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Endoscopic View of an “Empty Nose”

Figure. A: Telescopic view (4 mm, 0°) shows the wide left nasal cavity with loss of normalanatomyof the left lateral nasalwall. Band C: Bleeding occurs easily on even slight manipulation of themucosa of the leftlateral nasalwall. D: Coronal CT scanof the sinuses shows theexcessively patent leftnasalairway. A 74-year-old man presented with recurrent nasal bleeding and nasal crusting. He reported a history of nasal and sinus surgery performed on the left side for polyps 42 years earlier. For 40 of the 42 years he accepted the infrequent nosebleeds, but since requiring daily aspirin as a blood thinner for the previous 2 years, he was having more frequent and troublesome nosebleeds on the left side. This was particularly bothersome after he used saline irrigations, which had been part of his daily routine since his original nasal surgery. Examination by nasal endoscopy revealed an excessively patent left nasal airway with extreme loss of the normal anatomy of the left lateral nasal wall (figure, A). The mucosa of the left lateral wall bled easily on even slight manipulation (figure, B and C). Computed tomography (CT) of the sinuses revealed an excessively patent left nasal airway, or left "empty nose" (figure, D).' It was not unusual in the years before the advent of functional endoscopic sinus surgery (FESS) for rhinologic surgeons to remove large amounts of intranasal tissue in cases of extreme polyposis. This excessivetissue removal frequently involved removal of the middle and inferior turbinates. This extreme loss of anatomic structure resulted in a "gun barrel" nasal airway or empty nose, as seen in our patient. The empty nose syndrome usually is defined by excessive loss of normal nasal tissue and loss of anatomic landmarks, which results in a widely patent airway with excessive crusting (ozena) and easy nasal bleeding and dryness of the nasal mucosa.' The introduction of FESS stressed functional and precise endoscopically controlled surgical dissection, preserving normal tissue and anatomy;This surgical approach to chronic sinus disease has diminished the possibility of the difficult empty nose.