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BackTable / ENT / Podcast / Transcript #89

Podcast Transcript: Turbinates, Nasal Congestion, and the Dreaded Empty Nose

with Dr. Jayakar Nayak

In this episode of BackTable ENT, Dr. Shah and Dr. Agan discuss turbinate hypertrophy, turbinate reduction, and empty nose syndrome with Dr. Jayakar V. Nayak, associate professor of otolaryngology at Stanford University. You can read the full transcript below and listen to this episode here on

Table of Contents

(1) The Anatomy and Impact of the Turbinates

(2) Nasal Vestibular Swell Bodies

(3) Clinical Presentation and Procedure

(4) The Importance of Nasal Regimens

(5) Conservative Measures and Treatment Progression

(6) Defining Empty Nose Syndrome

(7) Empty Nose Syndrome Symptomology

(8) Surgical Techniques to Avoid Open Nose Syndrome

(9) Diagnosing Empty Nose Syndrome: The Cotton Test

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Turbinates, Nasal Congestion, and the Dreaded Empty Nose with Dr. Jayakar Nayak on the BackTable ENT Podcast)
Ep 89 Turbinates, Nasal Congestion, and the Dreaded Empty Nose with Dr. Jayakar Nayak
00:00 / 01:04

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[Dr. Ashley Agan]
Hey, everybody. Welcome to the podcast. I'm Ashley Agan. I'm a general ENT.

[Dr. Gopi Shah]
My name is Gopi Shah. I'm a pediatric ENT. How are you doing today, Ash?

[Dr. Ashley Agan]
Doing great, Gopi. Always a great day to be podcasting with you. Today, with us as our guest, we have Dr. Jayakar Nayak. He is an associate professor of otolaryngology at Stanford and specializes in rhinology and school-based surgery. He's a surgeon-scientist and heads an NIH R01-funded basic science and translational research lab with three main areas of interest, including the use of nasal stem cells to treat airway disease, nasal epithelial responses following SARS-CoV-2 infection, and improving surgical procedures to optimize outcomes for nasal and sinus procedures. He's here today to talk to us about nasal breathing, nasophysiology, the evaluation and treatment of the empty nose syndrome. Welcome to the show, Jayakar.

[Dr. Jayakar Nayak]
Hey, pleasure to meet you. Thanks for inviting me to the show.

[Dr. Gopi Shah]
Thanks for coming on. Can you first just tell us a little bit about yourself and your practice?

[Dr. Jayakar Nayak]
Sure, yes. I've been part of the Stanford faculty for about 12 years now. Started in the East Coast where I grew up in New Jersey, college at University of Pennsylvania. Studied Neuroscience there, quickly got out of that, and pursued more basic science, and actually then clinical interests, in an MD-PhD program, which is this dual degree program because you're not sure if you want to do medicine research. I think I wanted to do both. My PhD was in immunology, and studying the immune responses to cancer. I then didn't realize my interest in surgery, but they developed quickly at a place like Pittsburgh, which is a very strong program I'd say in otolaryngology and all surgery specialties, actually.
Then finished, went into the program in ENT or otolaryngology in Pittsburgh. There I then garnered an interest in sinus and skull base disorders called rhinology, so I then pursued a rhinology fellowship back at the University of Pennsylvania. Went ahead and finished that, and finishing that fellowship year, really became super excited about this area of the nose, or the upper airway, sometimes we call it, and was recruited to Stanford here now. Again, 12 years ago, where I pursued both this medical and surgical interest in nasal and sinus problems.

Sometimes I work in neurosurgery to tackle the skull base tumors and pathology that intersect the junction between the nose and the brain. Then I've kept my interest in science alive with data science and translational efforts looking at, again, as you just mentioned, some of this nasal epithelial biology, both on the stem cell side, the epithelial side, and the immunology side. Looking at multiple facets of how the upper airway immune system and lining of the nose help us interact with the environment, and help us promote and form defenses against pathogens, and things like that. Again, thanks for having me on. It's great to be here.

[Dr. Ashley Agan]
Yes, fantastic. We've got some questions for you, sir. You are the expert today.

[Dr. Jayakar Nayak]
Sounds great. Happy to fill them.

(1) The Anatomy and Impact of the Turbinates

[Dr. Ashley Agan]
Let's just set the stage. When we're talking about the nose, and nasal obstruction, and the anatomy we're talking about, talk to us about the nasal turbinates, the nasal cycle, the nasal vestibular swell body, or swell bodies, or nasal turbinates, what's going on in the nose? What's all that stuff in there for, and how does it relate to how we're breathing?

[Dr. Jayakar Nayak]
Right. Thanks for the very broad and open-ended question. That's very sweet of you. No, it's really early morning on Saturday for this. In terms of just nasal breathing, one of the things that rhinologists, and general otolaryngologists, and pediatric otolaryngologists see is one of the major complaints that patients come in for is, "I can't breathe through my nose. My nose is congested. My nose is stuffy." We have a job of trying to figure out why that might be. There are so many reasons patients can have nasal obstruction, we'll just call it that for ease.

Nasal obstruction can be from something like a deviated septum. The septum is the midline central wall of our nose, ideally would be central and divide our nose into left and right sides evenly, but many times that structure is crooked. That wall is bent to the left, to the right, actually to both sides. Sometimes that wall is fractured from trauma, or from a sports injury, things like that. That's one major and very common reason for nasal obstruction. Two are nasal polyps. Growths in the nose, inflammatory growths in the nose that can block either left or both nasal cavities.

In kids, adenoids. Adenoids are in the very back of the nose, and that can lead to blockage of air passage from the nose into the throat and lungs. Another major component of nasal breathing are these other dynamic structures in the nose called turbinates, and what we termed the nasal vestibular bodies, back in 2016. We actually coined that term. The turbinates are these shelf-like structures, torpedo-shaped structures that hang, in many cases, from the side walls of the nose, which are the inferior turbinates, and are pendant-like chandeliers into the airway, and the lower part of the nose.

Those are the inferior turbinates. There are two sets of turbinates in the central part of the nose called the middle turbinates, and two others that are even higher in the nose, and they are called the superior turbinates. Those two turbinates are more attached to the skull base centrally and superiorly. Again, all three, though, hang and are suspended within the nose. They are directly involved in our airflow and in the sensation of airflow. I think one of the remarkable facts about turbinates is that all mammals have turbinates. All mammals have at least six turbinates.

The inferior ones are the ones that are just behind our nostrils. Again, there's these finger-like or torpedo-like structures that are about 5 centimeters long from front to back. The middle turbinates, again, are higher, and then superior turbinates are higher than that, but the six sets of turbinates are on all species, and they must be there for a reason. Through evolution and development, all mammal species have evolved this mechanism for breathing through the nose through this tubular torpedo-like structure. Now, the lower mammals have more turbinates.

They're called ethmoturbinals, they're in the back of the nose because other lower vertebrates are more dependent on sense of smell, so those more turbinates are thought to be more involved in smell. We've lost those other turbinates because we are thought to have more dependence on sight and sound. At least those six turbinates are preserved throughout so many species, so, again, their importance must be there. With that said, the lower turbinates, those inferior turbinates in humans, I think more than any other species, I don't know about the other species too well, the inferior turbinates somehow tend to swell or hypertrophy in humans.

Because they're right behind the nostrils, they can completely congest or obstruct the nose, and they tend to take a life on their own. This is a major and very common cause of nasal obstruction in patients. Understanding what are the actual cause of that nasal obstruction, again, it could be multifactorial, or sometimes just one cause, but turbinate hypertrophy is extremely common as a cause for nasal obstruction. Then finally, we identified one because I see so many patients with nasal obstruction, and now empty nose syndrome, which we're going to talk about.

These are little swell bodies that I started to see so commonly in some patients with persistent and recalcitrant nasal obstruction. Then these swell bodies are more towards the nasal floor, if you look at the nose from the front, if you think of the nostril like a clock, the six o'clock position of the nostril, or the four o'clock, and the eight o'clock positions of the nostril in a way. Just in the corner, just behind the nostril, there's these swell bodies that tend to form. A good number of patients, about 25% to 30% of patients have these little swell bodies too.

That can naturally also take up some of the room of your nostril, just like a turbinate can, and just like a deviated septum can. Any of those things can contribute to your sense of poor airflow or a lack of airflow. In the end, you've asked me what these structures are, so I think I try to define what the general makeup is from the nasal obstruction, and what can contribute to it. Then, what the turbinates actually do, we learn in residency that the turbinates are there to filter airflow. They filter pollutants, bacteria, and viruses. They're our first screen for air from our nose to get trapped into the mucus so that those particles don't end up in your lungs and trachea.

That's one. Two, because the turbinates have such a good blood supply, and all of the tissue in our nose is pink compared to the skin, the skin is a different texture to it, and different color to it because the vessels are a little lower. In the nose, the tissue is pink because the vessels are so close to the surface. It's a very thin epithelium compared to the skin on our hands and feet. Because of that, therefore, the blood supply and the air that enters our nose can be warmed more easily because it comes in closer contact to the mucosa of the nose, the pink tissue of the nose.

It's thought that the nasal tissues, and the turbinates, and the general nasal mucosa warms the air that we breathe. That's another function of the nose, and the nasal physiology, and turbinates. We've also found that, from our research, it seems to be that another role of the turbinate is actually almost serving as a magnet for airflow so that the air is actually attracted to these. Especially in the lowest four structures, the two inferior turbinates left and right, the two middle turbinates left and right. Absence of one of those turbinates actually leads to very aberrant airflow because the magnet is gone, and then airflow is distributed in an abnormal way.

Whereas when the turbinate is present, it almost attracts air to it. It must be because of its tubular structure and tubular appearance. That must be part of the nasal physiology again because its absence in some patients, not all patients, can lead to very aberrant and uncomfortable airflow.

[Dr. Ashley Agan]
You mentioned nasal vestibular swell bodies on the floor and anteriorly. What about the swell bodies that we talk about sometimes on the septum? Is that a thing, if you will, as well? Is that recent, or does that contribute to nasal airflow or obstruction?

(2) Nasal Vestibular Swell Bodies

[Dr. Jayakar Nayak]
Great question. We coined the term nasal vestibular body based on that previously coined term called the septal body. The nasal septum there, you can have multiple swell bodies in the nose, I should say that, throughout the length of the septum. I have such a variety of patients out there now who see me for persistent nasal obstruction, and complex nasal obstruction issues. I have seen swell bodies throughout the length of the posterior septum, which isn't something we learn about, the central septum, but the septal body is this anterior or front of the nose, superior, top of the nose swelling that can happen 2 centimeters in, and 2 centimeters superiorly to the nostril.

Yes, it can. I've seen some patients that have such a large septal swell body that it seems to obstruct and almost descend towards the nostril and contribute to nasal obstruction. When I decongest that structure with some topical decongestants we have in the office, and only that structure, some patients will say, "Wow, that's so much better. I can breathe so much better." Again, people can have multiple components to this, but the fact is that airflow typically happens in the lowest one-third in the nose. The majority of airflow happens in the lowest one-third of the nose, which is basically, if you think of the nose in thirds, the lower part of the nostril to the top of the nostril, they'll call that one-third.

That part, to the bottom of your eyes, another third, and there's a top third above that. Most of the airflow happens in the lowest one-third of the nose. If you looked at the vectors of airflow that are modeled in computer modeling, it's in the lowest one-third of the nose, and maybe the lowest part of the second third. That means right around the nostril area, right around the inferior turbinates, and just the base of the middle turbinates, that's where most of the airflow goes. The septal body, therefore, is usually above that. It's not really always involved in airflow, but it can be when it's enlarged enough.

Similarly, the middle turbinates aren't extremely involved in airflow. Maybe 10% to 20% of the airflow versus 80% in the lower 1/3 of the nose. Some people have enlarged middle turbinates, now that descend and can really compress or restrict the airflow so that even a middle turbinate can be part of that. I'd say the majority of patients, it's mostly inferior turbinates. If there's a septal deviation or crookedness that's there or a polyp that descends all the way into the lower one-third of your nose, those are the things that'll contribute to true nasal obstruction.

[Dr. Ashley Agan]
For these swell bodies that develop, is there a hypothesis or a known reason why some people are developing these, it's almost like extra turbinate tissue in the nose, is it? What's the thought?

[Dr. Jayakar Nayak]
Yes, no, it's a great question. I don't think we know. We actually are looking at the histology of that nasal vestibular body, and towards the floor of the nose, and these front corners of the nose. The histology seems to be similar to turbinate tissue and to especially the septal swell body tissue, just an area of a buildup of some piloerector tissue, some just excessive soft tissue. It's dynamic because there's definitely some vessels in that, that swell and unswell. All of these structures that I was mentioning before are not static structures.

The turbinates can swell and unswell, and there's something called diurnal variation of the nose that you learn also when you do our specialty, where the left side turbinate might swell every 8 to 12 to 16 hours. If that's happening, then the opposite turbinate, the right turbinate, is shrinking. Similarly, if you take a CAT scan of that patient, then one day later it might be the opposite, where now the right turbinate has hypertrophied and the left turbinate has shrunk down. There's clearly some sympathetic or parasympathetic innervation to those turbinates that are providing this alternating variation, left side, and right side.

Some patients can even notice this. I've never noticed nasal obstruction on either side at any time except for standard viral cold or rhinovirus, URI. Other than that, my turbinates are swelling and unswelling on the left and right sides, and yours might be too, but I don't notice it. Some patients they'll say, "I notice right away I'm always blocked on my left side and tomorrow, it's going to be the right side." If they sleep on a certain side, the side that's down towards the pillow, congests more. "I've switched to the side that I'm sleeping on, and that side congests."

Sometimes that means they're extremely aware of this. One thing about the nose that will always be the case I think, is the nose is a very subjective place. You might have the most severe 100% blockage of your nose on the left side from a severe cartilage and bone septal deviation. Some patients will say, "I can't breathe through my left side. I hate my left side of breathing." Then you survey another 50 patients, and they'll say, "I love my breathing. I have no breathing problems whatsoever," even though they had the same degree of obstruction. That's because they're breathing so well through the right side, they never noticed their left side.

That happens frequently. Some people have severe turbinate hypertrophy, and they'll swear that they've never had a breathing problem, they don't snore. They've never had complaints about any aspect of their breathing, and they're completely fine.

[Dr. Ashley Agan]
You'd mentioned the diurnal system, the subjective sensation when patients come in and they say they sleep on one side. I don't really know how to explain, I don't think I really understand when they come to me with that kind of complaint. How do you respond to patients with some of those observations that they have? You know they have those symptoms, but I don't always know how to say why they have those symptoms.

[Dr. Jayakar Nayak]
Yes. First, the nose has so many differences between every individual compared to other structures. Let's just say just compared to the heart. The heart is such a tightly regulated and tightly defined structure. It's a structure that's within our chest, behind skin, muscle, bone, ribs. It's always roughly the same size and roughly the same angle and position. It has chambers and the valves are even the same size in virtually everybody, virtually all adults, and so when you have a valve problem, everyone has the same physiology.

Everyone is going to have some kind of heart issue. They're going to have weakness, fatigue. You'll need to see a doctor, you might need a procedure done. Also, surgery for the heart is very well-defined. There's so much more research and thousands of doctors who do research every year compared to ENT specialties, or there aren't many labs, and that much research going on. Again, the idea being that that's a tightly regulated system by size, by physiology, by even constants, numerics. We know about all the blood flow and chambers and strength, and so many aspects of cardiac physiology and flow.

Compare that to the nose where you just look around any room, the nostril size is different in everybody. The nasal shape is different. Some people have curved and angled noses. Some people have broad nostrils and longer noses, wider noses, smaller noses. Similarly, we have all these variables of deviated septum and turbinate enlargement or not, some people have surgery or not. The point is, I think that the airflow is so different for everybody. Also, what's going to happen and what's going to affect my ability to breathe through my nose is how much lung capacity I have.

If I have, my lungs don't work so well, then I'm not expecting to breathe so well through my nose. You're used to that, and you just get used to those things. Again, I think so many variables go into our nose shape, anatomy structure, and airflow that I think that as a result, everyone's sensation of airflow, and what they get used to is so subjectively different. That's one. Then I think that we don't know too much about this yet, but the innovation that I think people have and the receptors people have for that sense of airflow might be very different in individuals.

That some people seem to be extremely sensitive to little changes in the airflow. It might be some of those patients I mentioned before, that they notice the left side versus right side. Others don't. Some people we know are very hypersensitive to perfumes and changes in the environment and the humidity. "I know right away I'm going to get congested today." I've never felt that. I don't have that kind of barometer that's so tightly tuned. In any case, I think that there might be those kinds of receptor changes and differences between people, that again, make us different and just individual.

Those things will be ferreted out with time, but for now, I think that's, it's just something that we accept. Similarly, we accept other variations. If you have fingers that are different sizes, you just get used to it. It's not like there's anything wrong with you. It is just considered a variation in the size of certain parts of your body. It's okay, it's within the normal range. I think that also it is something that we just learn to get used to. If we get that used to in our hands and our joints, then we probably get used to it with our nose.

(3) Clinical Presentation and Procedure

[Dr. Ashley Agan]
Yes, that makes sense. Moving on towards clinical presentation, when patients come to you, what are some of the main complaints, or how do they present that? More importantly, what are you always asking in the history? What are some of the things that you always remember to ask your patients?

[Dr. Jayakar Nayak]
When patients come to see me, there are, again, I have a wide range of patients. I do have some primary patients who may have heard about me, or they want to see a Dr. Stanford, and they've never had surgery in their nose. Just yesterday, I saw someone who had a surgery she was very unhappy with, from another state, and I've had other patients who come in after nine surgeries in their nose. Either way, you try to assess everyone in the same general capacity. What specifically are your symptoms? Are they left-sided primarily, right-sided primarily, or you just can't tell? You want to see what their nasal regimen is. Are they doing anything that makes them feel better?

Saline rinses, nasal steroid sprays, a combination of sprays. Some patients are using moisturizer in their nose, ointments, or certain gels, things like that. Naturally, you want to know about any past surgeries, past procedures, trauma to the nose. Then, what generally is their goal? Maybe they came in because they had a recent diagnosis of sleep apnea, and they actually have no nasal obstruction, but they were told that their nose is a problem because they can't tolerate the CPAP mask for positive pressure. You may have to find out maybe what you can do to help them just tolerate their CPAP mask more. Sometimes that's not a nasal obstruction complaint, that's, "I came here because my doctor told me to come here." Those are a range of things I think that are important to suss out when you're meeting a patient.

[Dr. Ashley Agan]
On your exam, are you scoping every patient that comes in? Do you always decongest?

[Dr. Jayakar Nayak]
Actually, to go back to the last question, the one thing I also try to figure out is what helps them, and again, what their nasal regimen is. Does Afrin help them or not? Does a nasal decongestant like Afrin or something called major decongestant? There are multiple decongestants out there. Does that help them, or do they feel worse on that? That really helps to put them into a category of that tissue enlargement is causing their problem. Therefore, tissue shrinking from Afrin or a decongestant, really impacts their quality of life, impacts their sleep.

That's a big aspect of what you can learn from someone just from interviewing them without even looking in their nose. Now, in the Stanford rhinology practice, because the patients have both sinus and nasal problems, I rarely use a nasal speculum anymore. Virtually everybody in my practice gets an endoscopy. Everyone gets an endoscopy of the anterior nasal cavity, left side and right side, prior to any decongestant. I see every new patient negative, no spray of any kind. Just want to see that vestibular bodies are present or absent. The presence of hypertrophy even to the anterior head of the turbinate, presence of caudal or anterior septal deviation on the left side or right side.

Then once that's documented and everything is archived, we have photo documentation of everything, and it's saved on our servers. Then after that, if they, for example, have empty nose syndrome or something like that that I have to test, then I'll do a cotton test, which we can get into. If they don't, and it's just standard nasal obstruction or sleep apnea, or something like that, then I will put in a topical decongestant. I try to do it on a cotton swab or a pledget because I don't want the spray going globally. I just want to address that lower one-third nasal obstruction.

I try to put cotton pledgets and decongestant on the turbinates and on the swell bodies, and then leave them in for only a minute and a half or so, and then take them out. Then I ask if patients are feeling better. They usually don't know what I'm doing. I ask them to just trust me because I want them to just not be biased by everything I'm doing. Just, "I did something to your nose. Do you like it or not?" Many times they're just amazed. They've never tried Afrin, and they're like, "Yes, I love this. I love this breathing. This is exactly how I want to breathe.

This is amazing." That kind of thing. That's great because they're not really know what's coming. They just heard that I'm the doctor to see or I'm one of the doctors to see. They have an experience that they know is very beneficial for them, which is great. Then from there, we can decide what the best pathway is for them. Now, some patients, that's why you do it, they will say to you, "No, I feel exactly the same with Afrin." "Okay, so great. I just needed to know that. Then let's figure out what else might be the problem." They do find other pathology that might be there. It might be, again, a completely different issue than you were expecting at the time. Then, of course, some patients come in with imaging, so, yes, we're going to analyze that imaging. In those cases, CAT scans or MRIs. That will help you determine where the issue might be.

[Dr. Ashley Agan]

Can we go back to how you decongest the nose? You're not spraying the Afrin. Are you using the sinus surgery pledgets, the long, 1 by 3 pledgets, dip it in the Afrin, and then, with a bayonet, packing the nose? Is that what you mean?

[Dr. Jayakar Nayak]
The truth be told, I actually even like cotton balls that I unroll. They come in like a little rolled confirmation. In any case, I just separate them out, and I make my own pledgets that are 2 centimeters by 1 centimeter. I just like them a lot better because they're just softer and not the woven cotton that you get in these surgical pledgets that we use in the operating room. They have a string on them. I just don't do it that way. I just make these pledgets beforehand. Then having these little containers, so each patient gets a container that has just decongestant in it, like Afrin, for example, or phenylephrine.

That'll just place with a bayonet, right onto the turbinates, and then I'll just ask them if they're breathing better. Then separately, I'll decongest separately with a smaller pledget, the nasal vesicular body on the left side and right side. Then ask them, "Okay, are you better by 50% with a turbinate, or now, are you better or not with the second thing we did?" Sometimes they'll say no. Sometimes they'll say, "Absolutely." Things like that. I just try to even ferret out and try to investigate, is it just your turbinate hypertrophy that's causing your obstruction on your left side or right side? Is it just your swell body on the left side or right side that's contributing to, again, your sense of nasal obstruction?

Then again, do you enjoy this or not? They'll be decongested for about two or three hours after you place that in. Then they get to experience that for a few hours at least on their drive home, or hotel, or wherever. Yes, that's how I like to do it. The reason is that sometimes our sprays, especially if the spray has lidocaine in it, patients just don't like it. So much of the visit is sometimes spent like, "I don't know, my throat is really uncomfortable." They're coughing and hacking, and they need water. [chuckles] All this extra spray goes down the throat, and it just turns into this slightly traumatic experience and visit.

I'd rather just keep it at nasal as much as possible and just talk about the nasal problem and not deal with this little dripping of the posterior throat and swelling to the throat that they feel. Anyway, I'm just trying to make it as clean as possible, but it does take time to do it.

[Dr. Ashley Agan]
How long do you leave them in there for?

[Dr. Jayakar Nayak]
I leave them in there for about a minute, maybe a minute each side. Then I'm always alternating sides, so then I'll take it out. I'll put it in the left side, then I'll put it in the right side. Then we'll talk for 30 seconds, we'll get into a little part of history. Then I'll take it out of the left side and right side. Then I'll take pictures again, by the way. I'll do another photo documentation of them after decongestion. You'll see that some patients even need two rounds of decongestion. Their turbinates are so huge or their swell body is so huge, they have to do a second round.

Then they're like, "Yes, oh, I didn't even feel that. Whenever any doctor did this, it was only 10% better. Now you did this twice, and you took the time to do that, now I see." That's because many patients have central and posterior turbinate hypertrophy that the first pledget couldn't even get to. The first pledget was placed in the first 2 centimeters. Now that you can see that first 2 centimeters, and you should take a photo of that, oh, I see, I still can't see the choanae. I can't see the back of the nose. All right, let's try again, so then I put a second pledget deeper in.

Now I decongest the entire length of the 5-centimeter turbinate on both sides. They're like, "Oh, that is some of the best breathing I've had in years or so." Then you can really say, okay, they have nasal obstruction from, just anterior head hypertrophy of the turbinate, which is that front part of the turbinate, or the central or the posterior. I'd say actually, with some of the redo and recalcitrant patients that I have seen over the years, many of whom thought they have empty nose syndrome, for example, it turns out that just looking in their nose as a new observer and analyzer of what's happening to them, many of these patients who don't like their breathing, and they, again, subjectively think they have this empty nose syndrome problem, a good fraction of them just have posterior turbinate hypertrophy.

That's it. They came for miles and sometimes other states and everything for that. All I do is decongest their nose, but before, because surgery helped give them this conundrum, then, in that case, I'll ask them to use Afrin at home once a week. Just once a week because your nose can get addicted to Afrin. I just have them spray in this decongestant spray on their own. Just continue your nasal regimen six days of the week, but every Sunday, I want you to document for me, with a spreadsheet, what your symptoms were 0 to 10 during the 6 days.

Then on the seventh day, when you used the Afrin, how was your nasal obstruction symptom on the left side or right side? If it every time improves to a lower number, lower for me is better on a number scale, then great. Then I think we've proven that even in your home environment in Nevada, in Southern California, in the Bay Area, in New York, wherever they're coming from, okay, that where you live, you have the same experience that you had in my office. Okay, then it is posterior turbinate hypertrophy. I think we were right about that. Then we can talk about what to do about that. I do think that just that little test is just underutilized. I think we're sometimes under-analyzing the patients' nasal cavities.

(4) The Importance of Nasal Regimens

[Dr. Ashley Agan]
Let's go into nasal regimens. I typically think of saline, I think of some Flonase. Do you have an algorithm, or what do you like to have patients try, or what do you think helps, doesn't help if they've done the Flonase or Dymista and that doesn't work? What's your regimen?

[Dr. Jayakar Nayak]
I usually say to patients that being on some kind of nasal regimen is just necessary for us to assess what the best things are that'll help you. At the minimum, they need to be on a nasal regimen because if we do a procedure, saline spray is going to be part of their care and part of their healing process, so they should get used to being on a regimen anyway. What's important in a nasal regimen, is a nasal saline of any type. Frequent use of saline mist, frequent use of Ocean spray, Deep Sea spray. Those are just little spritzer bottles of salt water or a NeilMed or similar type of saline rinse where patients mix it themselves with an 8-ounce bottle of clean water, and they put in a salt packet that's buffed with both sodium bicarbonate and salt.

[Dr. Ashley Agan]
Do you think sinus rinses that we're talking about now is better for the turbinate hypertrophy nasal obstruction patients, or do you think saline mist or drops are the same or enough?

[Dr. Jayakar Nayak]
I don't know. That's a great question. I don't think anyone knows. I personally feel like just anything that they're putting in their nose that's saline is better than not putting it in. I think that as long as you're doing it-- There are some patients who just insist that nasal rinses go up their ear, making them uncomfortable, so I'd rather them do some kind of saline like a mist than not. I do think that larger volume rinses have changed rhinology practice. Every study that's ever looked at nasal saline has shown benefit. I think thousands of surgeries have probably been canceled or postponed because patients have benefitted from the use of nasal saline.

I just think of it just as a generic wash for the nose. I think of it like, and I would describe it as brushing your teeth. You feel better after brushing your teeth. You feel a little more sanitary, a little better, a little cleaner, and I think that clearing out mucus from the nose, for a lot of patients, is great with the saline. Also, water is thought to be-- Follow the salt water. A little bit of salt water outside of the tissues will draw fluid away from the tissues, and hopefully, reduce hypertrophy even for a short amount of time, reduce some of the swelling from the tissues and the nose. I think a larger volume is always better, but again, it's in terms of patient tolerance. If you're dealing with children, it's hard to get any kind of spray in the nose, so we'll take anything.

[Dr. Ashley Agan]
I tell them it's like brushing their teeth or flossing. Their rinses are my flossing. If I don't floss, I get cavities. That's just me. If they aren't rinsing, we're going to have boogers. They're going to be everywhere, just what it is.

[Dr. Jayakar Nayak]
Right, no, there you go. Anyway, I think that saline is the main safe care no matter what. Just, it's been around for thousands of years, and there's nothing you have to worry about. There are so many patients who ask about the side effects of every medication and everything. This is not a medication even. This is just a home remedy that's been around for thousands of years. We use it, it's safe. Then I always have a recommended nasal steroid spray of some kind. Similarly, there are spritzer bottles like the three over-the-counter ones of Flonase, Nasacort, and Rhinocort.

There are about seven plus prescription ones. Whatever is best for the patient is fine. They're all just different variants of steroids, just different slight versions, and percentages of steroids, so, the user's choice on if they want to go over-the-counter. If their insurance covers whatever spray, I'll use that.

[Dr. Ashley Agan]
Does your body get used to them? Do you have to change the amount every six months, or do you believe in that?

[Dr. Jayakar Nayak]
Yes. I usually start with some of the generics and the over-the-counter ones. Some patients feel like it wasn't working for them, and then like the Flonase stopped working for them for some reason. Then sure, we can try that. I don't know if it's well documented that there's tolerance to these medications. They're just considered to be standard, tens of thousands of patients have been studied over decades, that is, so we know it's safe. I don't think that there's a tolerance per se to any of these medications. They're such low concentration.

There's 0.25% steroid in these bottles. That's why they're probably so much less harm in general, but it's a rare patient who comes in and says that. It's also a rare patient that comes in, and they do say this, that when they use X nasal steroid spray, "I get palpitations, I get jittery. I can't." I'm like, "1 in 1,000." I'll say that, but they'll say it, and then you have to adjust. It might be true. Initially, I dismissed it, but again, enough patients have said it over the years, I was like, "Okay, maybe it's true."

The other thing is that I try to put patients on topical, actually rinses again. Then I try to get two birds with one stone. I put saline rinses that they've made at home, the NeilMed squeeze bottle is the most commonly known I'm pretty sure. Then you add in a budesonide steroid or mometasone steroid to it. budesonide is easily found. It's FDA-approved for asthma and reactive airway disease, but most rhinologists I know use it very liberally in the nose or in the sinuses for its utility for post-operative healing, things like that. Beauty of that now wash that had the saline benefit, but also has a slight higher dose steroid in it and higher dose in Flonase, now, you're adding this to the tissues and it's permeating the lower node nasal cavity and that central third of the nasal cavity.

Then I think that's a really good benefit for a lot of patients. I have a lot of patients who said that "Saline and Flonase didn't help me, but saline plus budesonide, that combination rinse really benefited me for pain or for some of this facial pressure, for just nasal congestion, for CPAP working better." I definitely try those things first. For some reason then if we have a known allergy component, I'll add in one of the antihistamine sprays, Astelin or Astepro. That's a great nasal regimen in my book. That they can continue safely for years if they never come back, or if they come from a far distance from Stanford, so don't worry about those as much.

Then if they're on budesonide rinses though, really the data has only been published for six months for safety, so I try not to add people on budesonide rinses except for that short period of time, maybe up to six months or so. Then I try to get them off of that and try to get them on one of the standard regimens of saline plus X nasal steroid spray.

(5) Conservative Measures and Treatment Progression

[Dr. Ashley Agan]
Do you like to see that they've tried something conservative for an X certain amount of time before you start talking about different procedures like turbinate reductions and things, or just depend on the patient?

[Dr. Jayakar Nayak]
I think that no matter what, that it's best for so many reasons to have tried conservative approaches, medical management for any number of reasons in all of our fields probably, but especially in rhinology. One, it's relationship building. I just saw a new patient just yesterday, a new mild sleep apnea diagnosis. Had tried variations of sprays, isolated saline, isolated Flonase a few weeks here, a few weeks there. Then finally came through, but he just never tried anything consistently. It wasn't emphasized to him, and looking at his nose, it looked very blue, almost congested mucosa, very allergic.

I asked him about an allergy history, and he didn't tell me before . He had an allergy testing, his back was beet red from all the allergens he was positive to. He just never tried immunotherapy before. For him, I said, "We have to go back to your allergist. We have to really be on immunotherapy for one or two years because no matter what, if I do a procedure in your nose, you're going to have this baseline inflammation that's going to be present. It's not going to be fair to you. You're going to have probably repeat nasal congestion earlier than you should even after a procedure.

You might be initially better, but I think we're going to be fighting this baseline inflammation. Let's get better, regular use of topical regimen," which is instituted for him, consistent saline followed by nasal steroid spray. He was using Flonase, and he'd never heard of Astelin. I put him on this antihistamine spray. He'll try to use that consistently for the next six months. He'll actually initiate. He was hesitant about immunotherapy. I said, "I just think that it's a mainstay of your care in this case," and at this point, I'll see him in a year, and we'll see where things are.

From there, then I think it's also relationship-building. He knows that I didn't just rush to surgery. I didn't rush to a procedure. He gets on a regimen that I think, for insurance reasons, they would love to see because most patients in my practice try to get insurance coverage for their procedures. That's fine with me, but insurance wants to see that documentation then. Then also, it's just for the fact that procedures can go badly. Procedures can go south sometimes. Again, thankfully it's not that common, but when it is, I think it's nice for anyone to agree to talk to the family or talk to the patients.

They're like, "We tried all the conservative stuff, and so that's why we went to a procedure. I'm sorry that you're having basically that issue, and maybe there's more pain than I told you it would be, or you're having a longer recovery than I thought it would be, but at least we tried everything else, and we all felt your best with Afrin. There's no way I can give you an Afrin consistently because of those addictive properties and those problems. The only way we can get you the Afrin effect is if all the sprays and the nasal regimens and the conservative measures aren't doing it. If that's what we're going for, then we have to talk about the procedures, which can be done in the office or the OR."

[Dr. Ashley Agan]
The steroid, sprays, or the saline, does it help for the swell bodies whether it's the vestibular swell body or the septal swell body?

[Dr. Jayakar Nayak]
No, that's a great question. I don't know. We mostly think about them for the turbinates. I have documented, for some patients, with the photo archiving. I do think that I definitely have 5% to 8% of my patients who have remarkable responses to these sprays, which is also another reason I try them, of course, because they work. They have just good decongestant with regular use of these topical nasal regimens. It's not necessarily extremely common, but for that, let's call it 10% of patients, they're thrilled. There was a simple enough regimen for them to use.

They can do it twice a day just like brushing your teeth, you just get used to it. They have their nasal obstruction is significantly and remarkably improved, and they're in a much better place. That's great, but the actual swell bodies I've seen 20% to 30% of patients even have them to begin with. Septal swell body again is not always part of the airway and part of something that we document very regularly unless it's really descending into the nasal cavity and blocking your view even. I don't know if it's known as much about those. It's hard to directly tell. There are so many of these endoscopic differences you can convince yourself that it's better or worse just by zooming in and zooming out with your scope.

You think that it's bigger, and the swelling might be better or worse. It's hard to standardize some of these "measurements" because a lot of it is just your naked eye but some are very dramatically improved just with sprays, but every structure in the nose, are they improved? I don't know.

[Dr. Ashley Agan]
Like we talked about earlier, even it doesn't matter what it looks like if the patient feels better, sometimes the way it looks doesn't always match up with how they're feeling.

[Dr. Jayakar Nayak]
I agree with that completely. I have some patients who were congested. In fact, I had a lady who'd come in for severe nasal obstruction, "I cannot sleep. I need to do something. Something happened to me in the last two years during COVID. I didn't want to come in during COVID, but now I just can't take it."

I just put her on a standard nasal regimen, everything we just talked about, and then she became pregnant and came back. It was rescheduled for six months. I heard she was pregnant before I walked in the doors, so I assumed now with rhinosinusitis pregnancy, which is usually even worse than the initial nasal obstruction, and she came in just to tell me, thank you.

She is breathing so much better with saline plus budesonide rinse that I put her on. Now she's going to go back to just saline plus Flonase as approved by insurance. She said that she was breathing so much better and sleeping so much better even with pregnancy, and she just wanted me to know.

The solution for people all over the map, I think, it's just worth trying things. To me, when I looked in her nose, it looked just as bad. Just as hypertrophy, just as swollen her turbinates but to her, the main thing with her was at night. Somehow her turbinates were not congesting so much at night, and with turning side to side in bed. That was the first trimester of pregnancy, we'll see if it gets worse, but that's great. That's a great result.

Again, another testament to why we should try topical nasal regimens before performing procedures. They might be faster, there might be some billing benefits to it, who knows? The fact is that by trying those things, it's better for patients. Again, that's a relationship I didn't expect to build. I think she trusts me, and she'll send family to me for a simple standard trial nasal regimen, and it really worked for her.

[Dr. Ashley Agan]
In terms of topical sprays, do you ever do ipratropium or do you have anything else in your armamentarium, like any other tricks that you've used that have helped?

[Dr. Jayakar Nayak]
Oh, I don't know. This is like a divulging secrets podcast.

[Dr. Gopi Shah]
Oh, absolutely. Welcome to BackTable.

[Dr. Jayakar Nayak]
Okay, that's fine. I'll share some of my secrets, I'm kidding. The ipratropium, I really only use for the patient who really complains of recalcitrant, stubborn, and post-nasal drip. It's the only time I really use that.

Actually, I'm going to say, at first try, the three I just mentioned regularly. Before I start getting to Atrovent or this ipratropium bromide spray, which was thought to be a nasal drying agent, first try saline plus nasal steroid spray, X, Y, Z plus an antihistamine spray first. Tried and that, it just works for the great majority of people and it's just a standard nasal regimen throughout the US or throughout the world.

Now, if that helps you or doesn't help you, we'll find out in three or four months. Sometimes I'll just do a video visit and then like everything's the same or "Maybe the nasal obstruction is better, maybe my sleep is better, but I still have this nagging post-nasal drip." First, I make sure of their CAT scan, I make sure that I'm not missing some severe sinusitis or some other severe pathology, a concerning issue there that might need antibiotics and steroids, for example.

Assuming that everything else is okay, and it's just we're talking about a bad symptom of post-nasal drip, then I start them on three sprays of ipratropium left and right twice a day. That also is something that they can do for three or four months, and then we'll talk again. Now, they're on four sprays, saline plus nasal steroid spray, plus an antihistamine spray, and now a fourth spray of Atrovent. That's the regimen I would want them to do before we start talking about, again, procedures in my case.

When there are procedures now for post-nasal drip, that are quite effective, but I want them to only do that.

If they fail those things, again, for those reasons, I talked about relationship building, for confidence that it is time to embark on a procedure for both patient and doctor, but also there is actually some predictive value to using some of those sprays. For post-nasal drip, for example, if someone has successfully used Atrovent, they have a higher chance of success with cryotherapy to the posterior nasal nerve. If they have poor benefit and poor response to the Atrovent, for example, they only have a 30% chance versus 80% chance of success.

Things like that, for many reasons, it's worth trying these regimens, but I think I tried to do them in a sequential and graded fashion.

[Dr. Ashley Agan]
That makes a lot of sense. Pivoting to patients who you are considering surgery or doing a procedure for, can we talk about turbinate reduction? Are there certain techniques that are going to be more or less likely to cause problems? I guess the biggest most dreaded one being creating some sort of empty nose syndrome. Can you take too much tissue? How do you approach that, given that you're the guy that takes care of the empty nose in complication patients?

(6) Defining Empty Nose Syndrome

[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.

(7) Empty Nose Syndrome Symptomology

[Dr. Jayakar Nayak]
What are the symptoms? 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 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.

(8) Surgical Techniques to Avoid Open Nose Syndrome

[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]

[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 avoiding 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?

(9) Diagnosing Empty Nose Syndrome: The Cotton Test

[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 it 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 have a treatable form of empty nose syndrome. 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.

That's some of the take-homes, I think, from empty nose syndrome and things like that. I think that I appreciate the interest in this topic. I didn't expect [chuckles] that a few years ago doing this work-- I would just be curious about what this was. I saw a few patients with no turbinates and what is actually happening to them? I didn't realize there was both such controversy to this at the time and such mystery as to what's happening physiologically.

I think our papers finally show, and I'm not just trying to talk about our papers, but show that that magnet effect seems to be happening. That when we restore that turbinate contour with these surgeries, we work where there's a competitive food dynamics expert. It's like computer modeling of the nose, computer modeling in the airflow through the nose. He doesn't know the scores. He doesn't know the scores of how these patients are improving.

Many times after these implant surgeries, patients' empty nose syndrome scores will go from the 20s to single digits.

Single digits are like you and me. That's how we score on those six questions. We're going from 26s to a number like 7, 19 to a number like 3. Things like that so they're really very happy with their breathing, but I have their CAT scan.

For the research part of this, I try to do a CAT scan before and after surgery, for example. We published on this too, that we take their CAT scans and then we send them to this collaborative radiologist, who's at Ohio State. He doesn't know which one's pre-imposed per se. He's just going through it. He's shown since the beginning improvements in the nasal vectors of breathing, and also that the airflow seems to congregate down towards the new turbinate, almost like a magnet. That was the idea of the magnet effect of the turbinate.

I think the turbinates have a new function that we can ascribe to them, which is that they attract airflow and they allow and permit airflow. That's why the cotton test seems to work because we're just immediately applying a magnet through cotton and changing vectors of airflow through that. I think that's why the turbinate restoration surgery and reconstruction surgery might help so well. It's turned into quite an adventure, but I appreciate the interest.

[Dr. Gopi Shah]
Thanks for coming on the show. Thank you.

[Dr. Jayakar Nayak]
Sure. Take care.

Podcast Contributors

Dr. Jayakar Nayak discusses Turbinates, Nasal Congestion, and the Dreaded Empty Nose on the BackTable 89 Podcast

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 discusses Turbinates, Nasal Congestion, and the Dreaded Empty Nose on the BackTable 89 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses Turbinates, Nasal Congestion, and the Dreaded Empty Nose on the BackTable 89 Podcast

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

Disclaimer: The Materials available on 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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