Синдром пустой носовой полости: причины, симптомы и диагностика.

Empty nose syndrome (ENS) is a clinical syndrome, the hallmark symptom of which is a sensation of suffocation despite a clear airway. This syndrome is often referred to as a form of secondary atrophic rhinitis. ENS is a potential complication of nasal turbinate surgery or injury. Patients have usually undergone a turbinectomy (removal or reduction of structures inside the nose called turbinates) or other surgical procedures that injure the nasal turbinates. ENS patients may experience a range of symptoms. Commonly reported are feelings of nasal obstruction, nasal dryness and crusting, and a sensation of being unable to breathe. The overall incidence of ENS is unknown due to the small body of epidemiological study and the lack of a dedicated International Classification of Diseases (ICD 10) code, which would allow incidence reporting of the syndrome. In a 2019 study in the Facial Plastic Surgery Clinics of North America journal, study lead Jason Talmadge, MD posited that "many cases likely go unrecognized or underdiagnosed, and therefore unreported." The condition is caused by injury to the nasal turbinates, particularly with nasal procedures. This includes both minor procedures as well as total turbinate resection. It is usually observed in patients with unobstructed nasal passages following surgical intervention who report sensations of suffocation or obstruction following recovery. Early literature attributed ENS to complete turbinate resection, but later research demonstrated the syndrome in patients who had undergone a range of procedures that involved nasal turbinates. The syndrome's existence as a distinct medical condition is controversial, with adoption by a growing body of ear, nose and throat (ENT) practitioners and plastic surgeons. ENS is not fully understood and practitioner knowledge about altered nasal breathing in turbinate surgeries varies. Understanding why some patients exhibit ENS symptoms while others do not and incorrectly attributing symptoms to psychological causes such as anxiety are common reasons ENS patients do not receive care.

The major symptoms of ENS include a sensation of suffocation, nasal dryness, nasal burning, nasal crusting, and an impaired sense of airflow through the nose in patients who have had surgery or injury to nasal turbinates. ENS can greatly reduce a patient's quality of life and many patients struggle to complete activities of daily living. While ENS is physical in its origin, many ENS patients also struggle with depression, anxiety, and sleep disturbances. Individuals with ENS may experience all or some of these symptoms. A limited study of ENS patients found that ENS is associated with hyperventilation syndrome (HVS) in 77.3% of the study population. The study suggests that there could be an epidemiological link between ENS and HVS. Further studies are required to confirm these results. The authors hypothesize that the link between ENS and HVS could be explained by the nasal injury that occurs to the turbinates that alters the respiratory control system. A 2023 study found that ENS patients scored significantly higher on the Epworth Sleepiness Scale than control groups, and that severity of ENS symptoms correlated with severity of sleepiness. Sleep apnea was found to correlate with severity of ENS symptoms and high BMI in a 2022 study.

The cause of ENS is due to the body not accepting the new airflow in the nasal passages following surgical procedures. The nose is an incredibly complex area of the body and one that has been very poorly researched in terms of the effects on aerodynamics from surgical procedures. In many patients with ENS, the airflow is modeled as being more turbulent with less laminar flow across the mucosa. This change in airflow leads to an imbalance of /|O2 levels in the body, which will show hyperventilation like symptoms in patients. This reduced amount of mucus in the nose can also be attributed to the change in airflow often resulting in dry cool air hitting the back of the patient's throat. One possible cause may be changes to the nasal mucous membrane and to the nerve endings in the mucosa resulting from chronic changes to the temperature and humidity of the air flowing inside the nose, caused in turn by removal or reduction of the turbinates. It has been proposed, that the airflow in ENS patients is changed so that most of the air flows through the middle meatus, compared to most of the air flowing through the inferior meatus in healthy individuals. This can be corrected via inferior meatus augmentation (IMAP surgery).

No consensus criteria exist for the diagnosis of ENS and many ENTs will wait a year before diagnosing in hopes the patient accepts the new airflow; it is typically diagnosed by ruling out other conditions, with ENS remaining the likely diagnosis if the signs and symptoms are present. The ENS6Q is the first validated, specific, adjunct questionnaire to the SNOT 22. It can more reliably identify patients suspected of ENS. The ENS6Q is gaining usage in studies on ENS.

Attempt non surgical methods for an extended period of time prior to surgical intervention. Avoid any unnecessary nasal surgery, avoid any surgical treatment to the turbinates and septum, seek multiple consults for any nasal surgery, conduct imagery on the nasal passages prior to any surgical treatment, seek opinions from surgeons familiar with ENS. Many surgeons will tell patients that ENS is only seen in patients that have excessive turbinate reduction, but studies have shown that any surgery/procedure involving the nasal turbinates can potentially lead to ENS. For this reason it is critical that anyone planning any surgery to the nose for function or appearance should be aware of the high risk of ENS developing if the body does not accept the new airflow and exchange of gasses.

Treatment of ENS by many ENTs is extremely limited with very marginal success rates once diagnosed. Initial treatment is similar to atrophic rhinitis, namely keeping the nasal mucosa moist with saline or oil based lubricants and treating pain and infection as they arise; adding menthol to lubricants may be helpful in ENS, as may be use of a cool mist humidifier at home but has limited success and many ENT patients seek treatment from the few ENTs well educated in ENS surgical techniques. The term "Empty Nose Syndrome" was first used by Eugene Kern and Monika Stenkvist of the Mayo Clinic in 1994. Whether the condition existed or not and whether surgery was a cause, was hotly debated at Nose 2000, a meeting of the International Rhinologic Society that occurs every four years, and continued to be debated thereafter at scientific meetings and in the literature; as an example of how heated the debate became, in a 2002 textbook on nasal reconstruction techniques, two surgeons from University of Utrecht called turbinectomies a "nasal crime". according to Subinoy Das, another doctor who studies ENS, recognition among rhinologists was growing.