The cotton test redistributes nasal airflow in patients with empty nose syndrome

Abstract

Background: Empty nose syndrome (ENS) remains a controversial disease primarily associated with inferior turbinate tissue loss. Co on placement into the inferior meatus o en alleviates ENS symptoms within minutes, but the physiologic explanation for this phenomenon is unknown. Computational fluid dynamics (CFD) was employed to evaluate the mechanisms of altered nasal airflow conferred by co on testing. Methods:Six ENS patients (12 sides) with pre-existing sinus computed tomography (CT) imaging were enrolled a er marked symptomatic improvement (decrease in score on the Empty Nose Syndrome 6-Item Questionnaire [ENS6Q] of >7 points) with office-based co on testing. The fashioned co on plug was labeled in situ with iohexol contrast spray, and sinus CT was immediately obtained to detect co on contouring in the inferior meatus. CT imaging from pre-and post-co on placement was analyzed using comparative CFD techniques. Results:A er co on placement, significant symptomatic improvement and reduced ENS6Q scores (16.8 ± 4.1 to 3.1 ± 2.4; p < 0.001) were recorded. Using CFD, co on placement produced an expected 21% increase in upper airway resistance (p < 0.05). However, a significant shi in the nasal airflow distribution was also detected, with a transition of airflow vectors away from a middle meatus jetstream (−41%; p < 0.002). Conclusion:Objective CFD assessment confirmed that the co on test not only increases nasal resistance, but also restores airflow distribution to the inferior meatus in symptomatic ENS patients. These results highlight the potential efficacy of co on test in ENS patients and further bolster the utility of this tool in identifying appropriate candidates for the inferior meatus augmentation procedure. C 2020 ARS-AAOA, LLC.

Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling

“…Patients anecdotally report an increased, satisfying sense of “ability to draw air into their nose” following IMAP procedure. This change of airflow profile is highly consistent with CFD results from our previously published cotton test with contrast labeling, 13 although this theory requires more rigorous downstream testing.…”

“…We found that successful in-office cotton testing placement generated a dramatic clinical benefit that also resulted in an impressive shift in the nasal airflow distribution and promoted inferior mucosal airflow and mucosal stimulation. 13 Thus, the goal of this study was to use a similar approach to characterize changes in the profile of nasal airflow in ENS patients 6 months after IMAP surgery so that we may further understand the physiologic mechanisms driving the symptomatic improvement with tissue replacement surgery. We hypothesized that the restoration of inferior turbinate tissue bulk via IMAP would alter the characteristic ENS airflow pattern to the middle meatus, 11,12 and result in increased perception of airflow.…”

“…In a separate study, we further investigated the mechanism of symptom improvement in an independent ENS cohort following iohexol‐contrast‐labeled cotton placement/testing using computed tomography (CT) scan and computational fluid dynamics (CFD). We found that successful in‐office cotton testing placement generated a dramatic clinical benefit that also resulted in an impressive shift in the nasal airflow distribution and promoted inferior mucosal airflow and mucosal stimulation 13 . Thus, the goal of this study was to use a similar approach to characterize changes in the profile of nasal airflow in ENS patients 6 months after IMAP surgery so that we may further understand the physiologic mechanisms driving the symptomatic improvement with tissue replacement surgery.…”

Empty Nose Syndrome Pathophysiology: A Systematic Review

“…52 The utility of nasal implants are based on potential changes in airflow dynamics. 53,54 A number of studies and systematic reviews of surgical intervention in ENS noted improvement in patient-reported sinonasal symptoms after surgical implants. 55-59…”

The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate‐sparing techniques: A prospective self‐controlled study

“…Treatment options for ENS should include medical and procedural interventions. Procedural interventions vary but all have the same intention of creating tissue bulk to redistribute air flow to other areas of the nose that have proper trigeminal nerve function 7–9 . These treatment options can include injection of submucosal fillers or surgical augmentation of the inferior meatus 7,9 .…”