Patient-Reported Outcome Measures and Provocative Testing in the Workup of Empty Nose Syndrome—Advances in Diagnosis: A Systematic Review

Abstract

Background The last 5 years have seen a surge of both clinical and scientific interest in empty nose syndrome (ENS). Although ENS is still considered a controversial diagnosis plagued by a lack of standardized diagnostic criteria, ENS is increasingly becoming recognized as a legitimate, physiologic disease entity. As such, it is important for clinicians to understand the most up-to-date diagnostic tools to assess ENS, confirm the diagnosis, and create a more standardized means to counsel these complex patients. Objective Contemporary literature review to discuss diagnostic modalities in the evaluation of ENS, in order to introduce evidence-based diagnostic criteria. Methods A systematic review was conducted in PubMed and Embase (2013–2019) using the search term “empty nose syndrome” to identify peer-reviewed articles on the topic of ENS. Articles advancing contemporary methods of ENS diagnosis and testing were included. A quality assessment was conducted using The Rational Clinical Examination Levels of Evidence. Results The novel development of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) offers the clinician a validated patient-reported outcome measure to supplement history and physical examination. The in-office cotton test, performed by placing an endoscopically directed cotton plug in the site of tissue loss, may help to identify patients who may benefit from turbinate augmentation. Tools such as the sinus computed tomography scan, computational fluid dynamics, and intranasal trigeminal nerve function testing currently have insufficient evidence to support routine use in the workup of ENS. Up to 66% of ENS patients present with comorbid anxiety or depression. Conclusion The ENS6Q and cotton test assist in creating a standardized approach to the evaluation of patients suspected of ENS. These instruments should be used as an adjunct, rather than the sole criteria, on which to ascertain the presumptive diagnosis. Patients suspected of ENS should be screened for comorbid psychological dysfunction.

Impact of Psychologic Burden on Surgical Outcome in Empty Nose Syndrome

“…10 ENS patients experienced a great spectrum of severity and diversity of symptoms, including paradoxical nasal obstruction, breathing discomfort, suffocation, sleep disturbance, and significant psychological burden. 9,10 While still controversial and not widely accepted, abnormalities in neurosensory systems from improper mucosal healing and changes in nasal airflow after surgical resection of turbinate are believed to be responsible for the pathogenesis of ENS. 3,7 Surgical reconstruction decreased Fig.…”

“…[3][4][5][6][7][8] Common symptoms of ENS manifest as a spectrum of severity and diversity, including nasal suffocation, nasal burning, nasal obstruction, crusting, nasal dryness, and impaired air sensation through the nasal cavity. [8][9][10] Patients with ENS also suffer from significant comorbid psychiatric problems such as chronic fatigue, frustration, irritability, anger, anxiety, or depression. As a result, affected patients often report a significant negative impact on the quality of life (QOL), working productivity, and daily living.…”

The empty nose syndrome 6‐item questionnaire (ENS6Q): a diagnostic tool to distinguish empty nose syndrome from primary nasal obstruction

“…Although there are currently no standardized diagnostic criteria for ENS, the ENS6Q is a validated tool that can be an adjunct in a clinicians’ toolbox for this diagnosis 5,7,8 . However, the ENS6Q has been criticized for not including patients with PNO.…”

Editorial

“…Bui et al 17 evaluated 100 consecutive patients presenting to the emergency department for epistaxis to identify risk factors for bleeding and develop a consult algorithm to assist in the appropriate allocation of resources. A systematic review by Gill et al 18 discusses the benefits of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) and the in-office cotton test as adjuncts to ascertain the diagnosis of ENS. However, as the authors point out, there is a high incidence of psychological dysfunction in this patient population which further complicates successful treatment of these patients.…”

“…A systematic review by Gill et al. 18 discusses the benefits of the Empty Nose Syndrome 6 Questionnaire (ENS6Q) and the in-office cotton test as adjuncts to ascertain the diagnosis of ENS. However, as the authors point out, there is a high incidence of psychological dysfunction in this patient population which further complicates successful treatment of these patients.…”