Talk:Empty nose syndrome/Archive 1

Misc
Hi, This article reflects my personal understanding of Empty Nose Syndrome and the physiology of the nose, which I have cultivated through many years of researching those topics. My personal interest in this is great as I suffer from Empty nose Syndrome myself. Under the sub-tital "Quotes" there are direct quotes with their scientific references, from leading ENT journals. They are followed by a long list of scientific references.

Blacklisted external link (emptynosesyndrome.org)
I had to remove several external links that linked to the emptynosesyndrome.org site. I don't know why this URL was blacklisted, other than the discussion at:

http://meta.wikimedia.org/wiki/Talk:Spam_blacklist/Archives/2007/02#emptynosesyndrome.org

If these links are useful, perhaps someone with more knowledge of the subject matter can request an appeal of this blacklisting. WatchAndObserve 18:08, 16 February 2007 (UTC)

Complete cleanup
This article needs to fall in line with WP:MEDMOS, citations need to follow WP:CITET, writing must follow WP:MOS, and etc. etc. Moreover, I'm not convinced that this article really should stay. I'm considering a speedy delete. Orange Marlin Talk• Contributions 00:26, 20 April 2008 (UTC)


 * I must say I had never heard of it at all and was musing that it was a somewhat new synthesis when I first saw it..Cheers, Casliber (talk · contribs) 01:03, 20 April 2008 (UTC)
 * I'm having a hard time finding verified sources outside of a few individuals promoting their medical practice. I really think this is approaching original research.   Orange Marlin  Talk• Contributions 04:14, 20 April 2008 (UTC)

I wouldn't like to say that these individuals are promoting their practice as a lot of them belong to institutions that do not provide incentives for doing more surgery (they are on salary). Further if you really consider the science behind ENS (the fact that nerves that sense airflow are being taken out of the nose, and resistance is being taken away from the lungs) the real question that needs to be addressed is why MORE patients do not develop these problems (unique anatomy, nerves grow back/ change distribution) - Desmos —Preceding unsigned comment added by 207.237.234.129 (talk) 03:08, 9 August 2009 (UTC)

Complete Cleanup Part 2
Have to agree - the tone, style and format is horribly unencyclopaedic and glad to see a rewrite is planned. As Orange already stated, there seems to be very little about it in legitimate medical sources from my short look around. If it can meet the definitions for both notability and verifiability then I'm not sure speedy delete would be the way to go, but the article certainly needs to be rewritten in a more appropriate tone and layout as per the relevant wiki guidelines/policies.

Any idea if peer reviewed journals automatically infer notability, or if not, how many articles are needed to make it meet those criteria, for example? It is a little like Morgellons - the vast majority of the medical establishment thinks that it isn't what it asserts to be, and is explained by other explanations/diagnoses, but it would still meet the criteria to be verifiable and notable. A quick search of Pubmed brings up 32 results, only 5 of which actually referred to this condition. 1) 2008 - One refers to verious post-op problems including ENS but without reading the full thing I don't know what was said. 2) 2007 - A second states that "Patients were diagnosed as having ENS if they described characteristic symptoms, had evidence of prior nasal turbinate surgery, and their symptoms improved after they underwent a cotton test." - i.e. there are no real tests to diagnose it other than patients' description of symptoms post-op. 3) 2006 - One that has no abstract but the title of ENS. 4) 2001 - One had the same title but different authors, presented in a Chinese journal, and states that "some [of the 14 patients studied] presented symptoms of depression" - not all, that "Conservative treatment was effective in most cases." and that "Extensive turbinectomy may cause secondary nasal mucosal atrophy and a series of subsequent symptoms". 5) 2000 - One was a paper that mentioned rebuilding the nasal structure for what it termed "symptoms often associated with over-zealous resection of the turbinate (the "empty nose" syndrome)".

In comparison, Morgellons has 10 articles. From other searches, however, it seems that most of the symptoms described within this article are generally termed secondary (iatrogenic - that is, as a result of medical intervention) atrophic rhinitis and/or sinusitis - various searches produce anywhere from over 20 to over 140 articles that seem to match the appropriate criteria, depending upon the exact search terms - including the various papers from the specific search for EMS.

My conclusion, therefore, is the term has been used over the last 8 years in the medical literature, but so rarely and much more frequently is described as atrophic rhinitis as to be no more than an "alternative" label for what is - fundamentally - secondary iatrogenic atrophic rhinitis which results from some extensive turbinate resections (turbinectomy). I'm not totally convinced what differentiates so-called ENS from other secondary atrophic rhinitis cases, so I'm not totally convinced it truly deserves a full article to itself. Perhaps there is another appropriate article it could be breifly mentioned in and this article turned into a redirect, unless anyone feels strongly that it can be differentiated more starkly. 86.3.150.116 (talk) 01:28, 14 May 2008 (UTC) (I really must register one day...)

What differentiates ENS is that the symptoms can be caused by lack of nueral stimulation, lack of airway resistance, and lack of organized airflow without necessary atrophy of the nasal tissue. This has been show in ENS-type patients and in ENS patients such as myself that had 50% of all turbinate tissue resected but do not have atrophic rhinitis but rather have breathing difficulties relating to a too open airway, lack of airflow stimulation in nows, and airflow convergance to the nasal floor. - Desmos

Balance and quality
Until today, the article failed to acknowledge that ENS is a controversial entity, or that psychological contributors may be important. Even if editors personally disagree with these ideas, it's important that the article reflect the existence of the controversy. I've added a section that is supported by WP:MEDRS secondary sources. The rest of the article contains much opinion and assertion not supported by quality sources, or sources of any kind, and requires cleanup. It appears to be written as an opinion piece by someone with a very specific idea of what ENS is and its cause and treatment. Dubbin u &#124; t &#124; c 08:47, 8 May 2016 (UTC)
 * I went ahead and cleaned up the article. The main remaining weaknesses are the etiology, treatment and prognosis sections. All are too long and undersupported by suitable references. For the record I'm a physician but not an ENT surgeon nor do I have any personal interest in the syndrome - I came upon this syndrome via the Buzzfeed article and was disappointed by the Wikipedia article. Dubbin u &#124; t &#124; c 15:04, 8 May 2016 (UTC)
 * ,,, , , I think the balance and quality of this article has improved with quality secondary sources. Dubbin, I would add that you came onto this page as you were questioning if ENS really existed and felt the original Wikipedia article on ENS (which I did not write or was involved with) was an anti-turbinectomy diatribe. So, I would remind anyone editing that we all need to keep our biases in check when we start to edit on Wikipedia pages and that our thoughts conform to Wikipedia guidelines on neutrality WP:NEUTRAL and finding suitable sources WP:MEDRS - https://en.wikipedia.org/wiki/Talk:List_of_questionable_diseases EducatedonENS (talk) 13:32, 10 June 2016 (UTC)EducatedonENS
 * While I agree it's much better, please don't mischaracterise my position. I wasn't questioning the existence of ENS - my view on that is of no relevance; I wished the article to reflect that other people have and still do; and conversely, I wished to begin the process of improving the scientific content of the article supporting all substantiated points of view in a balanced way. It was a diatribe - a terribly biased, unscientific piece with next to no citations of any value. Dubbin u &#124; t &#124; c 13:53, 10 June 2016 (UTC)
 * Points well-taken. I apologize if there was any mischaracterization of your position.  I was referencing the unsigned comments Does Empty nose syndrome belong here? and What's the cutoff for controversial v questionable? in https://en.wikipedia.org/wiki/Talk:List_of_questionable_diseases EducatedonENS (talk) 14:28, 10 June 2016 (UTC)EducatedonENS
 * Right. When you reference something, please reference it. You will see that I went to that page to ask questions and described ENS as controversial. I was looking for the kind of help that eventually arrived via WP:WikiProject Medicine. The lack of signature was an oversight, now fixed, but well done on the detective work, I guess. Dubbin u &#124; t &#124; c 14:39, 10 June 2016 (UTC)
 * Thank you, Dubbin. I am glad to see improvements to the Wikipedia article, which were initiated because of your efforts.EducatedonENS (talk) 14:55, 10 June 2016 (UTC)EducatedonENS

'Over' resection
An IP editor keeps changing 'resection' to 'over resection' in the lead. To me this seems like a value judgement and non-neutral language. It is not supported by the citation that was added. By definition, each resection is felt reasonable by the patient and surgeon at the time, or it would not be done. The fact that partial turbinectomy is felt to be capable of causing the condition emphasises that it is not the amount resected but the response that is to blame.

This article is already terribly biased - let's at least aim towards neutrality, rather than away from it. Dubbin u &#124; t &#124; c 07:58, 28 May 2016 (UTC)

Removed references related to irritable bowel a GI condition
Removed references related to irritable bowel a GI condition

lets keep it on topic here please — Preceding unsigned comment added by 2601:44:C500:44FE:E096:9407:8BFD:A90A (talk) 04:02, 3 June 2016 (UTC)


 * Fair enough, but you also removed a highly relevant reference on functional MRI changes in the limbic system in ENS, claiming it was irrelevant because it concerned neurology not psychology. In fact, the limbic system is critically involved in the regulation of psychological states. I have restored it. The last few edits from IP addresses similar to yours have all been pushing a particular purely-physical viewpoint of ENS that aims ti downplay the evident controversy surrounding the condition and appears agenda-driven. Let's keep our edits WP:NEUTRAL here please. Dubbin u &#124; t &#124; c 11:28, 3 June 2016 (UTC)


 * You are claiming that references to a physical cause are "agenda driven" and claiming that it must be kept neutral. The issue with that perspective is that you are not sufficiently familiar with the history of ENS and the way evidence and publications have been rolled out. Since initially ENS was not well understood, there were claims that it is a psychological based condition since the physical connections to the symptoms had not been well described. Over the recent years, there has been much more research and publications relating to the physical causes of ENS. So for example, there is a reference to Payne stating that it's existence has been called into question but pointing out that American Rhinological Society (ARS) recognizes ENS. What is missing in this statement is that Payne's article is seven years old and the ARS has somewhat recently recognized ENS. The point being that the ARS has considered more recent evidence, downplayed the significance of many of the older claims about a psychological cause (and truthfully claims which are more assertions of a psychological connection versus substantiated psychological causes as these claims are not evidence based by for example studies linking prior psychological conditions) and decided to recognize ENS as a surgical complication. Thus, a neutral position should recognize that more recent evidence supports a physical connection and that there is not really substantiated evidence of a psychological connection.  — Preceding unsigned comment added by Contrib12 (talk • contribs) 15:21, 3 June 2016 (UTC)


 * That's not a neutral position, it's your position. A neutral position takes stock of history and the current consensus. Thankfully Wikipedia relies on third-party sources and recent coverage rightly acknowledges the controversy. The ARS recognising that resection patients sometimes complain of ENS symptoms is not the same as it being a fact that ENS is 'physical', nor that any controversy has disappeared. Indeed the ARS itself has stated "Patients with empty nose syndrome may also suffer from other co-morbidities, such as severe depression, anxiety, and/or other psychiatric conditions that can either be present before surgery or begin at the same time as their ENS symptoms."


 * I'm sorry you're unhappy that there is controversy about ENS. But your unhappiness does not mean that it does not exist. Rest assured that agenda-driven edits will not persist here. Dubbin u &#124; t &#124; c 22:14, 3 June 2016 (UTC)

Dubbin, we have a mutual desire to present a "neutral position that takes stock of the history and current consensus." I would respectfully suggest, however, that your comments reflect an inaccurate understanding of ENS as it is currently understood by medical practitioners, its full history, and are not neutral and actually appear agenda-driven, despite you stating otherwise. You acknowledged that you first came across ENS after reading the April 2016 BuzzFeed article and I think we can agree that an ENS Wikipedia article, most importantly, should reflect the current opinion in medical literature on ENS.

First, the medical literature from 2001-2016 is very clear in depicting ENS as a surgical complication which is always accompanied by physical signs and symptoms and sometimes, if not often, accompanied with psychological after effects, although these psychological problems can indeed be present before turbinate surgery. That said, I agree with the ARS statement that empty nose syndrome patients may have co-morbid psychological problems before and/or after incurring ENS. This does not suggest a psychological cause to ENS or that ENS is solely a psychological condition, however. Perhaps it would be more accurate to state that, ''While physicians initially believed there were psychological causes to blame for ENS or that ENS was simply a psychological condition, and they would therefore refer a patient to a psychiatrist without appreciating the physical nature of the condition, the experts are now in agreement that ENS patients suffer from a clear physical condition and sometimes, but not always, suffer from psychological aftereffects as well, which should also be addressed. These psychological problems may have been present before and/or after they incurred ENS.'' I am confident all the doctors cited in the BuzzFeed article and who are actively treating ENS would concur with the above statement.

Second, an understanding of ENS' full history would acknowledge that ENS was historically regarded as (secondary) atrophic rhinitis, a condition which was first cited in 1876. Atrophic rhinitis would be viewed by the current medical experts as an advanced stage of empty nose syndrome. Recent doctors, most notably Dr. Steven Houser, have described ENS as a distinct entity from atrophic rhinitis first appearing in the medical literature in 2007, in order to acknowledge that ENS patients often do not present with signs and symptoms of atrophic rhinitis, such as fetor, mucosal metaplasia, or, in a worst case scenario, mucosal atrophy.

Third, I am happy to acknowledge there is controversy surrounding ENS, but it is very important to note that the controversy (at present) is not over whether ENS exists or whether there is a psychological cause [this is a past controversy and it should be noted as such], but rather that the current controversy is over a consensus definition of ENS, its etiology, and its management.

Now, as to the history of this Wikipedia article, the original Wikipedia article was largely written by an ENS patient who was very well-versed in the literature on turbinectomies and actually contributed to the early medical literature on ENS, but opted for no name recognition. Removing parts of the wikipedia article in a purported attempt to make it neutral feels to me like early research on ENS has been removed.

Let's agree that, in order for this wikipedia article to be neutral, it should be most heavily based on medical literature and a complete understanding of its history, as opposed to a BuzzFeed article or the suggestion of ENS having either a psychological cause or solely a psychological condition, or simply comments taken out of context.

For the record, I am a patient who has been properly diagnosed as having ENS by the experts, I am a successful professional with a Master's Degree, but I did not have psychological problems before or after my turbinectomy.EducatedonENS (talk) 17:59, 5 June 2016 (UTC)EducatedonENS

Dubbin, So, you deleted the reference to Dr. Houser's 2015 peer-reviewed article published in the Laryngoscope entitled "Pathophysiology of empty nose syndrome," which I cited to support the claim that it is recognized as a physical syndrome, in your quest to portray ENS as a psychological syndrome with a questionable existence, yet you suggest I have  agenda-driven edits? As a doctor, you should you understand that peer-reviewed research should be the basis for a Wikipedia article, not a BuzzFeed article. I have spent countless hours reading the medical literature on ENS (yes, some patients can read and understand these) and I can assure you that you are not presenting the syndrome itself or controversy surrounding ENS accurately.

Frankly, out of respect for people suffering from ENS who already experience a "double victimization," as Dr. Subinoy Das calls it - victimization for both the physical suffering and then lack of recognition from the medical community - you should remove any discussion suggesting ENS is a psychological syndrome or questioning its existence until a medical expert on ENS  reviews this Wikipedia article. In fact, I have made slight adjustments about your questioning of ENS existence and your portrayal of it as a psychological syndrome to be accurate and neutral. Maybe I will ask one of the experts cited in the BuzzFeed article to review this, as I have a good relationship with them. For the record, Dr. Das helped write the American Rhinologic Society website article and, because of the regenerative medicine he has offered, he has probably treated more ENS patients than anyone else in the world, while Dr. Houser has published more on ENS than anyone else. I hope you will respect their expertise, if they do decide to contribute to this article. I also hope you can agree with me not to make further edits about the controversy around ENS or trying to paint it as a psychological syndrome, which it isn't, until a medical expert familiar with ENS can review this EducatedonENS (talk) 02:20, 6 June 2016 (UTC)EducatedonENS


 * Your enthusiasm and commitment are commendable, and I do hope that we can work together to improve this article. But this will not happen if all your effort is focused on sculpting the page into something that portrays your own view. You seem to think I believe ENS is purely psychological; I do not. Per my reading of the literature, it is a condition with physical and psychological contributors, the balance of which is likely different in every case. That you believe it is entirely physical does not make it so. You claim the controversy has moved on but citing individual references that support your position does not make that true either. The Buzzfeed article is a well-researched news piece that references experts across the spectrum and I too referenced some of the sources that the author consulted.


 * It seems you are new to Wikipedia and while this is not mandatory, it is always helpful to familiarise yourself with some of the guidelines. The most important here is WP:MEDRS which summarises what kind of sources are most appropriate for medical articles. I would draw your attention to "Controversies or uncertainties in medicine should be supported by reliable secondary sources describing the varying viewpoints". Two other important guidelines are WP:NPOV, which state that Wikipedia content should be written from a neutral point of view (in this case, a point of view that does not take an opinion on whether ENS is physical, psychological or both); and WP:ORIGINAL, which states that Wikipedia is not the place for original research - here, that means that statements about ENS must be limited to what is directly supported by suitable sources, not any editor's opinion or conclusions drawn from those sources. Dubbin u &#124; t &#124; c 14:02, 6 June 2016 (UTC)


 * To be clear, all my efforts are not focused on sculpting the page into something that portrays my view. It's fine if we need to acknowledge psychological contributors to ENS, for example, as my focus in editing this was putting the psychology into context (NOT denying it exists), as I want to provide context so ENS won't be misunderstood.  My hope for any reader is that they will have a complete and accurate view of my condition.  I didn't claim the controversy moved on, but that parts of the controversy has moved on, such as the current questioning as to whether it exists.  The doctors all know ENS exists and you will likely see a consensus definition in the near future (based on some knowledge I have), so I don't find it helpful suggesting there is still a controversy over whether ENS exists; there are multiple references I could provide all detailing it exists.  Spencer Payne, MD, who you quoted stated in a recent media interview that he knows "ENS exists, absolutely."


 * You're right, I am new to Wikipedia and I will spend time reviewing the policies before attempting any future edits. Thanks for adding your thoughts here.  I hope I can eventually help enhance the article.EducatedonENS (talk) 16:47, 6 June 2016 (UTC)

Dubbin
Removing three agenda-driven edits consisting of opinion either uncited or backed by citations that do not support the statements made. I suggest we reach consensus on the talk page before further significant e...

Dubbin it is very rude to accuse people of making "Agenda" driven edits.

Please refrain from doing so — Preceding unsigned comment added by 2601:44:C500:44FE:145E:466D:ED1:BCB0 (talk) 05:12, 6 June 2016 (UTC)

Dubbin, below are a few citations from the article, "Pathophysiology of empty nose syndrome," a journal article you removed which I cited. This article acts in part as a synthesis of what we currently know about the physical aspects of ENS while also as a primary source about some of the neuronal contributions to ENS. This article supports my claim that empty nose syndrome is a condition originating from a physical origin:

"ENS is a recognized complication of turbinate surgery..." (page 1, paragraph 2)

"The diagnosis is potentially missed often because most rhinologists are trained to look for physical signs of dryness and atrophy after turbinectomies, objective long-term complications, and may thus disregard the patients' subjective complaints of nasal obstruction or shortness of breath. These subjective complaints are often viewed as psychological manifestations.  Like many other otolaryngologic disorders (e.g., tinnitus), the fact that the symptoms are subjective and cannot be verified objectively does not mean they are not real and valid symptoms originating in a physical abnormality." (page 1, last paragraph). EducatedonENS (talk) 14:45, 10 June 2016 (UTC)EducatedonENS — Preceding unsigned comment added by EducatedonENS (talk • contribs) 12:27, 6 June 2016 (UTC)


 * Please try to understand that I am not trying to portray ENS as a psychological condition but pointing out that the scientific consensus is that the condition may have physical and psychological contributors in each case (like every medical condition). Again all content must comply with WP:NEUTRAL. "ENS is a recognized complication of turbinate surgery" is not the same as "psychological contributors are not considered important in ENS" or "there is no controversy surrounding the existence or nature of ENS". Edits that present your opinion or interpretation of the literature will likely be reverted and I will be requesting page protection to restrict edits to those that comply with the neutrality policy. Dubbin u &#124; t &#124; c 14:08, 6 June 2016 (UTC)


 * I appreciate that you are pointing out right here that every medical condition has psychological contributors. Like wise, please understand that my "agenda" is to present ENS as accurately and neutral as possible, with references from peer-reviewed medical journals.  I have spent a lot of time reading the medical literature on ENS and have a good understanding of the context on ENS and its political climate.


 * First, being that ENS has not been well-understood, I think it's very important to provide context when making a statement such as "suggesting psychological factors may be partly responsible for its symptoms." Look at the above direct quotes from the medical literature:  "...may thus disregard the patient's subjective complaints of nasal obstruction" and "These subjective complaints are often viewed as psychological manifestations and originating in a physical abnormality."  By you writing, "suggesting psychological factors may be partly responsible for its symptoms," without offering any context, you can see how Wikipedia readers may continue to view a patient's subjective symptoms, such as shortness of breath, as merely psychologically-based, even if that is not your intention.  (I, as an ENS patient, for example, don't appreciate being told my feeling of "not getting enough air" is psychological when there is a physical basis.)


 * Second, the statement ENS is a recognized complication of turbinate surgery, runs directly counter to your statement that the existence of ENS is currently in question, particularly as ENS is cited and recognized as a surgical complication in many journal articles. Furthermore, Dr. Das is cited in the BuzzFeed article as writing a letter to the ENS community (in 2015) that suggests the ear, nose and throat community no longer questions the existence of ENS.  Conversely, I recognize that the BuzzFeed article suggests there are still some doubters of the existence of ENS, despite the literature presenting a different angle, although the BuzzFeed article, in this specific instance, is acting as a primary source.  So your stating that its existence is currently controversial appears to be citing a primary source.  Synthesizing the medical literature in combination with Dr. Das' letter, my understanding is that the existence of ENS is not currently controversial, while the nature of ENS is what is being discussed or is controversial.  So, Dubbin, by you repeatedly stating the existence of ENS is currently controversial, which is the only part of the controversy I tried to remove, appears misleading and non-neutral.


 * I think this article could be much strengthened with more references and less opinion, such as providing the history of ENS, citing medical literature on the available treatment options (such as adipose-derived stem cells), clarifying the definition as it is reported in the literature, detailing the physical, cognitive and psychological symptoms associated with ENS, as well as citing third-party sources - there have been multiple media articles on ENS and I am aware of more to come. I would be happy to try to do that but I need you to respect my citation of literature or other reliable sources (which I will keep my opinion out of, of course), instead of removing any edit, suggesting all my edits are agenda-driven, and now requesting page protection for neutrality.  In fact, I would hope you would attempt to address me in the discussion section if you think a comment is non-neutral before removing my edits or trying to request page protection for neutrality, which you have done twice now.  Respectfully submitted...EducatedonENS (talk) 14:45, 10 June 2016 (UTC)EducatedonENSEducatedonENS (talk) 15:36, 6 June 2016 (UTC)EducatedonENS


 * Thank you, Ritchie333, for not just granting this empty nose syndrome Wikipedia page indefinite page protection, as Dubbin requested, as I am trying very hard to provide neutral edits backed up with medical literature (see the above discussion) in compliance with Wikipedia's neutrality policy. Dubbin completely removed the medical literature I cited (Pathophysiology of empty nose syndrome), as I strived to offer context and enhance accuracy to the controversy and psychological symptoms associated with ENS, yet he/she asserts all my comments are agenda-driven. I am glad to see Dubbin responded to my concerns in the discussion (above), even if it was only after he/she attempted to seek indefinite page protection, as I would like to participate in making this article better.EducatedonENS (talk) 14:45, 10 June 2016 (UTC)EducatedonENSEducatedonENS (talk) 16:33, 6 June 2016 (UTC)

Making progress during page protection
@EducatedonENS, I hope the temporary protection will serve as a useful window to reflect and for us to reach a productive way of updating this page together. You're under no obligation to do so, but I'd like to suggest you paste some suitably-cited draft edits here and I (and hopefully others) will gladly comment. I'm optimistic this can result in some edits that are factually correct, balanced and well-supported by suitable citations. I certainly agree the article needs more in the way of good-quality science, especially in the treatment section.

There are a few points I'd like you to consider in preparing your updates.


 * 1) I don't think you have any less validity as an editor because I'm an MD. I've used little of my medical knowledge (which is in neurology) in my work on this article - mostly my understanding of how medical literature works and how controversies in medicine tend to evolve.
 * 2) I don't think there is any conflict between something being recognised by a professional body such as the ARS, and its remaining a controversial entity.
 * 3) Similarly there is no conflict between something being recognised as having a physical origin, and its perpetuation being, in some cases, contributed to by psychological factors. Phantom limb pain after amputation would be a classic example of such a condition. 'It exists and begins with a physical trigger' is not the same as 'it is entirely physical'.
 * 4) Nothing that is written on Wikipedia about a condition in general should be taken to refer to any particular individual with that condition. Conversely, a Wikipedia article needs to encompass the whole condition, not just one person's experiences or understanding.
 * 5) Everything written in the scientific literature is written by human beings, none of whom is free from biases. It is almost always possible to cite articles that support a particular view. WP:MEDRS seeks to improve things by focusing on secondary sources, but review articles written by people with a particular viewpoint will also tend to reflect that view. WP:NEUTRAL is the overriding guideline.
 * 6) Controversy seldom disappears in science. Something that was controversial in 2000 is likely to remain controversial even if the majority opinion has shifted. Look at climate change or vaccination: despite strong scientific consensus, these unquestionably remain controversial even now, for better or worse. It doesn't take many dissenting voices to sustain controversy. Wikipedia needs to report that controversy while reflecting the balance of scientific opinion on a topic. Well-researched independent popular news sources like the Buzzfeed piece are good indicators of the state of controversy.
 * 7) Following on from (6), we might perhaps usefully define what would be required to tone down the statements about controversy. Other editors may disagree but I would suggest that in order to put mentions of controversy into a 'historical' category, it would be necessary to prove that most or all of those 'dissenting' scientists have now changed their minds. For instance, I would be interested to see the interview from which your Payne quote was drawn, and a fuller description of his current views.
 * 8) Whatever is changed in the text needs to be explicitly justified in the citations offered. It is not acceptable to justify edits based on the tone or spirit of a citation. The ARS guidelines are a good example here. They recognise the existence of ENS but that does not mean everyone does, nor that it is purely physical (indeed, as I quoted above, they explicitly mention the psychiatric comorbidity). However reputable and suitable a citation may be, it will be removed if what is claimed of it is not supported by it.
 * 9) The article is already founded upon unequivocal statements confirming many of the things you support about ENS - that fundamentally, it is recognised as something that occurs after turbinectomy.
 * 10) Our responsibility is to fact and truth, not to the feelings of readers. The feeling of not getting enough air you describe sounds terrible, and I'm genuinely sorry to hear of your experience with it, but actually the article takes no view on the specific cause of this or any other symptom. But if experts agree that psychological factors can be present, in fact that can often lead to useful treatments that can improve quality of life. That doesn't mean anything about you or any other individual's symptoms. The fact that you don't like a statement personally, or think others might be upset by it, is only of concern if it also happens to be factually incorrect. Though it's usually reserved for more extreme cases, WP:NOTCENSORED contains some wisdom here: "'being objectionable' is generally not sufficient grounds for the removal or inclusion of content."

I hope these general statements are helpful and look forward to working together on this article. Dubbin u &#124; t &#124; c 13:29, 7 June 2016 (UTC)


 * PS - as an example, I have no objection to describing ENS as "a recognized complication of turbinate surgery" - such a statement is clearly supported by the ARS guideline. Dubbin u &#124; t &#124; c 13:40, 7 June 2016 (UTC)


 * @Dubbin, thank you for taking your time to write the above. I do think we can work together and make this article much better.  I started to write some of my own thoughts, so I am going to copy and paste them below with modification to reflect what you said in the points above.  I am also going to re-read your above statements and take time to digest them.  In the end, my hope for any reader is that they will have a comprehensive and accurate view of my condition.  I am completely fine with seeing a statement on the Wikipedia article if it doesn't make me feel good or not, as long as it is factually accurate.  We both agree on that.


 * I am new to Wikipedia and I will spend much time reviewing the policies before attempting any future edits. However, I think the issue I am seeing in moving forward in editing this page is that, while you are well-versed in Wikipedia guidelines and are an expert in your area of medicine, which I fully respect, I do have a strong understanding of what the literature says about ENS, the current political climate, and my level of knowledge (as a patient) on ENS is well-respected by the physicians who are most familiar with ENS.  Knowing how they think and having had numerous conversations with some of the experts cited in the BuzzFeed article, I surmise they would agree with and respect most of what I would write here.  I am glad to hear that you also would respect me even though I don't have an MD after my name.


 * That said, you acknowledged that you first came across ENS by the BuzzFeed article and were disappointed with the Wikipedia article, and my perception is that your understanding of ENS seems heavily influenced by that article. I completely agree that the BuzzFeed article is a well-researched news piece that references experts across the spectrum, but it is not a peer-reviewed source (even if it cites peer-reviewed sources), which I think we both agree should be our mutual point of emphasis.  1., The BuzzFeed article has a heavy emphasis on the mental health aspects of ENS, such as doctors discussing screening patients for mental health problems prior to turbinectomies (which is mentioned nowhere in the literature), perhaps in large part because of the main person in the story who had psychological problems before and particularly after turbinate surgery, while a majority of the medical literature on ENS deals with the physical aspects of ENS.  In fact, Dr. Houser's recent journal article, "Pathophysiology of empty nose syndrome" is a synthesis of much of what we know about ENS, citing many sources, and actually gives little emphasis to the psychological aspects of ENS.  I am not denying at all that there are psychological contributors to ENS, such as the article you cited on how the sense of air hunger leads to changes in activation of the limbic system, but what I am emphasizing is that this needs to be put into context so it's not misunderstood.  ENS has a history of being a marginalized condition by the medical profession, in large measure because it's iatrogenic, and I am keenly concerned to make sure this condition is presented objectively as possible2., The BuzzFeed article also makes ENS seem like there is current controversy over its existence, which is probably in part to sell papers, although the medical literature generally provides a different perspective.  But like you wrote, maybe the controversy over its existence hasn't fully gone away, although it feels like it has to me.  When you summarize the researcher Coste in stating that "ENS is controversial" in the Wikipedia article, you left out "clinical entity" as Coste's full comment was  "...controversial clinical entity, the very reality of which is disputed by certain authors."  Also, in this case, you did not consult the original research.  Coste is citing Chabra and Houser (2009), yet if you take a look at Chabra and Houser's article, nowhere in this article does it suggest that the reality of ENS is being disputed; what Houser and Chabra are alluding to as controversial is there is no consensus diagnostic criteria for ENS and what degree of turbinate resection causes ENS.  This makes it appear as if Coste has an agenda or a spin on it as you noted happens at times, because it doesn't necessarily reflect the intent behind the original research.  Payne's recent comments/views on ENS can be found watching the short news clip entitled, Empty Nose Syndrome: Medical Mystery, CBS 19 News (https://www.youtube.com/watch?v=P89cQg5VVHY) 3, You contend with a different editor that "over-resection" is a biased or non-neutral statement, when in fact there is plenty of literature referring to ENS as resulting from "over-resection" of the turbinates, so I trust that editor will provide sources and you will then respect their edit.  In fact, I am questioning if there is much more peer-reviewed literature on ENS than you realize.  4. In moving forward, there are a lot of both original and secondary sources I could cite in enhancing the Wikipedia article.  For example, you questioned if much of the non-surgical treatments for ENS are from original sources.  To clarify, much of the non-surgical treatments for ENS, for example, are indeed cited in the medical literature on ENS, but the research behind these treatments stemmed largely from treatment of other sinus conditions involving mucosal inflammation, such as sinusitis or allergies. Many of these non-surgical treatments apply to ENS (if they are moisturizing),such as oils and irrigation, because the research has shown that the nasal mucosa for an ENS sufferer tends to be drier and warmer than it is for a non-sufferer.  There is not much  research showing this "non-surgical treatment directly improves ENS," however, and that research that is available is of low quality.  There is better research, such as a Cochrane review on surgical treatments for ENS such as implants.


 * Dubbin, I think we can best move forward in improving this article if I respect your understanding of Wikipedia guidelines and understanding of how science evolves, and I am familiarizing myself with Wikipedia (although Wikipedia seems full of editing debates on what is neutral vs. non-neutral), and you, likewise, respect the understanding I bring to an understanding of ENS. Thank you for the discussion.  I propose that this Wikipedia article is more fully fleshed out using an outline similar to the one for chronic fatigue syndrome: https://en.wikipedia.org/wiki/Chronic_fatigue_syndrome. Thoughts?  I welcome and anticipate others to contribute to the Wikipedia article as well.  Respectfully submittedItalic text EducatedonENS (talk) 14:41, 7 June 2016 (UTC) User:EducatedonENS|EducatedonENS]] (talk) 16:47, 6 June 2016 (UTC)


 * @EducatedonENS, thanks for the reply. I took the liberty of indenting it by adding ':' at the start - this is a useful convention on talk pages that helps us see who is replying to what. Rather than engage in a lengthy debate, I think it's best if you propose specific edits with citations, and we can use them as a basis for arriving at some edits we agree upon. Edits relying on primary rather than secondary sources are unlikely to be acceptable (per WP:MEDRS), and your experience will be most usefully applied if it is directed to finding good sources and producing good edits based on them, rather than giving your own descriptions of the field, your contacts or your experiences. Best wishes. Dubbin u &#124; t &#124; c 14:57, 7 June 2016 (UTC)


 * @Dubbin, thank you for the reply as well. I will now look for good sources and specifics going forward, but it was important to share the aforementioned first.


 * The first change to the Wikipedia article that should be made is starting it with a proper definition of ENS as an opening sentence to the article in a simple way. It currently starts by going into symptoms and then acknowledging it is controversial, which is confusing to any reader to understand what ENS is really all about.  It should clearly connect ENS as a direct consequence of nose surgery.  For example, a first sentence that reads, Empty nose syndrome is a complex medical condition which is a recognized complication of turbinate surgery....would be a good starting sentence and is non-disputable, so it does not need a reference.  — Preceding unsigned comment added by EducatedonENS (talk • contribs) 16:28, 7 June 2016 (UTC)


 * Well that's a good place to start. However the opening sentence of an article on a medical condition usually begins with a definition that takes the completely unfamiliar reader from knowing nothing about the syndrome to a decent overview of it. Migraine and vertigo are good examples. Your proposed change doesn't describe any of the clinical features of the syndrome, which is a problem for a clinically-defined syndrome. Only after the clinical description is established is it necessary to explain what causes it. I understand your enthusiasm for getting the fact that it is a recognised complication of turbinate surgery into a prominent position but I think first the reader needs to know what the syndrome consists of. Nor is it necessary to say that it is 'complex' - all medical conditions could be described this way and the complexity is evident from the article. So (and this is a big concession for me) how about we change the opening paragraph to:


 * Empty nose syndrome (ENS) is a clinical syndrome in which people experience abnormal airflow through the nose in the absence of a physical obstruction to the flow of air. It is a recognized complication of surgery to the turbinates in the nose, such as partial or complete turbinectomy. Symptoms include a sensation of excessive or inadequate airflow, temperature hypersensitivity, breathlessness, pain, headache, insomnia and fatigue. ENS is recognized by the American Rhinological Society but is the subject of controversy. Dubbin u &#124; t &#124; c 16:58, 7 June 2016 (UTC)

Greybridge (talk) 02:30, 8 June 2016 (UTC) , I would like to bring your attention to the fact the opening paragraph you have written has omitted a central, primary symptom of ENS, that of chronic severe nasal dryness. This dryness is often accompanied by nasal crusting. These two symptoms "indicate the complete decompensation of the humidifying function of the nasal mucosa". [see Gassner, Sherris, Friedman, "Rhinology in Rhinoplasty" in: Facial Plastic and Reconstructive Surgery. Ira Papel, ed. Tieme, 2009] This is to say, that the nasal physiology of the ENS patient no longer functions due to damaged and/or missing turbinate tissue. These facts are fundamental to the medical condition of ENS. Source material concerning these facts is easily obtainable and can be found not just in specialized works on ENS and atrophic rhinitis, but also in other general works published in the field of otorhinolaryngology, especially as they concern the nose.

Importantly, these two symptoms of ENS, nasal dryness and crusting, were added to an amended SNOT-20 (Sino-Nasal Outcome Test)inventory by Steven Houser, which now to comprise the SNOT-25 and is itself recognised, as a result of his study. The SNOT-20 is the universally used inventory in ENT to measure symptomology in rhinologic conditions and disease. I would note that Dr. Houser is the foremost world authority on ENS and it would benefit you to familiarize yourself with his work. So, you will note that ENS is not just a matter of people who "experience" abnormal airflow through the nose. I will be adding my own text about nasal dryness, crusting, nasal physiology and decompensation to the opening section.

As concerns breathing issues in ENS, it is best to stick to the accepted symptoms comprising the SNOT-25 specific to ENS patients. These are: "difficulty with nasal breathing", "suffocation", and "nose is too open". These symptoms are not addressed on the SNOT 20 and being specific to ENS patients, were thus included in the SNOT-25. You can find a very thorough explanation of these symptoms in Dr. Houser's study, Surgical treatment for empty nose syndrome (2007). These 5 additional symptoms offered by Dr. Houser have been discussed over the years since 2007 by other authors writing about ENS and so have found their way into the vocabulary of ENS, and are used by clinicians and researchers to diagnose.

Further to this, I would urge you when defining ENS in this opening section, to focus on the primary symptoms that have been published upon and are accepted by the ENT community. Just because there is no set diagnostic criteria as yet, does not mean there is not an already accepted, informal diagnostic criteria among clinicians and researchers. Insomnia and fatigue are not primary symptoms of ENS, they are secondary symptoms - complications that have arisen as a result of the primary symptoms. For example, the difficulty with nasal breathing that ENS patients experience commonly cause oral breathing during sleep. As I am sure you know from sleep medicine, this universally produces disrupted sleep and fatigue. I intend to remove these secondary symptoms from your opening paragraph. And, if they are noted later on, to have them placed in the context of secondary symptoms.

A further critique of your list of symptoms in the opening paragraph is that you merely list "pain". There are different ways to discuss pain in ENS. For one, I would note that Eugene Kern, M.D., in his early study of ENS, and elsewhere in his talks on ENS described a "facial pain". Kern said that the source of the pain he described in his work has its origin in the sphenopalatine ganglion, for which he used a block of xylocaine. These patients were mostly total turbinectomies. Patients who still have some remaining mucosa, may have some involvement of the ganglion, but they have not been studied as well with respect to pain issues. Pain in ENS patients also originates in the dry mucosa in the nasal cavity itself. This is expressed in the symptomology as "nasal pain". Nasal dryness is painful and is often described by patients as a "burning" pain. Clearly, the phenomenon of pain emanating from dry mucosal tissue has already been studied in medicine, though perhaps not widely in ENS patients or the nose - I think here of dry eye, atrophic vaginitis - conditions where there is dryness of the mucosal tissue and epithelium. And descriptors among these conditions are similar.

So, my question to you is, what do you mean by "pain"? For a Dr., you are not very precise. To me, my impression is that you take much of your information directly from Coste, who is not always a reliable reporter of the sources he cites in his work, Empty nose syndrome (2012), I would urge you to examine the original sources instead. Greybridge (talk) 02:30, 8 June 2016 (UTC)


 * Please keep your comments civil and refrain from making judgements about my professional credentials or skills. Further warnings will not be given. You make much the same point as ensadvocate on which symptoms should be included in the lead. I suggest the two of you work together to find a suitable WP:MEDRS source that lists the symptoms in order of frequency and we should just list the most common ones in the lead. The symptoms section is the place for a more detailed list with the kind of subtleties you mention, if you can back them up with suitable sources. As regards your comments about the  SNOT-20, this is relevant if and only if you can provide suitable WP:MEDRS sources supporting specific things you want to say in the article. That you consider a particular person an authority in ENS is not relevant - we need to present the scientific consensus, supported by suitable -- usually secondary -- sources. Dubbin u &#124; t &#124; c 12:23, 8 June 2016 (UTC)

Greybridge (talk) 14:45, 8 June 2016 (UTC), I spent a lot of time explaining the basis for my future edits in talk as you suggested be done. Now, I am locked out from editing. I object to you hijacking the page and forcing your erroneous statements concerning the "controversy" about ENS. I have read the Payne article. He says nothing of the kind. In fact, I want this to be published in the Controversy section instead: "Empty nose syndrome (ENS) is a poorly recognised but undoubtledly devastating clinical entity." [Leong SC, The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review. Laryngoscope. 2015 Jul;125(7):1557-62. doi: 10.1002/lary.25170.] This work fits the Wikipedia definition of secondary source. Leong's article includes a braod literature search and an examination of 8 studies concerned with surgical intervention of empty nose syndrome. ENS is poorly recognised". Its "existence" is not controversial.

You cite Spencer Payne, Empty Nose Syndrome: what are we really talking about? (2009) in support for this point. The quote from the article is: " The problem with ENS is probably not that it does not exist, it is that we can not adequately explain its existence by what we currently understand about the nose.". Payne continues: "To this end many otolaryngologists are unwilling to make a “leap of faith” and, instead of acknowledging the existence of something they do not understand, they are left skeptical of it in its entirety." This should give context to his meaning. Payne does not suggest that ENS does not exist. Dubbin, your words are erroneous. What you say is a mischaracterization. You said: "its [ENS] very existence has been called into question by experts, as noted by Dr Spencer Payne in 2009.” This is not what Spencer Payne said.

You cite Coste, Empty Nose Syndrome (2012)three (3) times in your Controversy section. If you rely on Coste for your assertions, then you are in error. Coste himself mis-characterizes his own sources - perhaps due to a language difficulty.

Let's dissect your Controvery section and see if your citations support your words.

1) “Empty nose syndrome is controversial.[16]" - Citation 16 is citing the article, Empty Nose Syndrome (Coste 2012).

The actual quote from the Coste article is:

“....empty nose syndrome (ENS) is a controversial clinical entity, the very reality of which is disputed by certain authors.”[2]

However, Coste in note [20 is citing, Diagnosis and Management of Empty Nose Syndrome, Chhabra N, Houser SM.Otolaryngol Clin North Am. 2009 Apr;42(2):311-30, ix. doi:10.1016/j.otc.2009.02.001.

Dubbin, this is a sloppy citation, you did not check to see if Coste rendered the original source accurately, and then you went on to truncate the quote from Coste, which altered its meaning, stripping it of context.

The full from Coste is: "empty nose syndrome is a controversial CLINICAL ENTITY”. [emphasis mine]. This is a different statement than "ENS is controversial".

In Diagnosis and Management of Empty Nose Syndrome, Chhabra and Houser spend much time explaining primary and secondary atrophic rhinitis {AR), how to distinguish ENS from AR. And repeatedly about how ENS is diagnosed through physical signs. What precise diagnostic criteria should be relied on is what is “controversial” if anything according to Chhabra and Houser (reflecting current consensus in ENT research)

Is this what Coste was mis characterizing in his statement? Let's see what Chhabra and Houser really said:

“ENS is a poorly understood and rare iatrogenic disorder resulting from the destruction of normal nasal tissue. In severe forms, it can be debilitating, and a lack of recognition and understanding of this disease process is at the expense of the patient. In this article, the authors have elucidated the distinction between ENS and atrophic rhinitis and have provided a systematic approach to the diagnosis and management of ENS."

For context for this quote,Chhabra and Houser urge a judicious and cautious approach to turbinate resection, to help prevent the occurrence of ENS as a sequela of nasal surgery. When encountered in practice, patients who have ENS can be rehabilitated and their quality of life substantially improved by using nasal augmentation as a means to help restore nasal anatomy toward the premorbid state. Astute clinical suspicion, coupled with an understanding and appreciation of the pathophysiology behind ENS, can greatly benefit the otolaryngology community.”

This is completely different in meaning to what you wrote, Dubbin.

Coste also wrote inaccurately, in the way he phrased it in his article, as to what Chhabra/Houser said. Perhaps Coste referred to its differentiation from Atrophic rhinitis (AR), or ENS's lack of diagnostic criteria as a new entity, but certainly not to wholesale deny its existence, as suggested by your truncation of Coste's unclear statement.

What did Coste really mean? And is your rendering of this words correct? No, your rendering is in error and so is Coste's of Chhabra/Houser.

If Coste intended to mean the lack of diagnostic criteria, this is what Chhabra/Houser said: “Because ENS is a recent area of interest and research, the literature does not elucidate a set diagnostic criterion, in particular because complaints of patients afflicted with ENS often are subjective.”

How Coste chose the term “controversial” is not known. If it is based on Chhabra/Houser's use of the term “controversy” in their article, then the meaning is clear and it differs from Coste's. (The term “controversial” is not used at all by Chabra/Houser.)

Here are all 4 instances of “controversy” in the Cnhabra/Houser article:

“THE CONTROVERSY SURROUNDING TURBINATE RESECTION” [Section Header in Chhabra/Houser article] “Still, given the debilitating effects of ENS on a patient’s quality of life, controversy exists as to whether physicians have become too cavalier in resecting turbinate tissue.”

“Stewart performed an extensive review of the literature and concluded that a randomized, controlled clinical trial may not resolve the controversy that exists regarding MT [middle turbinate] resection.”

“The authors have demonstrated that substantial controversy is present in the literature and that no gold standard recommendation exists regarding the resection of turbinates.” So, Dubbin, by your own sources, you see that you are in error.

I will not even deign to discuss the Buzzfeed article which is not written by a medical researcher or peer-reviewed.

In sum, I object to your use of the word controversial based on your erroneous citation of sources.Greybridge (talk) 14:45, 8 June 2016 (UTC)

New proposed opener
Dear EducatedonENS, Dubbin, Greybridge Dubbin were you able to watch that video by doctor payne that EducatedonENS posted?

also I strongly suggest that you listen to dr kerns lecture at the mayo clinic about empty nose syndrome at https://www.youtube.com/watch?v=LUUbHSEsJjM before you make any more edits. If you are truely interested in this condition.

Also the contraversey section where it suggests that ENS is related to psychological problems is totally unacceptable to me  because the wikipedia is a primary source of information for many people.

Because When someone  tries to explain to someone else that they have empty nose syndrome say their boss because they need accommodation at work because of there empty nose syndrome, or they when they need  help from their family or friends due to there disabilty, Or if they are trying to get corrective surgery for ENS and need financial help from family. 9/10 times people are are going to google it and look it up on the Wikipedia. and they see "ENS is associated with stress and more commonly found in patients with psychiatric and psychosomatic disorders, suggesting psychological factors may be partly responsible for its symptoms" they may think the person asking for help is NUTS rather than sick

As a physician Dubbin dont you want sick people to get help???

But that can wait for later discussion.

For the opener — Preceding unsigned comment added by 2601:44:C500:44FE:145E:466D:ED1:BCB0 (talk) 03:45, 8 June 2016 (UTC)

I suggest that we make the opener like this broader than your Suggested opener Dubbin so that it includes most of the possible symptoms of ENS

''Empty nose syndrome (ENS) is a clinical syndrome in which people experience abnormal airflow through the nose in the absence of a physical obstruction to the flow of air. It is a recognized complication of surgery to the turbinates in the nose, such as partial or complete turbinectomy. Symptoms can include but are not limited too a sensation of excessive or inadequate airflow, a sensation of suffocation, breathlessness, temperature hypersensitivity, nasal dryness, nasal crusting, nasal epistaxis, difficulty concentrating(nasal aprosexia),partial or total loss of sense of smell, facial pain, headache, insomnia, fatigue, sleep apnea or other undifferentiated sleep problems. ENS is recognized by the American Rhinological Society but is the subject of controversy''

EducatedonENS, Dubbin, Greybridge what do you think

please excuse my poor punctuation that can be fixed later — Preceding unsigned comment added by 2601:44:C500:44FE:145E:466D:ED1:BCB0 (talk) 03:23, 8 June 2016 (UTC)

I will no longer be making ip contubutions to this discussion my user name is ensadvocate — Preceding unsigned comment added by Ensadvocate (talk • contribs) 05:56, 8 June 2016 (UTC)


 * First, please refrain from making defamatory comments about my professionalism as a doctor. This is not acceptable and if it happens again I will formally complain about you.


 * Second, the page is currently edit-protected because of edits that were not compliant with WP:NEUTRAL. This has been extensively discussed above. The bottom line is that ENS is controversial whether you like it or not, and psychological factors are widely recognised as important by all the reputable sources. The wikipedia article needs to reflect that while summarising the best science. If you have proposed edits they will need to be backed by WP:MEDRS sources and that means secondary sources like good-quality review articles, not primary data articles or the views of indvidual practitioners. Any material not backed up by suitable sources will be removed and if it happens repeatedly, the page is likely to remain protected against edits.


 * The purpose of the lead is not to list all the symptoms of ENS, it is to summarise the most frequent. A full list belongs in the symptoms section. Your list is far too long for the lead. If you can find a suitable WP:MEDRS source that lists the symptoms in decreasing order of frequency, I suggest we list the most frequent 5-6. Dubbin u &#124; t &#124; c 07:38, 8 June 2016 (UTC)

Proposals for WP:LEAD
REMOVE: I propose that the current sentence in the Opening Statement be REMOVED: "It appears to be a health care caused condition but its existence, cause, diagnosis and management are controversial."

REPLACE: I propose that it be REPLACED with: "Empty nose syndrome is a medical condition, and a rare complication of nasal surgery, in particular resection of the inferior turbinate. [1] It is a poorly recognized, but devastating clinical entity. [2]"

Citation [1] = [Leong SC, The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review. Laryngoscope. 2015 Jul;125(7):1557-62. doi: 10.1002/lary.25170.] Original quote: "Empty nose syndrome (ENS) is a poorly recognised but undoubtledly devastating clinical entity."

Citation [2] = Varsha Joshi, Imaging of Paranasal Sinuses, An Issue of Neuroimaging Clinics, 1st Edition (2015). Original quote: "Empty nose syndrome is a rare complication of sinonasal surgery, particularly following resection of the inferior turbinate, and is likely caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and air conditioning function." Greybridge (talk) 16:06, 8 June 2016 (UTC)


 * Hi, thanks for making a proposal. When you cite sources, please make sure to include the Pubmed ID - the PMID.  The Wikipedia software automatically formats a link to the pubmed abstract, which we use for a bunch of things.  If you cite a book like you do in the 2nd ref, you need to give ISBN (the WP software also forms a link with that parameter) and also give the chapter info (authors and title) and the page number.  I just wasted about 15 minutes trying to figure out what that ref actually is. Not happy.
 * The book citation should be
 * Ginat DT. Posttreatment Imaging of the Paranasal Sinuses Following Endoscopic Sinus Surgery. pp 653-665 in Imaging of Paranasal Sinuses, An Issue of Neuroimaging Clinics, 1st Edition.  Ed, Varsha Joshi. Elesvier 2015 ISBN 9780323413435.  P. 663.
 * It was also indexed as an article by pubmed. So you could cite it like they do:
 * Ginat DT. Posttreatment Imaging of the Paranasal Sinuses Following Endoscopic Sinus Surgery. Neuroimaging Clin N Am. 2015 Nov;25(4):653-65.


 * To the point now. There are three actual review articles from 2015 that are cited in the article now.  Your citation #1 is one of them.  Those are much better than the book chapter - higher on our heirachy of sources in WP:MEDRS.   What we do in Wikipedia, is we read the most relevant sources (so the three recent review articles) and we summarize them. We don't just cherry-pick stuff.  The Leong source is really excellent and it says things like "Because there is no empirical evidence to support the diagnosis of ENS at present, it is argued that many otolaryngologists remain skeptical about its existence and are not willing acknowledge the diagnosis and offer treatment."  We cannot just leave stuff like that out.  This is what WP:NPOV means - we have to really represent the literature. Jytdog (talk) 17:10, 8 June 2016 (UTC)


 * Jytdog, I an not cherry picking. I am initiating a process. The Ginat article is just one reference I suggested. There are MANY, MANY Other references I intend to add. So many so, that it can not be construed as cherry picking. Why are you so quick to criticse the beginnings of a discussion? This is not my full time job. How dare you criticise me for wasting your time. This is a discussion area. I am not allowed to edit the actual article because I have been blocked for some reason. Should I be able to edit the actual aticle, my citations will conform with Wikipedia's rules. Greybridge (talk) 19:42, 8 June 2016 (UTC)


 * Leong cites Payne (2009 for the quote you have noted. As I have discussed elsewhere in my analysis of Payne, this is NOT what Payne says: ref= Leong = "Because there is no empirical evidence to support the diagnosis of ENS at present, it is argued that many otolaryngologists remain skeptical about its existence and are not willing acknowledge the diagnosis and offer treatment." . Again, your citation fails. This is an ERROR. Not a contrary empirically-based source. Greybridge (talk) 20:35, 8 June 2016 (UTC)
 * You are new to Wikipedia and are just learning how this place works - how we select sources and generate content based on them. Please don't claim there are "errors" until you understand Wikipedia better, and please don't WP:SHOUT. As I mentioned before, please read WP:MEDASSESS - it directly speaks to doing "peer review" on the content of sources. We spend our effort on identifying the best sources based on the kind of source it is, and its date, and then we do our best to summarize them, neutrally.  Please be aware that per WP:MEDRS we have three really great sources (the three reviews from 2015) and three additional very good, but not as good, sources (the reviews from 2012, 2011, and 2009) - you will see that by far the article as it stands relies mostly on the three 2015 reviews.  The article uses exactly one primary source, and that is there purely for historical context and the content is actually sourced to one of the 2015 reviews.  I used the popular press once (a high quality newspaper, not a blog), for the History section, which is fine per WP:MEDRS.  We have to think about what sources to use, and how to use them, carefully, based on the policies and guidelines. Thanks. Jytdog (talk) 01:31, 9 June 2016 (UTC)


 * Dubbin’s opening statement proposal:


 * "Empty nose syndrome (ENS) is a clinical syndrome in which people experience abnormal airflow through the nose in the absence of a physical obstruction to the flow of air. It is a recognized complication of surgery to the turbinates in the nose, such as partial or complete turbinectomy. Symptoms include a sensation of excessive or inadequate airflow, temperature hypersensitivity, breathlessness, pain, headache, insomnia and fatigue. ENS is recognized by the American Rhinological Society but is the subject of controversy."


 * As it appears now on Wikipedia:


 * "Empty nose syndrome (ENS) is a clinical syndrome in which people who have clear nasal passages experience a sensation of being unable to breathe, a feeling of nasal obstruction and dryness, and crusting, oozing, and foul smells inside the nose from infections, as well as pain in their nose or face, an inability to sleep and fatigue, and feelings of irritation depression, or anxiety; they may be constantly distracted by the sense that they are not getting enough air.[1] ENS is typically experienced after the complete or partial removal of turbinates in the nose in a surgical procedure known as turbinectomy.[1] It appears to be a health care caused condition but its existence, cause, diagnosis and management are controversial.[1]"


 * My thoughts for changing the current opening statement:


 * "Empty nose syndrome (ENS) is a clinical syndrome in which people who have clear nasal passages experience a sensation of being unable to breathe, a feeling of nasal obstruction and dryness, crusting, infections, as well as pain in their nose or face, difficulty concentrating, an inability to sleep and fatigue, and feelings of irritation, depression, or anxiety; they may be constantly distracted by the sense that they are not getting enough air.[1] ENS is typically experienced after the complete or partial removal of turbinates in the nose in a surgical procedure known as turbinectomy.[1]  ENS is recognized by the American Rhinologic Society but is the subject of controversy."


 * I stated my reasons for how to change the opening statement in a statement to Jtydog. I do feel that ENS recognized by the ARS should be mentioned with the discussion on the controversy elsewhere. Please comment.  Thanks....EducatedonENS (talk) 18:25, 8 June 2016 (UTC)EducatedonENS
 * The lead should summarise the article, not duplicate it. At present, it is overburdened with a shopping list of symptoms that are frankly undue. states: "The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea". That should be all that is necessary for the lead and I propose shortening the list of symptoms to those four. --RexxS (talk) 17:12, 9 June 2016 (UTC)


 * , I agree. did a great job of bringing the symptoms together but I think it impairs readability to have so many listed in the lead, especially when they are all set out in the symptoms section using the same wording. I suspect there will be objections from individuals who feel their most important symptom is being omitted from the lead, but this change is certainly supported by the most useful WP:MEDRS source. I think this is sufficiently rational and well supported so I'll make the change, carefully noting that other symptoms are also experienced. Dubbin u &#124; t &#124; c 18:08, 9 June 2016 (UTC)

arbitrary break to save scrolling

 * I made some changes to the LEAD here based on suggestions above. With regard to ARS I think it might be useful to have some content about how the various relevant societies here and abroad approach this topic.  Are you aware of a reliable source that discusses that?  In Wikipedia it is always best to rely on a secondary source that discusses things and contextualizes them, and we summarize that source here. Jytdog (talk) 01:56, 9 June 2016 (UTC)
 * On the psychosomatic thing, please note that Leung mentions the interesting phase, "rhinitis hystericus" in the intro, citing Payne, who appears to have coined this based on globus hystericus - a medically very polite way to say psychosomatic. Jytdog (talk) 02:22, 9 June 2016 (UTC)


 * Jytdog: I think the opening statement, classification and signs and symptoms seems nicely improved and fairly objective/neutral.  Thank you for your work on that.  You asked how the societies abroad approach the topic of ENS and I want to bring your attention to the following 1-page, quick article:


 * The below research article, which is about the Chinese ENS patient who killed his doctor, states the following:
 * (http://www.peertechz.com/Surgery-Surgical-Research/pdf/JSSR-1-108.pdf)
 * +ENS is described as “poorly understood”
 * +“Unfortunately, facing patients’ medical condition, some rhinological staff are absolutely ignorant of ENS.”
 * +Has a paragraph which describes ENS solely as a physical problem


 * I also want to direct your attention to statements from Houser & Sozansky (which is already cited):


 * "The diagnosis is potentially missed often because most rhinologists are trained to look for signs of dryness and atrophy after turbinectomies, objective long-term complications, and may thus disregard the patients' subjective complaints of nasal obstruction or shortness of breath. These subjective complaints are often viewed as psychological manifestations.  Like many other otolaryngologic disorders (e.g., tinnitus), the fact that the symptoms are subjective and cannot be verified does not mean they are not real and valid symptoms originating in a physical abnormality."


 * I present the above two quotes to show how a) ENS is viewed as a medical/physical problem internationally and in both articles; b) to show how ENS can be under-diagnosed or misdiagnosed as psychological; c) how this lack of recognition can impact a doctor-patient relationship; and d) to explain how the physiology can impact the mood. This is why I don't like the statement:  "psychological causes leading to a psychosomatic condition have been proposed" and do not think the references cited accurately reflect.  I do think the references are more in keeping with you statement that may have "neurological or psychosomatic aspects." The articles do suggest neuropsychological impact, but I would just want it in perspective.  Perhaps integrating these thoughts could be useful when discussing the "cause" section?


 * You mentioned Payne and describing ENS as a psychological issue and I would like to bring your attention to his quotes in a recent media interview below:


 * http://www.newsplex.com/content/news/Medical-Mystery-Empty-Nose-Syndrome--378189771.html
 * Payne is one of just a handful of doctors working with ENS patients.


 * He says people like Schneider exists in a medical paradox: they say they cannot breathe, but everything looks healthy.


 * Payne says, as a result, most doctors tell ENS patients that the disorder is in their heads.


 * "The doctor would say 'oh, it's because you're single. You're just stressed out that your not married yet,'" Schneider echoed, saying Payne is right, and most doctors believe she is suffering from some sort of psychosis.


 * But Payne disagrees. He thinks there is a very real cause for ENS, and it deals with the type of surgery many ENS patients received before developing symptoms.


 * "The common thread for people who've had surgery is that they've had really aggressive surgery," Payne said about the research he has done on ENS.


 * He believes some aggressive nose surgeries create nerve damage inside the nose of the patients, which in turn interferes with their breathing.


 * According to Payne, the nose has tubular structures called turbinates. Turbinates help heat and cool air passing through the nose, and he says that heating and cooling sensation is one way the body can tell it is breathing.


 * But in some patients, when those turbinates are altered, the body can no longer feel the heating and cooling inside the nose, either because too much of the turbinate was removed or because the surgery caused nerve damage.


 * As a result, Payne believes patients like Schneider are truly suffering.


 * "ENS absolutely exists," Payne said about the disorder. "It's just not necessarily certain what that means for every specific patient." EducatedonENS (talk) 02:50, 9 June 2016 (UTC)EducatedonENS
 * Thanks for your reply. Please do see the note I left on your Talk page here about formatting Talk page replies. More on the substance in a second. Jytdog (talk) 03:48, 9 June 2016 (UTC)
 * This source - http://www.peertechz.com/Surgery-Surgical-Research/pdf/JSSR-1-108.pdf - is labelled an Opinion - it is not a reliable source per WP:MEDRS and we won't use it for any health content. Likewise the interview is popular media and that too is not a WP:MEDRS source and we can't use it for content about health.  We can maybe use them elsewhere; let me consider that.
 * I do understand that you would like for ENS to be recognized and considered as a well defined condition with a clear diagnosis, treatment, etc, and that you and others would like more people to be aware of it. That has nothing to do with how we operate in Wikipedia. In Wikipedia we identify the best sources and we summarize what they say.   We cannot ignore anything in them.  The current content reflects an an effort look at all six recent reviews, and reflecting what they say, and giving the most WP:WEIGHT to what the most recent ones say.  This is what WP:NPOV is all about.
 * As far as I can see no one has denied that people with these symptoms suffer a great deal; the debate is ÷why and how. People tend to misunderstand what a "psychosomatic disorder" is - psychosomatic disorders are very real and people really suffer from them.  The psyschomatic thing is sourced primarily to one of the three recent reviews, not to Payne primarily.  Please also note that it is given much less WEIGHT than the caused-by-sinonasal surgery explanation.  We cannot not mention it.  Jytdog (talk) 03:56, 9 June 2016 (UTC)

I read the formatting page and did the bracket thing as I noticed you had three colons. OK, so the Chinese article and Payne's interviews are not acceptable. The point that I am trying to make, though, is also represented in Houser's article, which is that doctors may mistake the physical symptoms as psychological when they are not. It's also stated in his article (and many other literature) that ENS is poorly understood. I don't see why this couldn't be added to your statement that many doctors don't recognize ENS. For example, why couldn't it say many doctors do not recognize ENS and may in fact mistake the physical complaints as psychological. And because this is the case (as reported in a secondary source), a statement such as psychological or psychosomatic causes for ENS can perpetuate this potential misunderstanding. I just think this statement could be reworded, but still neutral so it doesn't perpetuate any misunderstandings, particularly knowing doctors are so quick to think ENS is always just a mental health problem.. A couple more thoughts then heading to bed -you mention ozena and foul odors in the opening statements - Houser's article you cite is probably the best defi ition for ENS and I don't see ozena or foul odors mentioned in that. It's not that I don't understand what a psychosomatic disorder is, but Houser's article is clear that ENS seems mainly physical and so does the article "the expansion of autologous adipose-derived stem cells for the functional reconstruction of nasal mucosa" suggest ENS is a physical problem first; but rather that I am mainly concerned with promoting a misunderstanding on ENS. A small typo I noticed is you spelled Kern as Kerm in the history section. Thanks for your consideration.74.106.192.64 (talk) 04:24, 9 June 2016 (UTC)EducatedonENS
 * Yes thanks for paying mind to the logistics. :) I hear you on the rest.  The thing is that all three of the recent reviews express a sense that removal of turbinate tissue does seem to be the trigger for ENS, but also note that it is not altogether clear and all of them make it clear that there are other things going on. The fact that this only happens in a very small percentage of people that undergo nasosinal procedures is the key difficulty, according to all these sources.   Stepping back - I can give you and and any 1,000 people a gram of cyanide and it will kill all of you dead.  And we understand how.  The causation is not ambiguous.   The fact that a 1000 people have a nasosinal procedure that affects the turbinates and only a few of them develop ENS symptoms means that there is something else going on, most likely in addition, but maybe not.  Scientifically speaking, it appears that having a nasosinal procedure that interferes with the turbinates may be necessary, but not sufficient, to cause ENS.   All of the sources also fudge on whether every person with ENS symptoms has had a nasosinal procedure; this is not clear yet, so it may even be that nasosinal surgery is not even necessary.    It is obviously something that the field is trying to figure out, but we don't know yet.  That is what the three best sources are saying, taken together.  One thing you must be very happy about is the appearance of three major reviews last year.  That is a sign of significant interest in the field.  My sense is that this article is going to be undergoing a lot of changes over the next few years as further data comes in and more reviews are published.  We will keep updating it, but we can go no farther than the sum of the best and most recent reviews. Jytdog (talk) 04:48, 9 June 2016 (UTC)

@JytdogMy strongest objection to the article, as it is written now, is the suggestion of psychological causes leading to psychosomatic condition is proposed because of the potential for misunderstanding; like you note, though, the article will likely undergo more changes in the future. This will be probably be my final suggestions in the talk discussion, as I know I have written a lot, but feel free to ask for more input if you have further questions.

You are right in that I am pleased to see three large reviews, but I want to point out that there was a turning point in 2014 for hope amongst ENS sufferers when Dr. Subinoy Das (www.usasinus.org) started treating ENS patients with regenerative medicine (acell/prp) [as well as recent interest among stem cell scientists – no citation to support this statement, though]; Dr. Das has now seen more patients than any other doctor. How does this apply to the Wikipedia article? First, in the treatment section, the discussion of implants looks like a rehashing of the abstract from Cochrane review rather than an appreciation for any specific findings of the study. Perhaps it could be re-worded. Second, I want to bring to your attention two research studies using regenerative medicine for empty nose syndrome to see if these can be included in the treatment section in light of the hope that regenerative medicine provides to ENS sufferers – or at least made mention of “ongoing research in this area”:

http://www.ncbi.nlm.nih.gov/pubmed/26388989

https://www.researchgate.net/publication/263204984_New_regenerative_approach_to_Atrophic_Rhinitis_using_autologous_lipoaspirate_transfer_and_platelet_rich_plasma_in_five_patients

EXTERNAL LINKS

Lastly, I think there should be a few links to reputable sources of information on ENS and I propose the following three:

http://ensassociation.org (this is the only official organization for people with ENS)

http://care.american-rhinologic.org/empty_nose_syndrome (the official position statement on ENS from the American Rhinologic Society).

http://www.usasinus.org/clinical-registry-for-empty-nose-syndrome/ (this is a Clinical Registry for ENS, as Dr. Das is presently treating more patients with ENS than anyone else in the world)

Thank you for taking into account my thoughts for enhancing the article and for the amount of time and thought you have put into this article; even if you have hated it, it could do a lot of good. If you have further questions, please ask. Also, I look forward to seeing changes to the article once more reviews and an ICD code is available. Thank you again. EducatedonENS (talk) 13:28, 9 June 2016 (UTC)EducatedonENS — Preceding unsigned comment added by EducatedonENS (talk • contribs) 13:17, 9 June 2016 (UTC)

Revision
It turns out there are three very recent reviews so I revised this based on them, and MEDMOS. If anybody needs them let me know and I can send them to you. We really need to stick with sources that comply with WP:MEDRS for sourcing, and we need to stick to MEDMOS for style. Happy to discuss anything I did. Jytdog (talk) 15:08, 8 June 2016 (UTC)


 * Jytdog: In the "New Proposed Opener section of Talk, I have placed a proposed edit to the Opening paragraph of the introduction. For some reason, even though I have proposed well-cited secondary sources in the Talk section, I cannot proceed with my edits. — Preceding unsigned comment added by Greybridge (talk • contribs) 16:10, 8 June 2016 (UTC)


 * The page is still protected from edits; proposed edits will need to be discussed here and experienced editors will incorporate any where a consensus is reached. I suggest consolidating them in this section so that Jytdog and others can easily respond. When replying, please use : at the start of the comment to produce an indent that helps us see who is replying to whom, and sign your posts at the end by adding four '~' symbols. Dubbin u &#124; t &#124; c 16:20, 8 June 2016 (UTC)

@Jytdog, THANK you for putting your time into significantly revising the Wikipedia article on empty nose syndrome. I think it looks much improved and represents our condition much better. I want to make some suggestions for your consideration. I don't have all the sources cited here, but I want to offer my thoughts for your consideration so you can research it and improve it as needed:

OPENING STATEMENT First, in the definition you put “oozing, and foul smells inside the nose from infections.” This tends to be more characteristic of atrophic rhinitis or what may be considered a very advanced stage of empty nose syndrome…..perhaps “chronic infections” would be more fitting, as one study showed that 50% of patients who had total inferior turbinectomies resulted in chronic sinusitis (chronic sinusitis a sequela of inferior turbinectomy, 1998). I think what’s missing from the initial definition is difficulty concentrating, referred to as “aprosexia nasalis” in the literature. People with ENS are affected on a physical, psychological, and cognitive basis – and, because of the breathing anomoly, difficulty concentrating can be an issue. In the last line, instead of saying health care caused, maybe “iatrogenic” would be better?

'CLASSIFICATION Where you write “As of 2015 many ear, nose, and throat doctors do not recognize the condition”,

I think it might be better to state “While the American Rhinologic Society officially recognizes this condition (to show that the ARS has recognized it and with the realization there may be an ICD code in 2016 or 2017 for ENS, as this was previously noted), as of 2015 many ear, nose and throat doctors do not fully appreciate the condition (the majority of ear, nose and throat recognize ENS exists, but don’t fully understand the symptoms with very few doubting it altogether, so is there a better way to write this??).”

CAUSE After you mention nerve damage in ENS, you may wish to paraphrase Dr. Houser’s article, Pathophysiology of empty nose syndrome, 2015, where he discusses “neurosensitive receptors,” in combination with a dry, warm mucosa playing a significant role in perception of nasal patency, Here, you might also try to integrate the research showing that the chronic sensation of air hunger impacts the limbic system (sorry, there is a research study which you can find on this). This should segue into your next point:

You wrote: “Because the occurrence of ENS is rare and investigators have been unable to identify consistent diagnostic features or precipitating features, psychological causes leading to a psychosomatic condition have been proposed.[4][6]  I don’t think this statement is accurate and needs to be reworded to reflect the current scientific opinion.

For example, in the research you cited, here is a paragraph from the abstract: Physiopathology (should be pathophysiology, a typo) remains unclear, but probably involves disorder caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and conditioning functions. Neuropsychological involvement is suspected. Furthermore, Payne (2009) who is probably the largest critic in the literature on ENS, writes an article, Empty nose syndrome: What are we really talking about? A large majority of his article is focused on (to paraphrase) “we strongly suspect ENS exists, but how do we explain the physical symptoms?” He only offers a small discussion at the end of the article discussing the high rate of psychological symptoms among people who suffer from the syndrome. Your statement above makes it look like his focus on the psychology of ENS when it is not.

I would also encourage you to read my comments (above) to Dubbin on Houser’s Pathophysiology of empty nose syndrome as it’s very important how the physiology impacts the mood. I just want context here. There is one research article showing that treating ENS (in some cases) as a psychosomatic disorder can lead to improvement, but this is very much the exception rather than the norm. No one, as I understand it, is debating if the psychological well-being of an ENS patient is causing his/her symptoms.

'''TREATMENT ''' I think in the study on implants, a few thoughts: as I understand the literature, the research on implants shows it is a safe, effective treatment option for ENS, but there is a somewhat risk of absorption and, to a much lesser extent, infection. Your statement makes it sound like absorption and, to a lesser extent, infection are large risks, when I really think these are minor risks. I also think it would be helpful to state why there is improvement, such as with respect to moisture, heat retention, nasal airflow resistance, and an ability to get our minds off the breathing (for instance). I was a participant in Houser’s original research so I have firsthand experience. I also think it should be mentioned the location of the implants and perhaps even mention how the materials for implantation are debated; Houser and most others initially opted for the septum, and still do some septal implants in certain cases, but most of the implants done today are on the lateral walls as it is a natural location less prone to obstruction. As to implant materials, it could be mentioned based on a research study that costal cartilage was found to be superior to auricular cartilage.

Second, I think it would be helpful to add a section about the research on adipose-derived stem cells in the treatment of empty nose syndrome. There are two research articles “the expansion of autologous adipose-derived stem cells for the functional reconstruction of nasal mucosa” and there is also a study on the same exact treatment option out of India (I tried, but I can’t find it right now). I think a discussion of these is in order. Currently, Dr. Das of Columbus, Ohio (www.usasinus.org) has been offering this treatment option since February 2014 in addition to the acell/PRP injections he has offered since 2016. It might be worth mentioning these treatment options, so people know these exist, even if you can't comment on the effectiveness of his treatment as it has not been published in research. In that light, it could be helpful to point out which doctors are offering implants, such as Dr. Houser and Dr. Nayak in the United States (this is noted in the BuzzFeed article)

EPIDEMIOLOGY and OUTCOMES I think it should be added that there are 500,000 turbinectomy procedures done in the US each year (Source: radio show "Wellness Wednesday and the Zika Virus"), although the CDC also should have historical statistics. 20% of patients who undergo total inferior turbinectomies will likely develop ENS (Dr. Houser in his “pathophysiology of empty nose syndrome” article) cites two other research articles suggesting this. Then you might want to state that doctors believe the rate of people incurring ENS is a much lower percent (Dr. Das states less than 1% of turbinectomy procedures on the radio show just quoted) because primarily conservative turbinate surgeries are employed today, although some might develop ENS even with conservative treatments, if there is a nerve damage to the mucosa (see a discussion of ENS-Type, which is cited in multiple sources).

NOT SURE if you can add this….. But I think links to valuable websites is in order, such as the American Rhinologic Society discussion of empty nose syndrome, the Empty Nose Syndrome International Association (ensassociation.org), usasinus.org, etc.

Thank you for your consideration.EducatedonENS (talk) 16:54, 8 June 2016 (UTC)EducatedonENS PS- No one is "recruiting editors of a specific viewpoint." Please try to understand that there are several people who have a strong understanding of the research, while conversely, the editors who are editing are new to ENS. People are passionate because this condition has been marginalized and misunderstood and sometimes the editing on Wikipedia is not in line with current scientific understanding and perpetuates the misunderstanding. Again, thank you for your understanding. I don't have much time to do all the research and update an article anyway, so I appreciate that Jytdog is doing some legwork on our behalf. Respectfully Submitted EducatedonENS (talk) 17:20, 8 June 2016 (UTC)EducatedonENS


 * You are welcome!   About all this, it is way too long and too much to deal with, so I have hatted it.   Please read the talk page guidelines for how to work here in Wikipedia.  (Key thing right now, is work on one thing at a time. That way we can have a focused discussion. But please do read the talk page guidelines)  Please also do read WP:MEDRS, which describes what kinds of sources we use, and also WP:MEDMOS, for how we write about medicine. Thanks. Jytdog (talk) 17:23, 8 June 2016 (UTC)

Thank you again. I have put a lot of time and thought into how we can make the Wikipedia empty nose syndrome page better. I have organized my thoughts on room for improvement, but I understand this is time-consuming. Thanks for what you were able to accomplish and hopefully others (if I am not able to) will edit in line to make this article more neutral and reflective of current scientific opinion.
 * I respect it, that this is very important to you. Jytdog (talk) 17:53, 8 June 2016 (UTC)

@Jytdog, I have been monitoring the various edits and the conversation regarding learning the protocol of editing WP so that I can attempt to follow the appropriate policies and I am working to adhere to them (hopefully I am putting this talk in the correct spot). So although there are several things I would like to see changed, at this time and I will comment on a particular change that has been mentioned above. I do not believe that the reference to "psychosomatic disorder" is appropriate in this page as I assert that for this point, it really is WP:Primary. Significantly, "psychosomatic disorder" does not appear in any other references including ones that Coste sites (as I search over 100 articles I have saved, I only find it referenced in Coste and no others). Overall the Coste article may be considered WP:secondary, but Coste references "psychosomatic disorder" for the first time in his review and even if there is an assertion that he has synthesized this from the other work (as there is no supporting research), this is effectively the first time this term has been used and thus should be considered WP:Primary on this topic and not included. In addition, since "psychosomatic disorder" appears only once that I can find in all the various literature, having it appear twice in a fairly short WP does not seem consistent with WP:NPOV as it provides too great an emphasis on this topic. There can be fair debate about proper reference to the psychological component of ENS but that is a separate topic from this one. Contrib12 (talk) 07:24, 9 June 2016 (UTC)
 * Thanks for your note! We don't need exact literal support - if that is what we were doing here, articles would be quotes. We summarize the best sources. I explained the rationale for psychosomatic with regard the Leung 2015 source here; I will add here that Kuan 2015 says: "The subjective symptoms of ENS are thus analogous to that in conditions such as fibromyalgia and subjective tinnitus, where the objective findings do not corroborate the subjective complaints.  Both of those conditions are also thought to potentially have a psychosomatic component.  It is explicitly supported by the Coste review and the Payne review.  An important concept in Wikipedia is WP:NPOV which says that we are sure to discuss majority views as well as minority views; what we do is that we give the most WP:WEIGHT  (space and prominence) to majority views, and we give less WEIGHT to minority views; we don't complete eliminate them. This is what the current does - it gives by far the most weight to causality from turbinectomy but also makes it clear that this cannot be the whole story, and offers this as one possibility along with something neurological.  Do you see?
 * And it is supported by those two secondary sources (reviews) not by any primary source. Jytdog (talk) 08:07, 9 June 2016 (UTC)
 * I agree with Contrib12. Jytdog your statement is not explicitly supported by Coste and Payne. This is unsubtantiated opinion from their respective works. If the entire literature search of ENS literature produces a small sample of works that assert a psychological basis or imply a psychosomatic origin, and you use them to the exclusion of other sources, then you are cherry-picking. Error= 1) citing sources on a subject (psychological basis of ENS) that are unsubstantiated (and therefore opinion not fact) and 2)cherry-picking through relyiance on a the minority opinion to prove a point, and omitting majority research and opinion. This is not neutrality. This is agenda-driven and biased.
 * , as a medical expert, could you assist Jytdog here? He seems to be having difficulty using and interpreting source material. In particular, his use of inadequate sources and his exclusion of sources with a differing opinion? Greybridge (talk) 14:15, 9 June 2016 (UTC)
 * I disagree with the above attempts to filter out conclusions of reliable secondary sources by amateur analysis. The whole point of relying on secondary sources is to make use of the expertise of the reviewer to pick out conclusions from the preceding literature and to form conclusions using their own knowledge and background. It is totally unacceptable for a Wikipedia editor to try to second guess what processes the reviewer went through in reaching their conclusions. You have no way of knowing what other evidence and research may have been part of any particular conclusion, and I should not need to remind you that the review itself has been peer-reviewed. The job of critiquing a secondary source falls to the peer-reviewers and the journal editor, not to some pseudonymous Wikipedia editor with five minutes experience. Coste 2012 states in the abstract: "Physiopathology remains unclear ... Neuropsychological involvement is suspected" and points out in the full article: "One point of contention concerns the frequent association with psychiatric disorder and possibly psychosomatic pathologies (fibromyalgia, functional colopathy, etc.) ... A possible role of psychological stress in certain patients, as suggested in tinnitus, has been raised ... A neurological component might also contribute to onset in the particular case of neuropathic patients". What equally reliable sources do you contend counter those statements? This is a direct challenge to quote your source, because all I've seen so far is a load of "I say so". --RexxS (talk) 17:43, 9 June 2016 (UTC)
 * I disagree with the above attempts to filter out conclusions of reliable secondary sources by amateur analysis. The whole point of relying on secondary sources is to make use of the expertise of the reviewer to pick out conclusions from the preceding literature and to form conclusions using their own knowledge and background. It is totally unacceptable for a Wikipedia editor to try to second guess what processes the reviewer went through in reaching their conclusions. You have no way of knowing what other evidence and research may have been part of any particular conclusion, and I should not need to remind you that the review itself has been peer-reviewed. The job of critiquing a secondary source falls to the peer-reviewers and the journal editor, not to some pseudonymous Wikipedia editor with five minutes experience. Coste 2012 states in the abstract: "Physiopathology remains unclear ... Neuropsychological involvement is suspected" and points out in the full article: "One point of contention concerns the frequent association with psychiatric disorder and possibly psychosomatic pathologies (fibromyalgia, functional colopathy, etc.) ... A possible role of psychological stress in certain patients, as suggested in tinnitus, has been raised ... A neurological component might also contribute to onset in the particular case of neuropathic patients". What equally reliable sources do you contend counter those statements? This is a direct challenge to quote your source, because all I've seen so far is a load of "I say so". --RexxS (talk) 17:43, 9 June 2016 (UTC)
 * I disagree with the above attempts to filter out conclusions of reliable secondary sources by amateur analysis. The whole point of relying on secondary sources is to make use of the expertise of the reviewer to pick out conclusions from the preceding literature and to form conclusions using their own knowledge and background. It is totally unacceptable for a Wikipedia editor to try to second guess what processes the reviewer went through in reaching their conclusions. You have no way of knowing what other evidence and research may have been part of any particular conclusion, and I should not need to remind you that the review itself has been peer-reviewed. The job of critiquing a secondary source falls to the peer-reviewers and the journal editor, not to some pseudonymous Wikipedia editor with five minutes experience. Coste 2012 states in the abstract: "Physiopathology remains unclear ... Neuropsychological involvement is suspected" and points out in the full article: "One point of contention concerns the frequent association with psychiatric disorder and possibly psychosomatic pathologies (fibromyalgia, functional colopathy, etc.) ... A possible role of psychological stress in certain patients, as suggested in tinnitus, has been raised ... A neurological component might also contribute to onset in the particular case of neuropathic patients". What equally reliable sources do you contend counter those statements? This is a direct challenge to quote your source, because all I've seen so far is a load of "I say so". --RexxS (talk) 17:43, 9 June 2016 (UTC)

Cause
Cause section

I propose that the following sentence be REMOVED: “Because the occurrence of ENS is rare and investigators have been unable to identify consistent diagnostic features or precipitating features, psychological causes leading to a psychosomatic condition have been proposed.[4][6]”

and REPLACED with: “The occurrence of ENS is rare and while there are accepted identifying features, investigators have not as agreed on formal diagnostic criteria to distinguish it from secondary atrophic rhinits.”

At the least, this part of the current sentence: “ psychological causes leading to a psychosomatic condition have been proposed” are NOT supported by the citations and this section must be REMOVED.

The two sources provided by the author are: Coste, Empty Nose Syndrome (2012) and Payne, Empty Nose Syndrome: What are We Really Talking About? (2009) showing that these sources do not support the contention that “ psychological causes leading to a psychosomatic condition have been proposed”.

Here is my analysis of these sources.

Coste (2011): search = psychological 4 results

“neuropsychological involvement is suspected” - no cite by Coste.

“A possible role of psychological stress in certain patients, as suggested in tinnitus, has been raised” - citing Payne (2009). But, Payne's sources on this subject are not cited. See My DISCUSSION OF THE ORIGINAL SOURCE MATERIAL OF PAYNE's BELOW.

N.B.The characterization by Coste of Payne concerns the “possible” role of psychological stress in certain patients [my emphasis].

“ENS is made more difficult to diagnose by the lack of consensual clinical definition, the variety of symptoms and the associated psychological and sometimes social distress.”      No citation given by Coste.

“we recommend neuropsychological counseling ahead of any decision to operate, given the possible psychological impact of surgical failure.” -           no citation given by Coste.

Coste Search = psychiatric/somatic 1 result

“One point of contention concerns the frequent association with psychiatric disorder and possibly psychosomatic pathologies (fibromyalgia, functional colopathy, etc.)” [3,6,9,14,15].

Coste cites a number of sources here – but no study concerns ENS patients. There is no evidence to support this contention. And drawing parallels to fibromyalgia or functional colopathies is not indicated here.

+++This could be considered a false analogy.+++

The articles cited are:
 * Payne SC. Empty nose syndrome: what are we really talking about? (2009)
 * Freund W, Wunderlich AP, Stocker T, et al. Empty nose syndrome: limbic system activation observed by functional 	magnetic resonance imaging. (2011)
 * Mertz H, Morgan V, Tanner G, et al. Regional cerebral activation in irritable bowel syndrome and control subjects with painful and nonpainful rectal distention. Gastroenterology 2000
 * Ren K, Dubner R. Descending modulation in persistent pain: an update. Pain 2002;100:1—6.
 * Gracely RH, Petzke F, Wolf JM, et al. Functional magnetic resonance imaging evidence of augmented pain processing f	ibromyalgia. Arthritis Rheum 2002;46:1333—43.

Of these, only one deals with ENS or rhinologic concerns.

Here is my analysis of Payne's work.

Payne (2009): search = psychological 0 results

Search = psychiatric/somatic 1 result

This is a direct quote from the article:

"Unsettled Issues – Psychiatric Comorbidity and Neuropathy One issue that is troubling with ENS as it is defined by Houser is the significant level of psychiatric findings in this patient population. One might question which disease may have given rise to the other. While I do not mean to classify the disease as rhinitis hystericus, it is possible that ENS could be likened to other phenomena where there seems to be a correlation between psychosocial distress and disease tolerance such as tinnitus.[25] Additionally, given the lack of pre-operative rhinomanometry before a patients initial turbinate surgery, it may be difficult to know to what extent they had objective nasal obstruction before surgery, especially for the ENS-type patients.”

As you can see, Payne is musing here, but does not supply any evidence for his assertion that there are psychological conditions responsible for ENS. Certainly, there can be a co-morbidity, but again no evidence. Anecdotal evidence suggests that ENS plays a causal role in the comorbidity, as many patients become anxious and depressed following the onset of the condition. These would be considered teriatry symptoms.

At best, Payne draws an analogy to tinnitus, which is the reference [25] in the paragraph. This article is: Andersson G, Westin V. Understanding tinnitus distress: introducing the concepts of moderators and mediators. Int J Audiol. Nov 2008;47 Suppl 2:S106-111. However, Dubbin, you would concede that an anaolgy without scientific evidence is not really support for your statement that there are psychological factors causing ENS.

In conclusion, neither the article by Coste, nor the article by Payne support your contention that “psychological causes leading to a psychosomatic condition have been proposed”. Your sources fail. You are in error.

Greybridge (talk) 17:07, 8 June 2016 (UTC)
 * This too is way too much to bite off. Please do read WP:TPG, WP:MEDRS, and WP:MEDMOS.  Please read  the part of WP:MEDRS called "Assess evidence quality" (shortcut, WP:MEDASSESS - you are doing what that forbids by "peer reviewing" the sources. Jytdog (talk) 17:26, 8 June 2016 (UTC)

Greybridge (talk) 20:00, 8 June 2016 (UTC)Jytdog, That you accuse me of "peer reviewing" is absurd. So what you really want is for Dubbin to say he can cite secondary source which assert unsubstantiated claims and insert it into the WIki article as truth. These secondary sources DO NOT say that ENS has "psychological causes leading to a psychosomatic condition have been proposed". At most, they suggest THERE COULD BE such a phenomenon. BUT, these are OPINIONS. No related studies on ENS as psychosomatic are referenced, nor is any evidence from psychosomatic medicine studies are given to back it up. Therefore, they are just Coste and Paynes' unsubstantiated opinions on the matter. If Dubbin chooses to call unsubstantiated opinions of Payne and Coste are fact, then he is wrong. I chose to evaluate the Payne and Coste articles to see if Dubbin had rendered them accurately. He did not. I also chose to evaluate the sources Payne and Coste vis. their claims regarding a possible psychological cause for ENS. If this is called peer-reviewing, then so be it. As far as I am concerned, my purpose was to check the accuracy of the sources cited.

How is mis-representing statements taken from a secondary source, medical article, that are themselves unsubstantiated opinion about a MEDICAL condition, considered to be accurate research fit to publish in the Wikipedia article?

The following sentence must be removed: "psychological causes leading to a psychosomatic condition have been proposed.[4][6]" Either get new sources or remove it. Greybridge (talk) 20:00, 8 June 2016 (UTC)
 * There's nothing absurd about the complaint that you're trying to do the job of the peer-reviewer. As Wikipedia editors, we summarise what the best sources tell us, not just selectively pick the bits we like, and you need to stop doing that. It is complete nonsense to suggest that another editor is using a "secondary source which assert unsubstantiated claims and insert it into the WIki article as truth". As far as Wikipedia is concerned, a claim made by a reliable secondary source is substantiated, and you need to understand that soon. is there any good reason why you haven't yet read WP:Verifiability yet? It would save us all from a considerable waste of time if you familiarised yourself with what Wikipedia understands as "truth", "fact" and "opinion" - you need to read Neutral point of view. Truth and fact are claims made by reliable secondary sources that are not contradicted by other equally reliable sources. Opinions are claims made by reliable secondary sources that are contradicted by other equally reliable sources, but we still use them by giving them weight in our articles in proportion to their prominence in the mainstream literature. Please let us know if there are any of our relevant policies that you still don't understand after you have read them. I'm sure that there are experienced editors at WPMED who will be able to help you. --RexxS (talk) 18:06, 9 June 2016 (UTC)
 * There's nothing absurd about the complaint that you're trying to do the job of the peer-reviewer. As Wikipedia editors, we summarise what the best sources tell us, not just selectively pick the bits we like, and you need to stop doing that. It is complete nonsense to suggest that another editor is using a "secondary source which assert unsubstantiated claims and insert it into the WIki article as truth". As far as Wikipedia is concerned, a claim made by a reliable secondary source is substantiated, and you need to understand that soon. is there any good reason why you haven't yet read WP:Verifiability yet? It would save us all from a considerable waste of time if you familiarised yourself with what Wikipedia understands as "truth", "fact" and "opinion" - you need to read Neutral point of view. Truth and fact are claims made by reliable secondary sources that are not contradicted by other equally reliable sources. Opinions are claims made by reliable secondary sources that are contradicted by other equally reliable sources, but we still use them by giving them weight in our articles in proportion to their prominence in the mainstream literature. Please let us know if there are any of our relevant policies that you still don't understand after you have read them. I'm sure that there are experienced editors at WPMED who will be able to help you. --RexxS (talk) 18:06, 9 June 2016 (UTC)


 * My point of contention is that the reliable "secondary source" is written by an ENT, who has a special interest in ENS - these are his areas of knowledge and expertise. The author's (Payne)expertise is not in psychiatry. The author (Payne) has no empirical data to claim that psychological causes underlie ENS. So, just because it is a "reliable secondary source" does not mean that every part of it can be used in the same way as those parts which are evidenced-based. One can separate speculation from evidence-based fact. One can understand the difference between an author's statements, when he speaks as an expert and when he  speaks as a lay person  - and understand that both types of statements can exist within the same "reliable secondary source" . But such statements must be given different weight. Let's say Payne was testifying in a court of law. If statements were made outside his area of expertise and knowledge, and which were not evidence-based and empirically proven as guided by the medical profession, such statements could then not be taken as a "fact". Likewise, this is my argument here with the Wikipedia content. It has nothing to do with the broader question of whether the source is a "reliable secondary source" I am sure you can understand the distinction. I hope that in the spirit of neutrality and accuracy, my opinions will be treated fairly. Greybridge (talk) 18:22, 9 June 2016 (UTC)

Suggested Content (two additions)
"ENS is not simply a loss of mechanical volume, but is also a loss of functional sensation to airflow." [1]

[1][ Houser SM (2014) Does the Method of Inferior Turbinate Surgery Affect the Development of Empty Nose Syndrome?. J Otol Rhinol 3:3. doi:10.4172/2324-8785.1000159

AND

"The development of ENS is more closely related to the degree of mucosal damage than to the volume of excised tissue." [1]

[1][ Houser SM (2014) Does the Method of Inferior Turbinate Surgery Affect the Development of Empty Nose Syndrome?. J Otol Rhinol 3:3. doi:10.4172/2324-8785.1000159 Greybridge (talk) 22:28, 9 June 2016 (UTC)

Conflict of Interest
I would propose that statements emanating from the American Rhinologic Society be marked with "conflict of interest" as they pertain to ENS.

There is a long and unhappy political history surrounding ENS, and before that, surrounding turbinate surgery related secondary atrophic rhinitis.

This is due to the fact that ENS is solely surgically induced. It is widely recognised that ENS is due to aggressive or excessive damage or resection done to the turbinates (usually the inferior turbinates).

Doctors have a financial interest in performing turbinate surgeries. They have an interest in under-reporting its incidence (since such statistics rely on physician self-reporting). Doctors have a litigation protection interest to not diagnose ENS and not report it. There is a climate of silence surrounding ENS. The ARS is professional association for rhinologists interested in the profession of rhinology and promoting all treatments and interventions accepted by the profession, and therefore, has a conflict of interest.

This issue of the politics of ENS has been examined in the Chapter "Politics of Empty Nose" in: Having Nasal Surgery?: Don't You Become an Empty Nose Victim! Christopher Martin (2007). Greybridge (talk) 00:09, 9 June 2016 (UTC)
 * please stop adding your signature at the start of your comments. we need it only at the end. I removed it here. Jytdog (talk) 00:50, 9 June 2016 (UTC)
 * We don't "mark statements with "conflict of interet'" and I don't even know what that means. And I don't know what it means that an entire organization has a conflict of interest. If you want content about this, please propose specific content that is clear and well sourced. Thanks. Jytdog (talk) 00:53, 9 June 2016 (UTC)


 * An earlier citation was made quoting from the American Rhinologic Society (ARS). I dispute that the ARS can be used as a valid source of information on ENS, because of the conflict of interest issue. I am sure you can understand that ENS is a surgical complication and doctors try to underplay it, because there is a conflict of interest. I will delete any such citations. AGain, since I have been prevented from editing the article for no good reason, I must make what comments I can in the Talk section. The work I have done here will be presented to an administrator on Wikipedia in support of my right to edit & create the ENS article, and the way my attempts have been erroneously and unjustly shut down. — Preceding unsigned comment added by Greybridge (talk • contribs) 01:01, 9 June 2016‎ (UTC)
 * First, please read the note I left on your Talk page here about formatting comments on Talk pages. If you don't understand that, please ask me about it there.  I have indented and signed your comment above. Do not make me keep fixing your comments! Jytdog (talk) 01:09, 9 June 2016 (UTC)
 * Removing sourced content because you believe there is some COI is invalid and would be WP:DISRUPTIVE and would lead to you getting blocked and if you keep editing disruptively you will be topic banned. That is not a threat - that is how things work here.  You need to learn the policies and guidelines that govern content and behavior, and follow them.  You are choosing to be here, so you must follow the "rules" here.  Not just their letter, but their spirit Jytdog (talk) 01:12, 9 June 2016 (UTC)


 * I will conform with the rules. If there is a conflict of interest or a "controversy" I will note it. Just like the controversy section was started in order to gut the article of all of its peer reviewed medical articles. So, I can't say something is biased, or part of a controversy, or comes from a source that has a subtantial conflict of interest? But others are free to delete peer reviewed literature at will because it doesn't support their defintion and agenda focused defintion of "controvery"? which is to mis state that ENS does not exist. Greybridge (talk) 01:17, 9 June 2016 (UTC)
 * Again I had to fix your indenting. I am fed up. You need to pay attention to the logistics of how to comment here.  It is part of the very basic etiquette here and the longer you persist in ignoring it and making others fix your comments, the more you are expressing disdain for Wikipedia and other editors here. This is the last time I will speak to this and I will just ignore comments that make no effort to be formatted correctly in the future.  I am for example ignoring your comment above in the "cause" section.  I will respond after you fix it yourself.  Jytdog (talk) 01:22, 9 June 2016 (UTC)
 * Again any content you add to the article must at minimum be reliably sourced per WP:RS or WP:MEDRS if it is medical; this per the WP:VERIFY policy. There are other sources that play in as well. WP:SYN, NPOV, etc. Jytdog (talk) 01:24, 9 June 2016 (UTC)
 * This article no where says that ENS does not exist. Jytdog (talk) 01:25, 9 June 2016 (UTC)
 * How is one supposed to become adept without practice. I did't expect you would attend to anything I said. And, you are not going to "punish" me by ignoring my valid edits. It is all about shutting down any opposing viewpoints. I see that now. Greybridge (talk) 01:39, 9 June 2016 (UTC)
 * I have mentioned this to you several times, and have given you clear instructions on your Talk page, and you can look at any one of the milliions (!) of Talk pages in Wikipedia where these logistics are used every day. There is a "preview" button you can use to see how your comment looks, before you save it, if you want to practice.  You have to make an effort to learn the etiquette and follow it, and to learn the policies and guidelines and follow them too.   I am very happy to talk with people about content that aims to realize Wikipedia's mission, based on the best sources, the policies, and the guidelines and following the policies and guidelines governing behavior.  All those things exist for a very good reason - they prevent Wikipedia from become a Mad Max hell hole.  This is not some random website or blog - this is a 15 year old community that has created one of the greatest reference works in the world;  the policies and guidelines developed by the community are central to that effort.  Jytdog (talk) 02:04, 9 June 2016 (UTC)


 * That was a rhetorical question on becoming adept. The point was that you should not be so critical. Under what authority do you gatekeep and critcise threatening with punishment? I have repeatedly asked for reasonable edits. But all you do is shut me down. What do you mean by: "This is the last time I will speak to this and I will just ignore comments that make no effort to be formatted correctly in the future. I am for example ignoring your comment above in the "cause" section." This is proof to me that you have no intention of being neutral. I will keep to provide to an adminsitrator in an arbitration. Greybridge (talk) 02:12, 9 June 2016 (UTC)

As I explicitly said above here, I was not making threats. I was telling you how things work here - I am trying to help you. If you saw a guy about to fall into a hole he didn't know was there, wouldn't you try to warn him? In any case we are no longer discussing the content of the article. This Talk page is for discussing article content. If you want to continue this, please reply to one of the comments I have left on your Talk page. Thanks. Jytdog (talk) 02:33, 9 June 2016 (UTC)

ICD-10
I have been looking to find a source that discusses classification under ICD-10 and I have found nothing. Is anyone aware of a reliable source that discusses this? My sense is that it has no ICD-10 classification but we cannot state that without a source. Jytdog (talk) 02:32, 9 June 2016 (UTC)
 * There is no ICD code for ENS under any revision 10 or otherwise. That has been the struggle for patients who seek awareness and those researchers who publish on it. The literature has been accumulating, building the evidence to demonstrate the ENS is not the same as secondary AR, but represents a distinct clinical entity. Please read on secondary atrophic rhinitis. As you might realise, the attempt to reach consensus on diagnostic criteria has been difficult, especially in light of the political climate surrounding ENS. But, the multitude of studies on ENS examining different ways to diagnose (biopsy, cytology, fluid dynamics, rhinometry, fMRI among others) have advanced the conversation. A Dr treating an ENS patient will use the diagnostic code for atrophic rhinitis for insurance and administrative coding purposes, but will informally discuss ENS with the patient in that setting. Greybridge (talk) 02:57, 9 June 2016 (UTC)
 * The question is whether there is a reliable source that says this, so we can create content about it. Please don't use this Talk page to state personal opinions.  Again please read WP:TPG. Thanks. Jytdog (talk) 03:02, 9 June 2016 (UTC)
 * This is not a personal opinion. Fact: the literature of recent years on ENS has tried to establish it as a distinct clinical entity from atrophic rhinitis. Fact: there are studies on ENS which use each of the diagnostic tools I have named. Fact: patients with ENS are coded as atrophic rhinitis, this is noted in literature as well. This is all context in answer to your question. If you want citations for all of it, because you intend to place it in the article, please let me know, I can provide them. Greybridge (talk) 05:48, 9 June 2016 (UTC)
 * It would be good to have content in the article about the ICD-10. To have that content, we need a source. That's all that matters here. Nothing you wrote addresses that.  Talk pages are for discussing article content, based on sources and the policies and guidelines.  This is not a forum for general discussions about the article topic.   Jytdog (talk) 05:54, 9 June 2016 (UTC)
 * Explain to me this re: Wikipedia rules: If there are many medical articles examining methods to diagnose ENS, yet there is no one source saying this. This is a fact - I can look on pub med and else where and see reference to such articles. Do I need to cite each and every one in support? Think this is absurd. Every medical condition has published research and secondary sources published examining methods and tools for diagnosis. Why is there an extra burden of proof with regard to ENS. Why can't I say: "There are published studies examining methods to diagnose ENS, just as there are for other medical conditions". without me having to prove this statement?


 * , as a medical expert, surely you can help Jytdog here that there are some factual things within a specialized area of knowledge that do not need to be cited. Such as "there have been studies on ENS examining different diagnostic tools/methods." This is self-evident. It is an accepted condition, it is a legitimate subject of research within medicine. Obviously, there are studies published that examine how to diagnose. Greybridge (talk) 14:28, 9 June 2016 (UTC)


 * everything medical needs to be properly cited. If something you consider self-evident cannot be so supported, you need to lobby the medical research profession, not a Wikipedia talk page. Dubbin u &#124; t &#124; c 20:23, 9 June 2016 (UTC)


 * I don't believe there is a reliable source that says there is no ICD-10 code. There will likely be one in a year or two.74.106.192.64 (talk) 03:13, 9 June 2016 (UTC)EducatedonENS
 * Thanks Jytdog (talk) 06:30, 9 June 2016 (UTC)

Society and Culture
Please remove the following statement: "As of 2016, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological." The source is incorrect. If you are summarizing the words of Spencer Payne in the article/video report of Tomas Harmon [for CBS19 May 04, 2016 Medical Mystery: Empty Nose Syndrome], then you are incorrect. Dr. Payne does not know for sure that most doctors tell ENS patients that the disorder is in their heads. This is a generalization. Payne only knows perhaps that many doctors disbelieve (or seem to disbelieve) their patients. But, as to whether the particular doctor says to his ENS patient "everything looks fine" as opposed to "you have a mental disorder" is not known. It is certainly not known by Dr. Payne or Tomas Harden. For Dr. Payne to know why and how most doctors doubt that their patients have ENS, he would have to be in the room with "most doctors" or have a study to cite from containing specific information on what "most" or "all" doctors say to ENS patients when they encounter them. We just don't know what is said....doctors could say all manner of things to the patient. Your statement relies on OPINION and conjecture based on generalizations. No evidence. No facts. Greybridge (talk) 05:15, 9 June 2016 (UTC)
 * The source is the article accompanying the video. That source is from a CBS affiliate which is a reliable source per WP:RS - we don't need to use WP:MEDRS here because this is society and culture, not medical information.  The content and its source are: " As of 2016, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological." Source: Thomas Harmon for CBS19 May 04, 2016 Medical Mystery: Empty Nose Syndrome


 * The source says: "Payne says, as a result, most doctors tell ENS patients that the disorder is in their heads. "The doctor would say 'oh, it's because you're single. You're just stressed out that your not married yet,'" Schneider echoed, saying Payne is right, and most doctors believe she is suffering from some sort of psychosis."  That supports the content but to address your concerns, we can WP:ATTRIBUTE. I've changed it so it says "As of 2016 and according to Spencer Payne, a doctor who studies ENS, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological."  And please stop WP:SHOUTING. Thanks.  Jytdog (talk) 06:00, 9 June 2016 (UTC)


 * Jytdog: I suggest the following: ""As of 2016 and according to Spencer Payne, a doctor who studies ENS, many people with ENS symptoms commonly encounter doctors who consider their symptoms to be purely psychological. But, this is only a generalization. Many patients do encounter doctors who are dismissive, who use a variety of ways they dismiss patient complaints, not only telling patients they are psychological"


 * You cannot use example that generalizes and apply it to the entire medical profession - even if you quote Payne - without giving it some balance and neutrality. Not all doctors dismiss patient symptoms saying they are psychologically caused. They often say they don't see anything wrong, for example. A single statement from an alleged ENS patient taken from an edited interview cannot be expanded as if it is some universal truth. This is a logical fallacy to use a single example in this way. You are in error.


 * , you are a medical expert. You know that Jytdog's use of the reference is in error.Greybridge (talk) 13:52, 9 June 2016 (UTC)
 * (1) Why are you attempting to attribute a statement that is not contradicted? See WP:ASF. We reserve attribution for opinions, not facts. You are trying to cast doubt on a claim made in a reliable source - a common trick of someone pushing their own POV.
 * (2) Who says it's only a generalisation? You? What gives you the same authority as a reliable source? --RexxS (talk) 18:33, 9 June 2016 (UTC)
 * (2) Who says it's only a generalisation? You? What gives you the same authority as a reliable source? --RexxS (talk) 18:33, 9 June 2016 (UTC)

'''@jytdog ''' In the society and culture section, I think it’s worth pointing out that patient advocacy has been a vehicle behind empty nose syndrome awareness. A 2007 book written by patient Christopher Martin, entitled “Having Nasal Surgery? Don’t You Become An Empty Nose Victim!” was a collaborative effort between a patient and doctors/experts in ENS to share empty nose syndrome, it won an award, and it was translated into Spanish in 2015. This resource was used by patients to share with their doctors who could no longer say, “empty nose syndrome is just in your head.”  This resource was cited in the BuzzFeed article:

https://www.buzzfeed.com/joeloliphint/is-empty-nose-syndrome-real-and-if-not-why-are-people-killin

Secondly, in 2014, as a result of patients writing a letter to the American Rhinologic Society and then engaging in an open dialogue (no source here), the American Rhinologic Society published a statement on empty nose syndrome. Perhaps it could simply be mentioned that in 2014, the ARS published the following statement in recognition of ENS:

http://care.american-rhinologic.org/empty_nose_syndrome

Third, the BuzzFeed article in April 2016 was another breakthrough for ENS awareness among the media, as it had 500,000 hits in two days and now the media is in process of doing more interviews for ENS.

https://www.buzzfeed.com/joeloliphint/is-empty-nose-syndrome-real-and-if-not-why-are-people-killin EducatedonENS (talk) 13:29, 9 June 2016 (UTC)EducatedonENS
 * added some content based on the buzzfeed article in the Society and culture section. Good ref for that. Jytdog (talk) 04:29, 10 June 2016 (UTC)


 * , Thank you for adding some content based on the buzzfeed article to the society section.


 * I copied RexxS’ quote from a different section to here to make this discussion easier to follow


 * RexxS wrote: I'm sorry but none of the external links are suitable for our article. There a guidance page (of course!) at Wikipedia:External links desribing the sort of external links that are suitable, and those that are not. In brief, Wikipedia is determined to remain a self-contained encyclopedia, and we don't provide external links just because a reader might find them useful; we're not a directory of other web-based resources. The ENS International Association website would be acceptable if we were writing an article about ENS sufferers, but it can't really be an official website for a medical condition. On the other hand, it would make a decent reference if there were a discussion in the Society and culture of the difficulties faced over the years by sufferers in gaining recognition of their condition, or perhaps among other sources examining the problems of funding research into ENS.


 * My reply to RexxS (others, please feel free to answer) you stated the ENS Association website would make a decent reference if there were a discussion in the Society and culture of the difficulties faced over the years by sufferers in gaining recognition of their condition. Three brief questions.  First, now that there is a discussion in the Society and culture section about difficulties faced by ENS (as added by jytdog), how do we reference the ENS international Association website (http://ensassociation.org) in this section?  Second, I noted the book written by Christopher Martin in 2007, which was written by the author with Dr. Houser writing the foreword (Dr. Houser is the leading expert in the journals on ENS), as this is another example of an effort for an ENS sufferer to  raise awareness, and I am aware that his book won an award and was translated into Spanish in 2015.  This book is cited in the BuzzFeed article.  I think that should be added to the society and culture section as it again shows the struggle for ENS to gain awareness. Third, can we make a statement that the American Rhinologic Society recognizes ENS (as of 2014), even if we can't site the website article?EducatedonENS (talk) 16:50, 10 June 2016 (UTC)EducatedonENS

Inability to stop thinking
First and foremost I'd like to commend you on your scholarly overhaul of the page and your invaluable and extremely patient efforts to help contributors here. I have one small query. I'm unclear on what is meant by the phrase "inability to stop thinking" in the treatment section - does this mean thinking excessively about the symptoms? I feel there is probably a clearer way to word this but first I wanted to check exactly what you meant by it. Thanks again! Dubbin u &#124; t &#124; c 12:24, 9 June 2016 (UTC)


 * Dubbin, Jytdog refers here to aprosexia nasalis an old ENT term (19th century) that was resurrected during the early ENS days to describe a psychophysical phenomenon of being unable to concentrate because of the nasal problem. This is a very simplified explanation. A proper explanation requires context concerning its original use, and its later use, together with modern medical understanding. Incidentally, there is no proof related to this proposed symptom of ENS. And, even if there were it is not a primary symptom. I am sure you can agree that it is good medicine to focusing the primary symptoms and not explore the alleged problems caused by these primary symptoms, which themselves that are already well-established and for which there is empirical date in the literature.


 * This example of misunderstanding underscores the fact that Jytdog has only the most rudimentary understanding of ENS, medicine, and the issues surrounding ENS, and should not be the central gatekeeper and determiner of what is and isn't citatable medical literature. Jytdog doesn't even know how to render publsihed material correcting into the text he creates for the article.


 * I have been trying to assist Jytdog but I am shut down at every turn. Dubbin, I hope you can see from my writings here in Talk, that I do have a very good knowledge and understanding of ENS and its related literature. Greybridge (talk) 13:45, 9 June 2016 (UTC)Greybridge (talk) 18:05, 9 June 2016 (UTC)


 * Nobody is questioning your experience and familiarity with ENS and the literature. But in this situation, experience is much less important than rigour, specifically rigour in choosing and using appropriate citations. You have written thousands of words in this page but virtually all of it has been your own interpretation of the literature. Jytdog has done an excellent job of identifying appropriate sources and using them to produce a balanced article. What's more he has repeatedly explained what standards are needed but the nature and quality of your proposals and complaints has not really changed. He is not seeking to be the central gatekeeper of anything - you would get exactly the same responses from any experienced Wikipedia editor and he is much more experienced than I. I don't think I can do anything more to help you to understand how to turn your experience and passion into usable wikipedia content, but I do look forward to hearing Jytdog's answer to my question. Dubbin u &#124; t &#124; c 15:01, 9 June 2016 (UTC)


 * - you asked Jytdog about "inability to stop thinking". I produced a point of research. I said that this was sloppy rendering of an alleged symptom of ENS, in actuality is "aprosexia nasalis". This term appears in ENS literature.


 * I also said that if you consult the literature using this term "aprosexia nasalis" you will find that there is no evidence to support its existence. It is something bandied about in the literature in a speculative way.


 * This is furthering the discussion.


 * Why do you never reply to the substance of my comment?Greybridge (talk) 17:33, 9 June 2016 (UTC)
 * Why should anybody reply to you when you insult and attack them? What Jytdog understands about ENS is none of your business, and completely irrelevant to a discussion about improving this article. Unlike you, he is not attempting to write the article from personal experience and bias, so he doesn't actually need anything at all beyond an ability to identify the best sources and accurately and neutrally summarise them. When you've gained that skill, you'll be in a position to comment in an informed way. As anyone can check, "aprosexia nasalis" returns 718 Google web hits and 107 on Google Scholar, including Houser 2007 which states "The symptom that most often indicates ENS is paradoxical obstruction ... The constant abnormal breathing sensations cause these patients to be consistently preoccupied with their breathing and nasal sensations, and this often leads to the inability to concentrate (aprosexia nasalis) ...". So please don't tell us that "you will find that there is no evidence to support its existence". Where do you get these peculiar misconceptions from? --RexxS (talk) 18:50, 9 June 2016 (UTC)
 * There have been no medical or research studies examining the phenomenon of "aprosexia nasalis". If you read the articles, you will see that it is merely a term that was adopted, and subsequently invoked in the absence of evidence-based medicine. This is not a peculiar misconception of mine that I ask for empirical evidence to be extracted from medical articles if it is going to be incorporated into the Wiki article. I am not insulting anyone. You insult me. I am trying examine the source material. I refer you to my discussion on "reliable secondary sources".
 * Does Houser in his 2007 article use the term "aprosexia nasalis" to refer to an inability to concentrate in the context of ENS symptoms? - or not? How can you claim that "you will find that there is no evidence to support its existence" when the evidence of its existence is there before your eyes? Here's a repetition of my earlier warning: Stop "trying examine the source material" [sic] - as you put it. Find it, read it and summarise it. That's all you should be doing. "Analyse it" and "draw your own conclusions from it" are not part of our job. --RexxS (talk) 19:23, 9 June 2016 (UTC)
 * There have been no medical or research studies examining the phenomenon of "aprosexia nasalis". If you read the articles, you will see that it is merely a term that was adopted, and subsequently invoked in the absence of evidence-based medicine. This is not a peculiar misconception of mine that I ask for empirical evidence to be extracted from medical articles if it is going to be incorporated into the Wiki article. I am not insulting anyone. You insult me. I am trying examine the source material. I refer you to my discussion on "reliable secondary sources".
 * Does Houser in his 2007 article use the term "aprosexia nasalis" to refer to an inability to concentrate in the context of ENS symptoms? - or not? How can you claim that "you will find that there is no evidence to support its existence" when the evidence of its existence is there before your eyes? Here's a repetition of my earlier warning: Stop "trying examine the source material" [sic] - as you put it. Find it, read it and summarise it. That's all you should be doing. "Analyse it" and "draw your own conclusions from it" are not part of our job. --RexxS (talk) 19:23, 9 June 2016 (UTC)


 * (re: turning my passion into usable Wikipedia content)This is a suggestion I made which was rejected without good reason: [see above section Proposals for WP:LEAD]


 * REMOVE: I propose that the current sentence in the Opening Statement be REMOVED: "It appears to be a health care caused condition but its existence, cause, diagnosis and management are controversial."
 * REPLACE: I propose that it be REPLACED with: "Empty nose syndrome is a medical condition, and a rare complication of nasal surgery, in particular resection of the inferior turbinate. [1] It is a poorly recognized, but devastating clinical entity. [2]"
 * Citation [1] = [Leong SC, The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review. Laryngoscope. 2015 Jul;125(7):1557-62. doi: 10.1002/lary.25170.] Original quote: "Empty nose syndrome (ENS) is a poorly recognised but undoubtledly devastating clinical entity."
 * Citation [2] = Varsha Joshi, Imaging of Paranasal Sinuses, An Issue of Neuroimaging Clinics, 1st Edition (2015). Original quote: "Empty nose syndrome is a rare complication of sinonasal surgery, particularly following resection of the inferior turbinate, and is likely caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and air conditioning function." Greybridge (talk) 16:06, 8 June 2016 (UTC)
 * Citation [1] = [Leong SC, The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review. Laryngoscope. 2015 Jul;125(7):1557-62. doi: 10.1002/lary.25170.] Original quote: "Empty nose syndrome (ENS) is a poorly recognised but undoubtledly devastating clinical entity."
 * Citation [2] = Varsha Joshi, Imaging of Paranasal Sinuses, An Issue of Neuroimaging Clinics, 1st Edition (2015). Original quote: "Empty nose syndrome is a rare complication of sinonasal surgery, particularly following resection of the inferior turbinate, and is likely caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and air conditioning function." Greybridge (talk) 16:06, 8 June 2016 (UTC)
 * Citation [2] = Varsha Joshi, Imaging of Paranasal Sinuses, An Issue of Neuroimaging Clinics, 1st Edition (2015). Original quote: "Empty nose syndrome is a rare complication of sinonasal surgery, particularly following resection of the inferior turbinate, and is likely caused by excessive nasal permeability affecting neurosensitive receptors and inhaled air humidification and air conditioning function." Greybridge (talk) 16:06, 8 June 2016 (UTC)


 * Dubbin, I have suggested content. This is but one example. Each one, however, is summarily shut down. You (and Jytdog) use the power of editing to silence other voices. But, I am not allowed to criticise your selection of source material.


 * please indent and sign your comments properly as Jytdog has asked you to do repeatedly. My question was for Jytdog to help me understand whether there was a better way of phrasing that specific phrase. This talk section is not for discussing anything else and the only relevant reply can come from Jytdog. Your edits continue to be editorial interpretations of secondary sources that would destroy the WP:BALANCE of the article. It is not OK to ignore wikipedia's basic rules and guidelines. Dubbin u &#124; t &#124; c 18:19, 9 June 2016 (UTC)


 * I am replying to your assertion that I have not suggested any content. I have You said: "I don't think I can do anything more to help you to understand how to turn your experience and passion into usable wikipedia content." Please don't continue to ignore my content suggestions. Greybridge (talk) 18:47, 9 June 2016 (UTC)


 * We are all here voluntarily and nobody is compelled to reply to anyone, particularly if their tone is aggressive and they have repeatedly chosen to ignore advice offered in the spirit of helpfulness. I said "usable content", but I am not surprised to find myself misquoted. I have given you all the information you need. Dubbin u &#124; t &#124; c 18:51, 9 June 2016 (UTC)


 * Sorry for the oversight. Could you let me know what Wiki criteria governs what is "usable" content? Who makes the determination if content us "usable"? And how to rectify the power differential between you (editing privilege) and myself ( unjustly blocked from editing)?Greybridge (talk) 19:13, 9 June 2016 (UTC)
 * The Wikipedia criteria for usable content are laid out in the opening sentence of Identifying reliable sources. I suggest you read that page in full. In particular, for medical articles, you will need to understand Identifying reliable sources (medicine) as well. The way to rectify the power differential between yourself and is to make 1,400 edits over 10 years to 490 different pages, as he has. --RexxS (talk) 19:35, 9 June 2016 (UTC)


 * The tone here has been very disrespectful from the start. I came to this place in good faith, to contribute to an article I found of interest. I had thought this was a place of consensus and egalitarian fellowship. Instead I find a place of elitism, disrespect, aggression with an authoritarian mindset that uses (misuses?) the rules of Wikipedia to browbeat, exclude and intimidate new editors. I was unjustly marginalized from day one I have never seen the like of it. If you have any compassion, Dubbin, as an M.D. and can separate this from your cold dispassion as a researcher, and remember the human side of things, perhaps we could remedy the tone and marginalization problem. I didn't come here to fight. I came here to cite peer-reviewed source material in the most careful way possible using my understanding of the subject. I am sorely disappointed on many levels including, today, my view of humankind. What, I ask, has happened to the liberty and openness that once was the "internet"?. Sadly, the internet been slowly transformed into a totalitarian, crony-capitalist controlled zone, and where once it was the hope of humankind in freeing them from the oppression of the political and intellectual elites, now it seems to be just a shell of what it formerly was.  (just to contextualize my grave disappointment - please don't berate me for it.)Greybridge (talk) 20:59, 9 June 2016 (UTC)


 * Entering any community is subject to rules and conventions. Your previous high esteem for Wikipedia is actually a product of those rules. They produce remarkable reliable content contributed by volunteers willing to learn. Your argument is not with Wikipedia. It is with the research community that has failed to produce the kind of evidence you'd like to be able to cite. Humanity will be just fine. Dubbin u &#124; t &#124; c 21:34, 9 June 2016 (UTC)

The other side of the controversy

 * @Dubbin - I think jytdog has done a good job in attempting to write-up this article, as I realize it's a complex topic. But there are two sides to every controversy and one side of it has not been presented yet or elaborated appropriately upon, as it should be in a neutral article.  The article makes it very clear that ENS patients have psychological problems and, to a lesser extent, it also discusses the physical aspects.  In the CAUSE paragraph, for example, there are 4 reference citations to the comment "psychological causes leading to a psychosomatic condition have been proposed" with 2 to the mucous membranes as a cause, even though the literature is far more abundant in discussing the physical aspects of ENS.  If you want to leave that quote on psychosomatic condition in there, then OK.  But the other side of the controversy, which has not yet been presented, is that a majority of the literature on ENS, acknowledges ENS moreso as a) a physical problem first and foremost (even though there are psychological aspects of course); and b) the physiology may lead to psychological changes (http://www.ncbi.nlm.nih.gov/pubmed/22024858).  Taking a direct quote from Houser, who is arguably the world expert on ENS and this article is a secondary source with similar comments made throughout the literature; and placing the below direct quote in the Cause section, would present the other side to the controversy:


 * "The diagnosis is potentially missed often because most rhinologists are trained to look for signs of dryness and atrophy after turbinectomies, objective long-term complications, and may thus disregard the patients' subjective complaints of nasal obstruction or shortness of breath. These subjective complaints are often viewed as psychological manifestations. Like many other otolaryngologic disorders (e.g., tinnitus), the fact that the symptoms are subjective and cannot be verified does not mean they are not real and valid symptoms originating in a physical abnormality."


 * This direct quote provides proper context in discussion of the cause and provides the other side to the controversy, so the reader can clearly see both sides to the debate, without giving undue weight to either side.EducatedonENS (talk) 15:44, 9 June 2016 (UTC)EducatedonENS


 * The number of citations supporting any statement is not what's important as concerns WP:BALANCE. That is completely irrelevant. Indeed, statements that represent a minority viewpoint may well require more citations in order to justify their inclusion. Something that is supported by 4 citations has not been given 4 times the prominence of something supported by 1 citation. What matters is how much of the text of the article is dedicated to each side of a controversy. Jytdog has explained this already. The article as a whole expends about 95% of its prose on the physical causes, features and treatments of ENS - what you call "the other side" of the controversy. I don't think there is a reasonable case for arguing the article is not balanced. But please, I created this talk section to discuss a very specific phrase, and I'd really like to make progress there. Dubbin u &#124; t &#124; c 16:05, 9 June 2016 (UTC)


 * Your points on the number of citations is well-taken and appreciated, even if jytdog said something similar in a different section, just like my insights into offering proper context and amount of time I have selflessly spent trying to enhance the article's content to objectively reflect literature should also be appreciated, yet you continually offer sarcasm (95% of the article is devoted to "what you call the other side of the controversy"; "jytdog has already explained this already") and complete lack of concern about context, which could enhance the reader's understanding of the debate. Sorry you think I am so dense.  Using the above direct quote would offer the reader an enhanced understanding of the debate on causes for ENS.  You could also provide a contrary quote to show the other side - why a doctor thinks it has psychological causes.  The article could also make mention of the research showing the connection between physical and psychological symptoms, for example, such as "air hunger causes changes in mood."  And if I read the balance section correctly in Wikipedia, it stated - "This involves describing the opposing views clearly."  I apologize to jump into a section where you inquired about a very specific phrase (I am sure jytdog will respond soon), but I get the impression that my insights are unappreciated on here and my time is being wasted.EducatedonENS (talk) 18:30, 9 June 2016 (UTC)EducatedonENS


 * I am unfortunately inclined to agree that it is unlikely this discussion can produce useful progress. Dubbin u &#124; t &#124; c 18:44, 9 June 2016 (UTC)
 * And so you are acknowledging that you are carelessly dismissing a point of view as presented in a secondary source, which would be useful to enhance the reader's understanding in a Wikipedia article, without any explanation on your end. I see.EducatedonENS (talk) 19:13, 9 June 2016 (UTC)EducatedonENS
 * Well, let's not whinge about an inability to convince one editor of your view; there are plenty of other editors. I'm easy to convince, so just tell me, concisely, what text you would like to see in order to reflect that "point of view as presented in a secondary source", and precisely what that secondary source is, please. I'm afraid I've been unable to unpick that information from the preceding exchanges. --RexxS (talk) 19:46, 9 June 2016 (UTC)
 * Update: Apologies, did you really mean you wanted us to quote a chunk of text verbatim from a source? We prefer not to do that, so could you not summarise the point in your own words? --RexxS (talk) 19:51, 9 June 2016 (UTC)
 * Update: Apologies, did you really mean you wanted us to quote a chunk of text verbatim from a source? We prefer not to do that, so could you not summarise the point in your own words? --RexxS (talk) 19:51, 9 June 2016 (UTC)


 * @RexxS - I paraphrased Houser’s statement, which is cited as #2 in your list of references, and I also put where I thought it should go in the Cause section with the statements in bold already in the article - note - "poorly understood" is stated multiple times in the literature....


 * ….. difficult to determine if this is a cause.[1]


 * Because ENS tends to be “poorly understood,” Houser asserts that most otolaryngologists are trained to look for dryness and atrophy after turbinate surgeries and consequently may disregard patient complaints of nasal obstruction or shortness of breath, viewing such complaints as psychological in nature.  Even though they are subjective like other conditions (e.g., tinnitus) does not mean they are not real or stem from a physical origin. (#2 in references)    Further, a patients’ adverse rating of nasal patency may be associated with worse moods, suggesting the possibility of neuropsychological involvement http://www.ncbi.nlm.nih.gov/pubmed/22024858; . (#3 in references).


 * …..Because the occurrence of ENS is rare....


 * Also, Rexx, because you are onto my topics, could you take a look at my suggestions for three reputable external links and addition to the treatment section (see directly above Welcome, ENS forum members, which I directed to jytdog). Also, please consider looking at my suggestions for improvement to the Society and Culture section (also directed to jytdog), as I cited three breakthroughs in ENS awareness and recognition.  *I know there is a lot on this page and jytdog may be busy, so I wanted to direct you to these few details, as I think they could significantly enhance the article.*  Thank you.  EducatedonENS (talk) 00:21, 10 June 2016 (UTC)EducatedonENS   — Preceding unsigned comment added by EducatedonENS (talk • contribs) 00:19, 10 June 2016 (UTC)
 * Could we take things a bit a time, please? I'll try to give you responses as far as I can. I'm really sorry, but although I can understand the points you're making, I still don't see what change you want to make to the article. It looks to me as if it recognises all of what you are saying already concerning the physiological mechanism of the syndrome versus the possible psychological root of some of the symptoms.
 * I'm sorry but none of the external links are suitable for our article. There a guidance page (of course!) at External links desribing the sort of external links that are suitable, and those that are not. In brief, Wikipedia is determined to remain a self-contained encyclopedia, and we don't provide external links just because a reader might find them useful; we're not a directory of other web-based resources. The ENS International Association website would be acceptable if we were writing an article about ENS sufferers, but it can't really be an official website for a medical condition. On the other hand, it would make a decent reference if there were a discussion in the Society and culture of the difficulties faced over the years by sufferers in gaining recognition of their condition, or perhaps among other sources examining the problems of funding research into ENS. The position statement by the ARS is clearly best used as a reference as it contains useful material on the nasal cycle, which our article doesn't mention, but is implied to be a significant factor in the way in which ENS affects sleep. It can't be an external link as it "does not provide a unique resource beyond what the article would contain if it became a featured article" (WP:ELNO Number 1). Frankly, I'd let this current round of debate subside and then propose an addition to the Causes section, to discuss the nasal cycle in this context. But be prepared to provide exact wording and expect that some editors may feel it is too speculative if it only appears in one source. Finally we simply won't provide external links to sites that merely provide services, no matter how respectable, because there's no way of drawing the line - every article would be weighed down by myriad sites purporting to be a useful resource. I know it seems counter-intuitive, but Wikipedia has never intended to be a central clearing house for every other site associated with a particular topic, sorry. If a site actually contains encyclopedic information, it should be considered as a source, but otherwise we can't use it.
 * I'll try to address your other points tomorrow, but it's late here (2 am) and unpicking the debates on this page needs more concentration than I can bring to bear right now. --RexxS (talk) 01:17, 10 June 2016 (UTC)
 * I'll try to address your other points tomorrow, but it's late here (2 am) and unpicking the debates on this page needs more concentration than I can bring to bear right now. --RexxS (talk) 01:17, 10 June 2016 (UTC)


 * - No problem. Thank you for taking a look at my suggestions and giving me your thoughts on the above paraphrased statement and the external links.  I will look forward to your thoughts tomorrow on the treatment ideas (which is directly above the "Welcome, ENS forum members" section), your thoughts on my society and culture suggedtions, and adding the link to the ENS association website.  You said that the ENS Association website may be appropriate if the culture and society section included a citation of ENS sufferers trying to get recognition for their problem.  You will notice that that I suggest that section include a citation of Christopher Martin's book, which is cited in the BuzzFeed article, so I think that may be an example of an ENS sufferer striving to gain awareness and a reason to add the ENS Association website as an external reference. Thanks.EducatedonENS (talk) 01:27, 10 June 2016 (UTC)EducatedonENS


 * answer to the OP - all the sources say that a key symptom is obsessing about the feeling that you can't breathe. In other words, you can't stop thinking about it.  I was just doing WP:PLAINENG but I guess "obsess" is plenty clear. Will fix that. Jytdog (talk) 21:30, 9 June 2016 (UTC)


 * thanks. I'm sure just changing to "thinking about the symptoms" will do it Dubbin u &#124; t &#124; c 21:50, 9 June 2016 (UTC)

Classification
Please substitute this new sentence in place of the former.

"As of 2015 many ear, nose, and throat doctors do not recognize the condition because they already recognize the condition of secondary atrophic rhinitis.[3]"

Reason: We can infer this from the earlier statement in the Section saying ENS is aka secondary atrophic rhinitis. Thus, duplication of medical conditions with differing names is unnecessary. ["Empty Nose Syndrome (ENS), also called secondary atrophic rhinitis"]Greybridge (talk) 21:43, 9 June 2016 (UTC)


 * it's a completely separate point and it's suitably supported by a valid citation, so no. Dubbin u &#124; t &#124; c 21:55, 9 June 2016 (UTC)

Diagnosis
Suggested content.

"Recent research indicates that the poor understanding of ENS is a reflection of airflow sensation itself being poorly understood. Nasal mucosa contains multiple receptors for airflow, temperature and chemosensation. When these receptors are removed or damaged, airflow sensation is negatively affected. Mucosal nasal sensation can be diminished by any process (in particular, turbinate reduction) that affects the mucosal surface."

[ Houser SM (2014) Does the Method of Inferior Turbinate Surgery Affect the Development of Empty Nose Syndrome?. J Otol Rhinol 3:3. doi:10.4172/2324-8785.1000159 ]Greybridge (talk) 22:12, 9 June 2016 (UTC)


 * Houser 2014 is a commentary article, not a systematic review but basically an opinion piece. It is a poor candidate for WP:MEDRS, which says "Peer-reviewed medical journals ... contain a mixture of primary and secondary sources. Journal articles come in many types, including primary research (ranging from vast studies to individual case reports), literature reviews, editorials and op-ed pieces, advocacy pieces, speculation, book reviews, letters to the editor and other forms of commentary or correspondence, biographies, and eulogies. It is usually best to use reviews and meta-analyses where possible." Dubbin u &#124; t &#124; c 23:16, 9 June 2016 (UTC)

Suggested Content: "The pathophysiology of ENS is not yet fully understood. Recent publications indicate that the cause of ENS appears to concern three factors:anatomic changes leading to changes in the airflow patterns in the nose and local environment; disruption of mucosal cooling; and disruption of neurosensory mechanisms governing the sensaution of airflow through the nose."

CT. Flint†, M. Esmaily-Moghadam, A. Thamboo‡, N. Velasquez‡ AND P. Moin, Computational investigation of empty nose syndrome Stanford University Center for Turbulence Research Annual Research Briefs 2015 https://ctr.stanford.edu/sites/default/files/24_flint.pdf

Note: this is a secondary source containing a literature review. Greybridge (talk) 23:49, 9 June 2016 (UTC)


 * nope, it's not independently peer-reviewed so fails WP:MEDRS. Dubbin u &#124; t &#124; c 00:05, 10 June 2016 (UTC)
 * Nevertheless, I found it to be a useful read in that it clearly set out so much of the background to the syndrome and suggested multiple sources that are MEDRS-compliant. It's the sort of article that would be useful to cite in the History section, rather than trying to reconstruct the history ourselves. It's not usable to support biomedical claims, as you say, because of its lack of peer-review. But at the very least, it might be mentioned in a Further reading section because of its relative accessibility to the lay reader as an overview.
 * I'm sorry if I seem to be piling more reading onto you, but it is now apparent that you will have to understand our policy on Plagiarism. The text you suggest is simply far too close to the text of the last paragraph of page 252. It's not an exact copy, but I don't believe it is your own words. There is a helpful page at Close paraphrasing that I sincerely recommend, as it will clearly be helpful to you. --RexxS (talk) 00:22, 10 June 2016 (UTC)
 * It is not plagiarism. It is an attempt to stick to the wording as closely as possible. In my "real" life I would not find this acceptable. But, since I have been shut out at every turn, I thought it best to leave the final edit to someone who is permitted to edit. I have been criticised for straying too much from the original material, now I am criticised for sticking to closely to the original. I will note from here on out if I am suggesting a near direct quote, so as not to mislead anyone. For the purposes of medical citation, I would err on the side of being too close to the original given all the criticism here. I am not a novice at writing cited papers. Your patience is appreciated. Greybridge (talk) 00:51, 10 June 2016 (UTC)
 * Look - it's a Goldilocks problem. If you stray too far from the source, you're wrong. If you copy the source too closely, you're also wrong. But, honestly, there is a broad middle ground where you can get it "just right" and thousands of editors manage it every day. If you want a tip, try this: read what two or three good sources say about a topic; then without looking back at the sources, try to write a précis of all of them from memory. It's actually easier if it's a topic you're not very familiar with, but you won't have that advantage, I guess. Anyway, I can vouch for the fact that editing Wikipedia actually gets easier with practice. You know you can try out edits in your sandbox, I guess? Or are there any uncontroversial edits you could make to a related topic like turbinate or nasal cycle? --RexxS (talk) 01:33, 10 June 2016 (UTC)
 * Look - it's a Goldilocks problem. If you stray too far from the source, you're wrong. If you copy the source too closely, you're also wrong. But, honestly, there is a broad middle ground where you can get it "just right" and thousands of editors manage it every day. If you want a tip, try this: read what two or three good sources say about a topic; then without looking back at the sources, try to write a précis of all of them from memory. It's actually easier if it's a topic you're not very familiar with, but you won't have that advantage, I guess. Anyway, I can vouch for the fact that editing Wikipedia actually gets easier with practice. You know you can try out edits in your sandbox, I guess? Or are there any uncontroversial edits you could make to a related topic like turbinate or nasal cycle? --RexxS (talk) 01:33, 10 June 2016 (UTC)
 * Look - it's a Goldilocks problem. If you stray too far from the source, you're wrong. If you copy the source too closely, you're also wrong. But, honestly, there is a broad middle ground where you can get it "just right" and thousands of editors manage it every day. If you want a tip, try this: read what two or three good sources say about a topic; then without looking back at the sources, try to write a précis of all of them from memory. It's actually easier if it's a topic you're not very familiar with, but you won't have that advantage, I guess. Anyway, I can vouch for the fact that editing Wikipedia actually gets easier with practice. You know you can try out edits in your sandbox, I guess? Or are there any uncontroversial edits you could make to a related topic like turbinate or nasal cycle? --RexxS (talk) 01:33, 10 June 2016 (UTC)

Can we say this? "Computational fluid dynamics may offer a tool to better understand, diagnose and prevent ENS. Recent research in computational fluid dynamics has begun to shed light on the pathophysiology of ENS through nasal airflow, visualization and quantification of airflow characteristics. These studies can provide informational modeling for both reconstruction of the ENS airway and as a surgical planning tool. One such study was published by Stanford University's Center for Turbulence Research." [1]

''It is important to note developing tools for diagnosis, treatment and prevention of ENS. ESPECIALLY tools that provide objective measurement.'' Greybridge (talk) 01:29, 10 June 2016 (UTC)

[1] CT. Flint†, M. Esmaily-Moghadam, A. Thamboo‡, N. Velasquez‡ AND P. Moin, Computational investigation of empty nose syndrome Stanford University Center for Turbulence Research Annual Research Briefs 2015 https://ctr.stanford.edu/sites/default/files/24_flint.pdf
 * A Research section in the article, perhaps? What do you think? could we make a viable section on research without it becoming a dumping ground for every source that doesn't quite meet MEDRS? My own preference is to encourage growth of the article, but I appreciate the desire to keep it focussed. --RexxS (talk) 01:37, 10 June 2016 (UTC)
 * A Research section in the article, perhaps? What do you think? could we make a viable section on research without it becoming a dumping ground for every source that doesn't quite meet MEDRS? My own preference is to encourage growth of the article, but I appreciate the desire to keep it focussed. --RexxS (talk) 01:37, 10 June 2016 (UTC)


 * I appreciate this suggestion to place it in Research. But, could there also be somewhere in Diagnosis for "Diagnostic Tools"? or Methods of Diagnosis (A subsection like this about CFD and others d/x methods/tools in "Diagnosis" would be helpful) Since quantification of ENS has been the main criticism of those who do not full accept the ENS diagnosis, it is important to let readers know of research and tools. For example, there is burgeoning CFD research that gives objective evidence (Flint et.al.). I would add, that this is not the only study of its kind. Incidentally, there are ENTs interested in developing it as a surgical planning tool right now. See for ex. http://www.triomeetingposters.org/wp-content/uploads/2012/12/015.pdf Greybridge (talk) 01:50, 10 June 2016 (UTC)
 * For any biomedical information (which includes diagnosis) we need to stick to MEDRS sources. research sections are for discussing trends as described in reviews, not for highlighting specific research described in specific primary sources.  Please see the essay WP:Why MEDRS? for an explanation of why using reviews is so important in biomedical topics.  Thanks.   Jytdog (talk) 04:27, 10 June 2016 (UTC)


 * As far as I can tell, this 'journal' is just an in-house digest from that institution, and is not independently peer-reviewed, so it doesn't really count as a primary research source. I'm with Jytdog that anything in 'diagnosis' is medical and should follow WP:MEDRS. If we had a 'research' section, it should aspire to the same standards. In such a controversial field, touching inevitably on research with clinical implications, we have to stick to good-quality review articles before permitting any research finding prominence. Dubbin u &#124; t &#124; c 07:38, 10 June 2016 (UTC)

Prevention
Suggested content:

"The least invasive process should be used to effect airway improvement. Procedures that appear safe are turbinate outfracture and conservative submucosal reduction. Surface cautery and laser reduction (i.e., reduction approached via mucosal damaging procedures) should be abandoned in favor of safer techniques."

[ Houser SM (2014) Does the Method of Inferior Turbinate Surgery Affect the Development of Empty Nose Syndrome?. J Otol Rhinol 3:3. doi:10.4172/2324-8785.1000159 ]Greybridge (talk) 22:20, 9 June 2016 (UTC)


 * see my response above. Not a suitable WP:MEDRS source. Dubbin u &#124; t &#124; c 23:17, 9 June 2016 (UTC)

Suggested Content

"Empty Nose Syndrome usually follows aggressive resection or over reduction of the inferior and sometimes middle turbinates." [1] [2]

[1] Allergic and Non Allergic Rhinitis, Corren, Baroody, Pawankar in: Middleton's Allergy: Principles and Practice N. Franklin Adkinson, Jr., Bruce S. Bochner, Wesley Burks, William W. Busse, Stephen T. Holgate Elsevier Health Sciences, Nov 1, 2013 ISBN 978-0323085939 ISBN-10 0323085938

and [2] Septoplasty, Turbinate Reduction, and Correction of Nasal Obstruction, Gehani and Houser in :Bailey's Head and Neck Surgery: Otolaryngology Jonas Johnson: Lippincott Williams & Wilkins, Jul 9, 2013 ISBN 978-1609136024 ISBN-10 1609136020

N.B : Two "near quotes" merged. I have kept as much of the original language as possible in my content suggestion. Reason: Medical technical description and not wanting to misrepresent causality. Of importance are the terms "aggressive" and "over" resection/reduction. Others have criticized their use, but they are frequently used in ENT. I kept them for this reason. Medical accuracy. Greybridge (talk) 00:55, 10 June 2016 (UTC)
 * The claim that it "usually follows" is not supported by anything - this is a very rare condition, by all accounts. Jytdog (talk) 03:13, 10 June 2016 (UTC)
 * You are reviewing or critiquing the literature. I paraphrased it close to the original. The original quote by Corren is: "Empty nose syndrome usually follows aggressive resection of the inferior and occasionally middle turbinates and manifests with symptoms of severe nasal obstruction and inability to sense airflow through the nose despite complete patency of the nasal airways." [emphasis added] This is a peer-reviewed, major textbook belonging to a specialized field of medicine. Just as I have to abide by the rules you quoted to me, so have you. Please recall your advice to me: "please read WP:MEDASSESS - it directly speaks to doing "peer review" on the content of sources." As RexxS explained to me on "peer reviewing" : "The job of critiquing a secondary source falls to the peer-reviewers and the journal editor." I augmented the proposed content with Gehani and Houser, in order to add the concept of "over-resection" of the turbinate.


 * It is clear that Corren et. al. in their phrasing mean to suggest that ENS must follow a turbinate reduction, not that all turbinate reductions result in ENS. A way to emphasise that there is no other cause for ENS. Greybridge (talk) 04:19, 10 June 2016 (UTC)
 * Sorry when I said "anything" I meant the MEDRS sources that we are relying on, all of which make it clear that ENS is rare following sinonasal procedures. The sources you are bringing are WP:PRIMARY and we don't use those WP:TERTIARY and we don't override recent secondary sources with them per WP:MEDRES and we for sure don't over ride what recent secondary sources say with primary sources. Sorry for not being more clear. Jytdog (talk) 04:26, 10 June 2016 (UTC) (redact, made an error.  sorry Jytdog (talk) 05:06, 10 June 2016 (UTC))


 * I am confused. You criticised me for critiquing or peer-reviewing two secondary sources you used (Coste, Payne). I had objected to your use of them given the content you posted. You said the following: This too is way too much to bite off. Please do read WP:TPG, WP:MEDRS, and WP:MEDMOS. Please read the part of WP:MEDRS called "Assess evidence quality" (shortcut, WP:MEDASSESS - you are doing what that forbids by "peer reviewing" the sources. Jytdog (talk) 17:26, 8 June 2016 (UTC)"


 * Please let me know what the difference is here and how you are not now "peer=reviewing"? My sources, "Middleton's Allergy" and "Bailey's Head and Neck" are "ideal" reliable medical sources. They are both " recognised standard textbooks by experts in a field" just as WP:MEDRS explains.


 * So, you dislike the phrasing. Well, I repeated the same phrasing for accuracy purposes, because causality is still a point of contention among the skeptics of ENS. You will understand my need to stick as close to the language and phrasing of this reliable medical source, as supported in WP:MEDRS.


 * On what grounds has my suggested content been rejected?Greybridge (talk) 05:00, 10 June 2016 (UTC)
 * The sources. Recent reviews (secondary sources) are stronger sources than textbooks which are tertiary sources.  This is discussed in MEDRS Jytdog (talk) 05:04, 10 June 2016 (UTC)
 * Just to clear, are you really intending that our article communicates that ENS is very common after aggressive turbinate reduction? Just wanting to make sure?  Jytdog (talk)


 * I said no such thing. You objected to "usually follows". I said I quoted directly that phrase from the source Corren. You misunderstood it. I explained that the author means to say that the only way one "gets" (the cause) ENS is following a turbinate reduction/resection.


 * I did not say ENS is common. I said, that since causality is STILL a point of contention among those who choose to disregard the condition, that I was very careful to use the same phrasing of Corren.


 * Within these authoritative texts, are discrete chapters, written just like a secondary source article. These are not some text books written by one guy in his bedroom. These are teaching texts, written by leaders in their respective fields, and peer-reviewed. How can it be an "ideal" MEDRS source and you downgrade it to tertiary? Are you familiar with Bailey's Head and Neck? I object that you call it a tertiary source. Could you point me to the definition of tertiary medical resources, and let me know how my selected sources fit the definition?Greybridge (talk) 05:25, 10 June 2016 (UTC)
 * I asked for a clarification. I am done interacting with you; you are too aggressive and shouty for my taste, and I have more productive and enjoyable ways to spend my time in WP. Others can respond to you if they wish, of course. Jytdog (talk) 05:33, 10 June 2016 (UTC)

"Secondary atrophic rhinitis most commonly occurs in older patients who have undergone multiple nasal sinus surgeries. In addition, trauma, irradiation, and granulomatous diseases (e.g., leprosy, sarcoidosis, Wegener granulomatosis, syphilis) of the nose have been reported to result in secondary atrophic rhinitis. As in the primary disease, manifestations may include crusting, obstruction, halitosis, and recurrent epistaxis. The so-called empty nose syndrome often is included with secondary forms of atrophic rhinitis. Empty nose syndrome usually follows aggressive resection of the inferior and occasionally middle turbinates and manifests with symptoms of severe nasal obstruction and inability to sense airflow through the nose despite complete patency of the nasal airways. This clinical picture may be associated with a profound sense of dyspnea in the absence of any objective findings of pulmonary disease."
 * Just pulling these quotes so we have them if we want them.
 * The Middleton source says on page 670:

"Operative procedure section: Over the course of the years, numerous techniques have been developed to address the hypertrophic inferior turbinate, including partial or total inferior turbinectomy, outfracture, submucous resection, laser, electrocautery,  cryosurgery,  and  radiofrequency ablation. Partial or total inferior turbinectomy was widely practiced in the early 1900s; however, concerns of postoperative bleeding, crusting, dryness, atrophic rhinitis, and empty nose syndrome made this technique fall out of favor."
 * The Gehani/Houser chapter in Bailey's: (No pages as it is an ebook; we would just site the chapter)

"Complications section: Rhinitis sicca and empty nose syndrome may develop after turbinate surgery. Classically, these entities occur with partial or total turbinectomy; however, they may also occur with excessive injury to the turbinate mucosa. The inferior turbinate is much more commonly involved than the middle turbinate. Patients with empty nose syndrome present with paradoxic nasal obstruction despite a widely patent nasal airway on examination. Patients report a feeling of nasal stuffiness in addition to the lack of nasal airflow sensation, which may lead to subjective complaints of difficulty breathing, shortness of breath, or even suffocation. Empty nose syndrome occurs in a small percentage of patients who undergo turbinate procedures, but the clinician should be aware of this entity and strive to maintain the integrity of turbinate mucosa to avoid this complication. Atrophic rhinitis is a distinctly different condition; atrophic rhinitis is a chronic, degenerative condition characterized by inflammation and atrophy of the nasal mucosa. Patients present with significant crusting, foul odor, and nasal obstruction. Klebsiella ozaenae is often the culpable bacteria. Anatomically, empty nose syndrome and atrophic rhinitis patients may look similar, and submucosal implantation may benefit both conditions, although they have different origins."

"Highlights section: Overly aggressive inferior turbinate reduction or resection may lead to rhinitis sicca or empty nose syndrome postoperatively." - Jytdog (talk) 05:49, 10 June 2016 (UTC)


 * Interesting quotes, I think it would be helpful to discuss the use of "aggressive resection" and "over-resection" (here, not in the article) since they are apparently a particular focus on the ENS community and one trigger that brought us so many new and enthusiastic contributors. 'Aggressive' is used in surgery to mean 'more extensive' but if used in WP:PLAINENGLISH it has connotations of recklessness that I think are too pejorative for a medical wikipedia article. Over-resection is a subtle one, since at the time of resection, the procedure performed is by definition the one the surgeon thinks is sensible, and the one consented to by the patient. Nobody ever signed a consent form for 'over-resection of the turbinates'. As we have established, ENS is a rare complication of resection, and even if there is a quantitative association between resection extent and risk of ENS, there are plenty of people who've had total turbinectomies who don't get it. Thus, it is only called 'over-resection' post-hoc, and cannot really be used to guide treatment decisions. If we were to use either term in the article, (1) it would require such extensive explanations and caveats that we are better finding better terms that are more precise in plain english; and (2) it would require a very high standard of evidence and need to be presented as the opinion of the author(s) in question. I think we already do a good job of acknowledging the link between resection extent and risk of ENS, and the idea that less extensive surgery is preferred. Dubbin u &#124; t &#124; c 09:42, 10 June 2016 (UTC)
 * I think the prevention section is OK as it is. Jytdog (talk) 15:56, 10 June 2016 (UTC)
 * Good. I agree, but you know what they say about the antimicrobial activity of sunlight. Dubbin u &#124; t &#124; c 18:22, 10 June 2016 (UTC)

A mess
This page is only get harder and harder to use. Would you all please
 * a) keep your comments concise and focused on content based on sources and the policies and guidelines
 * b) discuss one topic in one' section
 * c) stop copying big chunks of content and adding to it? I was pinged in this dif] and I have no idea where that is - I spent a minute looking and I am not going to waste more time looking for it.

This is all described in the WP:TPG. Jytdog (talk) 17:01, 10 June 2016 (UTC)


 * I agree it's a mess. I spent one and a half hour today trying to format/condense/remove my edits so my comments would be condensed and much easier to follow, but Dubbin correctly rolled them back and pointed out that I should put a strikethrough rather than remove existing comments (with a statement nearby explaining why).  I totally respect that Wikipedia guideline, but I don't have time anymore to do anything with my comments, so I'll just leave them as is. Sorry it's a mess and thank you all for your efforts.  I have put my final comments I was hoping could be responded to below.  This is it for me as I am exhausted and trust that the efforts by everyone involved has helped the final product. I would appreciate a courtesy reply below (to the three brief questions).  Thank you.EducatedonENS (talk) 17:25, 10 June 2016 (UTC)EducatedonENS (talk) 16:50, 10 June 2016 (UTC)

ELs

 * Jytdog - Thank you for adding some content based on the buzzfeed article to the society section.


 * I copied RexxS’ quote from a different section to here to make this discussion easier to follow


 * RexxS wrote: I'm sorry but none of the external links are suitable for our article. There a guidance page (of course!) at Wikipedia:External links desribing the sort of external links that are suitable, and those that are not. In brief, Wikipedia is determined to remain a self-contained encyclopedia, and we don't provide external links just because a reader might find them useful; we're not a directory of other web-based resources. The ENS International Association website would be acceptable if we were writing an article about ENS sufferers, but it can't really be an official website for a medical condition. On the other hand, it would make a decent reference if there were a discussion in the Society and culture of the difficulties faced over the years by sufferers in gaining recognition of their condition, or perhaps among other sources examining the problems of funding research into ENS.


 * My reply to RexxS (others, please feel free to answer) you stated the ENS Association website would make a decent reference if there were a discussion in the Society and culture of the difficulties faced over the years by sufferers in gaining recognition of their condition. Three brief questions. First, now that there is a discussion in the Society and culture section about difficulties faced by ENS (as added by jytdog), how do we reference the ENS international Association website (http://ensassociation.org) in this section? Second, I noted the book written by Christopher Martin in 2007 sharing his experiences, which was written by the author with Dr. Houser writing the foreword (Dr. Houser is the leading expert in the journals on ENS), as this is another example of an effort for an ENS sufferer to raise awareness, and I am aware that his book won an award and was translated into Spanish in 2015. This book is cited in the BuzzFeed article. I think that should be added to the society and culture section as it again shows the struggle for ENS to gain awareness. Third, can we make a statement that the American Rhinologic Society recognizes ENS (as of 2014), even if we can't site the website article? Thank you again.EducatedonENS (talk) 17:25, 10 June 2016 (UTC)EducatedonENS (talk) 16:50, 10 June 2016 (UTC)EducatedonENS
 * There is a fine line between saying that people with ENS are advocating for things, and the WP article itself becoming a site for advocacy, which it cannot become, per the policy, WP:SOAPBOX. One thing that keeps us on the correct side of that line are things like the sourcing guidelines WP:MEDRS and WP:RS and the external links guideline, WP:ELNO.  We can't do anything that with that book, as it was self-published.  We generally don't list patient advocacy groups. I will list the ARS page as an EL.  Jytdog (talk) 17:37, 10 June 2016 (UTC)


 * Fair enough on the book and thank you for listing the ARS site. Even though you state that we generally don't list patient advocacy groups, RexxS stated [about the ENS Association Website], it would make a decent reference if there were a discussion in the Society and culture of the difficulties faced over the years by sufferers in gaining recognition of their condition.


 * So I would be interested in RexxS' opinion on whether it could be mentioned in the Society and culture section stating after….. People who experience ENS have formed online communities to support one another[1] and to advocate for recognition, prevention, and treatments for ENS. In 2015, the EducatedonENS (talk) 18:39, 10 June 2016 (UTC)EducatedonENS
 * You couldn't link to the website within the text like that: Empty Nose Syndrome International Association . We don't allow external links in normal article text. It would be best if Wikipedia had an article on Empty Nose Syndrome International Association, then you could make the internal link, but that would require you to find three or four independent sources, like national newspapers or major broadcasters, who have written about the Association (not just mentioned them) to establish notability in accordance with the general notability guidelines. Perhaps the creation of the new article is a project for you for the future?
 * Nevertheless, you could probably make a good case for briefly mentioning the formation and purpose of the Association in the Society and culture or History section, but you would use the website as a reference like this: . If you wrote that, unfortunately we would probably have to remove the one from the External link section, as we have a convention that we generally don't repeat sites that have already been used as references. Hope that helps. --RexxS (talk) 19:22, 10 June 2016 (UTC)
 * Part of the problem with picking one is that there are many. What about http://www.emptynosesyndrome.org/ and https://ens3.wordpress.com/ and http://guest.fr.yuku.com/directory#.V1sVZeYrKV4 and http://emptynosesyndrome.blogspot.com/ ?? Jytdog (talk) 19:35, 10 June 2016 (UTC)
 * @Jytdog, Although you could select other websites, the reason I would choose the ENS Association website is because it is the only one which is an official patient organization, and you can tell that by seeing its tax exempt status on its pages.RexxS OK, I am not sure if I have editing capabilities at this point or not. At this point, I don't have the energy to write a webpage like you suggested, but I appreciate the suggestion :-)  So here is what I will attempt to write.....in the Society and culture section, after ".....treatments for ENS." - In 2014, ENS sufferers formed the   in order to raise awareness and promote research into its treatments.  If I can't add this sentence and another editor thinks it looks good, please feel free to add this.  Thank you.EducatedonENS (talk) 19:41, 10 June 2016 (UTC)EducatedonENS


 * Tax-exempt status doesn't mean an organisation is "official", it means it is tax exempt. Any non-profit organisation can get such a status, including any of the others Jytdog listed. There is no such thing as the "official" organisation of a disease. Inclusion depends on notability, and notability depends on mention in multiple reliable independent sources. Dubbin u &#124; t &#124; c 07:19, 11 June 2016 (UTC)


 * To my knowledge, the http:/www.emptynosesyndrome.org site is most widely cited due to its age, but it may or may not be cited in independent reliable sources and it is not the most active community of members. I suggested the ensassociation.org website because is the only organization that is very active for ENS members and it has done a good job of providing a source of information on ENS (Dr. Kern, the doctor who coined empty nose syndrome and past president of the ARS and International Rhinologic Society, I believe has an honorary role with it, but don't quote me) but, because it is relatively new, it may not be cited in multiple independent reliable sources (yet).  So I guess we don't include this now?EducatedonENS (talk) 12:39, 11 June 2016 (UTC)EducatedonENS

Epidemiology and outcomes
There have been over 50 comments on the talk page since I logged off last night, so I'm not hopeful that I can ever catch up on all the threads. However, in the case discussed above, I think part of the underlying problem with the article is the very thin Epidemiology section. I read very often in the sources used in the article that ENS is a rare consequence of turbinectomy and related procedures. My suggestion is that the article should make clear that correlation and the low incidence (did I see figures of 2% - 20% quoted somewhere?) in a neutral manner within the Epidemiology section. I'm sure from what I've read that we could say more than "The incidence of ENS is unknown but is considered rare." Giving the reader some idea of the pattern and causes as well as the affected population in that section might hopefully also go a long way towards meeting the ENS sufferers' concerns about the article. What do others think? --RexxS (talk) 16:08, 10 June 2016 (UTC)


 * RexxS This was the collapsed section in which I made the suggestions to jytdog -
 * I think it should be added that there are 500,000 turbinectomy procedures done in the US each year (Source: radio show "Wellness Wednesday and the Zika Virus"), although the CDC also should have historical statistics. 20% of patients who undergo total inferior turbinectomies will likely develop ENS (Dr. Houser in his “pathophysiology of empty nose syndrome” article) cites two other research articles suggesting this.  Then you might want to state that doctors believe the rate of people incurring ENS is a much lower percent (Dr. Das states less than 1% of turbinectomy procedures on the radio show just quoted) because primarily conservative turbinate surgeries are employed today, although some might develop ENS even with conservative treatments, if there is a nerve damage to the mucosa (see a discussion of ENS-Type, which is cited in multiple sources).EducatedonENS (talk) 16:29, 10 June 2016 (UTC)EducatedonENS
 * When three sources say "we don't know" with regard to incidence/prevalence I take that seriously and don't add a bunch of noise around that. All three reviews say "rare/extremely rare but we don't know". Jytdog (talk) 16:33, 10 June 2016 (UTC)
 * Respectfully, I'm going to disagree strongly in this case. Epidemiology is defined by the WHO as "the study of the distribution and determinants of health-related states or events (including disease), and the application of this study to the control of diseases and other health problems". The first three sources in the article have this to say:
 * "Empty nose syndrome (ENS) is a rare, late complication of turbinate surgery." -
 * "Neural healing following a surgical insult may not result in a return to a normal physiologic state." -
 * "... it is a rare complication of nose or sinus surgery, and of inferior turbinectomy in particular." -
 * I'm sorry, but a description of the population of potential ENS sufferers as those who have undergone nose or sinus surgery and especially turbinate surgery is not "noise" and is plainly supported by the best sources, including one that comments on possible causality. That is epidemiology, pure and simple, and there is no good reason why that sort of information should not be in the Epidemiology section. I agree that actual incidence figures seem to vary wildly, so it makes sense to retain the adjective "rare", as our best sources agree on that. --RexxS (talk) 18:04, 10 June 2016 (UTC)
 * I'm sorry, but a description of the population of potential ENS sufferers as those who have undergone nose or sinus surgery and especially turbinate surgery is not "noise" and is plainly supported by the best sources, including one that comments on possible causality. That is epidemiology, pure and simple, and there is no good reason why that sort of information should not be in the Epidemiology section. I agree that actual incidence figures seem to vary wildly, so it makes sense to retain the adjective "rare", as our best sources agree on that. --RexxS (talk) 18:04, 10 June 2016 (UTC)


 * I don't think you are disagreeing, really? It seems to be a consensus that there is just too much noise to produce reliable % estimates but Jytdog's analysis agrees that the best descriptor is "rare". For anything better, we have to wait for the ENS researchers to do the studies properly. It's (probably) a postoperative complication; it shouldn't take long to produce reliable figures. But it's not Wikipedia's job to guesstimate what those figures might be. "Rare" seems a reasonable working description. "Noise" would be attempting to come up with numbers, but I don't think anyone thinks that's wise. Dubbin u &#124; t &#124; c 18:11, 10 June 2016 (UTC)


 * RexxS I am happy with you taking a shot, as long as you respect the bottom line unknown-ness. :) But sure, write what you believe is supportable - it will at least give us a more clear idea of what you want. Jytdog (talk) 18:16, 10 June 2016 (UTC)
 * I think we may have been talking past each other a little bit. Because I understand epidemiology to cover more than just prevalence, e.g. a description of the susceptible population, I want us to state something in the first paragraph along the lines of:
 * "Empty nose syndrome has been observed to affect a small proportion of people who have undergone surgery to the nose or sinuses, particularly those who have undergone turbinectomy (a procedure that removes some of the bones in the nasal passage). The incidence of ENS is variable and has not yet been quantified, but it is considered rare.[1][2][3][4][7]"
 * I'd keep the second paragraph as it is. I know it's a bit wordy, but I like to parenthetically explain jargon if I can do so in a few words. I'm not attached to any particular wording, so feel free to do with it as you wish. Cheers --RexxS (talk) 18:59, 10 June 2016 (UTC)
 * I am good with that. We also don't know anything about gender, age, etc, if it worth saying anything about population. Jytdog (talk) 19:15, 10 June 2016 (UTC)


 * ENS is a surgical complication - this is an established fact in the literature. As you know in medicine (at least in the U.S>), the # of actual surgical complications in all areas of medicine are not known, just estimated numbers, because the system relies on voluntary reporting by medical professionals. Mandatory reporting has been advocated, but never implemented, except in the case of death, serious injury or serious medical errors as outlined by the National Quality Forum. In the US, mandatory reporting systems are those run by State departments of health (individual states of the USA) that require hospitals to report. The AMA and American Hospital Organization have opposed mandatory reporting, on the grounds that it would impact liability and discourage reportin. If you want to understand some of the short-comings in the literature about ENS, this is the reason why - liability. In light of these facts, it is not a mystery why there are no clear statistics on the incidence of ENS. [moved this to confirm with sequence] Greybridge (talk) 19:57, 10 June 2016 (UTC)


 * yet another comment that's just arguing for its own sake and adds nothing to the discussion about how to improve the article. Dubbin u &#124; t &#124; c 20:01, 10 June 2016 (UTC)


 * Suggested content: "There are no reliable statistics concerning the incidence of ENS in the United States. Because ENS is a surgical complication, and reporting of surgical complications in the United States is not mandatory, the true numbers are unknown. ENS (et atrophic rhinitis) is considered a minor complication of nasal surgery. Surgical complication reporting focuses on major complications. " [1] [2] [3] [4]


 * [1] Healy MA, Mullard AJ, Campbell DA, Jr, Dimick JB. Hospital and Payer Costs Associated With Surgical Complications. JAMA Surg. Published online May 11, 2016. doi:10.1001/jamasurg.2016.0773.


 * [2] Bhattacharya K, Cathrine AN. Reporting surgical errors - Myth or reality? Indian J Surg 2004;66:15-8.


 * [3] Visser, A., Slaman, A. E., van Leijen, C. M., Gouma, D. J., Goslings, J. C., & Ubbink, D. T. (2015). Trigger tool versus verbal inventory to detect surgical complications. Langenbeck’s Archives of Surgery, 400(7), 821–830. http://doi.org/10.1007/s00423-015-1337-4


 * [4] Hosemann, W., & Draf, C. (2013). Danger points, complications and medico-legal aspects in endoscopic sinus surgery. GMS Current Topics in Otorhinolaryngology, Head and Neck Surgery, 12, Doc06. http://doi.org/10.3205/cto000098


 * Others are invited to reply.Greybridge (talk) 20:36, 10 June 2016 (UTC)
 * What's so special about the US? Don't countries like the UK, Canada, Australia, India do nasal surgery? Are there no reliable statistics in all other countries because of non-mandatory reporting? or concerns about liability? Seriously, you can't build a case about a lack of reliable statistics just by looking at one country. --RexxS (talk) 21:12, 10 June 2016 (UTC)


 * Nothing is special about the U.S. It is an relevant exemplar. The question here is, how can we properly explain the lack of data, when the reasons differ for its absence throughout the world? Can we give an example within the Wiki article? There are no universal statistics, because the condition is not recognized in some countries. You realize this, right? So, in those countries that do recognize ENS, such as the United States, the question is: can we say more than "we don't know"?


 * I disagree with other editors that expert opinion of ENTs speaking in their area of expertise and knowledge published in secondary source articles, which estimates ENS incidence at 2-20% should be dismissed. However, if they are dismissed, then again, how do we say more than "no one knows"?Greybridge (talk) 21:25, 10 June 2016 (UTC)


 * Our job isn't to explain why there are no accurate figures. It is to see whether they exist in a suitable source and report them if they do. You may be right as to the reasons why the prevalence is not accurately known, but it is not for the wikipedia article to speculate. If you could find a MEDRS source that set out evidence for failed attempts to establish the prevalence and the reasons behind these failures, we could consider it, but it seems by definition unlikely that such a source exists. Dubbin u &#124; t &#124; c 06:50, 11 June 2016 (UTC)

I have one concern about the current text. Somewhere in this PhD thesis of a talk page, one of you mentioned that it wasn't actually 100% certain in MEDRS sources that ENS is always a complication of surgery. If it is not established beyond doubt, we should probably add a suitably referenced caveat to the epidemiology section. Dubbin u &#124; t &#124; c 07:24, 11 June 2016 (UTC)

@Rexxs and anybody else is this source appropriate as per WP:MEDRS
The turbinates in nasal and sinus surgery: a consensus statement.

http://www.ncbi.nlm.nih.gov/pubmed/12619458

Full text @

Would this consensusus statement be acceptable reference material as per WP:MEDRS

It is peer reviewed secondary material correct??

The journals website said it was peer reviewed

Ensadvocate (talk) 03:21, 10 June 2016 (UTC)
 * Note, I redacted the freelibrary link per WP:ELNEVER Jytdog (talk) 03:54, 10 June 2016 (UTC)
 * I just went and looked at that source, and it is labelled clearly in the original publication as a "Guest Editorial". Editorials are not MEDRS sources.  Could incorporate this in the history section maybe as say the third sentence there - something like, "Also in 2001 at the annual spring meeting held jointly by several otolaryngological societies, a panel of 6 ENT surgeons including Kern was convened to discuss various issues concerning surgery of the middle and inferior turbinates; one of its conclusions was: "The excess removal of turbinate tissue might lead to empty-nose syndrome" and it recommended that surgeons should "be conservative in the management of the turbinates but willing to do what is necessary to achieve the desired result." (cited to the ref above).  What do you think, User:RexxS and User:Dubbin? Jytdog (talk) 04:23, 10 June 2016 (UTC)
 * I'd say that would be undue given the weakness of the source. Alexbrn (talk) 05:20, 10 June 2016 (UTC)
 * Thx alexbrn. Jytdog (talk) 05:58, 10 June 2016 (UTC)
 * agree with Alexbrn. Such a statement is really just opinion on clinical management (which needs a MEDRS source), hardly a significant turning point in the history of the syndrome. Dubbin u &#124; t &#124; c 09:29, 10 June 2016 (UTC)
 * I am good with that. Jytdog (talk) 14:56, 10 June 2016 (UTC)


 * I dissent with the opinion that this material is unusable for the history section. I do not understand why redaction of the link i posted occurred as per WP:ELNEVER I respectfully request clairification as too why the link i posted was redacted as per WP:ELNEVER btw thank you for your hard work   Ensadvocate (talk) 02:02, 12 June 2016 (UTC)


 * The link you posted was redacted because we never link to sites that violate copyright, even from talk pages. This has nothing to do with the reason the article you posted was rejected - Jytdog found the full text of it and established it was an Editorial. Editorials are not suitable MEDRS sources. History sections don't need MEDRS sources but they need solid historical sources. Three editors agree the source is 'weak' because it is an editorial which amounts to an opinion piece. Dubbin u &#124; t &#124; c 02:11, 12 June 2016 (UTC)

Treatment
The below represents my comments in response to jytdog (copied from a different section) to make it easier to follow, as it has not yet been replied to:

You are right in that I am pleased to see three large reviews, but I want to point out that there was a turning point in 2014 for hope amongst ENS sufferers when Dr. Subinoy Das (Columbus, Ohio, www.usasinus.org) started treating ENS patients with regenerative medicine (acell/prp) [as well as recent interest among stem cell scientists – no citation to support this statement, though]; Dr. Das has now seen more patients than any other doctor.

How does this apply to the Wikipedia article? First, in the treatment section, the discussion of implants looks like a rehashing of the abstract from Cochrane review rather than an appreciation for any specific findings of the study. Perhaps it could be re-worded?

Second, I want to bring to your attention two research studies using regenerative medicine for empty nose syndrome to see if these can be included in the treatment section in light of the hope that regenerative medicine provides to ENS sufferers – or at least made mention of “ongoing research in this area”:

http://www.ncbi.nlm.nih.gov/pubmed/26388989

https://www.researchgate.net/publication/263204984_New_regenerative_approach_to_Atrophic_Rhinitis_using_autologous_lipoaspirate_transfer_and_platelet_rich_plasma_in_five_patients EducatedonENS (talk) 16:09, 10 June 2016 (UTC)EducatedonENS
 * "there was a turning point in 2014" ← is this your personal view or something for which we have a reliable 3rd-party source? Alexbrn (talk) 16:22, 10 June 2016 (UTC)
 * The American Rhinologic Society recognized ENS at the same time (in 2014) as this regenerative treatment became available. Furthermore, there are three large reviews on ENS in 2015 (as noted by jytdog). However, calling it a turning point is my personal viewpoint. Hope that clarifies EducatedonENS (talk) 16:33, 10 June 2016 (UTC)EducatedonENS
 * Until the stem cell stuff is discussed in a review we cannot bring it in, not even to the research section. Sorry for not responding sooner.  That stem cell treatment is not "available" ( i hope). That was a very small, single arm study - no placebo, no double blind.  Yikes.   Jytdog (talk) 16:34, 10 June 2016 (UTC)


 * @jytdog, You can leave out the two small studies on adipose-derived stem cells cited above, but consider the meta-analysis of 128 people you discussed in the treatment section is a smaller number of people than the 180 people Dr. Das has injected with PRP/Acell injections from 25 countries, with 82% reporting improvement, since 2014.  These numbers are cited in the BuzzFeed article and I thought a passing reference to people pursuing this regenerative medicine might be appropriate to mention (perhaps without comment on its efficacy) in the treatment section, even though we can't comment on the results or efficacy as there is no review in the medical literature on this for ENS.  EducatedonENS (talk) 17:50, 11 June 2016 (UTC)EducatedonENS
 * Please stop advocating for introducing content that is not supported by a reliable source per MEDRS. Once the stem cell research is discussed in a review in the biomedical literature we can summarize that discussion.  Not until then.  Not responding to this again. Jytdog (talk) 18:48, 11 June 2016 (UTC)


 * Wow, if we can't cite the research done as noted in a BuzzFeed article as a notable reference, that's fine. Settle down.  Your rudeness and short temper is unappreciated and out of line.  EducatedonENS (talk) 20:06, 11 June 2016 (UTC)EducatedonENS
 * Sorry, it is a bit much with all four of you looking to add content that we are telling you cannot be added to WP.  Dubbin, RexxS, Alexbrn are trying to explain how things are done here but it doesn't seem to stopping the flow of unworkable proposals.
 * Sir/Madam: I have not been involved in this subject of discussion. Kindly don't include me. As to the general criticism of "unworkable proposals", it is a bit overwrought. It has been only a few days, and I believe progress is being made in acclimating to the "way things are done" as you are so fond of saying. I don't appreciate the excoriation from you about the errors I make during this time of acclimation and learning. Refraining from F-bombs would be appreciated. My efforts are genuine and I hope you can find it within yourself to be less truculent. Greybridge (talk) 02:18, 12 June 2016 (UTC)
 * You have no idea how pushy the four of you are being. I have been editing here for about 6 years and have dealt with tons of advocates - and that is what the four of you are - and this is some of the worst I have ever seen.  Listen  - out of all the articles in the medical field in Wikipedia -- all of them - which is about 20,000 articles -- this one has the most edits in the last week by far.   Why is that?  Because four selfish advocates cannot slow down, read the policies and guidelines like we keep telling you to, and instead just keep pushing and pushing proposals we have already said no to, in your efforts to twist this Wikipedia article into an advocacy website.  Every editor trying to work with you has a job and many other articles we care for.  I have 7,000 pages on my watchlist and about twenty articles that affect tons of people that  need serious work.  What I have "excoriated" you in particular for is not taking "no" for an answer and continuing to try to shove unworkable content into Wikipedia, and for attacking me for saying no to you.  I like teaching people.  You are too aggressive to teach.  Like most advocates you do not care about Wikipedia - you only care about how you can use it to advance the agenda you brought here with you.  If you wanted to make this a great article under the policies and guidelines and mission of Wikipedia' your behavior would be totally different.  There is no way in hell that you actuallly read the message I left on your Talk page nor the SOAPBOX policy nor the ADVOCACY essay nor the SPA essay linked in it, and reflected on that stuff. You in particular have no self-awareness of how selfish you are being. I know  exactly how harsh I am being. And if you track my interactions with the four of you, you can see me becoming increasingly sharp.  Jytdog (talk) 03:01, 12 June 2016 (UTC)


 * @jytdog. Whoa. Listen, I am done offering suggestions until a new review on ENS comes around.  The ENS article was completely redone this past week. I have learned a lot about how Wikipedia works this past week and I LOVE the neutrality emphasis.   When you first significantly revised the article, I spent hours organizing my suggestions and thanked you for your efforts.  Instead of saying thank you to me for my suggestions, but could you could put your organized suggestions in section breaks, you complained about hating to edit this article, how my suggestions are far too long, and just referred me to the talk guidelines.  I spent the entire week trying to get my organized comments responded to and lost many, many hours as a result. Some of my comments were incorporated into the article and some were not. Which is fine. At this point, I see that the contributions of Greybridge and I have both been put to good use (these are the only 2 contributors that I am seeing here, not 4), helping to make this a balanced article.  I sincerely appreciated that Dubbin wanted a balanced article on ENS and I am sorry you see it so differently.  Good luck.EducatedonENS (talk) 03:51, 12 June 2016 (UTC)EducatedonENS.74.106.192.64 (talk) 03:23, 12 June 2016 (UTC)EducatedonENS

EducatedonENS I am sorry you wasted time doing a bunch of work before you understood the content policies and guidelines. In any case you have been reasonable to work with for the most part - my sense is that this would have been somewhat different had only you showed up. Jytdog (talk) 04:20, 12 June 2016 (UTC)
 * And as to the "rehash" I will just say I read the whole fucking article and that was a careful summary of the results from the body of the article. Jytdog (talk) 16:40, 10 June 2016 (UTC)
 * Thanks for your work on this Wikipedia article EducatedonENS (talk) 17:28, 10 June 2016 (UTC)EducatedonENS

Early Publications on Turbinate Surgery & Atrophic Rhinitis
Suggested Content: "The role of the inferior turbinate as the most important organ of the nose was known more than a century ago. As early as 1914, partial or complete turbinectomies were known to cause dryness of the nasal cavity and throat, that was accompanied by thick mucous and respiratory complaints, and was said to resemble in its presentation, atrophic rhinitis."

Albert B Mason, M.D. A Plea for the Conservation of the Inferior Tubrinate, pp: 245-249, Journal Record of Medicine Vol. LXI. Atlanta, Ga., September, 1914. No. 6, in: Atlanta Journal-record of Medicine, Volume 61 via Google books https://books.google.com/books?id=UtsrAAAAYAAJ&pg=PA245&lpg=PA245&dq=pleas+for+the+conservation+of+the+inferior++turbinate&source=bl&ots=iWqPkGvPno&sig=Pw9h8MRic0dUsAhnWaafshi1T-0&hl=en&sa=X&ved=0ahUKEwj0tb7k1Z7NAhXKzIMKHeKkCXsQ6AEIHDAA#v=onepage&q=pleas%20for%20the%20conservation%20of%20the%20inferior%20%20turbinate&f=false

Dr. Mason speaks of general knowledge in his capacity as an expert about the profession vis. turbinate resections, as well as his particular experience and observations on a condition like atrophic rhinitis which followed partial or total turbinectomies.

"All I shall state is of common knowledge. I simply wish to enter my protest against the too frequent removal of all or part of the inferior turbinate, which I believe is the most important organ in the nose. Yet, it is slaughtered and removed with discriminate abandon more than any other part of the body, with the possible exception of the prepuce."

"I have also seen a condition resembling atrophic rhinitis follow the removal of part of the turbinate.I have had patients, upon whom turbinotomies had been done some time previously, complain of a dryness of the nose and throat, but I have never seen or heard of a case developing a dryness after a submucous resection.” [his ref to Kilian submucosal resection of the septum]"Greybridge (talk) 00:34, 11 June 2016 (UTC)


 * this is actually potentially interesting for the history section. It is not an MEDRS source but could provide an interesting quotation Dubbin u &#124; t &#124; c 06:00, 11 June 2016 (UTC)


 * Duly added. If editors feel I have quoted too liberally, please feel free to paraphrase instead. The work is out of copyright but the real reason to use the quotations is the prose is so delightful. Greybridge, I couldn't access the full text so please note we are relying on your transcription of a volume I presume you have in hardcopy? It would be helpful if you could just confirm that you do indeed, and check that the quotations and citation are completely accurate. Dubbin u &#124; t &#124; c 07:11, 11 June 2016 (UTC)


 * I located the full text on Google Books. It is still available at the link I provided. It appears to be a bound edition that was scanned. The bound edition is entitled, Atlanta Journal-record of Medicine, which I presume superceded the earlier title of Journal-Record of Medicine. The bound edition is numbered No. 61. It contains Vol. LXI 1914 No.1 through LXI 1915 (Mar) No. 12 along with some additional material (the entire edition is not available so I an just presuming the sequence and actual content). Within beginning pages of the bound edition is a page with reference to former ownership - "Boston Medical Library. 8 The Fenway".


 * The older prose is very enjoyable....there are other, older publications remarking on the turbinates in this way Dr. Mason did. I 'll see if I can locate such refs among my notes.


 * The quotes I checked again, and cut and pasted from the source:


 * "I have nothing new to offer for your consideration. All I shall state is of common knowledge. I simply wish to enter my protest against the too frequent removal of all or part of the inferior turbinate, which I believe is the most important organ in the nose. Yet, it is slaughtered and removed with ^discriminate abandon more than any other part of the body, with the possible exception of the prepuce.


 * "I have time and time again seen large inferior turbinates diminish in size after the removal of spurs that were pressing against them; and, I have also seen a condition resembling atrophic rhinitis follow the removal of part of the turbinate. I have had patients, upon whom turbinotomies had been done some time previously, complain of a dryness of the nose and throat, but I have never seen or heard of a case developing a dryness after a submucous resection." Greybridge (talk) 14:07, 11 June 2016 (UTC)


 * Since you revised my original, and discuss symptoms, it would be faithful to Mason's clinical observations,if you note two more symptoms from his article. These symptoms were also noted by Mason following removal of part or all of the inferior turbinate -  similar s/x to those today -   dried mucus and respiratory complaints - "dried mucus" and "hacking cough" (Mason descriptors). Greybridge (talk) 14:46, 11 June 2016 (UTC)


 * I'd not support further use of this source as it would be undue - and also a kind of WP:OR since no secondary source uses this text as a history of ENS (or does it?) - so we are not writing at the tertiary level as we should. Alexbrn (talk) 14:57, 11 June 2016 (UTC)


 * Older medical literature is not like that of today. Alot of the medical literature, was authored by single physicians who published their clinical findings, along with remarks on the current state of treatment with reference to various of their colleagues, arguing in favor or against other points of view. There are a few references to older articles like Masons in contemporary medical literature. But, I don't know of many that really give a history. On that point, here one such source: "Christopher Martin, entitled “Having Nasal Surgery? Don’t You Become An Empty Nose Victim!” (2007) esp. pp. 80-81.


 * But, aren't we are also interested here, as part of a history section, in noting the historical awareness of the relationship between turbinate resection and atrophic rhinitis? In defense, I would say that Original expert information was cited in the Society and Culture section. The editor in this example said that only WP:RS was needed, not WP:MEDRS. I don't know if this applies in the History section, but I would advocate it should. Greybridge (talk) 15:37, 11 June 2016 (UTC)
 * It may be interesting, but this kind of writing is too good for Wikipedia. We are meant to be relaying accepted knowledge based principally in secondary literature. By conducting research to unearth a primary source and cleverly constructing our own work which relates it to the history of ENS, we are creating a secondary, original work - and not writing an encyclopedia. Alexbrn (talk) 15:43, 11 June 2016 (UTC)
 * Exactly, Alexbn. We cannot do WP:OR/WP:SYN and construct a history here that exists no where else. Jytdog (talk) 15:54, 11 June 2016 (UTC)
 * I can see what you are saying. I am asking how we can we avoid excluding entire body of medical literature that differs from contemporary standards? Greybridge (talk) 16:31, 11 June 2016 (UTC)

What makes you think it's something we need to avoid? We should just skim the top off received scholarship on this matter and leave the interesting details beyond that to researchers and writers in other tiers. Alexbrn (talk) 17:26, 11 June 2016 (UTC)
 * You said that the source (Mason) is WP:OR and suggested it not be used any more extensively. I said I differ with the opinion that it should be treated as [[WP:OR] which by definition, would exclude this whole class of med. literature.


 * If I show you examples on Wiki where old medical articles have been cited within a history section to provide description of early observation of a medical condition, using extensive quotes, would you then consider acceptable for use in this article? Greybridge (talk) 17:38, 11 June 2016 (UTC)
 * Mason is not WP:OR, but its use may be. I'm not interested in other article as WP:OSE - we have a lot of poor articles. I'm interested for now in this article following the WP:PAGs. Alexbrn (talk) 17:45, 11 June 2016 (UTC)


 * I agree with your analysis and we certainly shouldn't include anything more than a cursory nod to this 1914 mention. If you feel the mention and quotes I've already added are too primary, please say so or revert - I won't mind at all. I'm more at home with MEDRS than with judgements on historical passages. Dubbin u &#124; t &#124; c 18:14, 11 June 2016 (UTC)

Suggested Content
"During the 19th century, rhinologists developed a number of surgical techniques to reduce turbinate volume. Turbinectomy appeared in the later 19th century, and became the most common rhinologic surgical procedure. Soon after its introduction, reports linking it to atrophic rhinitis appeared. [1] Criticisms of turbincectomy continued to be published through the1960's. [2]"

[1] Functional Reconstructive Nasal Surgery Egbert H. Huizing, John A. M. de Groot Thieme (2015) ISBN 1-58890-081-9 [2] Hol MK, Huizing EH. Treatment of inferior turbinate pathology: a review and critical evaluation of the different techniques. Rhinology. 2000 Dec;38(4):157-66. PMID: 11190749 Greybridge (talk) 21:19, 11 June 2016 (UTC)

Suggested Content
“A 1924 publication critical of turbinectomy described the 'over-zealous' rhinologist. [1][2] [3]”

[1] Hol MK, Huizing EH. Treatment of inferior turbinate pathology: a review and critical evaluation of the different techniques. Rhinology. 2000 Dec;38(4):157-66. PMID: 11190749 [2]Spielberg, W. (1924), The treatment of nasal obstruction by submucous resection of the inferior turbinate bone. Report of cases. The Laryngoscope, 34: 197–203. doi: 10.1288/00005537-192403000-00006 [3] Ehsan-Ul-Haq Pak J Surg 2014; 30(4): 355-361 Surgical reduction of hypertrophied inferior turbinate: a review and critical analysis of different techniques, Pak J Surg 2014; 30(4): 355-361 http://www.pjs.com.pk/journal_pdfs/oct-dec14/355.pdf Greybridge (talk) 21:19, 11 June 2016 (UTC)

Suggested Content
“The total turbinectomy continues to be discouraged for its association with atrophic rhinitis and the dry nose. [1][2][3]"

[1] Hildenbrand T, Weber RK, Brehmer D. Rhinitis sicca, dry nose and atrophic rhinitis: a review of the literature. Eur Arch Otorhinolaryngol. 2011 Jan;268(1):17-26. doi: 10.1007/s00405-010-1391-z. Epub 2010 Sep 29. PMID: 20878413 [2]Kridel, Strum-O'Brien “Nasal Septum” in: Cummings Otolaryngology - Head and Neck Surgery. Paul W. Flint, Bruce H. Haughey, K. Thomas Robbins, J. Regan Thomas, John K. Niparko, Valerie J. Lund, Marci M. Lesperance Elsevier Health Sciences, Nov 28, 2014 ISBN-13: 978-1455746965 ISBN-10: 1455746967  Retrieved from Google Books. [3] Rice DH, Kern EB, Marple BF, Mabry RL, Friedman WH. The turbinates in nasal and sinus surgery: a consensus statement.Ear Nose Throat J. 2003 Feb;82(2):82-4. PMID: 12619458 Greybridge (talk) 21:19, 11 June 2016 (UTC)


 * these 3 content suggestions are all about atrophic Rhinitis and turbinectomy, both of which have their own articles. The 1914 publication was of interest as apparently the earliest mention of something like ENS but we don't need to include every time someone criticises turbinectomy or urges minimising it - these are already covered in the article Dubbin u &#124; t &#124; c 21:39, 11 June 2016 (UTC)


 * I am trying to add to the history. We have nothing about when turbinate surgery began nor any specific descriptions of surgical techniques. Here I offer a simple statement about its origins (in the modern medical era).


 * "During the 19th century, rhinologists developed a number of surgical techniques to reduce turbinate volume." [1][2]
 * [1] Functional Reconstructive Nasal Surgery Egbert H. Huizing, John A. M. de Groot Thieme (2015) ISBN 1-58890-081-9
 * [2] Hol MK, Huizing EH. Treatment of inferior turbinate pathology: a review and critical evaluation of the different techniques. Rhinology. 2000 Dec;38(4):157-66. PMID: 11190749Greybridge (talk) 21:56, 11 June 2016 (UTC)


 * Same answer. That suggestion and those sources are all about turbinectomy which has its own article. This article needs to be focused strictly on ENS. Dubbin u &#124; t &#124; c 22:44, 11 June 2016 (UTC)


 * Incidentally, because of criticism over use of old medical literature like Mason, I was prompted to search for secondary sources discussing such older literature re: turbinectomy and atrophic rhinitis. I apologise for the way I phrased and presented things. Obviously, I lost my focus when combing through these secondary sources because they are so packed with info.Greybridge (talk) 22:08, 11 June 2016 (UTC)

This talk page section was recently added to but I propose archiving it. Dubbin u &#124; t &#124; c 11:28, 12 June 2016 (UTC)

Archiving
I archived some of the longer, older discussions with a fairly low threshold for considering discussions closed. They can be brought back or, preferably, linked to if further discussion is desired. Dubbin u &#124; t &#124; c 11:20, 12 June 2016 (UTC)

Prevention suggested content
[ I don't know how to link or continue from Archive 1 as was suggested]

"David Poetker, co-author of the ENS informational page on the American Rhinologic Society website, said in a 2015 interview that patients should hear about the risk of ENS before turbinate surgery.”

This statement references the need for informed consent vis. ENS.Greybridge (talk) 18:19, 12 June 2016 (UTC)
 * No. Content about health needs to be sourced per WP:MEDRS. If you don't understand MEDRS, please ask at your talk page or someone else's. Jytdog (talk) 19:53, 12 June 2016 (UTC)

Society and Culture - Addition
Greybridge (talk) 20:10, 12 June 2016 (UTC) "David Poetker, co-author of the ENS informational page on the American Rhinologic Society website, said in a 2015 interview that patients should hear about the risk of ENS before turbinate surgery.”

Upgraded to B quality
Our article was reviewed by an independent editor from WikiProject Medicine and upgraded from C to B class. It's been harder than necessary but all those of us with a genuine interest in improving the quality of the article can feel proud about this. Dubbin u &#124; t &#124; c 20:58, 12 June 2016 (UTC)

Prevention
Huizing reference.A supporting reference as you said this needs is:

Actually, this comes from the exact same paragraph in Huizing as "nasal crime" reference 1 in the History section. Here is the full quote: "In our opinion turbinectomy is a nasal crime. We feel there is no reason (apart from malignancies) to resect more than one-third to one-half of the inferior turbinate." page 278 (2003 ed.).

If this is insufficient (in your opinion), I would suggest then that the article content be changed to: "A total or subtotal turbinectomy should not be performed."

Treatment of inferior turbinate pathology relevant quote: "In our opinion, there is no justification for performing a total or subtotal turbinectomy in patients with a hypertrophic inferior turbinate. Turbinectomy is not compatible with the goal of 'preservation of function'. Turbinectomy is irreversible and deprives the nose of one of its important organs. There is thus no place for this technique in modern functional nasal surgery."

Greybridge (talk) 20:59, 12 June 2016 (UTC)


 * This is WP:CHERRYPICKING and not supported by the range of reliable sources we have at hand. This also strays into WP:NOTHOWTO by being too directive.  Jytdog (talk) 21:04, 12 June 2016 (UTC)
 * . It is one of many sources concerning the same medical advice/research determination. What do you mean "not supported by the range of reliable sources we have at hand?" What do I need to do to avoid cherry picking? Provide more sources saying same?
 * "nasal crime" comes from this source, even though you quote Kuan. These are the professors from Utrecht.Greybridge (talk) 21:11, 12 June 2016 (UTC)
 * I only quoted the "nasal crime" thing to show how heated the debated became. If anything you make it clear that the content you want to add is not neutral as it comes from same passage as the "nasal crime" thing which is obviously coming from one wing of the debate.  In any case please deal with the WP:NOTHOWTO objection. Please read WP:MEDMOS if you don't understand.   Thanks. Jytdog (talk) 21:16, 12 June 2016 (UTC)
 * . Huizing, in both sources, extensively reviews all turbinate surgery methods. He actually advocates for many. The one he does not is total or subtotal removal of the inferior turbinate. This prohibition is widely accepted practice among ENTs - who state in the literature "preserve function", and "tissue sparing" techniques. How many corroborating sources are necessary?Greybridge (talk) 22:06, 12 June 2016 (UTC)
 * . You and other editors discussed the "over" resection issue and wondered if there was an amount measured that would constitute this. Well, there is - no total or subtotal turbinectomies.Greybridge (talk) 22:06, 12 June 2016 (UTC)
 * That's a grave misrepresentation of the discussion about the phrase "over-resection". More cherrypicking. Dubbin u &#124; t &#124; c 21:36, 12 June 2016 (UTC)


 * With regard to you dismissing Huizing as non-neutral - As I said elsewhere: There is no real "minority" opinion on supporting total turbinectomy in this day and age.Greybridge (talk) 22:06, 12 June 2016 (UTC)
 * that's a personal opinion absolutely not supported by the good-quality sources. You cannot pretend your view is gospel truth. This approach will get you nowhere. Dubbin u &#124; t &#124; c 21:38, 12 June 2016 (UTC)
 * Your comment here was great on this issue, Dubbin. Jytdog (talk) 22:07, 12 June 2016 (UTC)
 * I'll consider responding when you sign your last two posts here. Jytdog (talk) 21:37, 12 June 2016 (UTC)


 * I see you had to amend the article with respect to "nasal crime" that is because you quoted Kuan without consulting the primary source and thus, you did not have the context. Now you have written off Huizing for no good reason. I doubt you have looked at his voluminous work.


 * This is exactly what I have been saying in my criticism. I have been concerned about this Wikipedia method of sourcing and prohibition again so-called "peer-reviewing" which has a very broad definition. I would suggest when citing a secondary source, you at least consult the source that is being cited within that secondary source.Greybridge (talk) 22:31, 12 June 2016 (UTC)

Society and Culture
@Jytdog Please provide clarification on my content suggestion that you said was WP:COATRACK

How does this differ from quoting Payne in the same section? I know that Dr. Poetker has special involvement with ENS at the American Rhinologic Association, that is why he co authored the Empty Npse Syndrome Article on the ARS website.

Poetker is also mentioned in the Buzzfeed article as being on the board of the ARS.

I thought the phrasing provided authority to the quote. I am happy to accept a revision.

Greybridge (talk) 20:10, 12 June 2016 (UTC) "David Poetker, co-author of the ENS informational page on the American Rhinologic Society website, said in a 2015 interview that patients should hear about the risk of ENS before turbinate surgery.”Greybridge (talk) 21:07, 12 June 2016 (UTC)

]


 * It's not society and culture, it's prevention in the wrong section. Dubbin u &#124; t &#124; c 21:10, 12 June 2016 (UTC)
 * See the sequence of events above where you proposed this under prevention for which this is not adequately sourced.. Read WP:COATRACK.  You cannot try to add content about prevention in the society and culture section.  Advocates try to wedge their advocacy-driven content based on poor sources into the Society and culture section after it is rejected from medical sections all the time.  You are not the first advocate to arrive in Wikipedia and by far not the first to try this move.  It is not valid. Jytdog (talk) 21:12, 12 June 2016 (UTC)

Society and Culture

 * @ Jytdog Please stop calling me an advocate. What am I am advocate for in your opinion? Greybridge (talk) 21:20, 12 June 2016 (UTC)


 * This discussion is not appropriate for an article talk page. Please take it to a user page or simply reflect internally upon it. Dubbin u &#124; t &#124; c 21:24, 12 June 2016 (UTC)
 * I agree. I am sick of the controversy. But, what recourse is there if Jytdog calls me an advocate and uses this to dismiss suggested content? If anything, I advocate for the article to reflect current medical practice and a fair presentation of the literature on ENS as a physical condition. There is no real "minority" opinion on supporting total turbinectomy in this day and age. That is all I have to say on the matter. Thanks. Greybridge (talk) 21:31, 12 June 2016 (UTC)
 * Your proposals are being rejected on the basis of the content policies and guidelines. Not because you are an advocate.  You keeping making proposals that fail because like most advocates, you have not taken the time to understand Wikipedia's content policies and guidelines. Jytdog (talk) 21:39, 12 June 2016 (UTC)

Turbinectomy Turbinate Reduction Turbinate Surgery
The literature uses different terms. They are at times confusing. I use the term turbinectomy the way Huizing does. IF you would take the time to look at his work (which, yes a just a claim here, but is in the lit) you would see the differing modalities of treatment. Some have been abandoned a long time ago as harmful. I have been trying to say that turbinectomy - total and sometimes subtotal are discouraged and are not advocated in mainstream practice.

You have in the article "tissue sparing techinques" in the Prevention section. You see, if a Dr. removes all the inferior turbinate in a turbinectomy this is not "tissue sparing". Let's have some precision in terminology, so that you don't end up through some neutrality-driven idea, giving readers the idea that a total turbinectomy is an alternative...because to counter those ENS "advocates" you to post minority (and barely accepted) views.

This is the ref, although it is better in his book. Treatment of inferior turbinate pathology: a review and critical evaluation of the different techniques Greybridge (talk) 22:18, 12 June 2016 (UTC)


 * once again (for the fourth time?) this article is about empty nose syndrome. Turbinectomy has its own article. This page already summarises the suitable sources that actually examine the relationship between ENS and Turbinectomy. We get that you disapprove of turbinectomy. This is not the place to advocate against it. Dubbin u &#124; t &#124; c 22:22, 12 June 2016 (UTC)

Cost
I had made an error and thought that the cost of the procedure described in the Buzzfeed article was general, for any of the reconstruction procedures discussed in our article, using any of the materials we discuss there. This edit by Ensadvocate made me realize that the cost was specific for the procedure with Alloderm. The information then became a point, rather than a generalization, and not encyclopedic, so I removed it, per my edit note. It would be useful to have the ballpark cost for the reconstruction procedure. Jytdog (talk) 07:29, 13 June 2016 (UTC)


 * There are multiple reconstruction procedures available for ENS the two that I am aware of are available that cost can be verified are alloderm implants which cost approx $9,000 to $14,000 procedure as per buzzfeed. And there are  PRP/Matristem injections to turbinates $1985 for initial bilateral inferior turbinate injections  $1635 for repeat bilateral turbinate injections done by dr das see link http://www.usasinus.org/empty-nose-syndrome. I agree that this information would be helpful for the article at the very least to signify that health insurance does not cover the costs any ideas? Ensadvocate (talk) 08:03, 13 June 2016 (UTC)
 * holy shit that is a huge price differential. Das charges only ~$1.5K for implants??  (his site says he implants matricell and injects PRP)  I wonder if the difference is just human-derived vs pig-derived.  But that is editorializing.  Two points is better than one but to be really encyclopedic and not a "shoppers guide" (which WP is WP:NOT) it would be best to have a source that provides costs generally speaking, which is what I thought the buzzfeed article offered. poop. {PS, you don't need to ping me; this article is on my watchlist :) } Jytdog (talk) 08:21, 13 June 2016 (UTC)
 * I am not against including prices in articles where it can be seen to be encyclopedic, but I would ask you all to consider folks like myself, who live in a country with a National Health Service, and for whom all the talk about health insurance and the cost implications of one procedure versus another simply seem a little bizarre. It's not enough for me to want to argue WP:UNDUE, but please remember that an issue in the USA may be quite different in other English-speaking countries and so sourcing needs to be strong; and I'd appeal to you to try to focus on world-wide aspects of a topic, rather than just those pertaining to a single country - even if it is the good ol' USA. Cheers --RexxS (talk) 11:40, 13 June 2016 (UTC)
 * Makes sense, thanks for the reminder. Jytdog (talk) 11:43, 13 June 2016 (UTC)
 * hmmm :( Jytdog (talk) 11:44, 13 June 2016 (UTC)
 * But here is a mention (the only mention) at NICE, in the writeup for a debrider device used in turbinoplasty for inferior turbinate hypertrophy Jytdog (talk) 11:47, 13 June 2016 (UTC)
 * But here is a mention (the only mention) at NICE, in the writeup for a debrider device used in turbinoplasty for inferior turbinate hypertrophy Jytdog (talk) 11:47, 13 June 2016 (UTC)


 * @jytdog, I was very impressed by your initial decision to state a surgical implant costs $9k-$14k, and insurance doesn't cover this (per BuzzFeed), as it reflects the financial insult/lack of insurance coverage that ENS sufferers face, making the article a bit more complete. The cost of PRP/Matristem injections should not be cited here because that regenerative medicine treatment cannot be included in the treatment section, per our discussion (MEDRS guidelines). Plus, it is understood among the ENS population and per Dr. Das that most people getting PRP/Matristem injections get multiple injections, so the costs add up either way.  Perhaps it would not be best to include the $9k-$14k price, though, as ENS sufferers seem to state there is wide variability in price between countries, although there is a lack of coverage (out of pocket cost) no matter where you go, I believe even where there is National Health Insurance. Perhaps, IMHO, it would be most objective and less like a shopping experience to simply acknowledge that the cost for surgical implants is expensive (or costs thousands) and variable, without insurance coverage." - with a reference to the BuzzFeed articleEducatedonENS (talk) 12:16, 13 June 2016 (UTC)EducatedonENS
 * hmmm but that is just a price for Alloderm which is ECM from humans. Matricell (which is also implanted, like alloderm) is ECM from pigs so cheaper.... Jytdog (talk) 13:08, 13 June 2016 (UTC)
 * True, Matricell can be implanted as sheets (and I have heard of a few cases of this for ENS), but the example above of Matricell is in injections, which it is in powder form.EducatedonENS (talk) 13:13, 13 June 2016 (UTC)EducatedonENS
 * Ah yes like the big picture with the syringe shows. yes.  that would make the procedure itself a lot cheaper.  thanks! Jytdog (talk) 13:19, 13 June 2016 (UTC)
 * We can only write what the sources tell us. We can't use a reference that mentions the cost of a single procedure to make a generalisation about costs and insurance coverage. We either need a single source that reports a general problem, or several sources reporting problems getting different kinds of treatment. Dubbin u &#124; t &#124; c 13:17, 13 June 2016 (UTC)
 * @jytdog, I actually can't access the BuzzFeed article right now to see how it is worded and to comment. But take a quick look at the article (https://web.archive.org/web/20160415014742/http://www.buzzfeed.com/joeloliphint/is-empty-nose-syndrome-real-and-if-not-why-are-people-killin#.pdnbB2Rqaa) and see if it reports a "general" problem or not, as I like the idea of re-including your original statement if the article is reporting a general problem.  Much appreciated.  EducatedonENS (talk) 13:53, 13 June 2016 (UTC)EducatedonENS
 * I'd much prefer not to attempt to collate multiple separate sources in order to survey a range of prices (for example). It starts to run counter to WP:OR and particularly WP:SYNTH, whereas using a single summary source is much more in line with our policy of letting published experts do the analysis and surveys for us. It's OK to use multiple reliable sources from different countries to illustrate different approaches to an issue, but I'd counsel against quoting, say, just a US source of costs alongside a Canadian source of costs, because of the implications of us then becoming the ones making comparisons. Hope that makes sense. --RexxS (talk) 13:58, 13 June 2016 (UTC)


 * Makes sense, RexxS, which is why I was suggested to just look at the BuzzFeed article as the source (as I'm pretty sure you will not find any good information from reliable sources on costs/lack of insurance coverage for ENS implants elsewhere). I found a way to get access to the article.  The BuzzFeed article states "For patients Houser diagnosed with ENS, he developed an AlloDerm implant to mimic the lost turbinate tissue.  Insurance didn't cover the $9,000 to $14,000 procedure, but it seemed to be working.  One of his patients self-published a book about his ENS experience:  Having Nasal Surgery? Don't You Become An Empty Nose Victim!  Houser wrote the foreword."  When I look at this statement, it's not reporting it as a general problem, just one doctor's policy, so I don't think it can be included.EducatedonENS (talk) 15:42, 13 June 2016 (UTC)EducatedonENS


 * Unfortunately I agree. If a journalist phones you up, be sure to tell him the cost and coverage of all the treatment options! Dubbin u &#124; t &#124; c 15:49, 13 June 2016 (UTC)

2 refs

 * Jose J, Coatesworth AP. Inferior turbinate surgery for nasal obstruction in allergic rhinitis after failed medical treatment. Cochrane Database Syst Rev. 2010 Dec 8;(12):CD005235.

Just got this and read it. They found "The number and types of procedures to the inferior turbinates have mushroomed over the years and seem to be driven by the adoption of newer technologies rather than firm evidence that any of these procedures are beneficial for the patient. Moreover, these procedures could potentially result in complications, for example haemorrhage and atrophic rhinitis." (not mention of ENS per se). What did they find?

"We assessed a total of 261 titles and abstracts following full searches in May 2005, November 2009 and July 2010. From these we selected 60 as potentially relevant and obtained these in full text for further assessment. We obtained translations of studies not published in English through the Cochrane Ear, Nose & Throat Disorders Group (Chinese, Japanese and Spanish). .... Following assessment of full-text articles, there were no articles that fulfilled the inclusion criteria of the review. ...Inferior turbinate surgery is commonly performed after failed medical treatment for allergic rhinitis. In the absence of evidence in the literature with regard to its effectiveness, particularly longterm results and complications, one needs to be cautious about selecting this procedure until such evidence becomes available." Jytdog (talk) 11:59, 13 June 2016 (UTC)

Author information Abstract PURPOSE OF REVIEW: There are numerous surgical managements of hypertrophic inferior turbinate. Controversy still exists involving the optimal surgical technique for hypertrophic inferior turbinate. The current review will discuss the most commonly used techniques for turbinate surgery and highlight their recently published clinical outcomes. RECENT FINDINGS: Microdebrider-assisted turbinoplasty, along with total removal of inferior turbinate mucosa, turned out to have no negative impact on healing time and no adverse postoperative events. The majority of recently published studies were focused on surgical outcomes of radiofrequency ablation. It appears that radiofrequency ablation could improve nasal resistance, sense of smell, and nasal mucociliary function. A 1470-nm diode laser was found superior to a conventional 940-nm diode laser in reducing scar formation. Ultrasonic bone aspirator was used to manage hypertrophic inferior turbinate caused by bone enlargement. Few recent literatures report turbinectomy. SUMMARY: Inferior turbinate surgery offers benefit and improves nasal obstruction in patients with hypertrophic inferior turbinate refractory to medical treatment. Rigorously designed study including subjective and objective measurements, control or comparison group, and long-term follow-up should be carried out in the future.
 * Ye T, Zhou B. Update on surgical management of adult inferior turbinate hypertrophy. Curr Opin Otolaryngol Head Neck Surg. 2015 Feb;23(1):29-33.

Says at the end: "Therefore, resection range of inferior turbinate should be based on the severity of nasal obstruction. For example, one-third reduction might be sufficient for patients with mild nasal obstruction; subtotal or total resection might be required for patients with severe nasal obstruction" Jytdog (talk) 12:09, 13 June 2016 (UTC)


 * The first sentence in the aforementioned statement is in line with the scientific consensus, as I understand it - a more aggressive procedure is done to relieve worse nasal obstruction. However, the second sentence is not in line with my understanding of the current scientific consensus that has shifted toward conservative procedures as best, with very, very few doctors performing total resections.EducatedonENS (talk) 12:29, 13 June 2016 (UTC)EducatedonENS


 * I think both of these are really talking about clinical decision-making around turbinate surgery per se, which is best discussed at the turbinectomy page. It doesn't seem like like either has much to say about ENS, and for MEDRS I think we need them to be explicitly about this condition, and the relationship between surgical technique and sebsequent development of ENS, to warrant inclusion. Dubbin u &#124; t &#124; c 13:11, 13 June 2016 (UTC)

Society and Culture - Michael Jackson
I think it would be notable in the society and culture section to cite Michael Jackson and ENS. During the Jackson wrongful death trial (on August 21st, 2012), his family practitioner, Dr. Alimorad Farschian, testified that his insomnia was a direct result of a ‘possible’ “empty nose syndrome.

Secondary source - https://web.archive.org/web/20160415014742/http://www.buzzfeed.com/joeloliphint/is-empty-nose-syndrome-real-and-if-not-why-are-people-killin#.pdnbB2Rqaa

Original Source - https://www.youtube.com/watch?v=vzf3TNHGS3k EducatedonENS (talk) 16:25, 13 June 2016 (UTC)EducatedonENS


 * I think this would be reasonable, as long as we are clear that we are saying it was suggested on the prominent platform, not that MJ had ENS. Suggest waiting for 1 or 2 more replies before adding it. Dubbin u &#124; t &#124; c 17:19, 13 June 2016 (UTC)


 * Sounds good. To save time,  you can see the direct quote at the above youtube link/news clip at 1:50-2:20.  The reporter states that doctors theorized his insomnia was linked to cosmetic surgery, a key part of his nose missing. Then Dr. Farschian remarks, "It's possible he produced what they call empty nose syndrome.". The BuzzFeed article discusses Michael Jackson right after sharing Brett's opening story and before discussing Dr. Houser.  BuzzFeed states " his insomnia could have been a result of empty nose syndrome."EducatedonENS (talk) 20:28, 13 June 2016 (UTC)EducatedonENS


 * Since nobody else has chimed in, why don't you see if you can edit now (you have probably been autoconfirmed so should be able to)? Add a cautiously worded sentence with a brief quotation and cite the Buzzfeed article. Dubbin u &#124; t &#124; c 22:45, 13 June 2016 (UTC)


 * I agree a cautiously worded sentence is appropriateEnsadvocate (talk) 23:06, 13 June 2016 (UTC)


 * OK, I will try to do this in a little bit. Thanks.EducatedonENS (talk) 23:38, 13 June 2016 (UTC)EducatedonENS


 * absolutely no. Hell no. We do  not put this kind of conjectural bullshit into Wikipedia and especially not about famous people.  WP:NOTGOSSIP.  Jytdog (talk) 00:37, 14 June 2016 (UTC)


 * I strongly disagree. It would be total conjecture if a doctor who personally treated Michael Jackson didn't testify at a prominent platform that his insomnia may be related to ENS (as famous doctors in fact conjectured he had ENS and many ENS sufferers also conjectured he had ENS and tried to contact him about ENS while he was still alive), but that's exactly what happened, and this was reported on both the news as well as the BuzzFeed article. It's not gossip.  However, with such strong feelings here, I would like be very interested to hear the viewpoint of RexxS on this matter.EducatedonENS (talk) 01:03, 14 June 2016 (UTC)EducatedonENS
 * key words - "may be". Jytdog (talk) 01:34, 14 June 2016 (UTC)
 * True, but we are not creating news, just relaying what has already been said to the world in reputable sources. Dubbin thought a very carefully worded sentence seemed reasonable, you are strongly opposed...I really would like RexxS to weigh in. EducatedonENS (talk) 01:50, 14 June 2016 (UTC)EducatedonENS
 * I'm really the wrong person to try to give an unbiased view on this issue, because I passionately hate any sort of trivia section in articles. I know this isn't exactly 'trivia' but I have to ask why we would be mentioning this in the article? Is it because Michael Jackson was such a well-known figure? For example, there have arguments in the past over things like "Famous people, past and present, with Parkinson's disease" - you always get battles over whether x, y or z were famous, or "Whether [Muhammad Ali] had Parkinson's disease or a parkinsonism related to boxing", and so on. My preference is always to avoid those sort of problems by just not mentioning people who suffer from a particular condition, although I can understand that having a celebrity who suffered from that condition can help to raise awareness of it. I think I'd feel more comfortable given a solid, sourced diagnosis, but I'm definitely wary of a doctor speculating that "It's possible ..." --RexxS (talk) 01:58, 14 June 2016 (UTC)
 * http://www.mjworld.net/news/2013/07/25/dr-alimorad-farshchian-testifies/ Dr Farshchian said Michael always had trouble sleeping.. “To me his insomnia was caused, possibly, you have this area inside the nose…called turbinates, if you reduced it, it’s called empty nose syndrome, to me that was the cause of that.
 * “Parts of his nose were missing?” Putnam asks.
 * "Portions of his nose were taken out. MJ was very private with everything.” He then explained that at one time he was complaining of insomnia and he was seeing a herbologist for it. Source: ABC& Court News & MJWN....This quotation above makes it seem that Dr. Farschian clearly thought MJ likely suffered from ENS, even if his words are a bit jumbled. There is such little history to ENS and it seems other news sources highlighted the connection early on in their story, such as the BuzzFeed article.  Because Dubbin is the one who really advocated for a nice Wikipedia article, I think he/she should look at all our comments and then make a determination whether we should or should not include this in the article. Thanks for the discussion.EducatedonENS (talk) 03:50, 14 June 2016 (UTC)EducatedonENSEducatedonENS (talk) 02:26, 14 June 2016 (UTC)EducatedonENS
 * "Portions of his nose were taken out. MJ was very private with everything.” He then explained that at one time he was complaining of insomnia and he was seeing a herbologist for it. Source: ABC& Court News & MJWN....This quotation above makes it seem that Dr. Farschian clearly thought MJ likely suffered from ENS, even if his words are a bit jumbled. There is such little history to ENS and it seems other news sources highlighted the connection early on in their story, such as the BuzzFeed article.  Because Dubbin is the one who really advocated for a nice Wikipedia article, I think he/she should look at all our comments and then make a determination whether we should or should not include this in the article. Thanks for the discussion.EducatedonENS (talk) 03:50, 14 June 2016 (UTC)EducatedonENSEducatedonENS (talk) 02:26, 14 June 2016 (UTC)EducatedonENS


 * Well this is an interesting discussion. To me, as regards celebrity health stories, there is a spectrum between pure gossip ('Vanessa Feltz: Friends Fear She's Drinking Custard Again') and demonstrable fact that contributes to a cultural significance for a condition (Billy Connolly announces he has Parkinson's disease). In the latter case, many articles about diseases have a list of celebrities that have the disease.


 * Somewhere in the middle, there are allegations with various degrees of substantiation which become notable because they are the subject of reflection by learned people in reputable sources. Vincent van Gogh's health has a whole article, for instance.


 * This case is in the middle of the spectrum but I think the case is solid.


 * - A doctor who treated him directly...
 * - ...testifies in a court of law that he suspected MJ had the condition, mentioning it by name
 * - ... and this is reported in a third-party news source.


 * The suggestion wouldn't be worthy of inclusion had it happened on Ellen, nor would the testimony be per se had it not been mentioned in a news article about ENS, but to me the combination of all three strengthens the case for a mention that the suggestion was made.


 * For the record I'm surprised to find myself arguing in favour of this! Dubbin u &#124; t &#124; c 07:59, 14 June 2016 (UTC)
 * an orthopedic surgeon treating MJ for drug addiction with naltrexone implants and then making a diagnosis of NPS.   There is nothing about MJ that is not tabloid, it seems.  Jytdog (talk) 08:17, 14 June 2016 (UTC)


 * I thought more about this and it seems to me that there is an important distinction here between a diagnosis made and reported in life, versus one suggested after death. I suggest that the latter (as with Van Gogh) is reasonable to include if it is appropriately conducted and reported as an exercise in scientific/historical scholarship. The former is reasonable to include if (as with Billy Connolly) it is announced and reported and verifiable. We are in a situation that actually meets neither standard - ultimately he's a single doctor making a suggestion after his death. If we had news reports of a confirmed diagnosis made during life it would be a different matter. It's really borderline, still, but I'm minded to err against inclusion (sorry EducatedonENS). Dubbin u &#124; t &#124; c 09:29, 14 June 2016 (UTC)
 * Dubbin No reason to apologize. As a newbie to Wikipedia and the TalkPage format, I thought this was a very healthy discussion and an appropriate, thoughtful, reflective use of the talk page.  A brief musing - my bigger bone of contention is not really with whether MJ should be cited in Wikipedia or not, but rather why MJ's doctor did not acknowledge he had ENS while he was still alive, as he clearly thought he had ENS; further, other doctors speculated there was no way he could have had so many nose surgeries and not have ENS; and it is this issue which is indicative of a far larger problem that ENS patients confront, which has had a huge impact on prevention, understanding, and treatment; in fact, it's amazing there are as many reviews as there are on ENS considering the obstacles.  I will be back when I can find an important, properly sourced piece of information or a new review for ENS.EducatedonENS (talk) 13:44, 14 June 2016 (UTC)EducatedonENS