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may, at times, be related to dry air, air conditioning, changes to weather, and transitioning between indoors
[9]
and outdoors .
Aerodynamic studies have helped characterize nasal airflow patterns to better understand the profound
implications of turbinate loss. In sinonasal models with bilateral radical inferior and middle turbinectomies,
parameters including velocity, pressure, streamlines, air flux, and wall shear stress were measured during a
[10]
laminar flow study . Around the inferior turbinates, streamlines were less organized with decreased airflow
rates near the inferior meatus, which may clinically correlate with the increased feelings of crusting and
dryness that patients feel. Around the middle turbinates, velocities were increased around the
sphenopalatine ganglion during inspiration and expiration, which is speculated to cause the headaches
associated with respiration due to increased nerve stimulation. Computational fluid dynamics studies also
demonstrated lower nasal resistance with lower air-mucosal stimulations, which were associated with worse
symptoms . While additional aerodynamic studies including an increased number of models are required
[6,7]
for further investigation, these changes to airflow and turbulence can help explain the pathophysiology of
the underlying disease.

SYMPTOMS
There are four different subtypes of ENS depending on the turbinate missing: inferior turbinate (ENS-IT),
middle turbinate (ENS-MT), both inferior and middle turbinate (ENS-both), and after turbinate “sparing”
procedure (ENS-type) . ENS-IT is the most common subtype; patients typically present with complaints of
[11]
paradoxical nasal obstruction despite no anatomical hindrances to airflow on examination and endoscopy.
Other frequently reported symptoms include nasal congestion, nasal/pharyngeal dryness, crusting,
headaches, and feelings of suffocation. Dyspnea, hypersensitivity to cold air, difficulty falling asleep, and
general fatigue may also occur . As nasal breathing is most physiologically preferred over mouth
[12]
[13]
breathing, a drastic change in breathing pattern can cause significant distress .

Affected patients can also report a profound impact on quality of life and exacerbation of underlying mental
health conditions. Psychological symptoms including anxiety, depression, fatigue, or lack of productivity are
commonly associated with ENS. One systematic review with six studies found that anxiety and depression
were elevated in ENS patients (65%-73% and 51%-71%, respectively) . One cross-sectional study found a
[8]
high prevalence of anxiety and depression warranting treatment, with decreased productivity at work and
other activities . Symptom severity correlated with depression and anxiety severity, overall pain/
[14]
discomfort, and impairment in activities of daily living. In another study, suicidal ideation was identified in
23 of 62 (37%) ENS patients prior to nasal reconstruction surgery and in 4 patients after surgery . While
[15]
many patients with ENS can experience significant psychological distress, most studies to date have not
analyzed preoperative psychological metrics . It is also important to consider early psychiatric referral if
[8]
concerned for an underlying psychiatric condition, as demonstrated in a case report of a patient ultimately
diagnosed with somatic symptom disorder after having undergone numerous unsuccessful surgeries for
ENS . Close monitoring of the psychological burden of ENS is critical to ensure that patients receive
[16]
multidisciplinary, specialist attention for comprehensive care.

ROLE OF TURBINATE SURGERY IN RHINOPLASTY
The aim of septorhinoplasty is to alter nasal anatomy for cosmesis and to relieve nasal obstruction for
functional improvement. As inferior turbinate hypertrophy can be a frequent source of obstruction, many
[17]
plastic surgeons concurrently address the turbinates in the operating room . Hypertrophy is a
[18]
heterogeneous disease process, with a multitude of surgical approaches to reduce tissue bulk . Different
types of turbinate reduction techniques include both mucosal and submucosal resection involving the use of