need. I have several patients like that. No problem. Now the patient says, they're like, "I can't come back for those repeat injections. I just want you to make it more permanent." Then you can do something called a cadaver rib graft, this is what I advocate. We publish on that too, and there's videos on how to do that, now available in public and other journals and YouTube.
That way you can make a submucosal pocket where tissues are missing and place a very fashion piece of cartilage long, three-centimeter piece of cartilage, try and replace that turbinate stock, trying to replace that contour where again, all mammals seem to need it, and that you're trying to replace as many of the turbinates as possible, especially in the inferior one-third of the nose.
Turbinate Reduction Surgical Techniques to Reduce Risk of Empty Nose Syndrome
Dr. Nayak shares his unique approach to turbinate reduction surgery, aiming to reduce the size of the turbinate while maintaining its shape and position. In order to reduce the risk of Empty Nose syndrome, Dr. Nayak advocates for standardization of turbinate reduction techniques and draws attention to the current lack of consistency in the field. Dr. Nayak believes that Empty Nose Syndrome is a preventable consequence of surgery, rather than a neurological condition and calls his colleagues to challenge their own beliefs on the topic.
[Dr. Ashley Agan]
Two questions for you then. Does technique and technology even matter then? Meaning, is submucous resection better than just trimming externally? Is the coblator better than the microdebrider or do any of those factors really matter?
[Dr. Jayakar Nayak]
Well maybe I can tell you what I do and then I can tell you what I've seen.
[Dr. Ashley Agan]
Okay.
[Dr. Jayakar Nayak]
What I do is, again, go for that goal of reducing this caliber of the turbinate, reducing the size of the turbinate, while keeping it in shape and position. What I do is I make an incision in the anterior head of the turbinate, either with a blade or actually with a low setting of a needle-tip cautery. I then find the bone of the turbinate and the turbinate is one of those soft tissue structures that has a bone in the center of it. You can find this bony plane and like a septoplasty, raise a flap, and I raise this medial flap.
The turbinate is a very interesting structure. It has a medial flap which is closest to the septum. It has a central bone and then a lateral flap, which is closest to the maxillary sinus. The medial flap is three or four times the width in the depth of the lateral flap. Basically, you don't want to touch the lateral flap. I try not to ever touch that really ever at all.
Once I have this plain elevated like a septoplasty, then I actually take some of the turbinate bone itself with a pediatric, what we call a small forceps instrument, and I leave the bone that attaches it to the side wall. I leave the superior part of that turbinate bone, but I take out the central meaty part of the turbinate bone. You see this on a CAT scan.
Some patients just have a lot of turbinate bone and that's the reason they have turbinate hypertrophy or at least a big common of turbinate hypertrophy. It's actually not soft tissue, but actually bony. I think that's really important to know and I think all of us at Stanford actually, do limit it to substantial bone resection within the turbinate.
Now we have this submucosal channel, so it's all submucosal, by the way, and this dissection I'm talking about. I try to leave the surface tissue entirely intact. Then I use a pediatric microdebrider, the 2.0 millimeter turbinate blade for microdebrider use. I just shave from posterior to anterior, a superior channel within this submucosal tunnel on the medial flap only. And then a central channel and then an inferior channel and trying to really reduce the thickness of that medial flap, making it more like a lateral flap. I try to never get a hole, ideally, a tear in a turbine flap.
I only go to the front anterior two-thirds of the length of the turbinate. I never really shave or do this microdebrider submucosal reduction in the posterior one-third because that's where the artery is. I've had a few turbinate bleeds in my time.
Then with that all done and now, we have a much more reduced turbinate from the partial bone resection and from medial flap reduction, and then put a little FloSeal or surgicel in that pocket so to avoid bleeding, sew up the anterior head. Now I have a very nice airway. I would usually have already done the septoplasty if they need it first. Now I can almost completely see the choanae and I can see from the nostril rim all the way to the choanae. Then what I'll do is, I'll use a radiofrequency ablation wand. I'm testing out another device for-- There are two or three types of radiofrequency ablation out there. I'll put a radiofrequency wand, it's a thermal wand almost into the posterior one-third of the turbinate where that artery is, just reduce that posterior aspect to avoid that problem I had mentioned before, about residual posterior turbinate hypertrophy.
Now I have a nicely symmetrically reduced turbinate from front to back. That's my technique. It takes about 20- 25 minutes per turbinate. It's a pretty involved procedure. I think what I did in residency was a five-minute-- Intending to leave the room, call me when the next patient's ready, just a very rapid turbinate reduction. It's no one's fault. It was just that's how I think, the turbinate was treated. I just quickly reduced the turbinate and get out of there.
I actually think it's one of the most important parts of the surgery because of the things I mentioned before about how to avoid empty nose syndrome, avoiding tissue loss. I think that my numbers speak for themselves. I think that having 3,000 plus turbinate reductions, that means about 1,500 patients who have turbinate reductions and 2 sides each. You actually usually do both. That's how I got to 3,000. So it's 1,500 patients, 3,000 turbinate reductions.
I think I've gotten tissue loss unexpectedly in about three of those patients. Why that happened, I don't know. Because of the same surgery and the same patient on the same day and the right turbinate looked awesome, but somehow the left turbinate had a little bit of a scar to it or a little bit of a buckle to it or something like that, where you could tell that they had little difference in how they were breathing. They were satisfied on the right side, for example, and maybe not on the left side. They might've said something like, "I don't know. I feel more blocked on that side." "Really? You're pretty open."
That's that paradoxical nasal obstruction named empty nose syndrome. You're saying you're congested, even though you look pretty open, but then I just usually leave it. We just had surgery, we'll see you in six months, things like that. Many times those symptoms thankfully resolve or sort themselves out. In general, they're getting a new sense of their airways, like, "Okay, I know I'm breathing better. I know I'm sleeping better," things like that, and "Generally, I'm improved."
In two cases, I think, I've had to do something about the empty nose syndrome part of it, and I could talk to you about that. That's what I've seen and that's what I do.
Now, the problem I think with turbinate reduction surgery is that I think we should get to a goal of hopefully, in the next 20 years, where I think I'll have to retire anyway. Around 20 years time, where we try to get a little bit more standardized in how we reduce turbinates. If you go around the world, there are 20 ways to skin a turbinate. You can use scissors. You can use direct cautery on the turbinate surface. You can do coblader. You can do radiofrequency ablation technique number 1, number 2, number 3. You can do a combination of those things.
Again, cardiac surgery. I think there's two or three ways to sew a valve. If you don't do it that way, it's like, what are you doing? As we do this, and as we hopefully appreciate that empty nose syndrome exists and that it's an avoidable issue, it's an avoidable circumstance.
If we just respect that principle that all mammals need six turbinates, and we should try to keep that shape and size and that contour, you'll avoid this dreaded issue and these dreaded symptoms in patients and have more satisfied patients. If we just keep the shape and structure, just reduce its size, then I think there should be two to four techniques out there that we all use in the world, wherever country we're in, as the accepted standard for how we reduce turbinates in a general sense. Again, unfortunately, doctors will do what their mentors taught them, and that's how we do it, but still, there should be the data out there.
Hopefully, with time and with institutions doing evidence-based medicine and taking on literature and reading it and stuff like that, it'll permeate. Those practitioners who swore by their technique that may have led to some empty nose syndrome patients, wherever it might be, well, eventually we do retire, no matter what. I think the data speaks for itself.
We have 18 publications or 20 or something on empty nose syndrome, and there are others out there from Korea, from Europe, that to say that empty nose syndrome is something you don't believe in, or to say that "Empty nose syndrome doesn't exist, and I think that's a neurologic disease," I think that at this point, with the data that's out there in the last 10 years, that's head in the sand thinking, that your procedure may or may not have contributed to it, that it's all in a patient's head. That just doesn't work anymore because the data's so strong that turbinate surgery and over-section or some aspect of turbinate surgery may have led to this. There are simple ways, I think, of addressing empty nose syndrome sometimes, and more complicated ways, but again, it's all out there and published.
[Dr. Ashley Agan]
Let's get into it. How soon after turbinate surgery will a patient present with empty nose? You had mentioned the cotton test earlier, and if you could explain that to us?
Podcast Contributors
Dr. Jayakar Nayak
Dr. Jaykar Nayak is a a professor of otolaryngology head and neck surgery at Stanford in Palo Alto, California.
Dr. Ashley Agan
Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, February 14). Ep. 89 – Turbinates, Nasal Congestion, and the Dreaded Empty Nose [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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