What is empty nose syndrome?

What is Empty Nose Syndrome?

Empty nose syndrome (ENS) is a rare, debilitating iatrogenic condition that develops after excessive surgical removal of nasal turbinate tissue, characterized by the paradoxical sensation of severe nasal obstruction despite objectively wide nasal airways. 1

Clinical Definition and Pathophysiology

ENS most commonly arises following total or near-total inferior turbinate resection, though it can occur after aggressive middle turbinate surgery as well. 2, 3 The condition represents a complex pathophysiologic process involving:

• Anatomical changes: Loss of turbinate tissue creates abnormally wide nasal cavities with resorption of underlying bone and absence of identifiable turbinates on CT imaging—the characteristic "empty nose" appearance. 1

• Disrupted airflow dynamics: The reduction of nasal mucosal tissue paradoxically increases resistance to airflow, which patients perceive as severe nasal congestion despite objective patency. 1

• Mucosal dysfunction: Progressive atrophy of nasal mucosa leads to loss of pseudostratified epithelium, squamous metaplasia, and atrophy of glandular cells, resulting in profound nasal dryness. 1

• Neurosensory disruption: Deficient neural sensation from loss of mechanoreceptors and thermoreceptors in turbinate tissue contributes to the paradoxical obstruction sensation and dyspnea. 4, 3

Clinical Presentation

The cardinal symptoms of ENS include:

• Paradoxical nasal obstruction: Sensation of blocked nasal breathing despite wide nasal passages 1, 2, 3
• Nasal dryness and crusting: Caused by loss of glandular cells and mucosal atrophy 1, 3
• Persistent dyspnea: Feeling of suffocation or inability to breathe adequately 4, 2
• Nasal burning sensation 4
• Foul odor (fetor): May develop with secondary bacterial colonization 1

Psychological Burden

ENS carries a clinically significant psychological burden that must be recognized and addressed. 5 Patients with ENS demonstrate:

• Moderate to moderately severe depression warranting treatment (mean PHQ-9 score 17.9) 5
• Moderate anxiety symptoms (mean GAD-7 score 12.7) 5
• 62% reduction in work productivity and 65% impairment in daily activities 5
• Intense fixation on nasal obstruction perception 2
• Correlation between ENS symptom severity and worsening depression, anxiety, pain, and functional impairment 5

Distinction from Primary Atrophic Rhinitis

ENS should be distinguished from primary atrophic rhinitis, as they represent different entities with different etiologies. 1

• Primary atrophic rhinitis: Idiopathic condition more prevalent in developing countries with warm climates, with uncertain etiology possibly involving bacterial infection (Klebsiella ozaenae, S. aureus) or genetic factors 1

• Secondary atrophic rhinitis (ENS): Develops directly from iatrogenic causes including excessive turbinate surgery, trauma, irradiation, or chronic granulomatous disorders 1

Diagnostic Approach

Diagnosis is primarily clinical but challenging due to poor correlation between subjective symptoms and objective findings. 3 Key diagnostic tools include:

• Empty Nose Syndrome 6-item Questionnaire (ENS6Q): Validated diagnostic tool with scores ≥11 highly suggestive of ENS 6, 7
• CT imaging: Shows characteristic absence of turbinate tissue and wide nasal cavities 1
• Cotton test: Office-based provocative test where temporary turbinate augmentation with cotton reproduces normal sensation 2
• Documentation of prior turbinate surgery: Essential for confirming iatrogenic etiology 8

Management Strategy

Treatment requires a multimodal approach addressing both anatomical deficits and psychological burden. 5

Medical Management (First-line)

• Continuous nasal hygiene: Intranasal saline or sodium bicarbonate irrigations 1
• Topical moisturization: Emollients and humidification 2, 3
• Periodic crust debridement when necessary 1
• Topical antibiotics (e.g., mupirocin in lavage) for purulent secretions 1
• Systemic antibiotics when acute infection is present 1

Surgical Management (For refractory cases)

Surgical reconstruction should be reserved for patients who fail medical management and involves turbinate augmentation using implantable biomaterials. 9, 2, 3 Recent systematic review data shows:

• Statistically significant improvements in ENS6Q, SNOT, anxiety, and depression scores up to 1 year post-surgery 9
• Promising long-term efficacy after surgical intervention 2
• Surgical intervention appears to be the current mainstay of definitive treatment 9

Psychological Management

Behavioral and psychiatric assessment and treatment are essential components of ENS management. 2, 5 Given the significant depression and anxiety burden, cognitive-behavioral therapy combined with surgical intervention may provide optimal outcomes. 5

Prevention

Prevention through turbinate-sparing surgical techniques is paramount, as ENS is a feared and potentially devastating complication. 1, 2, 3

• Atrophic rhinitis (ENS) is very rare when only submucous resection rather than turbinectomy is performed 1
• Recent prospective data shows subtotal middle turbinate resection for chronic rhinosinusitis with nasal polyps does not cause ENS (no patients developed ENS6Q ≥11) 6
• Medial flap turbinoplasty with or without submucosal reduction is unlikely to cause ENS 7
• Minimize inferior and middle turbinate tissue loss during surgery 2