Empty nose syndrome

Overview

Empty nose syndrome (ENS) is a rare and often misunderstood condition that occurs when the nasal passages feel overly open and dry, despite having normal or even narrowed airflow. Paradoxically, patients often experience a sensation of nasal obstruction or suffocation. ENS typically develops after surgical procedures that remove or reduce the size of the nasal turbinates—structures that warm, humidify, and regulate airflow. The condition can significantly affect quality of life and may lead to chronic physical discomfort and psychological distress.

Causes

The primary cause of empty nose syndrome is the over-resection or destruction of nasal turbinates, usually as a result of nasal or sinus surgery. Contributing factors include:

• Turbinate reduction surgery: Partial or total removal of inferior or middle turbinates during procedures like septoplasty or sinus surgery

• Aggressive surgical technique: Excessive tissue removal leads to disrupted nasal airflow and mucosal drying

• Impaired nasal sensation: Damage to nerve endings may alter perception of airflow, creating a false sense of obstruction

• Secondary atrophy: Chronic inflammation or trauma can cause further deterioration of nasal lining and airflow regulation

Symptoms

ENS symptoms can vary widely in intensity and may include both physical and psychological complaints. Common symptoms include:

• Sensation of nasal obstruction despite clear passages

• Paradoxical difficulty breathing or “air hunger”

• Dryness and crusting inside the nose

• Burning or stinging sensations

• Frequent nosebleeds

• Reduced or altered sense of smell (hyposmia or anosmia)

• Headaches and facial pressure

• Sleep disturbances, fatigue, and anxiety

• Depression or feelings of despair due to chronic symptoms

Diagnosis

Diagnosis of empty nose syndrome can be challenging and is often based on a combination of clinical history, symptom reports, and exclusion of other conditions. Diagnostic steps may include:

• Medical history review: Focus on past nasal surgeries, especially turbinate reduction

• Physical examination: Nasal endoscopy may reveal widened nasal cavities, scarring, or dryness

• CT scan: Used to assess turbinate loss and anatomical changes

• Questionnaires: ENS-specific symptom scoring tools (like ENS6Q) can quantify symptom severity

• Cotton test: Temporary placement of moistened cotton in the nasal cavity to simulate turbinate presence—improvement in symptoms may support ENS diagnosis

• Exclusion of other disorders: Such as chronic sinusitis, allergic rhinitis, or neurologic conditions

Treatment

Treatment for ENS focuses on symptom relief, improving nasal function, and in some cases, surgical reconstruction. Management options include:

• Moisturization therapy:

  • Saline sprays, nasal gels, or humidifiers to reduce dryness and crusting

• Nasal implants or reconstruction:

  • Surgical intervention to restore nasal volume using grafts (e.g., cartilage, alloderm, fat)

  • Goal is to mimic turbinate function and restore normal airflow patterns

• Topical medications: Antibiotics or anti-inflammatory agents for secondary infections or irritation

• Psychological support:

  • Counseling or psychiatric care to address anxiety, depression, and emotional burden

  • Cognitive behavioral therapy (CBT) may be beneficial

• Experimental treatments: Research into nerve regeneration, mucosal healing, and stem cell therapy is ongoing

Prognosis

The prognosis for empty nose syndrome varies by individual. While some patients experience partial relief with medical or surgical treatment, others continue to suffer from persistent symptoms. Early recognition and a comprehensive, multidisciplinary approach can improve outcomes. ENS can have a significant psychological impact, so mental health support is often a critical component of care. Preventing ENS through conservative surgical approaches and preserving turbinate function during nasal procedures remains the best strategy.