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Page 4 of 9 Go et al. Plast Aesthet Res 2024;11:11 https://dx.doi.org/10.20517/2347-9264.2023.110

radiofrequency, laser, turbinate shaver, and microdebrider. One systematic review assessing fifty-eight
articles reporting surgical treatments and outcomes of inferior turbinate hypertrophy demonstrated that
procedures such as partial and total turbinectomy and submucosal resection were associated with higher
[19]
rates of crusting and epistaxis . However, gentler techniques like cryotherapy and submucous diathermy
failed to definitively address the underlying hypertrophy. Instead, submucosal resection and radiofrequency
ablation were recommended as modalities that could provide lasting results while preserving turbinate
function. Resection of the turbinate bone without destruction of the submucosa or mucosa has also been
[20]
reported to have excellent postoperative functional results with improvement in nasal obstruction .
Though inferior turbinate resection is frequently performed as an adjunct to septorhinoplasty, there are
mixed reports of the procedure’s long-term efficacy and quality-of-life benefits. A randomized controlled
[21]
trial by Lavinsky-Wolff et al. compared fifty patients undergoing septorhinoplasty with and without
inferior turbinate reduction through submucosal diathermy. Looking at septorhinoplasty outcomes
assessments, there was no significant difference between groups in Nasal Obstruction Symptom Evaluation
(NOSE) scores, quality of life metrics, or acoustic rhinometry recordings, although patients with treatment
used less topical corticosteroids. Similar findings were reported in a study of fifty patients undergoing
septorhinoplasty with or without partial inferior turbinectomy (defined as the excision of one-third of
inferior turbinates) . There were no differences in complication rates between the two groups, but surgical
[22]
time was considerably higher in the patients undergoing adjunct surgery (212 min vs. 159 min). One of the
largest studies, including a total of 567 patients (391 undergoing septorhinoplasty alone, 176 with
septorhinoplasty and turbinate resection), again corroborated an improvement of septorhinoplasty on
disease-specific and general health quality of life outcomes . Techniques included medial flap inferior
[23]
turbinoplasty, microdebrider, electrocautery, or coblation submucosal resection. When controlling for
patient characteristics and sinonasal comorbidities, patients with the combined procedure demonstrated a
significant 6-point improvement in NOSE score compared to the septorhinoplasty group, though this was
not clinically significant as the minimum clinically important difference for the NOSE score is 30 points.
There is mixed evidence regarding the most efficacious approach of inferior turbinate reduction. One
randomized double-blinded study found that patients undergoing medial flap turbinoplasty had less
decongestant use and required less revision surgery compared to the electrocautery and submucosal
approaches .
[24]

As some literature has reported a significant improvement in disease-specific outcomes irrespective of
inferior turbinate reduction, it is important to evaluate the necessity of the procedure which can be
associated with increased overhead operating costs, lengthened anesthesia time, and potential
complications. Most importantly for this publication, turbinectomy may also contribute to ENS, which may
not develop for years after the initial surgical insult. To date, there are currently no studies with long-term
follow-up to determine the exact incidence of ENS after any nasal surgery.

DIAGNOSIS
Diagnosis of ENS is challenging due to the lack of objective data; clinicians must typically rely on patient-
reported symptoms, which are highly variable in severity and presentation. The sino-nasal outcome test
(SNOT-22) was initially created as a validated, self-administered questionnaire to assess chronic
[25]
rhinosinusitis patients . The SNOT-25 is an updated version that includes three additional questions
assessing the impact of symptoms on job and household tasks . The empty nose syndrome 6-item
[26]
questionnaire (ENS6Q) was developed as an adjunct to SNOT-22 for patients with suspected ENS,
including six disease-specific quality of life metrics assessing degree of "dryness", "lack of air sensation going
through your nasal cavities", "suffocation", "nose feels too open", "nasal crusting", and "nasal burning”