CC: Understanding Empty Nose Syndrome

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Empty Nose Syndrome brought to you by the Modern Nose Clinic

So this is Doug Skarada, and I'm at the Modern Nose Clinic. And I kind of have a sad topic to talk about today; it's empty nose syndrome. I thought I might show you my fishbowl, which is my office, before we get started. So this is where I live. I'm gonna go backwards. This thing here is – says 22 in the car backwards because I'm holding my phone backwards, and we are a  SNOT-22 clinic, so I love that number. And then over here I've got my workspace, which I'd love to tell you is super clean and – but I feel – obviously blocking a lot of stuff and – dry erase board! I love – I'm a creative person, and I'm very visual. So anyway. I'm gonna walk on out, and we're gonna talk about a somewhat sad topic today which is empty nose syndrome. Okay.

So. Since this is somewhat about - not a happy topic, let's get some privacy in this room here. Okay? This is actually one of our clinic rooms here. So, empty nose syndrome is something that, first of all – it deserves a lot more attention than it gets. I had someone comment on one of our other videos – I think was physiologic nasal airflow – that they had empty nose syndrome and how terrible it was, and I promised them that I'd make a video on this topic. So it's a bit late-coming; I apologize, but here it is.

Okay. So. Empty nose syndrome. When you read about it on the internet – and I encourage you to read a little bit about it on the internet – there's a couple of incorrect things. For one thing, they say that it's a rare disease, and some ear nose and throat doctors are unsure if it really exists. Oh, it exists. There's no doubt it exists, and really, if an ear nose and throat doctor bothers to go to any rhinology meeting like the American Rhinology Society, which is fantastic. Plug for them. There's no one there who would tell you otherwise, so I wouldn't call it controversial in regards to its existence, but it's unclear why people get it. I can tell you some general terms that are general ideas to consider. It seems to happen when the nose has been overly resected. So if any of you out there are considering getting a nasal surgery, take your time and think about this potential complication.

So. At the Modern Nose Clinic, we have a philosophy of preserving normal anatomy. That per– that goes across all of our lines of care. We have this idea that the nose is designed the way it's supposed to be for a really good reason, and – so we take a very conservative and careful approach to modifying the nasal anatomy. Whenever a person will resect the entire inferior turbinate, for instance, and – in all fairness, I did this before also, so I'm not gonna say that I'm above this, in case there's an ear nose and throat doctor watching this video. I think that across the country, this was something that was routinely done and still done, where there's lots of destructive techniques for treating the inferior turbinate. So me personally, I don't do that anymore, so I would say I'm a reformed inferior turbinate abuser.

We have a whole bunch of techniques where we actually shrink down the inferior turbinate without using electricity or cryother– or I'm sorry not cryotherapy – or coblation or other destructive techniques. And it's beyond the scope of this video, but I would say that being somewhat conservative and the treatment of the inferior turbinate is the first place to start. Take a look at my physiologic nasal airflow video, and you'll see what happens if you resect the inferior turbinate; all the airflow will move along the floor of the nasal passageway. Let me show you.

So this is a very typical anatomic chart you'll see in an ear nose and throat clinic, and this piece here shows the inferior, the middle, and the superior turbine. And what most ear nose and throat doctors do is resect this, and I just saw a patient yesterday treated here in town by a physician, and the physician said he had never seen a patient with empty nose syndrome. And the patient came back multiple times, and all of the symptoms were consistent with those. What happened was they had this – almost this entire structure resected, so air flows into the nose along the floor and down the back. You're not ventilating the upper 90% of the nose, and therefore, you're basically crippling the nasal airway. You're not gonna filter out dirt and dust. You won't smell food or olfactory – you know – smelling particles that move across this olfactory nerve. You won't humidify the air, warm the air, condition the air, so if you go skiing, it could really hurt your nose as the icy cold air moves through the floor of the nose. So any ear nose and throat doctors who are watching, please take heed and consider alternative treatment options for the inferior turbinate.

Okay, so. What is it? We're back in the fishbowl. And we've turned to Wikipedia! That fund of awesome medical knowledge, and I just went up – you know – here's – this could've been the CT scan of my patient the other day. The inferior turbinates here have been resected. It's interesting that this gigantic Concha Bullosa's still there, and this is a pretty big middle turbinate up there. So – you know – now that looked a little bit like my patient the other day, but let's read this.

"Empty nose syndrome, one form of a secondary atrophic rhinitis," which means the nose has changes along the mucosa. They claim it's "a rare clinical syndrome." They are wrong. It is not rare. We see a patient almost once a week with this. "In which people have clear nasal passages experience a range of symptoms, most commonly [...] nasal obstruction, nasal dryness and crusting, and a sensation of being unable to breathe." And we discussed why that's the case. Air is flowing along the floor of the nasal passageway, and you cannot feel it move through the upper 90% of your nose. And when you have that much air moving across your mucosa, it will cause excessive dryness, and the crusting is something that could be managed for many people. Even if you have an empty nose syndrome, sometimes that could be managed with some topical ointments and whatnot.

"They've [People who experience ENS] usually undergone turbinectomy." True. "(Which is removal of or reduction of the turbinates, structures inside the nose) or they've had other surgical procedures that interfere with the turbinates; overall incidence is unknown but appears to occur in a small percentage of those who undergo nasosinal procedures." That's probably true, too. It's not the majority. You're probably safely gonna have your nasal surgery, but it's not rare.

And then it says, "It appears to be a healthcare caused condition," which I have problems with that! They're assigning blame! Wikipedia! Wow! You guys are so freaking knowledgeable! So you guys aren't all that smart. You don't know what's causing it cuz no one knows what's causing it. And there may be – it may be true that some people are more inclined to get it for other reasons we don't understand. I think the take-home point – the teaching point is that less is more. You want to preserve normal anatomy. You want to redirect nasal airflow. Please see my video on physiologic nasal airflow. This is a coin that's been – I'm sorry – term that we've coined here at the Modern Nose Clinic, of which means we made it up, but I like it. And it explains what we do. Alright!

So! So. To my patient who I spent an hour with last night. To the person who left the comment on our video physiologic nasal airflow. For any of you out there who may be suffering from an empty nose syndrome. I'm really really sorry, and that is not – not something that I wish upon anybody, and this is actually one of our little surgery rooms here. Kind of cool. It's actually a clinic room that we converted into a surgery room.

But please ask any questions in the comment section. I can't really give medical advice per se, but I thought this could be useful for anyone who would like to learn more about this. If you're thinking about surgery, the Modern Nose Clinic – we have a very modern approach to nasal surgery where we preserve normal anatomy, and – to the best of my understanding – we have not had a single case of empty nose syndrome in the 11 months of our existence. So we'll try to keep up that track record. Take care.

Signing off. Doug Skarada. Modern Nose Clinic. We know your nose.