Rhinoplasty and Empty Nose Syndrome

In Rhinoplasty – rhino nose – and plasty to reshape, the surgeon seeks to improve the nasal appearance. However, at the same time, if there is a breathing difficulty such as a nasal septum that blocks the airway, or a nasal valve that can be improved, that is done at the same time. Sometimes – Empty Nose Syndrome – ENS – is a result.
ENS symptoms are severe:
Patients report a sense of not getting enough air, despite normal blood oxygen and a wide-open nose
Constant dryness of the nose
Distortion of sense of smell
Poor sleep
Frequent Infections
Persistent Nasal Pain

The worst part of having ENS is that it is difficult for most doctors to understand how a patient can complain of not getting enough air, of having nasal blockage, when the doctor sees a wide open nose.

Nose Is Blocked Because
Normally when patients say they have a blocked nose, the doctor sees swollen nasal tissue, with the nose actually blocked, and little air passage. Or there may be nasal polyps – like large grapes – blocking the air passage. Or the nasal septum may be very crooked and block the airway. These are standard complaints and findings we ENT doctors see by the dozens. ENT doctors treat these regularly.

“Your Nose is Wide Open”
So why does a person complain of not being able to breathe through his/her nose, when the doctor sees lots of room to breathe? Plus their blood oxygen is normal! This is why:
In the normal nose there is a pathway followed by air on inhalation. There are sensors in the back of the nose that tell the body how much pressure there is and whether to regulate the force of the breathing. There is an ideal pressure at inhalation.
Think of a garden hose – you want to reach eight feet. You narrow the hose opening and water goes exactly eight feet.
Suppose your nozzle drops off? Now the hose is wide open, and the stream dribbles at your feet. A stream of air at a certain speed is at a lower pressure if the opening is too wide.
Similarly in ENS, because certain important buffers or “guides” have been altered, the sensors are not activated.

Nasal Turbinates
There are two main nasal turbinates that warm the air and provide liquid to the airway: these are important so that air reaches your lungs properly moistened. They enlarge and shrink according to the body’s needs. In bad allergy, the turbinates may be so large that they block the airway and cause mouth breathing. Or, they may enlarge and stay that way permanently. There is a procedure where the turbinate “skin” is incised and the tissues are reduced in size without damaging the important surface or mucosa.
The surface of the turbinates contain nasal cilia that move to remove bacteria out of the nose. If that surface is damaged, or removed, many of the ENS symptoms may follow.
A procedure that is performed to give more room to breathe, that results in excess damage to nasal turbinates, can alter the flow of air to the sensors. If too much surface tissue is removed, absence of nasal cilia reduces the ability to ward off infection.

More Details
Christopher J. Martin has written the best book on this subject, Having Nasal Surgery? Don’t You Become an Empty Nose Victim, You can read this for more details of how these complications occur.
As more doctors become cognizant of this physiology, there will be fewer such complications.

How to treat ENS
Most important is keeping the nose moist. Saline solutions applied liberally are important, as are water-soluble gels and ointments.
Frequent infections occur because of absence of normal nasal cilia. In the normal nose there are millions of tiny oars called cilia, which move like a whip to propel bacteria out of the nose. These may be reduced or oven absent, due to removal to turbinate tissue. Thus, substituting a pulse wave irrigation of enhanced saline, for example the Hydro Pulse™ Nasal/Sinus Irrigator with Breathe.ease™XL is used as a substitute for absent nasal cilia action. This wave action does what normal cilia do, so infection is reduced.
Humming is a form of vibration that vibrates the nasal tissue. It is a low tone of “oooommmm.” This hum activated circulation to the area and is therapeutic.
Dr Steve Houser of Cleveland does various implant surgeries to replace the normal air currents, which may give good relief.
Some patients benefit by placing wet cotton into the nose to reduce the wide opening, or they breathe through a wet cloth.

Bad Treatment
ENS patients are particularly sensitive to benzalkonium, an FDA approved preservative that is added to many saline and other preparations. This is why the Breathe.ease nasal spray is used and made fresh, without the benzalkonium.
ENS patients should avoid corticosteroid nasal sprays, as these tend to thin the nasal tissues.

ENS and Allergy
ENS patients can still get allergic rhinitis. I surveyed patients to find out if getting an allergy would help the symptoms by increasing circulation to the area, but those who responded said it did not. Antihistamine sprays such as Astelin or Patanase are safe to use for this allergy.

Sinusitis Therapy
Since ENS patients get frequent infections due to lack of good cilia, your doctor should try topical/nasal antibiotic ointments first before going to systemic antibiotics for sinusitis. Many doctors now simply add the indicated antibiotic to the Hydro Pulse™ irrigating solution, sending it directly into the nose/sinuses and avoiding antibiotic stomach irritation.

How To Breathe in ENS
Count one to four on inhalation, and one to six on exhalation. This has many benefits in reducing ENS symptoms and anxiety.

Don’t Get Empty Nose Syndrome
The more you and friends know about ENS, the fewer persons will end up with this difficult problem. As in any surgical procedure, a complete discussion with your doctor before surgery is your best means of prevention.