Empty nose syndrome (ENS) is an uncommon rhinological disease caused by iatrogenic or traumatic reduction in the size of the nasal turbinate. The amount of nasal turbinate reduction varies, but it has been observed with total turbinate resection, which causes a severe form of ENS with submucosal cautery [1]. ENS is commonly classified by the location of the nasal turbinate resection: 1) inferior turbinate type; 2) middle turbinate type; or 3) both [2]. Various medical and surgical methods have been suggested to tackle this problem with different success rates. However, inferior turbinate augmentation is considered a classical surgical intervention with a good response rate. To our knowledge, there is no mention in the literature of septal augmentation or surgery that might help treat ENS after the failure of inferior turbinate augmentation. In this report, we describe a novel technique for treating ENS using septal augmentation after nasal turbinate failure.

A 49-year-old male had a history of multiple nasal traumas and multiple nasal surgeries, including septoturbinoplasty in 1993 and revision septorhinoplasty in 2017, both of which were performed at different hospitals. However, the patient experienced persistent nasal congestion. One year later, he underwent inferior turbinate augmentation using a 4 mm hard Gortex implant in the left inferior meatus at our hospital for ENS. Four years later, he presented again to our hospital with persistent nasal congestion and underwent septoplasty, in which the high left septal deviation was corrected. Eighteen months later, he presented with nasal congestion and dryness. His nasal cavity examination revealed mucoid secretion in the nasal cavity and a widened left nasal cavity due to a left-sided septal concavity. Other nasal examinations yielded negative results. The patient had no known illnesses or allergies and was not taking any medications. His nasal obstructive symptoms evaluation scale (NOSE) score was 90, which indicates extreme nasal obstruction. His ENS 6-item questionnaire (ENSQ6) score was 14. Acoustic rhinomanometry (Fig. 1) and paranasal sinus computed tomography (CT) (Fig. 2) were performed. He was diagnosed with ENS due to septal deficiency, which caused a wider nasal cavity. We decided to perform septal augmentation using ear cartilage. The bilateral conchal cartilages were harvested and tied together to augment each other (Fig. 3). A modified Killian incision was made on the left side and the mucosal flap was elevated. The depressed septal area was identified (Fig. 4) and the double conchal cartilage was inserted on the left side of the nasal septum. The insertion location was confirmed and the nasal cavity was examined using nasal endoscopy (Fig. 4). Postoperatively, the NOSE and ENSQ6 were repeated, which yielded scores of 45 (moderate) and 9, respectively. To complete all postoperative investigations for comparison, the patient underwent acoustic rhinometry (Fig. 1) and paranasal sinus CT (Fig. 2).

Figure 1. Acoustic rhinomanometry (A) before surgery and (B) after surgery. Demonstrates narrowing of the nasal cavity following septal augmentation.

Figure 2. Computed tomography scans of the paranasal sinuses. (A) Preoperative scan shows septal thinning and depression on the left side. (B) Postoperative scan demonstrates septal augmentation and a narrowing of the nasal cavity.

Figure 3. Concha cartilage graft. (A) Anterior view, (B) lateral view.

Figure 4. Endoscopic view of septum. (A) Septal defect before insertion of the cartilage graft. (B) Elevation of defect after insertion of cartilage.

The Presentation of ENS varies but includes nasal obstruction, crusting, dryness, anxiety, and depression [3]. One challenging aspect of ENS is that the symptoms have a wide range of timing of onset ranging from months to years [4]. The mechanism of ENS development is poorly understood. Over the years, many researchers have suggested numerous mechanisms and associated aerodynamic findings, one of which is that reduction of the turbinate can reduce the contact between the inspired air and the surface, therefore causing the feeling of nasal obstruction [5]. The airflow after inferior turbinate resection changes from inferior to superior. This may contribute to the feeling of nasal obstruction that is evident after inferior meatus augmentation surgery, which reverses the airflow back to the inferior portion of the nose [6]. In our patient, we considered the possibility that a deficient nasal septum, and thus a wider nasal cavity, might affect the aerodynamics similarly to resection of inferior and/or middle turbinate, which could cause airflow to shift more superiorly. No single test can identify ENS, and the diagnosis is usually based on the symptoms, clinical findings, and patient history [4]. Multiple CT scan findings have been associated with ENS, which includes sinoseptal mucosal thickening and partial or complete resection of the middle/inferior turbinate [7]. ENSQ6 is a validated ENS questionnaire that was developed to help diagnose ENS. ENSQ6 is a six-question survey with a maximum score of 30. A score ≥10.5 suggests ENS [8]. In our patient, the NOSE score significantly improved from 90 (extreme) to 45 (moderate) pre- and post-intervention. In addition, the ENSQ6 scores improved from 14 pre-intervention to 9 post-intervention, in which suffocation, nasal airflow, and crusting improved by 2 points each, with the other elements of the questionnaire scoring 0 pre- and post-intervention. However, ENS treatment has some limitations. The best treatment for ENS is prevention with judicial surgical treatment of turbinate hypertrophy through reasonable turbinoplasty and avoiding total or partial turbinectomy. Medical treatments include increased fluid intake, nasal saline irrigation, and oil-based lubrication [9]. Many surgical treatments have been suggested, of which the best-known is middle meatus augmentation, which shows excellent long-term improvement in ENS symptoms and has become the most popular surgical intervention [10]. Middle meatus augmentation includes reconstructing and substituting the deficient tissue using different materials ranging from hyaluronic acid filler injection, acellular dermis allograft, autologous cartilage, and synthetic implants [11]. In our patient, we assumed that the reason for the lack of improvement after inferior meatus augmentation surgery was the wider nasal cavity caused by septal deficiency after aggressive septal resection. To our knowledge, this is the first time that this technique for addressing ENS has been described in literature.

ENS is uncommon. Nevertheless, it can affect the quality of life of patients and cause ambiguity in diagnosis and treatment resulting from the lack of a specific diagnostic method. Inferior meatus augmentation is the most common treatment method. However, septal augmentation, thinning, and depression should never be overlooked, as they might have the same effect as inferior/middle turbinate deficiencies.

None.

The authors have nothing to disclose.