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Page 6 of 9 Go et al. Plast Aesthet Res 2024;11:11 https://dx.doi.org/10.20517/2347-9264.2023.110

Table 1. Empty nose syndrome 6-item questionnaire (ENS6Q)
Symptom No problem /NA Very mild Mild Moderate Severe Extremely severe
Dryness 0 1 2 3 4 5
Sense of diminished nasal airflow 0 1 2 3 4 5
Suffocation 0 1 2 3 4 5
Nose feels too open 0 1 2 3 4 5
Nasal crusting 0 1 2 3 4 5
Nasal burning 0 1 2 3 4 5
[27]
NA: not applicable; This table is cited with permission from Velasquez et al. published in Int Forum Allergy Rhinol.

the missing turbinate. Overall, among the 128 patients included, there was a mean improvement in SNOT-
20 and SNOT-25 scores at the three-month postoperative time points, although not all patients derived
[34]
benefit . Among patients who felt that the intervention was beneficial, the biggest improvement was in the
SNOT subdomains of ENS symptoms and psychological issues. No material was favored to have superior
results compared to others, and implants included temporary fillers to semi-permanent and permanent
options.

There are several case studies detailing numerous temporary filler options for submucosal injections
including the use of carboxymethylcellulose/glycerin gel (Prolaryn, Merz Therapeutics) , hyaluronic
[35]
acid , and calcium hydroxyapatite . One case series assessing fourteen patients who underwent Prolaryn
[36]
[37]
injection to the inferior meatus found a significant decrease in ENS6Q, SNOT-22, general anxiety disorder 7
[35]
(GAD-7) and patient health questionnaire-9 (PHQ-9) scores at 1 month . Benefits of using fillers include
the transient, resorbable nature of the material, safety/efficacy, ability to perform in the office, no operative
room overhead costs, decreased healing times, and the ability for reversal in the case of hyaluronic acid.
Submucosal fillers are also an appealing option for patients who do not wish to undergo a permanent
surgical procedure or for those who may want to reduce symptoms until surgery can be scheduled in the
future. Demonstration of improvement with fillers can furthermore confirm the utility of surgical
augmentation. Downsides of fillers include resorption requiring revision procedures, limitation of adding
bulk compared to surgical implants, and spillage from thick injections.

Semi-permanent or permanent implants can be used based on patient and provider preference. One of the
earliest techniques utilized was acellular dermis, a material that is incorporated into the patient’s tissue 3-6
[38]
months post-implantation . Over time, the risk of infection from foreign body decreases as the dermis
becomes infiltrated with blood vessels and collagen. Porous polyethylene implant (Medpor, Porex Surgical
Inc.) is a biocompatible implant frequently used in aesthetic, reconstructive, and augmentation surgeries.
Implantation of Medpor to reconstruct the inferior turbinate was found to improve SNOT-25 scores at the
3-, 6-, and 12-month time points . A similar study found significant improvements in acoustic rhinometry
[39]
assessments, including nasal resistance, nasal volume, and minimum cross-sectional area . β-tricalcium
[40]
phosphate, a synthetic bone graft substitute that is replaced by vital bone in 6 to 12 months, has also shown
[41]
improvement in quality-of-life outcomes . Benefits of using a semi-permanent or permanent implant
include long-term and lasting benefits and increased tissue bulk compared to fillers.

With the many different implants described in literature, there is no clear consensus on the best material/
strategic approach for implantation. One meta-analysis including 6 studies found that autografts/allografts
were more effective than foreign body grafts when comparing preoperative and postoperative SNOT scores.
This study, however, only included one randomized controlled trial directly comparing autografts/allografts
(AlloDerm Regenerative Tissue Matrix, LifeCell Corporation, AbbVie) with foreign body grafts (silastic