Empty Nose Syndrome

How the nose normally senses airflow

The turbinates are bony shelves covered by soft, blood-rich tissue along the side walls of the nose. They warm and humidify air, filter it, and direct airflow over the nasal lining. Nerve endings in the lining, particularly cold receptors (TRPM8), detect the cooling effect of moving air. This cooling is what the brain interprets as "breathing through my nose".

When too much turbinate tissue is removed, airflow becomes abnormal, the lining dries and the cooling sensation is reduced. The brain may then interpret the nose as blocked, even though the passages are open.

Causes and risk factors

• Turbinate surgery: usually done for turbinate hypertrophy, often with a deviated septum repair. Total or near-total removal (turbinectomy) of the inferior turbinates carries the highest risk. Modern techniques that preserve tissue, such as submucosal reduction, make ENS rare.
• Middle turbinate resection during sinus surgery.
• Other surgery or injury that removes nasal tissue.
• Radiation therapy to the nose.

Not everyone with reduced turbinates develops ENS, and some people develop symptoms after relatively conservative surgery. Anxiety and other individual factors may influence how strongly symptoms are felt.

Symptoms

• a paradoxical feeling of nasal blockage or inability to feel air passing through the nose
• feeling of suffocation or air hunger, sometimes worse at night
• nasal dryness, burning, crusting
• a sensation of the nose being "too open" or of air rushing through
• thick mucus or post-nasal drip
• headaches and facial pain
• poor sleep (insomnia) and daytime fatigue
• difficulty concentrating
• anxiety, depression and, in some people, suicidal thoughts

Diagnosis

There is no single definitive test. An ENT specialist will:

• take a detailed history of symptoms and past surgery
• examine the nose with an endoscope, typically finding reduced or absent turbinate tissue and wide passages
• order a CT scan to assess remaining turbinate volume and exclude sinus disease
• use the ENS6Q questionnaire, which scores the six most characteristic symptoms
• perform a cotton test: placing moistened cotton in the area where tissue is missing for 20 to 30 minutes. If breathing feels better, it suggests ENS and predicts whether surgical rebuilding might help

Other conditions are ruled out, such as chronic sinusitis, a remaining septal deviation, nasal valve collapse, or rhinitis medicamentosa.

Treatment

Conservative care

• Humidify: use a bedroom humidifier and drink plenty of fluids.
• Saline sprays and rinses several times a day to keep the lining moist and clear crusts.
• Nasal gels and ointments: saline gel, or ointments recommended by your ENT doctor.
• Avoid irritants: smoke, dry heated air and decongestant sprays.
• Treat associated symptoms: sleep disturbance, anxiety and depression, with counseling, cognitive behavioral therapy and medicines when appropriate. Mental health care is a core part of treatment, not an afterthought.

Surgical options

For selected people with a positive cotton test, surgery can restore volume and redirect airflow by placing implants under the lining of the nasal side walls or septum. Materials include cartilage, acellular dermis or other grafts and synthetic implants. Studies report improvement in many patients, though results vary and the evidence comes mainly from smaller series.

Prevention

ENS is largely preventable. Most surgeons now avoid total turbinate removal and use tissue-sparing turbinate reduction. If you are considering nasal surgery, ask exactly what will be done to the turbinates and how much tissue will be preserved.

Outlook

ENS can significantly affect quality of life, sleep and mental health. Many people improve with a combination of moisturizing care, psychological support and, for some, reconstructive surgery. Symptoms often become more manageable over time.

Frequently asked questions

What is empty nose syndrome?

Empty nose syndrome is a rare condition where the nose feels blocked or the person feels short of air, even though the nasal passages are wide open. It usually follows surgery that removed or reduced the turbinates.

What causes empty nose syndrome?

It is mainly caused by excessive removal of turbinate tissue, which disrupts airflow, dries the nasal lining and reduces the nerve sensation of air moving through the nose. The brain interprets this as blockage.

How is empty nose syndrome diagnosed?

An ENT specialist uses your history, nasal endoscopy and a CT scan, along with the ENS6Q symptom questionnaire. A cotton test, placing moist cotton where tissue was removed, can show whether restoring volume improves breathing.

Can empty nose syndrome be treated?

Yes. Humidification, saline rinses and gels relieve dryness and crusting. Treating anxiety, depression and sleep problems is important. Some people benefit from surgery that places implants inside the nose to restore lost volume.