How To: Inferior Meatus Augmentation Procedure for Empty Nose Syndrome

by Michael T. Chang, MD, Murray Bartho, BS, Dayoung Kim, BA, Esmond F. Tsai, BS, Angela Yang, BS, Sachi S. Dholakia, BS, Ashoke Khanwalkar, MD, Vidya K. Rao, MD, Andrew Thamboo, MD, Matt Lechner, MD, PhD, and Jayakar V. Nayak, MD, PhD •

Introduction

Empty nose syndrome (ENS) is an uncommon disease characterized by a debilitating spectrum of symptoms such as paradoxical nasal obstruction, nasal dryness, nasal burning, and, for some patients, a withering sense of suffocation (Int Forum Allergy Rhinol. 2017;7:64–71). ENS has been strongly associated with aggressive nasal airway surgery, and, in particular, loss of inferior turbinate (IT) tissue volume (Int Forum Allergy Rhinol. 2017;7:64–71). A promising emerging intervention to reduce the symptomatic burden of ENS in affected patients is a procedure that we have termed the inferior meatus augmentation procedure (IMAP). With IMAP, we attempt to replace the missing tissue of the IT using fashioned cadaveric rib cartilage placed as an implanted graft in the site of the resected or retracted tissue in the lateral nasal airway. In the majority of patients suffering from ENS symptoms, there is typically insufficient IT bone remaining in this region to accommodate placement of a bulky tissue graft; therefore, the inferior meatus and inferolateral nasal wall become the next-best regional site to recreate the rounded, tubular contour and position of the native turbinate organ. The IMAP technique has demonstrated favorable long-term outcomes for this disease entity that has historically been difficult to manage and/or been deemed untreatable, with significant reductions in patient-reported symptoms as measured by the Empty Nose Syndrome 6-Item Questionnaire (ENS6Q) (Laryngoscope. 2021;131:E2736–E2741) and normalization of nasal airflow patterns as demonstrated by computational fluid dynamic studies (Int Forum Allergy Rhinol. 2021;11:902–909). Here we describe the operative and perioperative details for the IMAP.

Method

Preoperative Preparation

Patient selection is of utmost importance to ensure optimal surgical out – comes. Candidates for IMAP surgery must have a diagnosis of ENS as determined by an ENS6Q score >11 and at least two positive blinded in-office cotton tests in which the ENS6Q score improves by at least seven points each time (Int Forum Allergy Rhinol. 2017;7:64–71; Laryngoscope. 2017;127:1746–1752). Patients may also be candidates if they have had a positive response and symptomatic improvement following inferior meatus submucosal filler injection (Int Forum Allergy Rhinol. 2019;9:681– 687). Preoperative evaluation should also serve to optimize management of possible concurrent diagnoses, including trigeminal nerve dysfunction and psychiatric comorbidities, with appropriate referrals considered. Patients must also undergo a standard medical evaluation to ensure they are acceptable candidates for general anesthesia.

The surgery can be undertaken in an outpatient setting. The procedure is performed using standard equipment for endoscopic sinonasal surgery. Additional useful instruments to obtain are a 7200 Beaver blade for the mucosal incision, a #3 Rhoton or duckbill elevator for flap elevation, and #22 blades for rib contouring. The allograft material is irradiated cadaveric rib, which is routinely used for other indications (i.e., nasal reconstruction) and requires storage in a –80°C freezer.