OVERVIEW

What is Empty Nose Syndrome?

Empty Nose Syndrome (ENS) refers to nasal abnormalities and a series of complications caused by excessive resection of the nasal turbinates during turbinectomy. It is a disease resulting from structural loss and is also known as iatrogenic secondary atrophic rhinitis.

Is Empty Nose Syndrome a possible complication after all nasal surgeries?

No.

Destructive surgery on the inferior turbinates carries a risk of ENS, but the exact incidence rate remains uncertain.

What are the types of Empty Nose Syndrome?

• Inferior Turbinate Type: Secondary to inferior turbinate surgery, the most common subtype;

• Middle Turbinate Type: Secondary to middle turbinate surgery;

• Middle and Inferior Turbinate Type: Secondary to both inferior and middle turbinate surgery, the most severe subtype;

• ENS-like Syndrome: Minimal loss of nasal turbinate mucosal tissue after nasal surgery, with normal-appearing nasal volume but symptoms resembling ENS.

SYMPTOMS

What are the symptoms of empty nose syndrome?

The five common symptoms of empty nose syndrome are: paradoxical nasal obstruction; difficulty breathing; dryness of the nose and throat; reduced sense of smell; and depression.

Paradoxical nasal obstruction refers to objectively unobstructed breathing but a subjective feeling of severe difficulty breathing. This means the nasal cavity is overly wide, causing chaotic airflow, an inability to sense airflow, and difficulty breathing.

Is empty nose syndrome serious?

Patients with empty nose syndrome often experience intense suffocation, leading to sleep disturbances, difficulty concentrating, and challenges in performing daily tasks. Over time, psychological symptoms such as depression and anxiety may develop, potentially severely impacting quality of life.

CAUSES

What are the causes of Empty Nose Syndrome?

The nasal mucosa is densely distributed with glands and receptors (sensory, temperature, tactile), so the turbinates play roles in humidification, temperature regulation, air filtration, airflow control, and airflow sensing. The unique anatomical structure of the nose provides appropriate nasal resistance, regulating nasal airflow and ensuring laminar flow.

When the distinctive anatomical features of the nasal cavity are compromised, nasal resistance decreases, leading to severe airflow disturbances and reduced mucosal sensitivity and humidification efficiency for airflow.

Proper nasal breathing resistance is essential for good lung function. An abnormally enlarged nasal cavity alters nasal resistance, indirectly affecting lung function and causing complex symptoms such as breathing difficulties. Without timely treatment, persistent nasal obstruction and breathing difficulties may progress, with some patients experiencing a sense of suffocation. Additionally, the turbinates may serve as a source of nerve growth factors.

The occurrence of Empty Nose Syndrome can be attributed to two fundamental conditions:

• Surgery damages sensory nerves on part of the mucosal surface;

• The damaged nerves exhibit regenerative dysfunction.

DIAGNOSIS

How is Empty Nose Syndrome Diagnosed?

The diagnostic criteria include:

• Medical history: Previous history of middle or inferior turbinate resection, partial resection, or related surgeries.

• Clinical manifestations: Patients exhibit at least nasal obstruction, dryness in the nasal cavity, nasopharynx, and pharynx. Some may also experience nasal crusting, purulent discharge, bloody secretions, chest tightness, shortness of breath, or depression.

• Nasal examination: The nasal valve area appears abnormally wide and open, with a cylindrical nasal cavity. The nasal mucosa shows significant damage, dryness, and pallor, sometimes accompanied by crusts or purulent/bloody secretions. The turbinates are reduced to varying degrees or even absent.

• Nasal resistance measurement: Values are lower than normal.

• Cotton test: A saline-moistened cotton pad of appropriate size is placed at the site of intended turbinate repair or grafting. If the patient's symptoms improve significantly after 20–30 minutes of normal breathing, it supports the diagnosis of empty nose syndrome.

• Sinus examination: Some cases reveal mucosal atrophy in the nasal cavity or turbinates, with unobstructed nasal passages, serving as auxiliary diagnostic evidence.

TREATMENT

Which department should I visit for Empty Nose Syndrome?

Otolaryngology (ENT). If Empty Nose Syndrome severely impacts daily life, seeking help from the psychiatry or psychology department is advisable.

What are the treatment options for Empty Nose Syndrome?

Treatment for Empty Nose Syndrome is divided into conservative therapy and surgical intervention.

Conservative therapy focuses on nasal hygiene and moisturizing the nasal mucosa but cannot restore missing or damaged turbinates. Specific methods include:

• Daily nasal irrigation with saline solution;
• Oily lubricants to help keep the nasal mucosa moist;
• Using a humidifier while sleeping, etc.

Surgical treatment involves implanting materials to fill partially resected turbinates, reducing the excessively enlarged nasal cavity.

• Common implant materials include acellular dermal matrix, autologous cartilage grafts, and artificial bone.

What is the goal of Empty Nose Syndrome treatment?

To moisturize the nasal cavity and increase the size of remaining turbinate tissue to raise air pressure within the nose.

What are the ideal objectives of surgical treatment for Empty Nose Syndrome?

• Limit airflow to allow the nasal mucosa to better handle it while ensuring sufficient air passage for all respiratory needs (also known as normalizing nasal resistance);
• Restore normal nasal mucosal temperature and humidity;
• Normalize nasal airflow patterns;
• Increase the mucosal surface area in contact with airflow, enhancing airflow sensation to improve perception.

Will filling surgery cure Empty Nose Syndrome?

Undergoing filling surgery does not guarantee a cure.

Many patients fail to recover after multiple filling surgeries, either due to severe turbinate loss or insufficient preoperative research.

What precautions should be taken for Empty Nose Syndrome filling surgery?

Preoperative cotton packing testing is essential. This diagnostic and presurgical method simulates surgical effects to assist in planning and identifying optimal graft placement.

DIET & LIFESTYLE

What should be paid attention to in daily life with empty nose syndrome?

• Pay attention to nasal hygiene and keep the nasal mucosa moist;

• Regular physical activity and a healthy lifestyle are also important.

How should patients with empty nose syndrome be cared for?

• Patiently explain the condition and provide necessary psychological guidance;

• Avoid letting the patient complain excessively, and help them continuously learn and explore treatment options.

PREVENTION

Can Empty Nose Syndrome Be Prevented?

Empty Nose Syndrome may be related to excessive resection of the turbinates. Avoiding turbinectomy, preserving the entire inferior turbinate, and protecting the nasal mucosa can prevent Empty Nose Syndrome. Therefore, turbinectomy should be approached cautiously, and excessive surgical treatment must be avoided.