American Rhinologic Society about Empty Nose Syndrome

### Empty Nose Syndrome: An Overview

#### Introduction

Empty Nose Syndrome (ENS) is a rare but significant complication arising from nasal surgery, notably following the removal of lower turbinate tissue. Turbinates, key structures within the nasal passages, are essential for filtering, humidifying air, and sensing airflow. Conditions like allergic rhinitis or excessive use of decongestant sprays can cause turbinates to swell, leading to nasal obstruction. Surgical interventions are employed when medical treatments fail, aiming to enhance nasal airflow by altering the size and position of the turbinates. While surgery often alleviates nasal obstruction and reduces medication dependency, it can sometimes lead to ENS—a condition marked by a sensation of nasal dryness, crusting, and obstructive symptoms despite open nasal passages. The development of ENS is linked to aggressive tissue removal and nerve damage. Surgeons have adapted more conservative approaches to reduce ENS risk, utilizing techniques like submucous resection and radiofrequency ablation. However, the precise incidence of ENS remains unclear, with many patients still affected. Available treatments aim to improve quality of life for those suffering from this condition.

#### Symptoms

The hallmark of ENS is the perception of reduced nasal airflow. Despite open nasal passages, patients often feel their nose is too open due to decreased nasal resistance. Common symptoms include dryness in the nasal passages and throat, burning sensations, and crusting. Some patients report a suffocating feeling, accompanied by anxiety, depression, and poor sleep quality, which can significantly impact their daily life and work performance.

#### Causes

Nasal turbinates, composed of thin bone and mucosal lining with a rich blood supply, play a crucial role in warming and humidifying inhaled air. They also contain erectile tissue that periodically swells, creating alternating resistance patterns that may prevent pressure ulcers during sleep. The exact functions of turbinates are not fully understood, but they are believed to contribute to nasal resistance and airflow regulation. Removing large portions of turbinates can destroy many of the sensory nerves responsible for detecting air movement, leading to impaired regulation of nasal warmth and humidity. This results in dryness, crusting, and an increased presence of unhealthy bacteria. The altered airflow can also diminish the sense of smell and contribute to shallow breathing, potentially affecting oxygen exchange and causing a sensation of suffocation.

#### Diagnosis

Diagnosis of ENS often involves a thorough evaluation using the Empty Nose Syndrome 6-item Questionnaire (ENS6Q), which assesses the severity and impact of symptoms. Nasal endoscopy and computed tomography (CT) scans can help visualize nasal structures and identify any mucosal atrophy or other conditions. The Cotton Test, where saline-soaked cotton is placed in the nasal passages, may be used to determine if symptoms improve with added moisture, guiding potential nasal enhancement procedures.

#### Treatments

Conservative treatments focus on nasal hygiene and moisturization through saline sprays, gels, oils, and irrigations. Humidifying the environment and using menthol in topical treatments can offer temporary relief. However, these methods may need frequent application and can disrupt natural mucosal protection. In cases of bacterial overgrowth, topical antibiotics may help, and topical steroids can reduce inflammation. Other treatments like estrogen creams and phosphodiesterase inhibitors aim to promote mucosal growth. Living in a humid coastal climate can also alleviate symptoms. Despite these options, many patients find inconsistent relief from conventional therapies.

#### Surgical Options

For severe ENS cases, surgery may be considered after failed conservative treatments. Surgical approaches involve augmenting the remaining turbinate tissue or implanting materials in the nasal passages to restore resistance and improve airflow patterns. Temporary materials such as hyaluronic acid may be used initially to gauge effectiveness before more permanent implants are considered. Various implant materials, including Gore-Tex, acellular dermis, hydroxyapatite, and cartilage, have shown efficacy in improving ENS symptoms. However, complications, though infrequent, may include symptom persistence, eye tearing, implant extrusion, or chronic rhinosinusitis. Some centers offer regenerative therapies like platelet-rich plasma and stem cell treatments, though their effectiveness remains uncertain.

#### Psychological Impact and Support

ENS often leads to significant psychological distress, including anxiety and depression, due to the chronic discomfort and its impact on daily life. Insurance coverage for ENS treatments may be limited, exacerbating the stress for affected individuals. Cognitive behavioral therapy and counseling can provide support for managing anxiety and depression, and medications may also be beneficial.

#### Further Information

For more detailed information or to find a rhinology specialist, visit the American Rhinologic Society's website at [American Rhinologic Society](https://www.american-rhinologic.org/).