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"Empty Nose" Syndrome

What Is Empty Nose Syndrome?

The nasal turbinates are shelf-like structures in the nasal cavity (which begins where the inside of your nose enters your head). They serve to provide moisture, warmth, and airflow for breathing, and many of the body's natural defenses against infection. There are a variety of different problems associated with the turbinates. Sometimes the turbinates themselves are damaged by disease, and can shrivel and no longer function. In other cases the turbinates can swell and block breathing. There are journal articles recommending surgical removal of diseased turbinates in order to provide adequate airflow for breathing. After such a surgery, however, the turbinates can no longer provide mucus, cilia, and enzymes to protect against infection, and secondary infections can occur regularly and in turn may require additional surgery to clear the infection. Often patients will have 3 or 4 subsequent surgeries. There can be dryness, burning, crusting, and sometimes pain. The pain associated with this syndrome may come from the raw surface or the exposure of nerve endings or infection. All this adds up to the "Empty Nose Syndrome" as a side effect of surgery. In patients with removed turbinates, the X-ray of the the nose looks empty to your doctor, hence the term, "Empty Nose Syndrome" (ENS).

The worst symptom, in my opinion, is the feeling of not getting enough air. The turbinates acts like a pressure valve in the nose; they change the air pressure of the air you breathe much like using your thumb on the end of a garden hose. If you close the opening of the hose, the stream sprays a long way in a powerful jet. If you take your thumb away and leave the hose wide open, the water dribbles at your feet. In the same way, the change in the air pathway size due to the turbinate removal changes the flow of air into the lungs, and the patient feels he isn’t able to breathe adequately. This can lead to depression -after all, you breathe 24 hours a day, and the feeling never goes away. With most other ailments, like an upset stomach or broken finger, you know the pain will stop eventually.

The Empty Nose Syndrome term was first coined by Dr. Eugene Krems of The Mayo Clinic. He applied it to the persons complaining of pain and burning in the nose, a sensation of being unable to breathe through the nose, recurrent infection, heavy crusting and sometimes depression. The condition was recently described in the Los Angeles Times article by Aaron Zittner entitled "Sniffing on Empty Nose Idea" [sic] on May 10, 2001, based on interviews of people who complained of these symptoms.

What are Turbinates?

There are 3 "shelves" on the inside side of the nasal cavity. The first, the inferior turbinate, is near the "floor" of the nasal cavity on its side. The second, the middle turbinate, is roughly in the middle on the side of the cavity, and the third, the superior turbinate, is at the top of the side of the cavity. The turbinates normally enlarge and shrink many times a day. At night they serve to prevent bedsores. If you lay on your side to sleep, the turbinates on your lower side will fill with fluid. They fill and push on the septum, the nasal divider in the center, and this signals you to turn to your other side. This is repeated about 50 times a night.

Turbinate Surgeries

When the inferior turbinate is enlarged due to repeated infection, this is called a hypertrophied nasal turbinate. The enlargement may be allergic, or due to an increase in circulation, called vasomotor rhinitis. There may be huge pools of blood in the turbinate. There may be a physical swelling due to this enlargement that blocks breathing.

The middle turbinate is quite important, as it supports the structures of drainage from most of the sinuses. In persons with sinus problems, in order to enlarge the opening to the maxillary sinus, it may be necessary to remove part of this turbinate. The surgery sometimes loosens the entire turbinate so that it can fall forward and block the drainage of the frontal sinus. Thus, removal of the middle turbinate may be clearly required in some cases. The superior turbinate is different; it is rarely enlarged enough to impair breathing.

The turbinates provide much of the good, disease-fighting stuff in the nasal cavity and sinuses: mucus, cilia, and enzymes (such as lysozyme). If the inferior and middle turbinates are removed, the source of warming and moistening the air is gone, and then the dryness, frequent infections, crusting and local pain can result. With the absence of the mucus, cilia and enzymes, frequent infections of the sinuses can occur. This may lead to the need for further sinus surgery.

How do you prevent ENS?

Most sinus difficulties come from failure of the cilia and mucus, the mucociliary system, to do its job. Severe infection, toxic fumes, certain drugs — all can slow the cilia and this allows infection. If steps are taken to insure good cilia function, many sinus problems can be avoided. If pulsatile irrigation is used when the cilia are slowed — as is the case with chronic pus discharge– this often helps. Extreme dryness may impair the mucociliary system, so nasal moisturizers are also useful.

Sometimes the nose is blocked no matter what has been tried — allergy, irrigation, etc., and X-rays indicate serious sinus blockage. If surgery is indicated, speak to your doctor about procedures that spare the cilia. These include:

  1. Submucus resection of the turbinate. Here only the bone is removed and the turbinate shrinks and goes to the side so it doesn’t block airflow.

  2. Radiofrequency treatment. Here, a probe which emits radio waves is used to congeal the tissue under the mucosa. One such procedure is called a Somnoplasty

  3. Limited turbinate removal. Most doctors have the necessary skill to remove small portions of the turbinate without doing harm.

Procedures that may result in Empty Nose Syndrome when done improperly include wide chemical or electric cautery, laser cautery, and of course, surgical removal.

Once you have it, how do you treat Empty Nose Syndrome?

Fortunately treatment is available for this condition. For example,

Dr Steven Houser of Cleveland is developing a technique of implanting tissue that has helped these patients. Instead of just narrowing the wide-open area, he directs airflow so that the pathology is reduced.

DR Terrance Davidson of San Diego is the originator of adding antibiotics to pulsatile irrigation solution for clearing infection. His Nasal Dysfunction Clinic has extensive experience in treating sinus and nose related problems.

Since this condition includes the loss of function of nasal cilia, pulsatile irrigation with an enhanced nasal moisturizing formula is very beneficial. The pulsation mimics the cilia action, and can act as a partial replacement of this action. Pulsatile irrigation also removes crusts, bacteria and pollen which healthy turbinates would normally deal with.

The pain that many persons complain of may be due to inflammation and edema (swelling) of the sinus membrane. Proteolytic Enzymes lozenges, those with truly activity calibrated papaya and pineapple enzymes, are very useful for reducing this inflammation. These enzymes must be taken via the buccal route — dissolved in the mouth — in order to be effective. Other anti-inflammatories such as Aleve may be helpful.

In addition to the pulsatile irrigation, patients should use an enhanced nasal moisturizing formula several times a day since the nose isn’t providing moisture. Carry the spray container with you and spray 4 times a day. The soothing effects of the Locke-Ringer’s - type formula are quite useful; sometimes just this soothing action alone can reduce symptoms. For most persons cortisone sprays should be avoided. The nose is already too open and the membranes are already too thin. Make absolutely sure your nasal moisturizer is additive-free or you can cause more harm than good. Any product with the preservative Benzalkonium and other preservatives is liable to burn and cause increased symptoms.

With the Empty Nose Syndrome, because there is little mucus to dilute strong odors, any strong odor can cause symptoms. Carry a spray bottle in order to wash out offensive substances or aromas any time you may encounter them. Even perfume in an elevator can cause symptoms!

For most persons an antihistamine or decongestant may dry the nose further (though in some conditions, some patients do experience relief with such drugs – ask your doctor).

Some people actually seek out those things which cause excess nasal mucus! Perhaps if you are a person who gets mucus from drinking milk, you may want to try this, or whatever things stimilate mucus for you, if you have ENS - but be cautious. Start with small amounts and avoid any concentrated preparations.

Warm compresses to the sinus area brings circulation to the area, and this is desirable.

Skiing and other winter sports are very hard for persons with ENS. The dryness of winter and/or high altitude is very difficult. Dry atmosphere MUST be avoided. Moisture in the bedroom is essential; moisten the bedroom by hanging wet towels if you are traveling or if you haven't gotten a good humidifier. If breathing cold winter air is too much for you, a piece of cotton in the nose may help warm the air and reduce symptoms.

Flying is a problem because the air is very dry. Drink lots of hot tea and spray the nose with moisturizer regularly.

Dr. Kerns has done a good job of calling attention to this problem in the medical profession, I am confident that better management of ENS will result.

Copyright© 2001,2003 Dr. Murray Grossan

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Last Update 2003 October 1
Murray Grossan MD.