There are a number of commonly held myths and misconceptions about sleep apnea surgery by the general public. Almost every day, I see evidence of this on the internet, and it seems like this phenomenon is only increasing. As you may be aware, wrong information can multiple virally on the internet, and since errors can’t be erased, it keeps getting repeated and perpetuated. Many of these myths are not completely wrong, but in most cases, are not always true.
This blog post will be the first in a series of 7 articles exposing such common myths or misconceptions.
#1: Turbinate Surgery Causes Empty Nose Syndrome
The myth is that doing any type of turbinate surgery will cause ENS.
The turbinates are wing-like structures inside your nose, helping to smooth, warm, filter and humidify air before reaching your lungs. They are bony structures covered by mucous membranes. Just underneath the mucous membrane, blood vessels fill up with blood when irritated by allergies or any kind of inflammation. This can lead to a stuffy nose. Turbinate swelling, along with a deviated septum and flimsy nostrils, are the most common reasons for nasal congestion.
In the old days, surgeons used to removed most or all of the turbinates. Initially after the procedure, patients reported better breathing, but after some time felt like they couldn’t breathe anymore. This is what’s called empty nose syndrome, or ENS. Classically, patients are described to have congestion along with a profuse pussy, runny nose with a foul odor or crusting. These days, any symptom in the human body, when seen in light of turbinate surgery is oftentimes blamed on ENS.
Currently, surgeons don’t remove turbinate tissues aggressively anymore. In fact, the pendulum has swung too far in the other direction, leading to too conservative turbinate procedures. This can lead to recurrence of nasal congestion requiring more medical or surgical therapy.
However, whenever any amount of turbinates have been removed, and you have a number of severe symptoms like chronic fatigue, headaches, facial pain, anxiety, poor sleep or insomnia, then the possibility of ENS comes up whenever you Google your symptoms.
Due to this excessive fear of ENS, some people believe that just touching the turbinates surgically can cause ENS. In some cases, I see full normal and full-sized turbinates after healing from a minimal surgical procedures and patients ask if they have ENS.
We know from cancer surgery, for example that patients who have parts of their sinuses and all their turbinates removed rarely complain of ENS symptoms.
One potential treatment for ENS is to place implants inside the nose to provide more resistance to breathing. Few surgeons perform this procedure and although published results are convincing, it’s still not widely performed. An excellent resource on ENS is a book by Christopher Martin
I’m not doubting the existence of ENS. My main point is that some people (and even some physicians) are too anxious about any kind of turbinate surgery. In response to these fears, ENT surgeons are offering more conservative procedures, which in my experience may work initially, but almost always fail months or years later.
Trying to help patients with ENS can be challenging. While addressing their nasal concerns is important, it’s important to address any other area of breathing obstruction. Oftentimes, ENS patients will not have obstructive sleep apnea based on sleep study evaluation. However, what I find more often than not is that there is severe obstructed breathing downstream in the throat, either behind the soft palate, tongue base, or epiglottis. Patients will have frequent obstructions that don’t last long enough to quality as an apnea. This is the definition of upper airway resistance syndrome
, which I’ve discussed numerous times in the past.
One possible explanation for ENS is that due to much lower nasal resistance, there’s increased airflow through the throat, aggravating potentially collapsible structures such as the soft palate, tongue or epiglottis. Sometimes, flimsy nostrils may cave in as well. Recall from high school physics that the higher speed fluid moves, the lower the pressure created. Similarly, the faster air flows through a tube, the more likely the tube will cave in. This is called Bernoulli’s principle.
The problem is that doctors and patients are so focused on the nose, it’s difficult to convince them that there may be additional areas of obstruction. In some patients, looking at the airway during deep sleep under anesthesia can reveal the source of obstructed breathing. The few ENS patients that have been treated for other areas of obstruction beyond the nose have improved significantly.
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