Does Total Turbinectomy Always Lead to Empty Nose Syndrome? A Computational Virtual Surgery Study

Abstract

Introduction: Computational fluid dynamic (CFD) modeling has previously indicated that distorted nasal airflow patterns may contribute to empty nose syndrome (ENS); however, no data show that aggressive turbinate surgery always leads to ENS. We aim to use virtual surgery planning (VSP) to investigate how a total inferior turbinectomy affects airflow parameters compared with ENS patients.

Methods: We retrospectively recruited six nasal obstruction patients who underwent turbinate reduction surgery. We virtually performed total inferior turbinectomy on these patients to compare CFD modeling results to patients' actual surgical outcomes and to that of a previously collected ENS patient cohort (n = 27).

Results: Patients' actual surgery outcomes were excellent, with Nasal-Obstruction Symptom Evaluation (NOSE) score (pre: 72.5 ± 13.2 vs post-surgery: 10.8 ± 9.8, p < 0.001) and unilateral visual analog scale (VAS) scores of nasal obstruction (pre: 6 ± 2.56 vs post-surgery: 1.2 ± 1, p < 0.001) improved and was statistically significant. The virtual turbinectomy does not create the same distorted nasal airflow patterns as seen in ENS patients, with no statistically significant difference in nasal resistance as compared with post-actual surgery (virtual turbinectomy: 0.10 ± 0.03 Pa/mL*s; actual surgery: 0.12 ± 0.04 Pa/mL*s; ENS: 0.11 ± 0.04, p > 0.05) nor in regional wall shear force distribution, an important indicator of air/mucosa stimulation (inferior turbinate WSF%: virtual 47.3% ± 11.3% vs actual 51.5% ± 15.1%, p > 0.05); however, both are statistically significant higher than that of ENS patients (WSF: 32.2% ± 12.5%, p < 0.001), despite ENS cohort having wider inferior airway cross-sectional area (CSA) than actual surgeries.

Conclusion: Empty nose syndrome is likely a multifactorial disease process that cannot be solely attributed to aggressive turbinate reduction surgery.

Level of evidence: 3 Laryngoscope, 135:562-569, 2025.

Keywords: FESS; functional endoscopic sinus surgery; turbinate hypertrophy; turbinate reduction surgery.

Figure 1

(A) Surgical simulator with image guidance and real‐time physical rendering of CT. (B) Virtually operating on the inferior turbinate. (C) CT images of post‐virtual surgery: anterior (left) and posterior (right) inferior turbinate resection. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Figure 2

(A) Plot of nasal resistance for baseline, post‐actual surgery, post‐virtual turbinectomy, and a cohort of ENS patients. (B) Plot of cross‐sectional areas (CSAs) in the inferior, middle, superior meatuses, and total nasal airway for baseline, post‐actual surgery, post‐virtual turbinectomy, and a cohort of ENS patients. (C) Plot of regional airflow rates in the inferior, middle, superior meatuses, and total nasal airway for baseline, post‐actual surgery, post‐virtual turbinectomy, and a cohort of ENS patients. (D) Plot of wall shear force distribution (WSF) in the anterior, inferior, middle regions for baseline, post‐actual surgery, post‐virtual turbinectomy, and a cohort of ENS patients.

Figure 3

Coronal CT scans (1st row) of baseline, post‐actual surgery, post‐virtual turbinectomy of a single patient, as well as of a ENS patient (the last CT). Airflow velocity contour plots (2nd row) and the diagram (3rd row) of the inferior region (black), middle region (grey), and superior region (white), both on same cross section as the coronal CT. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]