Does Empty Nose Syndrome Occur following turninectomy in patients with a crowded nasal airway? Hoe successful is turbinectomy in relieving nasal obstruction and chronis sinus headaches

1. Turbinectomy Does Not Cause Empty Nose
Syndrome in the Crowded Nasal Airway
Rex Moulton-Barrett, M.D., Jory Statner , Natalie Niedzwiedz and Kara Babo
Rex Moulton-Barrett, FACS
Plastic & Reconstructive Surgery, Otolaryngology - Head & Neck
Surgery

2. “ Few Areas of surgical intervention are more
controversial than the procedures intended
to relief nasal obstruction secondary to
hypertrophy of the inferior turbinate ”
Elwany S and Harrison R, 1990
J Laryngol and Otol 104, 206-209

3. 1. > 50% pts with nasal obstruction + turbinate hypertrophy
fail medical therapy & 90% respond to turbinectomy
Aleem, et al, 2010: Pakistani Armed Forces Journal 4: November
2. Septoplasty + partial turbinectomy is more likely to lead to
long term relief of nasal obstruction in pts with septal
deviation and turbinate hyertrophy than septoplasty alone
Marais J, et al, 1994: Rhinology 32(3):145-7.
3. Chronic „4 finger sinus headache‟ which is refractory to
medical therapy responds to partial middle turbinectomy
Clerico, et al. 1997: Rhinology 35:98
4. 10% rhinoplasty pts following lateral osteotomy develop
nasal obstruction without reduction of the inferior
turbinate
Beekhuis GJ, 1976: Laryngoscope 86(4):540-8
4 Reasons Why I Perform
Turbinectomy

4. Paradoxical sensation of nasal obstruction,
following
partial or total inferior & or middle turbinate
resection
• +/- lack of sensation to air flow
• +/- stuffiness and too much air flow
• +/- nasal dryness
• +/- feeling of being „crippled‟ and
depression
Definition of Empty Nose Syndrome (
ENS )
Kern, 1997: Am Rhinologic Soceity Spring Meeting

5. Ozena: Triad of fetor, crusting and atrophy of nasal
structures
( Dr Bernard Frankel, 1876 )
• Anosmia
• Foul Odor
• Crusting
• Congestion sensation
• Enlargement of nasal cavity with loss of turbinates
• Squamous metaplasia
Not Ozena: obliterating endarteritis ( Ruskin, 1932* )
* Arch Otolaryngol 15(2):222-257
Definition of Atrophic
Rhinitis
( aka: Rhinitis Sicca )
..
..

6. • Partial turbinectomy ( 56%)
• Total turbinectomy ( 24%)
• Sinus surgery (10%)
• Radiation therapy (2.5%)
• Nasal trauma (1%)
• Granulomatous diseases (1%)
Sarcoid
Infections: Leprosy
Klebsiella
Rhinoscleroma
Tuberculosis
Causes of Atrophic Rhinitis
Moore & Kern. Amer J Rhin. 2001, 15(6): 355-361

7. • Spielberg W, 1924: overzealous resection might
cause
Laryngoscope 34:197-203
• Rustin SL, 1932: might cause atrophic rhinitis
Arch Otolaryngol 15(2): 222-257
• Goode R,1978: may occur with alpha blockers
J Otolarygngol 7(3):262-8
• Clayman LZ, 1979: in the „black‟ nose: too much air flow
Plastic &Recon Surg63(5):718-9 may worsen anterior rhinorrhea
Atrophic Rhinitis Following
Turbinectomy

8. •Moore GF, et al, 1985: 18 east coast pts: total bilateral inferior
turbinectomy
Laryngoscope 95:1095-1099 72% (13) + septoplasty follow-up (f/u) 3-5 years,
same patients < 3 years f/u no complications
reported
89%(16) reported new onset dryness and crusting
34% (6) new onset malodor detected
•Elwany S & Harrison 1990:
J Laryngol & Otol 104:206-209 20 egyptian patients „partial‟ inferior
turbinectomy
< / = 1 yr follow-up, variable amount resected
Is Inferior Turbinectomy Harmful ?: Yes

9. •Oburra HO, 1995: 34 kenyan patients total bilateral inferior
turbinectomy
East African Me d J72(2):101-2 22% complication rate with unspecified follow-up
15%(5) developed atrophic rhinitis
•Berenholz L, et al, 1998: 42 pts israeli underwent total turbinectomy
Am J Rhinol12(4):257-61 ? % bilateral, ? duration of follow-up
31%(13) developed new onset symptomatic chronic
sinusitis
•Passali, et al, 2003: 45 italian patients underwent inferior
turbinectomy
AnnOtol Rhinol Laryngol yearly follow-up for 6 years: unchanged
symptom scores
Is Inferior Turbinectomy Harmful?: Yes

10. •Courtiss E H et al, 1978: 88 pts, 110 total inferior turbinectomy
Plast & Recon Surg 62(20249-57 3.4% complication: bleeding, 1/3 required
transfusion
No other reported complications
“ Unable to find a documented atrophic rhinitis ”
•Martinez SA et al, 1983: 29 pts total inferior turbinectomy
Laryngoscope 93:871-5 27 bilateral , 75% with septoplasty
follow-up 2-60 months
2 with mild dryness and crusting, no ENS
•Carrie S, et al, 1995: 14 patients with bilateral total inferior
turbinectomy
Clin Otolaryngol 21:139-41 > 7 yr follow-up & acoustic rhinometry
No symptoms / signs of atrophic rhinitis /
Does Inferior Turbinectomy Cause Atrophic Rhinitis
?: No

11. •Pollack and Rohrich, 1984: 183 pts 1/3-1/2 partial inferior
turbinectomy
Plast &Recon Surg 74(2):227-236 90% long term relief nasal obstruction
80% >12 months follow-up (25% >3
yrs)
No patients developed atrophic
rhinitis
•Ophir, et al, 1985: 150 israeli pts total & bilateral inferior
turbinectomy
Arch Otolarygol 111:93-5 85% success in relieving nasal obstruction
4.6% (7) complication: bleeding, 2 required
transfusion
No symptoms / signs of atrophic rhinitis / ENS
•Mabry, 1988: 40 patients anterior 1/2 inferior turbinectomy
Does Inferior Turbinectomy Cause Atrophic Rhinitis?:
No

12. Houser, 2006: Arch Otolaryngol Head Neck Surg 133(9):858-63
• Single case report endoscopic subtotal middle turbinectomy &
endoscopic ethmoidectomy followed by revision 3 yrs later
& sphenopalatine ganglion ablation
• Complications: left nasal stuffiness, nasal cold air intolerance and
pain
• Underwent alloderm submucosal septal implantation and
Cymetra injectable into the septal implanted area
with > 40% improvement
Does Middle Turbinectomy Cause ENS?:
Yes

13. • Morgenstein & Kreiger, 1980: 36 pts underwent middle
turbinectomy
Laryngoscope 90:1596-603 19 for headache and 13 bilateral
2.7%(1) complication: bleeding &
synechia
No patients developed atrophic rhinitis
• Lawson, W., 1991: 1077 partial (1/2) middle turbinectomy & total
ethmoidectomy
Laryngoscope 101(4Pt1):367-71 follow-up at least 2 years
2 cases of hemorrhage
None developed atrophic rhinitis
• Giacchi, etal, 2000: 100 pts retrospective non randomised case study
J Rhinology 14:93-97 1/ 2 partial middle turbinectomy & endoscopic
ethmoidectomy
middle turbinectomy reduced recurrent sinusitis
Does Middle Turbinectomy Cause Atrophic Rhinitis?:
No

14. Grutzenmacher, et al, 2003: ORL 65:341-347
6 „normal noses‟ filled with silicone and acrylic molds were then
made:
4 Groups Each measured by acoustic & manometric rhinometry
Normal nose Even flow
distribution
Hyperplastic Reduced rhinometry+flow
acrylic polymer & even flow
distribution
(simulated)
„Turbinectomy‟ Turbulence increased &
& normal nose reduced air flow
resistance
(simulated)
Is Combined Turbinectomy Harmful:
No/Yes
inferior middle

15. • Fry HJ, 1973: 200 pts „judicious‟ partial inferior and middle
turbinectomy
Aust NZJ Surg 42(3):291-4 +/- reduction rhinoplasty
+/- septoplasty
+/- ethmoidectomy
middle turbinectomy reduced recurrent sinusitis
no cases of atrophic rhinitis / ENS
Does Combined Turbinectomy Cause ENS?:
No

16. • 2004 - 2011: retrospective case series, n= 87 patients
• Follow-up: data collected from May 2010 - January 2012
• All patients underwent detailed telephone interview
chart review
& office examination
• Post-surgery symptoms analysis was determined using a
Subjective
Units of Improvement Scale ( SUIS ): 0 - no improvement
10 - resolution
• The duration of post operative benefit was recorded
• A list of the most common post - operative symptoms was
Is turbinectomy safe to perform in my patients ?
Methods

17. • Indications for surgery
> nasal obstruction: > 6 months ( often many years )
> middle turbinate headache: > 6 months (often many years )
> refractory to medical therapy: > 6 weeks continuous therapy
> high risk for nasal obstruction following rhinoplasty: infracture
osteotomy
• Surgical Technique
> nasal obstruction: anterior 1/3, 1/2 or subtotal inferior turbinectomy
> chronic sinus headache: inferior 1/2 middle turbinectomy
> +/- combined with: uvelopalatoplasty,
submucous resection of the nasal septum,
nasal valve reconstruction,
tonsillectomy
endoscopic sinus surgery
rhinoplasty with in fracture osetotomy
• same surgeon
• all cases packed with Mericel sponge packing for 4 days
Methods

18. • 87 Patients
• Sex: 40 Female 47 Male
• Age: 16 years to 95 years: mean 55.5 years
• Follow-up: 2 months to 6 years: mean 42.4
months
• 172 turbinectomies performed
Results

19. Symptom(s) Subjective Units of Improvement Scale: 0-10
Symptom resolution marked mild none n=Specific
Procedure
10 >=7 <=6.9 0
Nasal Obstruction 5 4 2 3 14 S+BIT
(n = 50) 5 4 0 0 9 To+S+BIT
2 5 0 0 7 To+BIT
3 2 1 0 6 ESS+BIT+BMT
1 2 2 0 5
UVP+S+BIT
1 1 0 1 3 UVP+R+BIT
0 3 0 0 3 IT (1/3
Unilateral )
0 2 0 0 2 NVR+BIT+BMT
0 80% 0 1 20% 0 1
UVP+NVR+S+BIT
___________________________________________________________________________________________
_________
Nasal Obstruction & 1 6 0 1 8 UVP+BIT/MT/NVR
Headache 1 4 1 0 6
ESS+BIT+BMT
1 3 1 0 5
R+BIT+BMT/S
(n = 37)

20. 14 Persistent Symptoms in 13 Patients
Nasal Obstruction (13) 13/87 ( 14.9 %) 4: S+BIT
6 unilateral 2: ESS+BIT/MIT
7 bilateral 1: R+BIT+MIT
1: R+MIT
1: S+BIT+MIT
1: NVR+S+BIT
1: To+BIT
Headache (1) 1/37 ( 2.7%) 1: NVR+S+BIT *
* no MT surgery
performed
Results

21. Causes of Persistent Nasal Obstruction Pts ( n= 13 /87:
15%)
• Nasal valve collapse (NVC) 12
• ENS 1 ?
Causes of Persistent Headache Pts ( n=1)
• Untreated middle turbinate impaction on septum 1
Results

22. Complications of surgery ( 12/87 ) Number Patients Procedure(s)
Increased rhinorrhea 5 ( 5.7%) 2:S+ESS+1/2BIT
1: ESS+1/2BIT
1:NVR+BIT+BMT
1:To+S+BIT+NVR
Bleeding requiring repacking 4 ( 4.6%) 3:1/2BIT,1:BIT
Mild long term crusting * 2 ( 2.3%) 1:S+BIT, 1:NVR+BIT
*both associated with NVC
New onset nasal obstruction 1 ( 1.1%) 1:R+BIT * will
discuss
Results

23. Atrophic Rhinitis / ENS from Surgery Pts
Atrophic Rhinitis 0
ENS 1 ? *
* History: 54yr asian female
minimal complaint of nasal congestion
s/p forehead flap reconstruction of tip defect from
carcinoma
external valve narrowed L>R, retracted columella,
depressed tip
tight circumferential scarring of the nasal tip
angry at all 3 previous surgeons
unemployed for 3 years
Surgery: septal cartilage grafts, scar excision, local
flaps &
right 1/3 inferior turbinectomy, left 1/2 inferior
Results

24. 1. Persistent Nasal Obstruction following Turbinectomy is usually
caused by nasal valve collapse and not ENS
2. The extent of surgery should match the extent of the problem
Less <----- ie. how much to remove ? -----> More
Failed C pap & nasal obstruction severe allergic rhinitis / polyposis / septal
deviation
3. Differences in anatomy: narrow versus broad external nasal valve ?
Leptorrhine not = platyrrhine nose
4. Psychological profile: Gorney‟s „Simon vrs. Sylvia‟ ?
Single, immature, male, obsessive, narcissistic vrs. Secure, young, listens, verbal, intelligent,
attractive
5. Can turbinectomy cause intra-nasal RSD: Reflex Sympathetic
Dystrophy ?
5 Sources of
Controversy ?

25. Summary
• Turbinectomy: safe procedure in the crowded nasal airway
• Inferior Turbinectomy was associated with > 85% relief of nasal
obstruction
• Persistent nasal obstruction following inferior turbinectomy was due to
nasal valve collapse in 12 / 13 patients.
• Partial middle turbinectomy was > 97% successful in relieving
headaches
• Turbinectomy should be avoided when there is an enlarged airway or if
there is xero-rhinitis from whatever cause
• Exhibit caution in performing turbinectomy in patients with a:
a. platyrrhine nose: african - american & asian nose
b. abnormal psychological profile

26. “Rejoice while we are
young”
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