EMPTY NOSE
SYNDROME

Definition
• Empty Nose Syndrome (ENS) is an iatrogenic
disorder - a complication of nasal surgery - where
the nasal turbinates, especially the inferior
turbinates, have been excised or damaged as a
result of turbinate surgery causing the
destruction of normal nasal physiology.
• ENS can be considered a nasal breathing disorder
(characterized by paradoxical obstruction) along
with concomitant nasal dryness (atrophy).

Epidemiology
• Empty Nose Syndrome affects a small number of
the population and the incidence is not known
because there are no specific studies which have
investigated the incidence of ENS.
• The absence of incidence-related studies is
directly related to the lack of awareness about
ENS among medical professionals.
• This has resulted in the absence of diagnostic
criteria and omission of a diagnosis of ENS in
patient records.

Etiology
• ENS occurs following turbinate surgery and
can emerge months to years afterward.
• Some turbinate procedures increase the
likelihood of ENS, such as partial or total
resection of the inferior nasal turbinates, or
mucosal surface cautery.
• Risk of ENS increases the greater the
turbinates are excised or damaged.

CT before inferior
turbinate resection
CT after inferior
turbinate resection

Clinical Presentation
• Nasal congestion, even
though your passageways
are clear.
• Nosebleeds.
• A sensation that the air
you inhale is too cold or
dry.
• Dizziness.
• Reduced mucus
production.
• Severe nasal dryness.
• Reduced sensation of
breathing.
• Headaches.
• Sensation of drowning.
• Post-nasal drip.
• Pain.
• Inflammation.
• Problems with taste
(ageusia) or smell
(anosmia).
• Insomnia and daytime
sleepiness.
• Tiredness.

Classification
Four types have been proposed:
• ENS-IT: Inferior turbinate (IT) was fully or partially
resected.
• ENS-MT: Middle turbinate (MT) was fully or
partially resected.
• ENS-both: Both the IT and MT were both at least
partially resected.
• ENS-type: Patient appears to have adequate
turbinate tissue but suffers ENS symptoms due to
damage to the mucosal surface of the turbinates.

Diagnosis
• Diagnosing ENS can be difficult. There is still no definitive
diagnostic criteria or reliable tests for the syndrome.
• ENS is usually diagnosed by ruling out other conditions that
can cause similar symptoms.
• Some ENT specialists will diagnose it based on a person’s
symptoms and by checking turbinate damage on a CT scan.
• A person’s nasal passage airflow may also be tested. The
specialist may find that a person’s nose is too open, causing
a low rate of airflow
• If a doctor suspects ENS, they may perform a cotton test.
This is where a small piece of moist cotton is held where
the turbinate would be. If it provides relief, the person may
be suffering from ENS. However, the cotton test is not a
recognized diagnostic tool, and it should not replace a full
diagnosis.

Management
Some common treatments include:
• Using a humidifier at home.
• Saline sprays to moisturize nasal passages.
• Antibiotic nasal applications for infections.
• Applying hormonal creams to the inside of the nose to
increase turbinate tissue size.
• Sildenafil and other phosphodiesterase inhibitors to
increase nasal congestion.
• Nasal reconstructive surgery and regenerative
medicine treatments can result in some improvement
in symptoms.

Prognosis
• Moderate relief may be found through surgery or
medication. Controlling symptoms as much as
possible can help improve the person’s quality of
life.
• Mental health can also play an important role in
recovery for some people. Regular checkups can
help relieve the mental stress and anxiety
associated with the disorder.
• There is currently no cure for ENS. Working with
qualified ENT (ear, nose, and throat) specialists
and mental health professionals gives a person
the best chance of treating or reducing the
symptoms of ENS.