Empty Nose Syndrome

Empty Nose Syndrome (ENS) was first described in the 1990s as a post-surgical disorder characterized by paradoxical symptomatic nasal obstruction in a patient whose examination displays a patent nasal airway.  Patients may also experience dryness, nasal burning, and a sense of suffocation. Comorbid anxiety and depression often accompany symptoms with patients frequently becoming preoccupied with maintaining sensation of breathing or aprosexia nasalis.

The pathogenesis of ENS is poorly understood. Diagnosis is often difficult given the lack of reliable physical exam findings.  Moreover, symptoms may occur in patients with a grossly normal nasal exam.  Validated assessment tools such as the Empty Nose Syndrome 6-Item Questionnaire and the cotton test are available as adjuncts to assess symptom severity and potential candidacy for surgical intervention.

ENS symptoms, including psychological, can be managed after occurrence through moisturization, counseling, and, in select cases, tissue expansion.

The aggregate knowledge regarding ENS is limited, as the entity is quite rare.  Levels of evidence in the literature regarding ENS are quite low, with most of the literature being case series or expert opinion. Further research into this condition is warranted.

Sources:

1. Chang MT, Bartho M, Kim D, Tsai EF, Yang A, Dholakia SS, Khanwalkar A, Rao VK, Thamboo A, Lechner M, Nayak JV. Inferior Meatus Augmentation Procedure (IMAP) for Treatment of Empty Nose Syndrome. Laryngoscope. 2022 Jun;132(6):1285-1288. doi: 10.1002/lary.30001. Epub 2022 Jan 24. PMID: 35072280.
2. Coste A, Dessi P, Serrano E. Empty nose syndrome. Eur Ann Otorhinolaryngol Head Neck Dis. 2012 Apr;129(2):93-7. doi: 10.1016/j.anorl.2012.02.001. Epub 2012 Apr 16. PMID: 22513047.
3. Dholakia SS, Yang A, Kim D, Borchard NA, Chang MT, Khanwalkar A, Lechner M, Nayak JV. Long-Term Outcomes of Inferior Meatus Augmentation Procedure to Treat Empty Nose Syndrome. Laryngoscope. 2021 Nov;131(11):E2736-E2741. doi: 10.1002/lary.29593. Epub 2021 May 15. PMID: 33991117.
4. Huang CC, Wu PW, Fu CH, Huang CC, Chang PH, Lee TJ. Impact of Psychologic Burden on Surgical Outcome in Empty Nose Syndrome. Laryngoscope. 2021 Mar;131(3):E694-E701. doi: 10.1002/lary.28845. Epub 2020 Jul 21. PMID: 32692881.
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10. Talmadge J, Nayak JV, Yao W, Citardi MJ. Management of Postsurgical Empty Nose Syndrome. Facial Plast Surg Clin North Am. 2019 Nov;27(4):465-475. doi: 10.1016/j.fsc.2019.07.005.PMID: 31587766
11. Thamboo A, Velasquez N, Habib AR, Zarabanda D, Paknezhad H, Nayak JV. Defining surgical criteria for empty nose syndrome: Validation of the office-based cotton test and clinical interpretability of the validated Empty Nose Syndrome 6-Item Questionnaire. Laryngoscope. 2017 Aug;127(8):1746-1752. doi: 10.1002/lary.26549. Epub 2017 Mar 27. PMID: 28349563.
12. Passàli D, Lauriello M, Anselmi M, Bellussi L. Treatment of the inferior turbinate: long-term results in 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol. 1999 June;108(6):569-75. doi:
13. Manji J, Nayak J, Thamboo A. The functional and psychological burden of empty nose syndrome. Int Forum Allergy Rhinol. 2018 Jun;8(6):707-712. doi: 10.1002/alr.22097. Epub 2018 Feb 14.PMID: 29443458
14. Zhong Y, Deng Z, Chen H, et al. Evaluation of sinonasal-related quality of life of 49 patients undergoing endoscopic skull base surgery. Braz J Otorhinolaryngol 2024 Jan-Feb;90(1):101337. doi: 10.1016/j.bjorl.2023.101337. Epub 2023 Oct 3.PMID: 37983990

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Position statements are approved by the American Academy of Otolaryngology–Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.