Empty nose syndrome

Last updated
Empty Nose Syndrome
Other namesSecondary atrophic rhinitis
Empty-nose-after-80per-cent-partial-bilateral-turbinectomy.jpeg
Altered nasal anatomy after bilateral subtotal inferior turbinectomy, the removal of most turbinate tissue.
Specialty Otolaryngology
Symptoms Sensation of nasal suffocation despite clear airway
Complications Hyperventilation syndrome, depression, anxiety, fatigue
Usual onsetFollowing surgery or injury to the nasal interior
Differential diagnosis Anxiety, Hyperventilation
TreatmentArtificial nasal moisture, experimental corrective surgeries
FrequencyUnknown, but considered rare in medical literature

Empty nose syndrome (ENS) is a clinical syndrome, the hallmark symptom of which is a sensation of suffocation despite a clear airway. This syndrome is often referred to as a form of secondary atrophic rhinitis. ENS is a potential complication of nasal turbinate surgery or injury. [1] [2] Patients have usually undergone a turbinectomy (removal or reduction of structures inside the nose called turbinates) or other surgical procedures that injure the nasal turbinates.

Contents

ENS patients may experience a range of symptoms. Commonly reported are feelings of nasal obstruction, nasal dryness and crusting, and a sensation of being unable to breathe. [3]

The overall incidence of ENS is unknown due to the small body of epidemiological study and the lack of a dedicated International Classification of Diseases (ICD-10) code, which would allow incidence reporting of the syndrome. In a 2019 study in the Facial Plastic Surgery Clinics of North America journal, study lead Jason Talmadge posited that "many cases likely go unrecognized or underdiagnosed, and therefore unreported." [4]

The condition is caused by injury to the nasal turbinates, particularly with nasal procedures. This includes both minor procedures as well as total turbinate resection. It is usually observed in patients with unobstructed nasal passages following surgical intervention who report sensations of suffocation or obstruction following recovery. Early literature attributed ENS to complete turbinate resection, but later research demonstrated the syndrome in patients who had undergone a range of procedures that involved nasal turbinates. [3] [5] [6] [7] [8]

The syndrome's existence as a distinct medical condition is controversial, with adoption by a growing body of ear, nose and throat (ENT) practitioners and plastic surgeons. ENS is not fully understood and practitioner knowledge about altered nasal breathing in turbinate surgeries varies. Understanding why some patients exhibit ENS symptoms while others do not and incorrectly attributing symptoms to psychological causes such as anxiety are common reasons ENS patients do not receive care. [3] ENS as a distinct condition is subject to debate, including whether it should be considered solely rhinologic or whether it may have neurological or psychosomatic aspects. Growing awareness of the syndrome and an increasing body of research has led to more acceptance by ENT practitioners. [3] [5] [9] [10] [11] [12] [ excessive citations ]

Signs and symptoms

The major symptoms of ENS include a sensation of suffocation, nasal dryness, nasal burning, nasal crusting, and an impaired sense of airflow through the nose in patients who have had surgery or injury to nasal turbinates. [13] ENS can greatly reduce a patient's quality of life and many patients struggle to complete activities of daily living. While ENS is physical in its origin, many ENS patients also struggle with depression, anxiety, and sleep disturbances. [14] Individuals with ENS may experience all or some of these symptoms.

A limited study of ENS patients found that ENS is associated with hyperventilation syndrome (HVS) in 77.3% of the study population. The study suggests that there could be an epidemiological link between ENS and HVS. Further studies are required to confirm these results. The authors hypothesize that the link between ENS and HVS could be explained by the nasal injury that occurs to the turbinates that alters the respiratory control system. [15]

A 2023 study found that ENS patients scored significantly higher on the Epworth Sleepiness Scale than control groups, and that severity of ENS symptoms correlated with severity of sleepiness. [16] Sleep apnea was found to correlate with severity of ENS symptoms and high BMI in a 2022 study. [17]

Cause

The cause of ENS is due to the body not accepting the new airflow in the nasal passages following surgical procedures. The nose is an incredibly complex area of the body and one that has been very poorly researched in terms of the effects on aerodynamics from surgical procedures. In many patients with ENS, the airflow is modeled as being more turbulent with less laminar flow across the mucosa. This change in airflow leads to an imbalance of CO2/O2 levels[ citation needed ] in the body, which will show hyperventilation-like symptoms in patients. This reduced amount of mucus in the nose can also be attributed to the change in airflow often resulting in dry cool air hitting the back of the patient's throat. [ citation needed ]

One possible cause may be changes to the nasal mucous membrane and to the nerve endings in the mucosa resulting from chronic changes to the temperature and humidity of the air flowing inside the nose, caused in turn by removal or reduction of the turbinates. [3] [5] Direct damage to the nerves may be a result of surgical intervention; however, as of 2015, there is no technology that allows the mapping of the sensory nerves within the nose, so it is difficult to determine whether this is causative of ENS. [3] Investigators have been unable to identify consistent diagnostic or precipitating features, psychological causes leading to a psychosomatic condition have been proposed. [3] [9] [10] [12]

Squamous metaplasia of nasal respiratory epithelium. Squamous metaplsia of respiratory epithelium.jpg
Squamous metaplasia of nasal respiratory epithelium.

There seems to be a relation between reduced levels of nasal nitric oxide and depression/anxiety symptoms in ENS patients. Both have been shown to be reversible via implantation surgery. [18]

It has been proposed, that the airflow in ENS patients is changed so that most of the air flows through the middle meatus, compared to most of the air flowing through the inferior meatus in healthy individuals. This can be corrected via inferior meatus augmentation (IMAP surgery). [19]

Diagnosis

No consensus criteria exist for the diagnosis of ENS and many ENTs will wait a year before diagnosing in hopes the patient accepts the new airflow; it is typically diagnosed by ruling out other conditions, with ENS remaining the likely diagnosis if the signs and symptoms are present. [3] [5] [9] A "cotton test" has been proposed, in which moist cotton is held where a turbinate should be or in various locations in the nasal passages, to see if it provides relief and an airflow pattern that allows for natural breathing; while this has not been validated nor is it widely accepted, it may be useful to identify which people may benefit from surgery. [3] [5] [9]

As of 2015, protocols for using rhinomanometry to diagnose ENS and measure response to surgery were under development, [5] [9] as was a standardized clinical instrument (a well defined and validated questionnaire) to obtain more useful reporting of symptoms. [9]

A validated ENS-specific, 6-item questionnaire called the Empty Nose Syndrome 6-item Questionnaire (ENS6Q) was developed as an adjunct to the standard Sino-Nasal Outcome Test 22 (SNOT-22). [20] The ENS6Q is the first validated, specific, adjunct questionnaire to the SNOT-22. It can more reliably identify patients suspected of ENS. [21] The ENS6Q is gaining usage in studies on ENS.

Classification

All turbinates removed - Right lateral wall view. Illu nose nasal cavities.jpg
All turbinates removed – Right lateral wall view.
Anatomy of the nasal cavity Gray153.png
Anatomy of the nasal cavity

Four types have been proposed: [22]

Prevention

Attempt non surgical methods for an extended period of time prior to surgical intervention. Avoid any unnecessary nasal surgery, avoid any surgical treatment to the turbinates and septum, seek multiple consults for any nasal surgery, conduct imagery on the nasal passages prior to any surgical treatment, seek opinions from surgeons familiar with ENS. [3] [23] Many surgeons will tell patients that ENS is only seen in patients that have excessive turbinate reduction, but studies have shown that any surgery/procedure involving the nasal turbinates can potentially lead to ENS.[ citation needed ] For this reason it is critical that anyone planning any surgery to the nose for function or appearance should be aware of the high risk of ENS developing if the body does not accept the new airflow and exchange of gasses.

Treatment

Treatment of ENS by many ENTs is extremely limited with very marginal success rates once diagnosed. Initial treatment is similar to atrophic rhinitis, namely keeping the nasal mucosa moist with saline or oil-based lubricants and treating pain and infection as they arise; adding menthol to lubricants may be helpful in ENS, as may be use of a cool mist humidifier at home but has limited success and many ENT patients seek treatment from the few ENTs well educated in ENS surgical techniques. [3] For people with anxiety, depression, or who are obsessed with the feeling that they can't breathe, psychiatric or psychological care may be helpful. [3] [9]

In some people, surgery to restore missing or reduced turbinates or various fillers that correct the airflow in the nose may be beneficial. [3] Corrective surgical methods are experimental and limited to a few ENT practitioners worldwide.

Before and after surgical restoration of the lateral wall (arrow in right-side image) to simulate the function of the missing inferior turbinate. Before and after Alloderm implant to the lateral wall.jpg
Before and after surgical restoration of the lateral wall (arrow in right-side image) to simulate the function of the missing inferior turbinate.

A 2015 meta-analysis identified 128 people treated with surgery from eight studies that were useful to pool, with an age range of 18 to 64, most of whom had been experiencing ENS symptoms for many years. The most common surgical approach was creating a pocket under the mucosa and implanting material - the amount and location were based on the judgement of the surgeon. In about half the cases a filler such as noncellular dermis, a medical-grade porous high-density polyethylene, or silastic was used and in about 40% cartilage taken from the person or from a cow was used. In a few cases hyaluronic acid was injected and in a few others tricalcium phosphate was used. There were no complications caused by the surgery, although one person was over-corrected and developed chronic rhinosinusitis and two people were under-corrected. The hyaluronic acid was completely resorbed in the three people who received it at the one year follow up, and in six people some of the implant came out, but this did not affect the result as enough remained. About 21% of the people had no or marginal improvement but the rest reported significant relief of their symptoms. Since none of the studies used placebo or blinding there may be a strong placebo effect or bias in reporting. [9]

Outcomes

Data measuring the prevalence of Empty Nose Syndrome (ENS) after turbinate surgery is limited to a few single surgeon studies with variable results. Measuring prevalence is challenging as ENS symptoms may not show up for many years after the surgery and the surgeon may no longer be following the patients. Quantifying prevalence will also depend on a valid, standardized definition. [24] [4]

The lack of a reliable epidemiological study or ICD-10 code makes it difficult to understand the incidence of ENS. Qualitative feedback from ENTs that treat this disease indicate that the incidence is underestimated but the condition is debilitating for those that have it.

Untreated, the condition can cause significant and long term physical and emotional distress in some people; some of the initial presentations on the condition described people who committed suicide. Research on safety and efficacy of existing treatments is limited to a handful of published studies with a small number of participants and self-reported results from specialists treating this condition. [9]

History

As early as 1914, Dr Albert Mason reported cases of "a condition resembling atrophic rhinitis" with "a dryness of the nose and throat" following turbinectomy. Mason called the turbinates "the most important organ in the nose" and claimed they were "slaughtered and removed with discriminate abandon more than any other part of the body, with the possible exception of the prepuce." [25]

The term "Empty Nose Syndrome" was first used by Eugene Kern and Monika Stenkvist of the Mayo Clinic in 1994. [3] Kern and Eric Moore published a case study of 242 people with secondary atrophic rhinitis in 2001 and were the first to attribute the cause to prior sinonasal surgery in the scientific literature. [3] [1] Whether the condition existed or not and whether surgery was a cause, was hotly debated at Nose 2000, a meeting of the International Rhinologic Society that occurs every four years, and continued to be debated thereafter at scientific meetings and in the literature; [3] [26] as an example of how heated the debate became, in a 2002 textbook on nasal reconstruction techniques, two surgeons from University of Utrecht called turbinectomies a "nasal crime". [3]

Society and culture

As of 2016, according to Spencer Payne, a doctor who studies ENS, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological; [27] according to Subinoy Das, another doctor who studies ENS, recognition among rhinologists was growing. [28]

People who experience ENS have formed online communities to support one another [3] and to advocate for recognition, prevention, and treatments for ENS. [28]

Related Research Articles

<span class="mw-page-title-main">Otorhinolaryngology</span> Medical specialty of the head and neck

Otorhinolaryngology is a surgical subspecialty within medicine that deals with the surgical and medical management of conditions of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, head and neck surgeons, or ENT surgeons or physicians. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, head, and neck. These commonly include functional diseases that affect the senses and activities of eating, drinking, speaking, breathing, swallowing, and hearing. In addition, ENT surgery encompasses the surgical management of cancers and benign tumors and reconstruction of the head and neck as well as plastic surgery of the face, scalp, and neck.

<span class="mw-page-title-main">Sinusitis</span> Inflammation of the inner lining of the sinuses

Sinusitis, also known as rhinosinusitis, is an inflammation of the mucous membranes that line the sinuses resulting in symptoms that may include thick nasal mucus, a plugged nose, and facial pain.

<span class="mw-page-title-main">Rhinoplasty</span> Surgical procedure to enhance or reconstruct a human nose

Rhinoplasty, commonly called nose job, medically called nasal reconstruction, is a plastic surgery procedure for altering and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that changes the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery can also treat birth defects, breathing problems, and failed primary rhinoplasties. Rhinoplasty may remove a bump, narrow nostril width, change the angle between the nose and the mouth, or address injuries, birth defects, or other problems that affect breathing, such as a deviated nasal septum or a sinus condition. Surgery only on the septum is called a septoplasty.

<span class="mw-page-title-main">Allergic rhinitis</span> Nasal inflammation due to allergens in the air

Allergic rhinitis, of which the seasonal type is called hay fever, is a type of inflammation in the nose that occurs when the immune system overreacts to allergens in the air. Signs and symptoms include a runny or stuffy nose, sneezing, red, itchy, and watery eyes, and swelling around the eyes. The fluid from the nose is usually clear. Symptom onset is often within minutes following allergen exposure, and can affect sleep and the ability to work or study. Some people may develop symptoms only during specific times of the year, often as a result of pollen exposure. Many people with allergic rhinitis also have asthma, allergic conjunctivitis, or atopic dermatitis.

<span class="mw-page-title-main">Rhinitis</span> Irritation and inflammation of the mucous membrane inside the nose

Rhinitis, also known as coryza, is irritation and inflammation of the mucous membrane inside the nose. Common symptoms are a stuffy nose, runny nose, sneezing, and post-nasal drip.

<span class="mw-page-title-main">Nasal concha</span> Piece of bone in the breathing passage of humans and other animals

In anatomy, a nasal concha, also called a nasal turbinate or turbinal, is a long, narrow, curled shelf of bone that protrudes into the breathing passage of the nose in humans and various other animals. The conchae are shaped like an elongated seashell, which gave them their name. A concha is any of the scrolled spongy bones of the nasal passages in vertebrates.

<span class="mw-page-title-main">Septoplasty</span> Corrective surgical procedure

Septoplasty, or alternatively submucous septal resection and septal reconstruction, is a corrective surgical procedure done to straighten a deviated nasal septum – the nasal septum being the partition between the two nasal cavities. Ideally, the septum should run down the center of the nose. When it deviates into one of the cavities, it narrows that cavity and impedes airflow. Deviated nasal septum or “crooked” internal nose can occur at childbirth or as the result of an injury or other trauma. If the wall that functions as a separator of both sides of the nose is tilted towards one side at a degree greater than 50%, it might cause difficulty breathing. Often the inferior turbinate on the opposite side enlarges, which is termed compensatory hypertrophy. Deviations of the septum can lead to nasal obstruction. Most surgeries are completed in 60 minutes or less, while the recovery time could be up to several weeks. Put simply, septoplasty is a surgery that helps repair the passageways in the nose making it easier to breathe. This surgery is usually performed on patients with a deviated septum, recurrent rhinitis, or sinus issues.

<span class="mw-page-title-main">Aspirin-exacerbated respiratory disease</span> Chronic inflammatory disease affecting the sinuses and lungs

Aspirin-exacerbated respiratory disease (AERD), also called NSAID-exacerbated respiratory disease (N-ERD) or historically aspirin-induced asthma and Samter's Triad, is a long-term disease defined by three simultaneous symptoms: asthma, chronic rhinosinusitis with nasal polyps, and intolerance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Compared to aspirin tolerant patients, AERD patients' asthma and nasal polyps are generally more severe. Reduction or loss of the ability to smell is extremely common, occurring in more than 90% of people with the disease. AERD most commonly begins in early- to mid-adulthood and has no known cure. While NSAID intolerance is a defining feature of AERD, avoidance of NSAIDs does not affect the onset, development or perennial nature of the disease.

<span class="mw-page-title-main">Nasal congestion</span> Partial or complete blockage of nasal passages

Nasal congestion is the partial or complete blockage of nasal passages, leading to impaired nasal breathing, usually due to membranes lining the nose becoming swollen from inflammation of blood vessels.

<span class="mw-page-title-main">Post-nasal drip</span> Medical condition

Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of the throat. It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD), or by a disorder of swallowing. Other causes can be allergy, cold, flu, and side effects from medications.

<span class="mw-page-title-main">Rhinitis medicamentosa</span> Medical condition

Rhinitis medicamentosa is a condition of rebound nasal congestion suspected to be brought on by extended use of topical decongestants and certain oral medications that constrict blood vessels in the lining of the nose, although evidence has been contradictory.

Chronic atrophic rhinitis, or simply atrophic rhinitis, is a chronic inflammation of the nose characterised by atrophy of nasal mucosa, including the glands, turbinate bones and the nerve elements supplying the nose. Chronic atrophic rhinitis may be primary and secondary. Special forms of chronic atrophic rhinitis are rhinitis sicca anterior and ozaena. It can also be described as the empty nose syndrome.

<span class="mw-page-title-main">Nasal cycle</span> Subconscious alternation of the nasal cavities

The nasal cycle is the subconscious alternating partial congestion and decongestion of the nasal cavities in humans and other animals. This results in greater airflow through one nostril with periodic alternation between the nostrils. It is a physiological congestion of the nasal conchae, also called the nasal turbinates, due to selective activation of one half of the autonomic nervous system by the hypothalamus. It should not be confused with pathological nasal congestion.

<span class="mw-page-title-main">Functional endoscopic sinus surgery</span> Surgery to enlarge the paranasal sinus drainage pathways

Functional endoscopic sinus surgery (FESS) is a procedure that is used to treat sinusitis and other conditions that affect the sinuses. Sinusitis is an inflammation of the sinuses that can cause symptoms such as congestion, headaches, and difficulty breathing through the nose.

<span class="mw-page-title-main">Human nose</span> Feature of the human face

The human nose is the first organ of the respiratory system. It is also the principal organ in the olfactory system. The shape of the nose is determined by the nasal bones and the nasal cartilages, including the nasal septum, which separates the nostrils and divides the nasal cavity into two.

Young's operation is a surgery designed for the treatment of atrophic rhinitis, first described by Austen Young in 1967.

<span class="mw-page-title-main">Turbinectomy</span> Surgical removal of the turbinate bones in the nasal passage

A turbinectomy or turbinoplasty is a surgical procedure, that removes tissue, and sometimes bone, of the turbinates in the nasal passage, particularly the inferior nasal concha. The procedure is usually performed to relieve nasal obstructions. In most cases, turbinate hypertrophy is accompanied by some septum deviation, so the surgery is done along with septoplasty.

Nonallergic rhinitis is rhinitis—inflammation of the inner part of the nose—not caused by an allergy. Nonallergic rhinitis displays symptoms including chronic sneezing or having a congested, drippy nose, without an identified allergic reaction. Other common terms for nonallergic rhinitis are vasomotor rhinitis and perennial rhinitis. The prevalence of nonallergic rhinitis in otolaryngology is 40%. Allergic rhinitis is more common than nonallergic rhinitis; however, both conditions have similar presentation, manifestation and treatment. Nasal itching and paroxysmal sneezing are usually associated with nonallergic rhinitis rather than allergic rhinitis.

Nasal surgery is a medical procedure designed to treat various conditions that cause nasal blockages in the upper respiratory tract, for example nasal polyps, inferior turbinate hypertrophy, and chronic rhinosinusitis. It encompasses several types of techniques, including rhinoplasty, septoplasty, sinus surgery, and turbinoplasty, each with its respective postoperative treatments. Furthermore, nasal surgery is also conducted for cosmetic purposes. While there are potential risks and complications associated, the advancement of medical instruments and enhanced surgical skills have helped mitigate them.

Mary Despina Lekas Picozzi was an American physician. She was head of otolaryngology and Surgeon-in-Chief at Rhode Island Hospital from 1983 to 1996, professor of Clinical Otolaryngology at Brown University's Alpert Medical School, and president of the New England Otolaryngological Society.

References

  1. 1 2 Moore EJ, Kern EB (2001). "Atrophic rhinitis: a review of 242 cases". Am J Rhinol. 15 (6): 355–61. doi:10.1177/194589240101500601. PMID   11777241. S2CID   13747312.
  2. ↑ deShazo, Richard D; Stringer, Scott P (February 2011). "Atrophic rhinosinusitis: progress toward explanation of an unsolved medical mystery". Current Opinion in Allergy & Clinical Immunology. 11 (1): 1–7. doi:10.1097/ACI.0b013e328342333e. ISSN   1528-4050. PMID   21157302. S2CID   27205163.
  3. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Kuan, EC; Suh, JD; Wang, MB (2015). "Empty nose syndrome". Curr Allergy Asthma Rep. 15 (1): 493. doi:10.1007/s11882-014-0493-x. PMID   25430954. S2CID   43309184.
  4. 1 2 Talmadge, Jason; Nayak, Jayakar V.; Yao, William; Citardi, Martin J. (November 2019). "Management of Postsurgical Empty Nose Syndrome". Facial Plastic Surgery Clinics of North America. 27 (4): 465–475. doi:10.1016/j.fsc.2019.07.005. ISSN   1558-1926. PMID   31587766. S2CID   203850289.
  5. 1 2 3 4 5 6 Sozansky J, Houser SM (Jan 2015). "Pathophysiology of empty nose syndrome". Laryngoscope. 125 (1): 70–4. doi:10.1002/lary.24813. PMID   24978195. S2CID   29735233.
  6. ↑ Houser, Steven M. (2007-09-01). "Surgical Treatment for Empty Nose Syndrome". Archives of Otolaryngology–Head & Neck Surgery. 133 (9): 858–863. doi: 10.1001/archotol.133.9.858 . ISSN   0886-4470. PMID   17875850. Although total turbinate excision is most frequently the cause of ENS, lesser procedures (eg, submucosal cautery, submucosal resection, cryosurgery) to reduce the turbinates may cause problems as well if performed in an overly aggressive manner.
  7. ↑ "FFAAIR | Syndrome du Nez Vide (SNV)". www.ffaair.org (in French). Retrieved 2019-09-11. suite d'interventions endonasales diverses (turbinectomie, turbinoplastie, cautérisation)
  8. ↑ Saafan. "Empty nose syndrome: etiopathogenesis and management". www.ejo.eg.net. Retrieved 2019-09-11. ENS is a complication of middle and/or inferior turbinate surgery, most frequently total turbinate excision, but also with minor procedures such as submucosal cautery, submucosal resection, laser therapy, and cryosurgery if performed in an aggressive manner
  9. 1 2 3 4 5 6 7 8 9 Leong SC (Jul 2015). "The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review". Laryngoscope. 125 (7): 1557–62. doi:10.1002/lary.25170. PMID   25647010. S2CID   206202553.
  10. 1 2 Coste, A; Dessi, P; Serrano, E (2012). "Empty nose syndrome". Eur Ann Otorhinolaryngol Head Neck Dis. 129 (2): 93–7. doi: 10.1016/j.anorl.2012.02.001 . PMID   22513047.
  11. ↑ Hildenbrand, T; Weber, RK; Brehmer, D (2011). "Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature". Eur Arch Otorhinolaryngol. 268 (1): 17–26. doi:10.1007/s00405-010-1391-z. PMID   20878413. S2CID   34729974.
  12. 1 2 Payne SC (2009). "Empty nose syndrome: what are we really talking about?". Otolaryngol. Clin. North Am. 42 (2): 331–7, ix–x. doi:10.1016/j.otc.2009.02.002. PMID   19328896.
  13. ↑ Velasquez, Nathalia; Thamboo, Andrew; Habib, Al-Rahim R.; Huang, Zhenxiao; Nayak, Jayakar V. (January 2017). "The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q): a validated 6-item questionnaire as a diagnostic aid for empty nose syndrome patients". International Forum of Allergy & Rhinology. 7 (1): 64–71. doi:10.1002/alr.21842. ISSN   2042-6976. PMID   27557473. S2CID   40730623.
  14. ↑ Manji, Jamil; Nayak, Jayakar V.; Thamboo, Andrew (June 2018). "The functional and psychological burden of empty nose syndrome". International Forum of Allergy & Rhinology. 8 (6): 707–712. doi:10.1002/alr.22097. ISSN   2042-6976. PMID   29443458. S2CID   19782153.
  15. ↑ Mangin, David; Bequignon, Emilie; Zerah-Lancner, Francoise; Isabey, Daniel; Louis, Bruno; Adnot, Serge; Papon, Jean-François; Coste, André; Boyer, Laurent (September 2017). "Investigating hyperventilation syndrome in patients suffering from empty nose syndrome". The Laryngoscope. 127 (9): 1983–1988. doi:10.1002/lary.26599. ISSN   1531-4995. PMID   28407251. S2CID   25389674.
  16. ↑ Huang CC, Lee CC, Wu PW, Chuang CC, Lee YS, Chang PH, Huang CC, Fu CH, Lee TJ (February 2023). "Sleep impairment in patients with empty nose syndrome". Rhinology. 61 (1): 47–53. doi: 10.4193/Rhin22.117 . PMID   36306524. S2CID   253204069 . Retrieved 2023-10-06.
  17. ↑ Huang, Chien-Chia; Wu, Pei-Wen; Chuang, Chi-Cheng; Lee, Cheng-Chi; Lee, Yun-Shien; Chang, Po-Hung; Fu, Chia-Hsiang; Huang, Chi-Che; Lee, Ta-Jen (15 July 2022). "Identifying Obstructive Sleep Apnoea in Patients with Empty Nose Syndrome". Diagnostics. 12 (7): 1720. doi: 10.3390/diagnostics12071720 . ISSN   2075-4418. PMC   9323833 . PMID   35885624.
  18. ↑ Fu, Chia-Hsiang; Wu, Ching-Lung; Huang, Chi-Che; Chang, Po-Hung; Chen, Yi-Wei; Lee, Ta-Jen (2019-11-01). "Nasal nitric oxide in relation to psychiatric status of patients with empty nose syndrome". Nitric Oxide. 92 (92): 55–59. doi:10.1016/j.niox.2019.07.005. PMID   31408674. S2CID   199574745 . Retrieved 5 December 2022.
  19. ↑ Malik, Jennifer; Dholakia, Sachi; Spector, Barak M.; Yang, Angela; Dayoung, Kim; Borchard, Nicole A.; Thamboo, Andrew; Zhao, Kai; Nayal, Jayakar V. (2021-05-01). "Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling". International Forum of Allergy & Rhinology. 11 (5): 902–909. doi:10.1002/alr.22720. PMC   8062271 . PMID   33249769.
  20. ↑ Soler, ZM; Jones, R; Le, P; Rudmik, L; Mattos, JL; Nguyen, SA; Schlosser, RJ (March 2018). "Sino-Nasal outcome test-22 outcomes after sinus surgery: A systematic review and meta-analysis". The Laryngoscope. 128 (3): 581–592. doi:10.1002/lary.27008. PMC   5814358 . PMID   29164622.
  21. ↑ Velasquez, N; Thamboo, A; Habib, A-RR; Huang, Z; Nayak, JV (2017). "The Empty Nose Syndrome 6-item Questionnaire: a validated 6-item questionnaire as a diagnostic aid for empty nose syndrome patients". Int Forum Allergy Rhinol. 7 (1): 64–71. doi:10.1002/alr.21842. PMID   27557473. S2CID   40730623.
  22. ↑ Houser, Steven M. (2007-09-01). "Surgical Treatment for Empty Nose Syndrome". Archives of Otolaryngology–Head & Neck Surgery. 133 (9): 858–863. doi:10.1001/archotol.133.9.858. ISSN   0886-4470. PMID   17875850.
  23. ↑ Gehani, NC; Houser, S. (2013-06-21). "Chapter 42: Septoplasty, Turbinate Reduction, and Correction of Nasal Obstruction". In Johnson, Jonas; Rosen, Clark A.; Bailey, Byron J. (eds.). Bailey's Head and Neck Surgery. Lippincott Williams & Wilkins. ISBN   978-1-60913-602-4.
  24. ↑ Moore, E. J.; Kern, E. B. (2001). "Atrophic rhinitis: a review of 242 cases". American Journal of Rhinology. 15 (6): 355–361. doi:10.1177/194589240101500601. ISSN   1050-6586. PMID   11777241. S2CID   13747312.
  25. ↑ Mason, Albert (September 1914). "A plea for the conservation of the inferior turbinate". Atlanta Journal-record of Medicine. 61 (6): 245–249. PMC   9038343 . PMID   36020266.
  26. ↑ Zitner, Aaron (2001-05-10). "Sniffing at Empty Nose Idea". Los Angeles Times. Retrieved 2024-01-19.
  27. ↑ Harmon, Tomas (May 4, 2016). "Medical Mystery: Empty Nose Syndrome". CBS19. Archived from the original on 17 December 2019. Retrieved 9 June 2016.
  28. 1 2 Oliphint, Joel (April 14, 2016). "Is Empty Nose Syndrome Real? And If Not, Why Are People Killing Themselves Over It". BuzzFeed. Archived from the original on 2016-04-15.
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