What is Empty Nose Syndrome (atrophic rhinitis)?

From the Guidelines

Empty nose syndrome (ENS) should be treated with a focus on reducing crusting and alleviating foul odor through continuous nasal hygiene, such as nasal lavage and crust debridement, as well as the use of topical and/or systemic antibiotics when necessary, as recommended by the updated practice parameter 1. The treatment of ENS involves a combination of approaches to manage symptoms and improve quality of life. Some key considerations include:

• Nasal irrigation with saline or sodium bicarbonate solution to maintain moisture and reduce crusting
• Periodic debridement of crusts, if necessary, to alleviate foul odor and promote healing
• Use of topical antibiotics, such as mupirocin, in the lavage solution for purulent secretions
• Systemic antibiotics when an acute infection is present
• Maintenance of good nasal hygiene to prevent secondary infections and promote comfort It is essential to differentiate between primary and secondary atrophic rhinitis, as the treatment approach may vary depending on the underlying cause. Primary atrophic rhinitis is a chronic condition characterized by progressive atrophy of the nasal mucosa, nasal crusting, and fetor, while secondary atrophic rhinitis develops as a result of other primary conditions, such as chronic granulomatous disorders or excessive surgery to the nasal turbinates 1. The etiology of primary atrophic rhinitis is not yet established, but it is thought to be related to bacterial infections, such as Klebsiella ozaenae, or genetic associations, which require further confirmation 1. In clinical practice, a multidisciplinary approach involving ENT specialists, pain management, and psychological support may be necessary to address the significant impact of ENS on quality of life, including anxiety, depression, and sleep disturbances.

From the Research

Definition and Symptoms of Empty Nose Syndrome

• Empty nose syndrome (ENS) is a clinical entity without a consensual definition, characterized by paradoxical nasal congestion, nasal dryness, epistaxis, and suffocation 2.
• The most common signs and symptoms of ENS include paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea 3, 4.
• ENS is a rare, late complication of turbinate surgery, and its pathogenesis is not well understood 4.

Diagnosis of Empty Nose Syndrome

• The diagnosis of ENS is clinical, though often difficult to make due to the poor correlation between subjective and objective findings 4.
• Diagnostic tools to assess for empty nose syndrome include a validated patient questionnaire and the office cotton test 5.
• Diagnosis is founded on a range of symptoms that need to be precisely collated, and broad post-surgical nasal permeability 3.

Management and Treatment of Empty Nose Syndrome

• Conservative management is generally preferred for ENS, including mucosal humidification, irrigations, and emollients 4.
• Surgical therapy should be reserved for refractory cases and may involve turbinate reconstruction, most commonly using implantable biomaterials 4, 2.
• Treatment involves topical moisturization, behavioral/psychiatric assessment/treatment, and surgical reconstruction 5.
• Surgical options and recent tissue regeneration techniques have demonstrated efficacy in treating ENS, but more detailed investigations are necessary to establish a standardized treatment protocol 2.

Prevention of Empty Nose Syndrome

• Prevention is the most important strategy, and seeks to check the reality of nasal dyspermeability resistant to medical treatment before any surgery is envisaged 3.
• Prevention of this feared complication through turbinate-sparing techniques is essential 4, 5.
• Minimizing inferior and middle turbinate tissue loss can help prevent postprocedural ENS 5.