How Could Routine Nasal Surgery Increase Risk for Anxiety and Suicide?

Imagine feeling like you're suffocating every minute of the day. No matter how big a breath you take, you still feel like you can't get enough air. This is the reality for people suffering from empty nose syndrome (ENS), a complication of nose or sinus surgery.

Despite the condition being a horrifying reality for an untold number of people, it remains controversial, with some otolaryngologists (ear, nose and throat physicians) brushing it off as purely psychological.

However, ENS is becoming an increasingly recognized complication of sinus surgery, one that may occur in up to 20 percent of cases following a procedure known as turbinate resection.¹ With no known cure, and the condition so severe that sufferers cannot even gain respite while they sleep, some describe it as a "life worse than death"² — and many have committed suicide as a result.

What Type of Sinus Surgery May Lead to Empty Nose Syndrome?

People with a deviated (or bent) septum may suffer from nasal congestion and chronic sinus infections, leading their physician to recommend septoplasty and turbinate reductions to aid in opening the nasal passage. A septoplasty aims to straighten a bent or deviated nasal septum, which is the divider separating the two sides of the nose.

A turbinate reduction, or turbinectomy, (which is also sometimes recommended for sleep apnea) seeks to reduce or remove the curved structures sticking out from the side of the nose. These can be enlarged for various reasons, such as allergies or sinus inflammation. It is this loss of tissue that may cause some people to feel as though they can't breathe, despite having clear nasal passages.

Each side of your nose contains three sets of turbiantes (a low, middle and high). The low, or inferior, turbinate is most often the one that's reduced or removed, and physicians may use a variety of procedures, ranging from cauterization to radio frequency, to do so. The amount of turbinate that's removed also varies by case and physician, with some removing the bottom third and other removing a bit off the top.

It's a common procedure. In the U.S., an estimated 600,000 people undergo sinonasal procedures every year, which includes septoplasty, turbinate surgery and others.³ By some measures, turbinate reduction is said to be "the most common procedure in rhinology."⁴ In many cases, the procedure works, leaving patients to breathe easier. But in some people ENS is the agonizing result.

9 Symptoms of Empty Nose Syndrome You Should Be Aware Of

The primary symptom is a feeling of nasal obstruction, or the sensation of suffocating, difficulty breathing or breathlessness. Some people feel they have an "empty nose" while others may report the following, which may develop immediately after surgery or not until months or years later:⁵

Sensation of excessive airflow	Lack of sensation of nasal airflow
Hypersensitivity to cold air	Hyperventilation
Headache	Nasal pain
Nasal dryness	Difficulty falling asleep
Fatigue

The physical symptoms give way to a debilitating condition that often makes daily living difficult, and carries with it significant psychological symptoms as well. Anxiety is common, as is depression, with one study finding ENS sufferers experienced a 62 percent reduction in productivity at work and a 65 percent reduction in productivity in all other activities.⁶

Writing in the Huffington Post, Barbara Schmidt, who developed ENS in her 20s after a routine sinus procedure for chronic sinusitis, lives in a constant state of anxiety and described the condition this way:⁷

"Immediately after my procedure, I experienced a lack of air resistance when breathing and speaking, making these activities that ordinarily came naturally and effortlessly entirely exhausting. I needed to exert great effort simply to project my voice, and for decades I had to catch my breath after speaking just five or six words.

… Although I was in fact breathing and getting oxygen, my brain was no longer made aware of it, so it communicated to my body that it was suffocating, triggering an unremitting fight/flight response … my brain, perceiving suffocation, woke me up every night by generating nightmares when I drifted off.

… The suffering didn't end there: dehydration, dry eyes, ear and facial pain, and the jarring sensation of cold air piercing my lungs whenever I was in an unheated area were miserable, yet mere nuisances compared to the agony of never being allowed to enter into the deeper, restorative levels of sleep ― a torment that's been used as a torture tactic in war."

Still, there was more: Restlessness and simultaneously feeling exhausted yet wired. Unable to focus or articulate. Not sensing air all day, hyperventilating. The brain shocking the body day and night in a desperate attempt to escape the misperception of suffocation. The continuous coursing of stress hormones catabolizing the body, breaking down precious tissues. Constant, agonizing fear."

What Causes ENS?

Turbinates are involved in a number of processes that regulate your breathing. This includes making cold air feel warmer when it's inhaled, swelling and shrinking in size to regulate airflow through your nose, and controlling the amount of heat or liquid lost when exhaling.⁸

"Physiopathology remains unclear," researchers wrote in the European Annals of Otorhinolaryngology, Head and Neck Diseases, "but probably involves disorder caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and conditioning functions. Neuropsychological involvement is suspected."⁹

Likewise, in the journal Current Allergy and Asthma Reports, it's explained, "Little is known about the pathogenesis of ENS, though it is speculated that anatomical changes leading to alterations in local environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms are strongly implicated."¹⁰

It's a paradox of sorts, because while expanding the nasal pathways by reducing turbinates would theoretically seem to make breathing easier, one study that compared nasal aerodynamics before and after nasal surgery revealed a 53 percent reduction in flow resistance along with "radical redistribution of nasal airflow, as well as dryer and colder nasal microclimate for the postoperative case."¹¹

As for why ENS develops in some patients but not others, only hypotheses exist. One suggests climate may be a factor, with turbinectomy in warmer, humid clients not resulting in as many reported instances of ENS. Other hypotheses suggest ENS may be the result of sensory nerves in the surgical area not regenerating properly or perhaps due to surgical methods that damage nerves more so than others.¹²

It's also likely that the way air flows through an individual's nose also plays a role, so much so that researchers at Ohio State University's Wexner Medical Center are using 3D technology to design models to test surgery outcomes prior to the procedure. Using a computer model, they can simulate the removal of tissue to determine how it affects air flow, which could help surgeons be better prepared prior to surgery.

"Because the sinuses are surrounded by the brain and the eyes, you have be very precise, within millimeters," otolaryngologist Dr. Alex Farag said in a news release.¹³ In addition to ENS, other risks of sinus surgery include losing sense of smell or taste, for instance.

Are There Treatments for ENS?

Prevention is by far the most important strategy for avoiding ENS, which is why, if you're considering nasal surgery you should carefully weigh the benefits versus the risks before making a decision. At the very least, if you do undergo surgery, be sure the most conservative surgical techniques are used.¹⁴

"Ultimately, prevention of this feared complication through turbinate-sparing techniques is essential," the Current Allergy and Asthma Reports researchers wrote.¹⁵ That being said, if you or someone you love has had nasal surgery and is struggling with ENS, there may be some helpful treatments, including "mucosal humidification, irrigations and emollients" as well as surgery to reconstruct the turbinates using implants.

At least one study found that surgical treatment of ENS improved depression and anxiety,¹⁶ along with other symptoms. However, there's still much to be learned about which types of implants and placements work best.

"Recent studies have revealed that surgery may result in clinical improvement in patients with ENS but that it does not guarantee improvement in all patients, and insufficient evidence is available to favor any particular implant material," according to a study published in the Journal of International Medical Research.¹⁷

In some cases, people with ENS may also benefit from treatment to address individual symptoms, such as hyperventilation, which may be improved via respiratory rehabilitation.¹⁸ In Schmidt's case, she sought holistic treatment using Ayurveda, dietary changes, yoga, meditation and conscious breathing, as well as stress mitigation and careful attention to temperature and humidity in her environment.

In addition, she received injections of platelet-rich plasma and stem cells through Dr. Subinoy Das, CEO and medical director for the U.S. Institute for Advanced Sinus Care and Research, which is intended to stimulate new nerve and blood vessel growth and tissue remodeling of the turbinates. According to the U.S. Institute for Advanced Sinus Care and Research, they've had a greater than 75 percent improvement rate with these therapies.¹⁹

Alternatives to Surgery for Sinusitis and Sleep Apnea

ENS is iatrogenic, i.e., caused by a medical treatment, diagnostic procedure or physician. This means it's entirely preventable by avoiding nasal surgery. If you're struggling with the symptoms of a deviated septum, including chronic sinusitis, the following natural remedies may help:²⁰

• Drink hot liquids — Sipping on hot tea, bone broth or soup may help relieve congested nasal passages.
• Breathe in steam — Inhaling steam helps reduce the inflammation of your nasal tissues, allowing your breathing to return to normal.
• Stay hydrated — Drinking plenty of water may help reduce the pressure in your sinuses, which decreases the inflammation in your nose.
• Use a warm compress — The warmth from a hot compress may help relieve the pain and inflammation in your nasal passages.

If you're considering turbinate surgery due to sleep apnea, there are also nonsurgical options to consider including continuous positive airway pressure (CPAP), a special type of sleeping mask that mechanically restores your breathing by using air pressure to open your airway. Other potential treatment options include:

• Buteyko Breathing Method — Named after the Russian doctor who developed it, the Buteyko technique can be used to reverse health problems caused by improper breathing, including sleep apnea.
• Orofacial Myofunctional Therapy — Myofunctional therapy involves the neuromuscular re-education or repatterning of your oral and facial muscles. It includes facial and tongue exercises and behavior modification techniques to promote proper tongue position, improved breathing, chewing and swallowing. Proper head and neck postures are also addressed.
• Oral appliance — If your mild to moderate sleep apnea is related to jaw or tongue issues, specially trained dentists can design a custom oral appliance, similar to a mouth guard, that you can wear while sleeping to facilitate proper breathing.

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