Empty Nose Syndrome: Symptoms, Types, Causes and Treatment

Empty Nose Syndrome (ENS) is a perplexing and distressing condition that challenges both patients and clinicians. Despite an open nasal cavity, individuals with ENS experience a persistent sensation of nasal blockage, dryness, and a range of physical and psychological symptoms that can significantly impact quality of life. This comprehensive article explores the symptoms, types, causes, and treatment strategies for ENS, synthesizing current research to provide a clear and thorough understanding of this rare but impactful disorder.

Symptoms of Empty Nose Syndrome

Empty Nose Syndrome manifests with a variety of symptoms that can be both physically and psychologically debilitating. Patients often struggle to communicate their experience, as their complaints seem at odds with objective findings during medical examinations. Understanding these symptoms is critical for timely recognition and management.

Symptom	Description	Impact Level	Source(s)
Paradoxical Obstruction	Sensation of nasal blockage despite open airway	High	1, 2, 10
Nasal Dryness	Persistent feeling of dryness in the nose	High	2, 10
Crusting	Formation of nasal crusts or scabs	Moderate	2
Dyspnea	Sensation of breathlessness	Moderate	2, 3
Facial Pain	Discomfort or pain radiating to facial areas	Variable	1, 3
Cool Air Sensation	Abnormal sensitivity to cool or dry air	Moderate	1, 5
Psychological Symptoms	Anxiety, depression, sleep dysfunction	High	3, 4, 12
Loss of Smell	Reduced ability to detect odors	Variable	4, 10

Table 1: Key Symptoms of Empty Nose Syndrome

Paradoxical Nasal Obstruction

Perhaps the most striking and defining symptom of ENS is the sensation of nasal obstruction, despite the nasal passage being objectively open and unobstructed. This “paradoxical” blockage is especially frustrating for patients, as clinical examinations and imaging often reveal a wide, patent nasal cavity, which can lead to misunderstandings or misdiagnosis by healthcare professionals 1, 2, 10.

Dryness and Crusting

ENS frequently results in a persistent dry sensation within the nose, accompanied by crusting or scab formation. This is due to the loss of normal nasal tissue, which disrupts the natural humidification and filtration processes of the nasal passages 2, 10.

Dyspnea and Breathing Difficulties

Patients may experience a constant sensation of breathlessness or “air hunger,” even though airflow is objectively normal or increased. This may be accompanied by difficulty perceiving airflow, contributing to a feeling of not being able to breathe deeply or comfortably 2, 3.

Facial Pain and Sensory Abnormalities

Pain or abnormal sensations, such as cool air “shocks,” can occur in some patients. These symptoms may be triggered or worsened by exposure to cool or dry air, air conditioning, or abrupt environmental changes 1, 5.

Psychological Impact

The burden of ENS extends beyond physical discomfort. Anxiety, depression, sleep dysfunction, and even somatic symptom disorder can occur, often correlating with the severity of nasal symptoms 3, 4, 12, 15. These psychological symptoms can further amplify physical complaints and complicate treatment.

Loss of Smell

Some individuals report a reduced sense of smell, although objective testing may not always confirm this deficit 4, 10. The subjective perception of olfactory loss adds another layer of frustration and affects quality of life.

Types of Empty Nose Syndrome

ENS is not a one-size-fits-all diagnosis. Several subtypes exist, often categorized based on the specific nasal structures involved or the underlying mechanism. Recognizing these types helps tailor both diagnosis and management.

ENS Type	Key Feature	Typical Cause	Source(s)
Inferior Turbinate ENS	Loss/damage to inferior turbinate	Surgery (most common)	2, 10, 13
Middle Turbinate ENS	Loss/damage to middle turbinate	Surgery/resection	1, 10
Mixed ENS	Both inferior & middle turbinates	Extensive surgery	10
ENS-like Syndrome	ENS symptoms with intact turbinates	Non-surgical/unknown	10

Table 2: Main Types of Empty Nose Syndrome

Inferior Turbinate ENS

The majority of ENS cases are linked to the resection or substantial reduction of the inferior turbinate, a critical structure responsible for humidifying, warming, and directing airflow through the nose. Loss of this tissue most commonly follows surgical procedures intended to relieve chronic nasal obstruction or sinus disease 2, 10, 13.

Middle Turbinate ENS

Less commonly, ENS can develop after the removal or significant alteration of the middle turbinate. This variant may present similarly to inferior turbinate ENS but can have unique features depending on the side or extent of resection 1, 10.

Mixed ENS

Some patients experience symptoms following extensive surgeries that remove or damage both inferior and middle turbinates. This “mixed” form may exhibit more severe or complex symptoms due to the compounded loss of nasal structures 10.

ENS-like Syndrome (Non-Surgical ENS)

Interestingly, a subset of individuals presents with ENS symptoms despite having normal-appearing turbinates and no significant surgical history. The causes of this “ENS-like” syndrome remain unclear but may involve altered neurosensory processing or psychological factors 10.

Causes of Empty Nose Syndrome

The development of ENS is typically associated with surgical procedures but can also involve other contributing factors. Understanding the causes helps inform both prevention and management strategies.

Cause	Mechanism	Notes	Source(s)
Turbinate Resection	Loss of tissue/humidification/airflow	Most common cause	1, 2, 10, 13
Altered Airflow	Disrupted aerodynamics	May affect sensation	4, 7, 8, 9, 10
Neurosensory Dysfunction	Impaired trigeminal/thermoreceptor function	May explain symptoms	4, 8, 9, 10
Psychological Factors	Anxiety, depression, somatization	Often comorbid	3, 4, 12, 15
Environmental Triggers	Dry/cool air, weather changes	Exacerbate symptoms	5, 1

Table 3: Main Causes and Contributors to ENS

Turbinate Surgery and Tissue Loss

ENS most frequently develops after surgical reduction or removal of turbinate tissue—especially the inferior turbinate. These procedures are typically performed to treat chronic nasal obstruction, allergic rhinitis, or sinus disease. However, excessive removal can disrupt normal nasal physiology, leading to ENS 1, 2, 10, 13.

Altered Nasal Airflow and Aerodynamics

The turbinates play a pivotal role in directing and regulating airflow. Their loss or alteration can result in abnormal air currents, affecting the way air is sensed within the nose. Notably, computational fluid dynamics studies reveal that while overall airflow may not differ dramatically, subtle changes in distribution and sensation can contribute to symptoms 4, 7, 8, 9, 10.

Neurosensory Dysfunction

ENS is thought to involve impaired function of the trigeminal nerve and associated thermoreceptors, affecting the ability to perceive airflow and temperature. This neurosensory dysfunction may explain the paradoxical sensation of obstruction and air hunger in the absence of physical blockage 4, 8, 9, 10.

Psychological and Psychosomatic Factors

Anxiety, depression, and even somatic symptom disorder are frequently associated with ENS. Psychological distress can both result from and exacerbate nasal symptoms, creating a difficult cycle for patients. Some researchers advocate for considering ENS as part of a broader somatic symptom spectrum, especially in complex or refractory cases 3, 4, 12, 15.

Environmental and Triggering Factors

Although ENS is not restricted to any particular climate, exposure to dry or cool air, air conditioning, and abrupt environmental changes are commonly reported to worsen symptoms. However, large-scale studies have shown that overall climate and geography do not directly correlate with ENS severity 5, 1.

Treatment of Empty Nose Syndrome

Managing ENS is challenging and often requires a personalized, multi-faceted approach. Treatments range from conservative medical therapies to reconstructive surgery and psychosomatic interventions.

Treatment	Approach	Suitability	Source(s)
Nasal Humidification	Saline sprays, humidifiers	Mild/moderate cases	2, 10
Nasal Irrigation	Cleaning, moisturizing	Symptom relief	2, 10
Emollients	Lubricating nasal mucosa	Adjunctive therapy	2, 10
Hyaluronic Acid Gel	Injectable gel for mucosal repair	Less severe cases	11
Surgical Implants	Biomaterials, Medpor, Alloderm	Severe/refractory	1, 13, 14
Psychosomatic Therapy	CBT, antidepressants	Psychological symptoms	3, 6, 12, 15
Prevention	Turbinate-sparing techniques	All patients	2, 10

Table 4: Main Treatment Options for ENS

Conservative Medical Management

The first line of treatment for most ENS patients includes non-surgical, supportive therapies:

• Nasal humidification: Using saline sprays, gels, or humidifiers helps alleviate dryness and crusting 2, 10.
• Nasal irrigation: Regular rinsing with saline can keep the nasal passages clean and moist 2, 10.
• Emollients and lubricants: Application of ointments or gels (such as hyaluronic acid) can provide additional relief, especially in less severe cases 2, 10, 11.

Surgical Interventions

For patients with severe or refractory ENS, surgical options may be considered:

• Turbinate reconstruction: Implantation of biomaterials (such as Medpor, Alloderm, or hyaluronic acid gel) aims to restore nasal anatomy and function. These surgeries can provide meaningful symptom relief, although results may vary and complications can occur 1, 13, 14.
• Custom implants: Materials are shaped and sutured to mimic the missing turbinate tissue, partially filling the nasal cavity and improving airflow dynamics 1, 13.

Psychosomatic and Psychological Therapies

Given the high prevalence of anxiety, depression, and somatization in ENS patients, addressing psychological health is crucial:

• Cognitive behavioral therapy (CBT): Targeted psychotherapy can help manage dysfunctional beliefs and avoidance behaviors, leading to substantial improvement in both mental and physical symptoms 3, 6, 15.
• Pharmacotherapy: Antidepressants or anxiolytics may be indicated, particularly when psychological symptoms are prominent 3, 12, 15.

Preventive Strategies

The best approach to ENS is prevention:

• Turbinate-sparing surgical techniques: Surgeons should avoid unnecessary resection of the inferior and middle turbinates whenever possible 2, 10.
• Careful patient selection and counseling: Patients should be informed of the risks and alternatives before undergoing nasal surgery.

Conclusion

Empty Nose Syndrome is a complex, multifactorial disorder that can profoundly impact a person’s physical comfort and psychological well-being. While advances in research have improved our understanding, effective treatment remains challenging and often requires a holistic, patient-centered approach.

Key Takeaways:

• ENS is characterized by paradoxical nasal obstruction, dryness, crusting, and significant psychological burden 1, 2, 3, 4, 10.
• The main types are defined by which turbinate structures are affected, most commonly the inferior turbinate 1, 2, 10, 13.
• Causes include surgical tissue loss, altered airflow, neurosensory dysfunction, psychological factors, and environmental triggers 4, 8, 9, 10, 5.
• Treatment is multi-pronged, ranging from nasal humidification and emollients to surgical reconstruction and psychosomatic therapy 2, 10, 11, 13, 14, 15.
• Prevention through turbinate-sparing techniques and careful surgical planning is essential 2, 10.

A multidisciplinary approach, combining medical, surgical, and psychological strategies, offers the best hope for patients grappling with the profound challenges of Empty Nose Syndrome.