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Go et al. Plast Aesthet Res 2024;11:11 https://dx.doi.org/10.20517/2347-9264.2023.110 Page 7 of 9

implant), which found no difference in SNOT-25 scores, rates of injection, rejection, or allergic reaction
[42]
between both groups . Heterogeneity of outcomes may even exist within distinct material types, such as
cartilage. Among patients undergoing autologous cartilage implant, costal cartilage was superior to conchal
[43]
cartilage in terms of SNOT-25 scores and depression-related symptom outcomes . Another case series
using cadaveric rib cartilage for inferior meatus augmentation showed disease-specific improvement via
[44]
ENS6Q and SNOT-22 scores . When assessing techniques, though most reports in literature utilize a
submucosal implant, lateral nasal wall implantation may be superior to inferior nasal wall implantation .
[45]
Addressing psychiatric comorbidities
No matter which material and technique is selected for surgical augmentation, it is important to emphasize
a holistic and comprehensive approach to management. Psychiatry or psychology consult in patients with
comorbid psychological conditions is warranted. Patients with persistent pain issues should see a pain
specialist for personalized treatment options. In one case-control series, patients with ENS after submucosal
Medpor implantation experienced improvements in SNOT-25, ENS6Q, Beck Depression Inventory-II
(BDI-II), and Beck Anxiety Inventory (BAI) postoperatively at 1 year, but all parameters were still
significantly higher than those in the control group . Repeat testing with anxiety and depression
[46]
questionnaires can be helpful in evaluating the psychological burden of the disease and should be
undertaken at regular postoperative intervals.

APPROACH TO THE POST-RHINOPLASTY ENS PATIENT
The expression “an ounce of prevention is worth a pound of cure” is certainly applicable to mitigating the
risk of developing ENS after septorhinoplasty. Though commonly performed, turbinate reduction should be
limited unless truly required. While there is mixed evidence regarding the most efficacious approach of
inferior turbinate reduction, it is suggested that undergoing medial flap turbinoplasty may be superior to
electrocautery and submucosal approaches . In order to avoid unnecessary inferior turbinate surgery,
[24]
additional studies predicting which patients would best benefit from the intervention are important. A
thorough history and physical, as well as the use of validated objective outcome metrics including ENS6Q
and the cotton test, is necessary if highly suspicious of ENS. A realistic but empathetic discussion with
patients regarding pathophysiology, symptomology, and prognosis is warranted; refer to psychiatry or pain
specialists when appropriate. Higher quality studies researching preoperative psychological features are
necessary to predict which patients may be most at risk for developing ENS. Though there are a variety of
surgical approaches, depending on patient and physician preference, a submucosal autograft/allograft with
lateral nasal wall implantation appears to have the best evidence.

CONCLUSION
ENS is an iatrogenic condition after turbinate reduction that confers a significant physical and psychological
burden on the patient. Plastic surgeons performing septorhinoplasty should be aware of the risk of this
postoperative complication and be equipped with a variety of management strategies to best care for
patients. While initial studies in CT imaging and computational fluid dynamics are promising, future
studies involving more precise methods to accurately diagnose patients are warranted.

DECLARATIONS
Authors’ contributions
Performed acquisition, analysis, and interpretation for the work, drafted the work, gave final approval of the
version to be published, and agreed to be accountable for all aspects of the work in ensuring that questions
related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Go
BC