Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Empty nose syndrome riyadh

1,353 views

Published on

A slide deck that I delivered in Riyadh concerning Empty Nose Syndrome

Published in: Health & Medicine
  • Be the first to comment

Empty nose syndrome riyadh

  1. 1. Empty Nose Syndrome: Diagnosis and treatment Steven M. Houser, MD, FAAOA Associate Professor, Case Western Reserve University Cleveland Ohio, USA 5th RMH FESS and 3rd Rhinoplasty Course Riyadh Military Hospital Sunday, Nov 13, 2011
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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.
  8. 8. 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
  9. 9. ENS-IT right left
  10. 10. ENS-MT
  11. 11. ENS-both
  12. 12. ENS-type
  13. 13. 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
  14. 14. 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)
  15. 15. 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
  16. 16. 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
  17. 17. Septal Implantation
  18. 18. Lateral Wall Implant
  19. 19. IT augment “spear” technique
  20. 20. ENS grafted
  21. 21. 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
  22. 22. 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
  23. 23. • 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

×