Empty nose syndrome

Ross Hauser, MD

I am going to start this article surrounding research and treatments of Empty nose syndrome with a patient’s story here at the Hauser Neck Center at Caring Medical. Then we will discuss how Empty nose syndrome remains a medical enigma and describe possible paths of treatments.

In this case history below, I will describe an initial teleconference I had with a patient. It will show that Empty nose syndrome is not a disorder that sits in isolation, but rather a problem that is one of many conditions many of the people we see at our center suffer from. Empty nose syndrome can be caused by many problems. In this article, I will present one possible answer.

The acrobat is grounded: His symptoms had become overwhelming and too much for him to realistically handle as a high-flying acrobat.

A well-known acrobatic master contacted us at Caring Medical because he suffered from many different “neurologic-type” symptoms, had received many different diagnoses, had many treatments, procedures, and tests, and was finally diagnosed with Empty nose syndrome amongst his other problems. He contacted us because he felt his symptoms were related to atlantoaxial instability, vagus nerve compression, and cerebrospinal venous insufficiency.

To perform the acrobatic tricks and stunts he does, our patient needs to master his skills through demanding and repetitive practice. He reported to us that he could no longer practice his routines and without the confidence and precision needed to perform at a master’s level, our patient had to ground himself.

Symptoms, conditions, and medical history

The patient suffered from shortness of breath (dyspnea) and an inability to feel the air going through his nose. He cannot breathe at times and constantly feels like he is drowning in nasal and sinus fluids. Then he begins to hyperventilate.

He was always a nose breather until the symptoms started. He has always been in master’s level/elite athletic shape and now he is practically bed-bound.

To relieve his shortness of breath and to assist his nose breathing, he has visited numerous ENTs, pulmonologists, and other specialists who have prescribed a myriad of tests and treatments including various sprays, steroids, and medications, all to no avail. He sought out alternative medicine healers who have been unable to help.

The various tests he has had, including endoscopy, MRIs, blood gas analysis, x-rays, and many others, have not been helpful in figuring out what is causing his shortness of breath and inability to breathe out of his nose.

Other symptoms include:

It IS in his nose, BUT, it is coming from his neck.

This is just a partial list. So here we have a patient whose main complaint is the problem of being able to breathe through his nose, yet he suffers from all these other conditions. How do we treat a patient like this? Is his inability to breathe through his nose causing oxygen to shut off? His inability to breathe through his nose causing all these other problems? Is it all in his nose? In this one case we suggest, it IS in his nose, BUT, it is coming from his neck.

First, let’s explore some of the supportive research which may guide us in understanding that for many people, these symptoms including Empty nose syndrome can find their cause and origin in the cervical spine and neck instability causing compression on the arteries, veins, and nerves that make their way in and around the cervical spine vertebrae.

Making a connection with the trigeminal nerve

An August 2019 study in the journal Current opinion in otolaryngology and head and neck surgery (1) comes to us from the Department of Otolaryngology-Head and Neck Surgery, University of California Davis. Here are the points:

Note: Nasal turbinate size: The nasal turbinates are mucus-covered boney structures inside the nose. They regulate airflow in and out of the nose and help warm the air you breathe in. The nasal turbinates can fluctuate in size in response to illness, allergies, and sensitivities and cause a “stuffy nose.” In many patients we see, chronic sinusitis and problems with the nasal turbinates are frequent complaints.

Clearly, someone with problems breathing in and out of their nose, where the diagnosis may be confused or hard to find may eventually wind up in a discussion about the dysfunction of the nasal turbinates.

Impaired trigeminal nerve function

Demonstration of trigeminal nerve dysfunction would be a big clue in following a path that this patient’s problems with Empty nose syndrome were being caused by nerve compression from cervical spine instability. We have two very detailed articles on our website concerning Trigeminal neuralgia: The evidence for Trigeminal Neuralgia non-surgical treatments, and, Cluster headache treatment – cervical ligament instability and the trigeminal and vagus nerves. I am going to summarize them here in regard to Empty nose syndrome.

In our many years of helping people with chronic pain of the head, neck, jaw, and face we have seen many people with a diagnosis of Trigeminal neuralgia. For some of these people, possibly including yourself, it was not easy getting this diagnosis as this problem can be confusing and frustrating to understand. Not only for the patient but the doctor alike.

When a physician and a patient believes that this nerve is being compressed, it is easy to see why surgery would be recommended.

Trigeminal neuralgia centers on what is happening to the trigeminal nerve which carries pain, feeling, and sensation from the brain to the skin of the face. In the case of trigeminal neuralgia, most medical professionals cannot find the cause for why this pain started. This is borne out by the definition of trigeminal neuralgia. Trigeminal neuralgia means that there is nerve pain in the nerve distribution of the trigeminal nerveIt actually does not tell a person what is causing the condition.

Other related causes

Trigeminal Neuralgia can also be caused by simple daily acts.

Why do we examining the neck of a patient who comes in for a Trigeminal Neuralgia consultation?

The keyword is compression. The head and neck, as all parts of the body, live in complex relation. Something in the neck can cause problems in the jaw, face, and nose, etc.

At this point, we are going to quickly jump over to a 2017 paper that was published in the journal Laryngoscope (2). The title of this paper? “Intranasal trigeminal function in patients with empty nose syndrome.” Here are the learning points:

Note: Understand that the researchers are exploring that an inability to breathe is a messenger “nerve” problem. The possibility that trigeminal function is being impaired by bad messages. Where are these bad messages coming from? Let’s see if we can find out.

Results:

Simply: It is a nerve compression problem. Where are the bad messages coming from? The trigeminal nerve. How? Compression of the trigeminal nerve somewhere along the line is sending out bad messages because of “compression interference.”


Dysfunction of the Trigeminal Nerve

Ross Hauser, MD and Brian Hutcheson, DC discuss Trigeminal Neuralgia or dysfunction and the strange sensations through the face, throat, nose and ear.

The connection of the trigeminal nerve to the cervical spine

As described above, people with Empty Nose Syndrome can suffer from many conditions simultaneously.

There are connections between the upper cervical spine and the trigeminal nerve. There is an afferent or a stimulus that comes in from your upper neck. If you have cervical spine instability, if you have a terrible problem with loss of the natural curve of the neck. If you have a descending of your brainstem, anything that is a dysfunction, this can cause a “bad signaling” to come out of the trigeminal nerve.


Why many treatments do not work

If we are pursuing cervical spine instability as the primary cause of the problems related to Empty nose syndrome, it is easy to see why treating many of the symptoms of this disorder are prone to failure and then surgery that may not address the true cause of the problem would be recommended.

Many patients we see with nasal breathing dysfunction often report that they have tried all the standard of care symptom alleviate treatments with limited success. These would include:

The problems of cervical spine instability are usually not discussed.

Nasal inflammation /Rhinosinusitis / Sinusitis – is this a drainage problem caused by herniated discs?

In my article: Neck Pain and Cervical Spine Instability-Induced Chronic Sinusitis and Eustachian Tube Dysfunction, I discuss the problems of nasal inflammation. I will summarize and explain the connection here:

Malalignment of C1-C2 can impact sinus drainage

We have many articles and research studies that point out the possible problems misalignment of the C1-C2 or Atlantoaxial instability can cause. As I have also pointed out, the clue to a patient’s problems may lie in the fact that they suffer from many symptoms simultaneously and not from one or two isolated symptoms.

In the story of the patient that we are covering in this article, we see that he had many symptoms. People we see with Atlantoaxial instability can also suffer from drainage problems of the sinus and associated nasal congestion, headaches, hearing problems and ear infections, vision problems, balance, vertigo, dizziness, and nausea among many symptoms. Often they suffer all at once.

When the cervical spine is involved in nasal breathing problems, we suspect that the patient is having a drainage problem. The ear and sinus are not draining. One reason that they are not draining can be a bulging or herniated disc impinging on the cervical nerves in the C1-C2 region.

The start of the chase for the root cause of the problem. The connection between the vagus nerve and the trigeminal nerve and nasal problems

The vagus nerve, as illustrated below, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglion. This disruption or herniation of the nerve can cause among the many symptoms I have listed in this article.

What are we seeing in this image?

The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglia. This disruption or herniation of the nerve can cause among the many symptoms of nasal inflammation.

The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglia. This disruption or herniation of the nerve can cause among the many symptoms of nasal inflammation.

Our bodies have a left side trigeminal nerve and a right side trigeminal nerve. The trigeminal nerve separates into three branches. The ophthalmic (V1), maxillary (V2), and mandibular (V3) nerves.

In regard to the sinus:

  • The ophthalmic nerve (V1) serves the eye and parts of the nasal cavity. Damage or dysfunction of this nerve can impact sinus function and vision. This is why people have these symptoms concurrently. This could include sinusitis. Sinusitis can occur when the nerve messages are getting distorted and signals for proper drainage of the sinus are not getting through.
  • The maxillary nerve (V2) also serves parts of the nasal cavity and sinus as well as portions of the mouth. This is why sinus congestion and sinusitis can be reported by patients along with problems of the palate
  • The Vagus nerve serves the sinuses, the back of the throat (pharynx), and the larynx.

Restoring the natural curve of the spine and strengthening cervical spine ligaments – a possible treatment for Empty nose syndrome

Many patients we see when they come in for their first visit for issues of chronic pain and neurological symptoms, come in with an understanding that something is wrong with the curve of their neck and spine. This they learned through the many years of seeking treatments. This is why they also understand that the curvature of the spine is a complex problem.

In the story of our patient in this article, we noted that he had a military curve. A loss of the natural cervical spine curve.

The curvatures of the neck

What are we seeing in this image?

In our practice, we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to “S” shape curve.

In our practice we see problems of cervical spine instability caused by damaged or weakened cervical spine ligaments. With ligament weakness or laxity, the cervical vertebrae move out of place and progress into problems of chronic pain and neurological symptoms by distorting the natural curve of the spine. This illustration demonstrates the progression from Lordotic to Military to Kyphotic to "S" shape curve.

Repairing the ligaments and curve for a long-term fix

The goal of our treatment is to repair and strengthen the cervical ligaments and get your head back in alignment with the shoulders in a normal posture.

What are we seeing in this image?

In this illustration, we see the before and after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights.

In this illustration we see the before an after of neck curve corrections. Ligament laxity or looseness or damage, whether the cause is from trauma, genetic as in cases of Ehlers-Danlos syndrome, ultimately causes a kyphotic force on the cervical spine, stretching the posterior ligament complex of the neck. As can be seen in the x-rays of this image, patients with a whiplash injury, Joint Hypermobility Syndrome, and Ehlers-Danlos syndrome can have their cervical curve restored with Prolotherapy Injections and the use of head and chest weights, documented below.

Treating Cervical Instability-Induced Empty nose syndrome with Cervical Curve Correction and Prolotherapy

Prolotherapy is an injection technique that stimulates the repair of unstable, torn or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can stress tendons, atrophy muscles, pinch on nerves, such as the vagus nerve,  and cause other symptoms associated with cervical instability including problems of digestion among others.

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (3) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

In our clinical and research observations, we have documented that Prolotherapy can offer answers for sufferers of cervical instability, as it treats the problem at its source. Prolotherapy to the various structures of the neck eliminates the instability and the sympathetic symptoms without many of the short-term and long-term risks of cervical fusion. We concluded that in many cases of chronic neck pain, the cause may be underlying joint instability and capsular ligament laxity. Furthermore, we contend that the use of Comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

In this video, DMX displays Prolotherapy before and after treatments

  • In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy.
  • A before digital motion x-ray at 0:11
  • At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
  • At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
  • At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
  • At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
  • At 1:14 the previously completely closed neural foramina are now opening normally during motion

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding Empty Nose Syndrome. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References for this article:

1 Gill AS, Said M, Tollefson TT, Steele TO. Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies. Current opinion in otolaryngology & head and neck surgery. 2019 Aug 1;27(4):237-42. [Google Scholar]
2 Konstantinidis I, Tsakiropoulou E, Chatziavramidis A, Ikonomidis C, Markou K. Intranasal trigeminal function in patients with empty nose syndrome. The Laryngoscope. 2017 Jun;127(6):1263-7. [Google Scholar]
3 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]

 

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