Sunday, January 4, 2015

New(er) Treatments for Empty Nose Syndrome

Empty Nose Syndrome (ENS) has unfortunately been a controversial diagnose amongst Otolaryngologists (ENT physicians).  Many ENT physicians in the past refused to seriously acknowledge the patients moderate to debilitating and paradoxical symptoms which developed after re-sectioning of the inferior turbinates (I.T's) in particular the anterior portion or whole I.T. and/or part of the middle turbinates. Victims of ENS had suffered double victimization because their  surgeons would defensively and reflexively write them off simply as unhappy patients who must of coincidentally developed a latent mental health problem after their turbinectomies.  There are still some obstinate ENT physicians that still reject the diagnoses outright but many are finally waking up largely due to the ease of information available on internet where publications have scientifically explained the victims host of complaints.

The person most responsible for shedding light on this topic was retired surgeon Dr. Eugene Kerns of Mayo Clinic in Rochester Minnesota. He is credited for coining the term Empty Nose Syndrome.
It was after two of his ENS patients committed suicide that he decided to devote more time to this unknown misunderstood condition. Both patients led normal active lives prior to their turbinate surgeries with no history of mental illness. In 2000 Dr. Kerns gave a taped lecture on Empty Nose Syndrome to fellow rhinologists, Dr. Kern tells his audience that the nasal mucosa “is the organ of the nose.” He outlines the four main function of this organ: “Olfaction, defense, respiration, and cosmesis.” ‘Please think of it as an organ system, just as you think of the lungs, the liver…the kidneys, as organ systems.” He points out that his Empty Nose Syndrome patients lack cilia, lack functioning mucosa. “When we remove functioning tissue what happens?” he asks. “When we destroy mucosa…these respiratory functions and defensive functions can be significantly compromised. When we convert a nose to a mouth….it’s not aerodynamically efficient…wide open noses do not function…” “How much tissue can you remove and still have normal function? We know you can remove probably eighty to ninety percent of a liver and still have normal liver function. You can remove a kidney…and have the second kidney and still have normal function. How much nose can be removed? I don’t think we know that.”
He says it took about six years, on average, following surgery, for the residual tissue of the nose to fail, in his Empty Nose Syndrome patients.

In past decade Dr. Steven Houser has been recognized as a pioneer in the field offering surgical acellular dermal implant (alloderm)  and injectable liquid alloderm (cymetra) for ENS. Alloderm implants have already been implanted successfully for a few years now in a small but growing number of ENS patients. At four years follow-up, results seem stable and encouraging. It seems that Alloderm implants can't fully cure ENS but can help alleviate the symptoms with various degrees of success, depending on the individual condition of each patient. It is difficult or virtually impossible to use Cymetra on its own to achieve a large volume implant, but it can be used successfully to further augment prior Alloderm implants, thus perfecting the initial result achieved with regular Alloderm.

Does the Method of Inferior Turbinate Surgery Affect the
Development of Empty Nose Syndrome?
Steven M. Houser
Pub date:Feb 10, 2014
ENS, fortunately, is extremely rare. The degree of mucosal damage
relates more directly to the development of ENS than the volume of
excised tissue. Most surgical patients will never develop ENS.
Turbinate surgery should only be considered if medical management
(e.g., allergy medications in the face of allergic rhinitis) has failed.
Using the least invasive process to effect airway improvement in the
face of turbinate enlargement is then wise. Turbinate outfracture
appears safe, as do conservative submucosal reduction procedures.
Turbinate excision should be restricted to disease processes that
prohibit lesser approaches (e.g., cerebrospinal fluid leak repair may
necessitate middle turbinate sacrifice). Turbinate reduction
approached via mucosal damaging procedures (i.e., surface cautery
and laser reduction) should be abandoned in favor of safer techniques.
Poster nose1 on ENS forums has stated even a smaller amount of tissue being removed in such a way that leaves the mucosa damaged can lead to severe ENS symptoms. For example, turbinates that have been cauterized can result in quite severe ENS symptoms.

The term Empty Nose Syndrome fits descriptively well with those who have a structural turbinate deficit. But for those with nasal mucosa dysfunction and little to no structural deficit perhaps a more fitting term would be Nasal Mucosa Dysfunctional Syndrome (NMDS), if I may be so bold to coin a condition. Some who have had their turbinates excised will more likely have a combination of the two. The degree of how much mucosa is damaged/removed will likely coincide with the severity of one's symptoms. In regards to the Inferior Turbinate there's another factor at play. In partial resectioning of the I.T.  resectioning of the anterior portion is much more likely to result in ENS  then resectioning of the posterior portion of the I.T.  I myself can testify to this because my first turbinate surgery consisted of lateral and posterior excision of the I.T's. This did not cause me any ENS. However after my anterior portion was removed in another surgery years later i started to develop some of the symptoms associated with ENS. However I should point out a caveat here is that almost all my left I.T. is now missing. I don't have all the symptoms likely b/c my anterior portion was excised submucosally.  However inbetween those two surgeries I had underwent a cauterization procedure.  Note: I also did not experience ENS symptoms after my cautery of the I.T's where I then had partial lateral anterior I.T's and medial flap of the mucosa which was rolled up to form a smaller medial turbinate performed by the surgeon who performed my first turbinectomy.

Another treatment option now being explored for reducing ENS symptoms is PRP or PRL injections into the nasal cavity. 
PRP (Platelet-Rich Plasma)

Blood is taken from your body and put in a centrifuge. In the centrifuge the blood platelets will be separated. These platelets have great healing abilities which also work in natural wound healing. The out-coming concentrate can be injected to the damaged tissue.  The platelets collected in PRP are activated by the addition of thrombin and calcium chloride, which induces the release of these factors from alpha granules.. The growth factors and other cytokines present in PRP include:[1][2]
PRP has been applied for a some time in different applications (for e.g. nerve injury, bone repair and oral surgery), but only for a relatively short time for the nose.

The PRP might bring the nasal mucosa to a healthier level.

PRL (Platelet-Rich Lipotransfer)

PRL is combining PRP with a lipotransfer.
A lipotransfer is taking your own fat and placing it to another part of your body. The fat contains adult stem cells, which showed good regenerative effects. The stem cells in the fat can be enriched.
Lipotransfers are used for example in breast augmentation/ reconstruction, smoothening wrinkes and other tissue defects.

The therapy consists in the matching between platelet growth factors  and mesenchymal stem cells from adipose tissue taken from the abdomen / buttocks / hip of the patient, through a small liposuction under local anesthesia.

The adipose tissue is centrifuged and purified and subsequently combined with PRP: is thus obtained a compound called PRL (Platelet Rich Lipotransfer), which will be injected in the nasal mucosa in order to stimulate the regeneration of the turbinates and of other atrophic areas in nasal cavity. 

 Doctors, who treat ENS with PRP/ PRL

Prof. Valerio Cervelli, Italy

Dr. Enrico Donde, Italy

Dr. Lino di Rienzo Businco, Italy

Dr. Robert Bodlaj, Germany

PRP & ACell Implants now available at US Institute for Advanced Sinus Care & Research
 The newly created US Institute for Advanced Sinus Care & Research is now offering platelet-rich plasma injections combined with acellular dermis implants for patients with Empty Nose Syndrome. The Institute is physically located in Columbus Ohio.  Dr. Subinoy Das, former Director of Sinus Surgery at The Ohio State University, Audit Chair and Fellow of the American Rhinologic Society, and winner of the 2013 Fowler Award for the Top Basic Science Research Project in Otolaryngology is the new Medical Director.  The Institute collaborates with leading otolaryngologists throughout the
world in an effort to provide patients with advanced and rare sinus diseases with cutting edge therapies.

Hyaluronic acid gel in the treatment of empty nose syndrome. 
Marek ModrzyƄski

Because of its simplicity, safety, and fairly good, but impermanent clinical effects, HA injections appear to be worth considering in less severe forms of ENS. 


Acellular dermal (alloderm) grafts versus silastic sheets implants for management of empty nose syndrome.
 The objective of the study is to conduct a prospective randomized blind clinical study comparing the efficacy and safety of use of acellular dermal (alloderm) grafts versus silastic sheets submucosal implants for management of empty nose syndrome (ENS). . Both graft materials are well suited to this procedure with no statistical evidence for a significant difference between them. The silastic implant is inert and yet incorporated into the surrounding tissue because of the fashioned macropores. It is available and inexpensive. Acellular dermis graft is reliable, predictable, and readily shaped. Patients of both groups showed marked subjective and objective improvements. The surgical procedure is safe and relatively simple to perform. 

Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome.

CONCLUSION: The reconstruction of inferior turbinate with Medpor is a new promising approach to treat patients with empty nose syndrome. 

N.B. My understanding is that medpor is difficult to remove if need be since it incorporates itself with other surrounding tissue's. Therefore one should be skeptical to this approach using medpor, silastic sheets (silicone) or any unnatural products inside the nose.

More Info on Empty Nose Syndrome:

Monday, April 14, 2014

Innervation of the nasal septum and lateral wall

As I have already mentioned in past blog postings I ended up with severe chronic neuropathic pain after my failed nose revision surgery in 2005 .  What's interesting is that most rhinoplasty surgeons don't educate us lay people (patients) about the risk and complications that can arise from nerve injury during rhinoplasty. In fact not only are some rhinoplasty surgeons "apparently" at a loss about my complication, one reconstructive rhinoplasty surgeon mentioned to me during the consult that there are no nerves in area of where my pain is, which happens to be the lower third of my nose ( tip lobe area including columella). Really? Well a very quick search & scant amount of reading on the internet can easily debunk that tale. However if my memory serves me right he was the first one to suggest my nerve pain may be due to Traumatic Neuroma *1. Perhaps he meant there are no main nerve branches in the tip region where my pain seems to originate from. Anyway lets now turn our attention to the nerves within the human nose.

The upper most yellow region is: Olfactory bulb, & nerves
Surgical Anatomy of the nose by Natalie P Steele and J Regan Thomas (Ch.1 Rhinology and Facial Plastic Surgery Fred J Strucker & assoc. ) 

Nerve supply to the nose is externally derived from branches of the trigeminal nerve. The skin of the nose superiorly at the radix and rhinion is supplied from branches of the supratrochlear termination of the ophthalmic nerve. The anterior ethmoidal nerve, another branch of the ophthalmic, may traverse the dorsum of the nose to supply the tip [12]. In endonasal or in open rhinoplasty, this nerve bundle may be damaged by over-aggressive endonasal incisions violating the fibromuscular layer, or elevation of the S-STE (skin-soft tissue envelope) in the wrong plane, resulting in a numb nasal tip. The infraorbital nerve may also contribute branches to the lateral nasal walls, columella, and vestibule. Knowledge of this external nerve supply is necessary to perform adequate nerve blocks for closed reductions, or for rhinoplasty under local anesthesia with sedation. Intranasal anesthesia is also a prerequisite for these procedures. This may be performed with intranasal cocaine pledgets or other strategically placed topical anesthetics. Perhaps the most important target is the sphenopalatine ganglion located in the posterior portion of the nose just posterior to the middle turbinate. Internal branches of the anterior ethmoid must also be anesthetized in the superior portion of the nose to complete a total nasal block.  

Nasal skin is innervated by the infratrochlear and external nasal branches of the nasociliary nerve, and by the nasal branch of the infraorbital nerve.

 Olfactory Nerve (N I)    
The olfactory nerve is a special sensory cranial nerve that is responsible for the sense of smell. The receptors of these neurons are found in the olfactory epithelium and the axons pass through the cribriform plate of the ethmoid bone. These neurons synapse within the olfactory bulb which lies directly above the cribriform plate.

Interesting Observation To Note.  
I have been corresponding with someone who also developed nerve related pain and discomfort after revision rhinoplasty a few years ago.  The person also had the open approach technique repeated along same previous surgical incision, as was done with my nose.  This raises suspicion as to whether repeating the open approach technique along same scarred incision increases chances of developing neuropathic pain or neuroma's due to nerve trauma along skin tissue. Another possibility for explaining nerve pain or neuroma's is large removal of scar tissue along the columella /tip region resulting in a lot of new scar tissue development during healing period which may entrap nerve tissue. The open approach has become very popularized to the point that very few rhinoplasty surgeons are performing the more complicated but less invasive closed approach technique which has it's advantages as well as some disadvantages. So with more rhinoplasty surgeons performing primary and revision rhinoplasty with the open approach we may see a rise in unexpected complications due to trauma such as nerve trauma.

*1 Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. Synonyms include scar neuroma, amputation neuroma, or pseudoneuroma.,d.aWc

Friday, March 14, 2014

Why revision rhinoplasty surgeons should ask to see pictures of future patients unoperated fully developed nose

When a new revision patient visits a rhinoplasty revision surgeon for a consult the surgeon has no idea how much work was done prior in the reduction of the size of the patients original nose unless patient presents them with pictures of their un-operated fully developed nose. The patient may of presented their operative report at time of consult to the revision rhinoplasty surgeon however it still leaves the surgeon guessing & imagining what the nose looked like prior to the previous/original surgery.  I believe this is a critical error that could easily be rectified by new patients presenting the revision surgeon with images of their original [innate] fully developed nose. If you have had multiple surgery's I believe it would be beneficial as well to present the revision surgeon with all the before/after pictures the previous surgeon's took of your nose. The reason I feel so strongly about this is based on my own personal experience. When you have a very large natural nose and end up having a number of revision surgery's by surgeons who 'blindly' and unwisely keep reducing the size of it, this may lead to serious irreversible consequences.

 Example: The last revision surgeon i went to  wasn't very experienced or knowledgeable in complicated revision surgery and reduced my already surgically reduced tip. It was angled slightly too far upwards and was over projected. It wasn't in line with the bridge of my nose which was over-resected from previous surgery's. From previous surgery's I had my tip reduced/repositioned twice. I had made him aware of this and brought him my O.R's and my before/after from my previous surgery, but no pictures of my original un-operated fully developed nose. I had a consult with another revision surgeon before this last inexperienced surgeon operated on me, and his opinion in regards to how to correct my disproportionate tip/bridge profile  problem would of been the correct and safer approach. Let's refer to this experienced revision surgeon as Dr. C. and my last inexperienced surgeon as Dr. S. Dr. C.'s approach was to not reduce my tip but to increase the projection of my bridge (known as dorsal augmentation) thereby  bringing it in line with my tip by adding *1 rib cartilage. The estimated time of surgery was between 4 to 6 hours. Dr.S. told me he could prevent me from going through the pain of having rib cartilage and use some ear cartilage (however not in my bridge) but for collapsing nasal valves' which he ended up not doing, and he could 'bring down' my tip and do surgery all within 1and 1/2 hours.  I should of asked Dr. S. what he meant by 'bringing down ' my tip because I was under the impression he would simply rotate it downwards possibly with sutures instead of removing more of my lower lateral/medial cartilages which was already deficient, and remove what he considered heavy scar tissue all along my columella. In the end my tip was reduced and not as out of proportion with my bridge. Small consolation considering the grave consequences I ended up with. Cosmetically my profile looks short/weak for a male; structurally the tip is somewhat collapsed due to the accumulated effect of over re-sectioning of the supporting tip cartilages and *2 physiologically; I ended up with permanent painful neuropathy with associated side effects of allodynia/ hyperesthesia. 
Fig.1  Profile: Disproportionate tip to bridge ratio

Now whether presenting Dr.S. with pictures of my original sized un-operated nose would of changed his mind of doing another tip reduction like he did is unfortunately left to hindsight. To be clear Dr.S. just as previous surgeons including Dr.C. never requested or had such a picture of me. Considering Dr.S. had all my operative reports however he would of seen I had two prior tip reductions which should of been a red flag for doing another one especially when a different but more complicated approach would of achieved the desired results.  He also was aware I had two prior inferior turbinectomy's but that didn't stop him in doing another one in both nostrils, which he made a condition for going ahead with the surgery.  So in all probability presenting original pictures of my nose to Dr.S. would not of made the slightest of difference. But not all surgeons think alike. Each one is an individual who has their own beliefs, thoughts, idea's, aside from their education, preferred surgical methods and experience. The more information you can supply your future revision surgeon with the better informed he/she will be, presuming they take the time to study your past history. So I would still recommend strongly for a revision patient to dig up some old photo's of your un-operated fully developed nose and present it to your future revision surgeon making him aware of all the transformations which have already taken place. 

It's important to understand that your original un-operated fully developed nose contains/contained within it a proportionately developed network of nerve endings, vascular system, turbinate bone and tissue. Over re-sectioning of any specific area containing the aforementioned anatomy can lead to a breaking point where one can end up with serious consequences.

This hopefully will make your next revision nose surgeon think twice as to which surgical approach he/she will take with you and deter him/her from doing another reduction or aggressive reduction on your tip (as was done on me) * where you end up with similar disastrous results.

*1 The reason rib graft was recommended was because I didn't have sufficient septal cartilage to spare.

*2 Even though I developed painful neuropathy in the lower part of my nose after my surgery in 2005 the exact cause of my neuropathy is undetermined. This is because Dr.S. also over-resected my inferior turbinates which links to the trigeminal nerves. However i have my doubts that the origin of pain is related to the turbinates since many people who have had their inferior turbinates removed do not complain of nerve pain. 

*3 SEE