Empty nose syndrome riyadh

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Empty Nose Syndrome: Diagnosis and treatment Steven M. Houser, MD, FAAOA Associate Professor, Case Western Reserve University Cleveland Ohio, USA 5 th RMH FESS and 3 rd Rhinoplasty Course Riyadh Military Hospital Sunday, Nov 13, 2011

Transcript of Empty nose syndrome riyadh

Empty Nose Syndrome:Diagnosis and treatment

Steven M. Houser, MD, FAAOAAssociate Professor,

Case Western Reserve UniversityCleveland Ohio, USA

5th RMH FESS and 3rd Rhinoplasty Course

Riyadh Military Hospital

Sunday, Nov 13, 2011

Sensation to Airflow

• Airflow sensation poorly understood• Nasal vestibule most sensitive area• IT next sensitive, and decreases above

• Clarke Clin Otolaryngol 1992;17:383–7

• Wrobel Am J Otol 2006;20:364–8

• Trial: coat vestibule with vaseline• Feel stuffy, but can sense airflow

Etiology

• Nasal surgery typically involving resection of turbinates• or some turbinate surgery that damages the

mucosal surface, e.g., laser reduction

• Inferior turbinates most commonly involved

• Both IT & MT often involved

• Middle turbinates alone occasionally involved

Definition

• Paradoxical nasal obstruction• Widely patent nasal airway• Patient complains of a poor nasal airway

• “blocked,” “empty,” “hollow”

• Dry mucosa

• Thick mucus or possible crusts

• Poor smell

• Poor voice

• Respiratory dysfunction

Definition

• What is not ENS• Pain is variable and may be concurrent, but appears

to be a separate issue from ENS

• Iatrogenic atrophic rhinitis or secondary atrophic rhinitis

• Tissue is missing, not atrophic; no odiferous crusts

• Delayed ENS occurs – suggests atrophy or some delayed nerve injury possible

• Hormonal issues, depression, confusion,…

• Depression over symptoms is possible

ENS physiology

• Airflow easily diverts toward “empty” space

• Mucosa surrounding the “empty” space appears to have lost some sensitivity to airflow

• Normal mucosa has been robbed of airflow

• Conflicting messages to brain• Nose says “I’m suffocating”• Lungs/diaphragm says breathing fine

How common is ENS?

• 22.2% incidence of “atrophy” (likely ENS) following total inferior turbinectomy• Passàli D, Lauriello M, Anselmi M, Bellussi L. Treatment of the

inferior turbinate: long-term results in 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol. 1999;108(6):569-575.

• 8% of partial turbinectomy patients developed a dry nose• Courtiss EH, Goldwyn RM. Resection of obstructing inferior nasal

turbinates: a 10-year follow-up. Plast Reconstr Surg. 1990;86(1):152-154.

Definition

• ENS-IT• Inferior turbinate significantly resected

• ENS-MT• Middle turbinate significantly resected

• ENS-both• Both IT & MT significantly resected

• ENS-type symptoms• Appear to have adequate tissue, but symptoms

and cotton test suggest ENS is present

ENS-IT

right

left

ENS-MT

ENS-both

ENS-type

Diagnosis

• History of surgical intervention with turbinate resection/surgery

• Appropriate symptoms• Suffocation, dryness

• Improvement with “Cotton test”• Cotton placed into area of deficit to obstruct

airflow leads to a subjective improvement in nasal patency and moisturization

Planning

• Review CT & nasal endoscopy to identify defect

• Cotton placed at selected area(s) to simulate graft• Air shifted away from empty area, toward unoperated

area• Assess patient’s subjective sensation of nasal

breathing• Alternatively, site infiltrated with saline to swell the

site (e.g., IT injection)

Cotton Test

• Requires that NO anesthetic agent be applied

• Takes time for patient to assess benefit

• Move cotton into different locations

• Alter size of cotton• Record findings as

surgical plan

Surgical Repair Technique

• Implant tissue into location(s) identified per cotton test• Allogenic acellular dermis or autogenous tissue

• Septum

• Lateral wall

• Direct expansion of existing inferior turbinate • “Spear” technique• Need sufficient volume

Septal Implantation

Lateral Wall Implant

IT augment “spear” technique

ENS grafted

ENS implantation: my volume

• 67 cases performed on 44 different patients• Ranging from 1 to 5 case per patient• Performed from 2003 to 2011• ENS-IT 22, -both 10, -type 9, -MT 3

• Locations (may be >1 location/case)• Septum: 36• Lateral wall: 26• Inferior turbinate (spear): 17

Conclusion

• ENS is often a severly debilitating process

• Poorly understood

• Not accepted/believed by all ENT’s

• These patients can be made more comfortable and they tend to be very grateful

• New launch by AAOA and ARS

• Only journal to combine allergy

and rhinology

• Largest circulation of any

rhinology title

• First print issue Feb. 2011

• Free color for authors

• Top Editor-in-Chief and

International Editorial Board