Inferior turbinectomy

The inferior turbinate (IT) has long been recognized as a source of nasal obstruction, and seemingly every passing year brings a new technique to address this. Once medical management has failed, a plethora of options are available to reduce its size, including simple outfracture, extramural mucosal ablation (eg, superficial cautery or laser therapy), submucosal ablation (eg, intramural cautery, radiofrequency ablation, or powered resection), or partial or total resection of the turbinate. Over the years, the American literature has seen a trend toward recommending more conservative measures, so as to avoid the possibility of ENS or AR. In fact, one investigator reversed his prior recommendation of complete turbinate resection after finding, on further follow-up, that 89% of patients suffered from crusting while 39% had thick, foul-smelling secretions. Given this, a panel recommendation to avoid such extensive resection was published. One of the largest series of total inferior turbinectomy published within the last decade by Talmon and colleagues, however, found that 97.4% (342 out of 351) of patients noted improved breathing. The investigators further stated that there were no complications of AR, despite the study being performed in “a hot, dusty climate.” A comment regarding that article in a later issue also noted a lack of development of AR in 1,156 patients on whom subtotal or total inferior turbinectomy had been performed. Ophir and colleagues has also published a series of 186 patients in whom none developed AR after total inferior turbinectomy and, given the long-term follow-up of 10 to 15 years, it is unlikely that this represented an inability to capture a delayed presentation.

Middle turbinectomy

Perhaps even more controversial than IT resection is the removal of the middle turbinate (MT) during surgery. Giacchi and colleagues nicely summarized many of the main issues regarding partial or complete resection of the MT in their study, looking at its effect on frontal-sinus patency, in which they found no frontal sinusitis in their resection group. They agreed with Fortune and Duncavage, who felt that this specific risk was minimal after partial middle turbinectomy. Giacchi and colleagues additionally noted Lawson’s series of 1,077 intranasal ethmoidectomies with partial middle turbinectomies, in which none of the patients developed AR. Despite this, as noted by Houser, Kennedy argues that as an important structure within the nose, the MT, should not be arbitrarily removed unless obviously damaged or involved in the disease process, and this was echoed by Rice and colleagues. Several conditions in addition to tumor resection are noted, where its removal is considered appropriate by Rice, but neither investigator universally condemns its removal. Moreover, in none of the articles regarding MT resection is there any mention of the development of AR.

Controversy or not?

How then can we rectify the IT data with other reports of seemingly high numbers of AR or AR-like symptoms in other studies? Why is there no apparent reporting of AR in the middle turbinectomy patients quoted in these studies? And what of ENS? Are we certain this did not occur, especially if these investigators were using its original definition as a virtual synonym of AR? Closer inspection reveals that Talmon still had nine patients on follow-up who noted no improvement in their breathing. Eight and 11 patients out of 351 were also each noted to have complaints of crusting or pain/discomfort, respectively. Furthermore, Ophir also acknowledged that 11 out of 186 (5.9%) patients had no readily obvious reason for their continued complaints of nasal obstruction, despite a wide, clean airway. It is uncertain if these patients would go on to suffer from AR, but it remains concerning that their persistent obstruction may have been evidence of ENS. In the middle turbinectomy patients, most of whom had resection during the course of chronic rhinosinusitis (CRS) surgery, it may have been difficult to tease out persistent obstruction in the face of this more diffuse mucosal disease process. Furthermore, it is possible that in the CRS patient, hypertrophy of the nasal septum after turbinate resection would prevent AR- or ENS-like symptoms. The author has seen this many times, especially in those patients with polypoid (CRSwNP) type disease presenting for revision surgery. In addition, if mucosal inflammation and glandular hypertrophy were to continue after surgery, any crusting might be assumed to be secondary to the disease process.

Atrophic rhinitis versus empty nose syndrome

In Dr. Houser’s discussion in this issue, as well as his two prior publications on the subject, he discusses the significant differences which he has been able to elucidate between AR and ENS. He divides ENS into three subtypes representing and named for the turbinates that had been resected in each (either inferior, middle, or both; abbreviated as ENS-IT, ENS-MT, or ENS-both). He also characterizes a fourth entity that he dubs “ENS-type,” in which patients have symptoms similar to the other subtypes but with a seemingly normal-appearing airway. In addition to the major symptom of paradoxic obstruction, he notes that patients also develop “an inability to concentrate, chronic fatigue, frustration, irritability, anger, anxiety and depression,” as well as a decreasing sense of smell. ENS-MT, which he states is more controversial, given the wider support for MT resection compared with IT resection, is characterized by a sense of pain with breathing and is seen less frequently than in ENS-IT. Houser theorizes that this may be secondary to circulating, cool air striking the area of the sphenopalatine ganglion, which is no longer protected by the shielding effect of the MT. ENS-both represents those who may go on to become “nasal cripples,” as Kern has referred to them, lacking both major turbinate structures of the nose. More controversial is Houser’s ENS-type patient. These patients have undergone a partial turbinate procedure, yet present with similar symptoms of nasal obstruction despite the apparent normal airway. As the only real article to describe ENS as we are presenting it here, Dr. Houser’s work is landmark. His careful evaluation of patients who were most likely ignored by their operating surgeon and his adaptation of techniques used to rehabilitate the noses of patients with AR is commendable; however, several issues are raised by his article that require addressing before we can either fully understand ENS as it is described here or plan treatment options.

First, a concern is raised regarding such a small sample of only eight patients after three were lost to follow-up among the 11 originally undergoing an operative procedure. It is not clear why of the “dozens of patients” who had undergone evaluation for ENS, that more did not undergo an operation. One would assume one of the following: (1) many resolved with medical therapy, (2) subjective improvement was not seen with the cotton test, or (3) the patients refused surgery. Those falling into the second category represent an important statistic because, if a substantial number, it would indicate that something other than airway shape or size is playing a role. Second, Houser reports a significant improvement rate in the Sino-Nasal Outcome Test (SNOT-20) scores of the eight patients involved, from a median (the more appropriate way to report a nonparametric result) of 56 to 37.5. However, SNOT-20 results, to be considered clinically significant, require an improvement of 0.6 in their indexed score (ie, total score divided by 20). Of the eight patients in the study, only four of them had an improvement greater than 12 (0.6 × 20) in their total score, indicating a failure of 50% to reach clinically significant improvement. Given this, it remains uncertain if failure to improve was a result of the size or placement of the implant or if the patients’ symptoms rely on more than just the cross-sectional area of the nasal cavity. Houser does somewhat address this by discussing the possible contribution of poor nerve regeneration in the turbinate tissue after partial or complete resection of the turbinate. It would not seem logical, however, that one could then “fix” this with simply placing an implant in lieu of correcting the neurologic defect, especially at the risk of developing further neuropathy while raising the septal flap for its placement.

Neither of these two points invalidates the concept of ENS, but they do raise questions regarding what we understand, especially with what we can glean from a very limited study.