Empty Nose Syndrome

  • Edward C. Kuan
  • Jeffrey D. Suh
  • Marilene B. WangEmail author
Rhinitis (JJ Oppenheimer and J Corren, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Rhinitis


Empty nose syndrome (ENS) is a rare, late complication of turbinate surgery. The most common clinical symptoms are paradoxical nasal obstruction, nasal dryness and crusting, and a persistent feeling of dyspnea. Little is known about the pathogenesis of ENS, though it is speculated that anatomical changes leading to alterations in local environment, disruption of mucosal cooling, and disruption of neurosensory mechanisms are strongly implicated. The diagnosis is clinical, though often difficult to make due to the poor correlation between subjective and objective findings. Medical therapies include mucosal humidification, irrigations, and emollients. Surgical therapy should be reserved for refractory cases and may involve turbinate reconstruction, most commonly using implantable biomaterials. Ultimately, prevention of this feared complication through turbinate-sparing techniques is essential.


Empty nose Turbinates Atrophic rhinitis 


Compliance with Ethics Guidelines

Conflict of Interest

Edward C. Kuan, Jeffrey D. Suh, and Marilene Wang declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Financial Disclosures



Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.••
    Chhabra N, Houser SM. The diagnosis and management of empty nose syndrome. Otolaryngol Clin N Am. 2009;42(2):311–30, ix. doi: 10.1016/j.otc.2009.02.001. In-depth discussion of the differences between atrophic rhinitis and empty nose syndrome, with review of both medical and surgical therapies.
  2. 2.•
    Houser SM. Surgical treatment for empty nose syndrome. Arch Otolaryngol Head Neck Surg. 2007;133(9):858–63. doi: 10.1001/archotol.133.9.858. Review of techniques and outcomes of turbinate augmentation/reconstruction surgery. PubMedCrossRefGoogle Scholar
  3. 3.
    Payne SC. Empty nose syndrome: what are we really talking about? Otolaryngol Clin N Am. 2009;42(2):331–7. doi: 10.1016/j.otc.2009.02.002. ix-x.CrossRefGoogle Scholar
  4. 4.
    Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol. 2001;15(6):355–61.PubMedGoogle Scholar
  5. 5.••
    Sozansky J, Houser SM. Pathophysiology of empty nose syndrome. Laryngoscope. 2014. doi: 10.1002/lary.24813. Well-researched article highlighting the purported pathophysiology of empty nose syndrome.PubMedGoogle Scholar
  6. 6.
    Naftali S, Rosenfeld M, Wolf M, Elad D. The air-conditioning capacity of the human nose. Ann Biomed Eng. 2005;33(4):545–53.PubMedCrossRefGoogle Scholar
  7. 7.
    Scheithauer MO. Surgery of the turbinates and “empty nose” syndrome. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010;9:Doc03. doi: 10.3205/cto000067
  8. 8.
    Zhao K, Blacker K, Luo Y, Bryant B, Jiang J. Perceiving nasal patency through mucosal cooling rather than air temperature or nasal resistance. PLoS One. 2011;6(10):e24618. doi: 10.1371/journal.pone.0024618.PubMedCentralPubMedCrossRefGoogle Scholar
  9. 9.
    Zhao K, Jiang J, Blacker K, Lyman B, Dalton P, Cowart BJ, et al. Regional peak mucosal cooling predicts the perception of nasal patency. Laryngoscope. 2014;124(3):589–95. doi: 10.1002/lary.24265.PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Sullivan CD, Garcia GJ, Frank-Ito DO, Kimbell JS, Rhee JS. Perception of better nasal patency correlates with increased mucosal cooling after surgery for nasal obstruction. Otolaryngol Head Neck Surg. 2014;150(1):139–47. doi: 10.1177/0194599813509776.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Lindemann J, Tsakiropoulou E, Scheithauer MO, Konstantinidis I, Wiesmiller KM. Impact of menthol inhalation on nasal mucosal temperature and nasal patency. Am J Rhinol. 2008;22(4):402–5. doi: 10.2500/ajr.2008.22.3194.PubMedCrossRefGoogle Scholar
  12. 12.
    McBride B, Whitelaw WA. A physiological stimulus to upper airway receptors in humans. J Appl Physiol Respir Environ Exerc Physiol. 1981;51(5):1189–97.PubMedGoogle Scholar
  13. 13.
    Freund W, Wunderlich AP, Stocker T, Schmitz BL, Scheithauer MO. Empty nose syndrome: limbic system activation observed by functional magnetic resonance imaging. Laryngoscope. 2011;121(9):2019–25. doi: 10.1002/lary.21903.PubMedGoogle Scholar
  14. 14.
    Ophir D, Schindel D, Halperin D, Marshak G. Long-term follow-up of the effectiveness and safety of inferior turbinectomy. Plast Reconstr Surg. 1992;90(6):980–4. discussion 5–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Talmon Y, Samet A, Gilbey P. Total inferior turbinectomy: operative results and technique. Ann Otol Rhinol Laryngol. 2000;109(12 Pt 1):1117–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Eliashar R. Total inferior turbinectomy: operative results and technique. Ann Otol Rhinol Laryngol. 2001;110(7 Pt 1):700.PubMedGoogle Scholar
  17. 17.
    Lawson W. The intranasal ethmoidectomy: an experience with 1,077 procedures. Laryngoscope. 1991;101(4 Pt 1):367–71.PubMedGoogle Scholar
  18. 18.
    Lee DH, Yoon TM, Lee JK, Joo YE, Kim IY, Jang WY, et al. Clinical utility of the inferior turbinate flaps in the reconstruction of the nasal septum and skull base. J Craniofac Surg. 2012;23(4):e322–6. doi: 10.1097/SCS.0b013e3182543410.PubMedCrossRefGoogle Scholar
  19. 19.
    Schumacher MJ. Nasal congestion and airway obstruction: the validity of available objective and subjective measures. Curr Allergy Asthma Rep. 2002;2(3):245–51.PubMedCrossRefGoogle Scholar
  20. 20.
    Lam DJ, James KT, Weaver EM. Comparison of anatomic, physiological, and subjective measures of the nasal airway. Am J Rhinol. 2006;20(5):463–70.PubMedCrossRefGoogle Scholar
  21. 21.
    Yepes-Nunez JJ, Bartra J, Munoz-Cano R, Sanchez-Lopez J, Serrano C, Mullol J, et al. Assessment of nasal obstruction: correlation between subjective and objective techniques. Allergol Immunopathol (Madr). 2013;41(6):397–401. doi: 10.1016/j.aller.2012.05.010.CrossRefGoogle Scholar
  22. 22.
    Jang YJ, Kim JH, Song HY. Empty nose syndrome: radiologic findings and treatment outcomes of endonasal microplasty using cartilage implants. Laryngoscope. 2011;121(6):1308–12. doi: 10.1002/lary.21734.PubMedCrossRefGoogle Scholar
  23. 23.
    Thomas 3rd WW, Harvey RJ, Rudmik L, Hwang PH, Schlosser RJ. Distribution of topical agents to the paranasal sinuses: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 2013;3(9):691–703. doi: 10.1002/alr.21172.PubMedCrossRefGoogle Scholar
  24. 24.
    Papay FA, Eliachar I, Risica R. Fibromuscular temporalis graft implantation for rhinitis sicca. Ear Nose Throat J. 1991;70(6):381–4.PubMedGoogle Scholar
  25. 25.
    Jung JH, Baguindali MA, Park JT, Jang YJ. Costal cartilage is a superior implant material than conchal cartilage in the treatment of empty nose syndrome. Otolaryngol Head Neck Surg. 2013;149(3):500–5. doi: 10.1177/0194599813491223.PubMedCrossRefGoogle Scholar
  26. 26.
    Saafan ME. Acellular dermal (alloderm) grafts versus silastic sheets implants for management of empty nose syndrome. Eur Arch Otorhinolaryngol. 2013;270(2):527–33. doi: 10.1007/s00405-012-1955-1.PubMedCrossRefGoogle Scholar
  27. 27.
    Rice DH. Rebuilding the inferior turbinate with hydroxyapatite cement. Ear Nose Throat J. 2000;79(4):276–7.PubMedGoogle Scholar
  28. 28.
    Modrzynski M. Hyaluronic acid gel in the treatment of empty nose syndrome. Am J Rhinol Allergy. 2011;25(2):103–6. doi: 10.2500/ajra.2011.25.3577.PubMedCrossRefGoogle Scholar
  29. 29.
    Goldenberg D, Danino J, Netzer A, Joachims HZ. Plastipore implants in the surgical treatment of atrophic rhinitis: technique and results. Otolaryngol Head Neck Surg. 2000;122(6):794–7.PubMedCrossRefGoogle Scholar
  30. 30.
    Jiang C, Shi R, Sun Y. Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome. Laryngoscope. 2013;123(5):1106–11. doi: 10.1002/lary.23908.PubMedCrossRefGoogle Scholar
  31. 31.
    Tam YY, Lee TJ, Wu CC, Chang PH, Chen YW, Fu CH, et al. Clinical analysis of submucosal Medpor implantation for empty nose syndrome. Rhinology. 2014;52(1):35–40. doi: 10.4193/Rhin.PubMedGoogle Scholar
  32. 32.
    Jiang C, Wong F, Chen K, Shi R. Assessment of surgical results in patients with empty nose syndrome using the 25-item Sino-Nasal Outcome Test Evaluation. JAMA Otolaryngol Head Neck Surg. 2014;140(5):453–8. doi: 10.1001/jamaoto.2014.84.PubMedCrossRefGoogle Scholar
  33. 33.
    Young A. Closure of the nostrils in atrophic rhinitis. J Laryngol Otol. 1971;85(7):715–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Lobo CJ, Hartley C, Farrington WT. Closure of the nasal vestibule in atrophic rhinitis–a new non-surgical technique. J Laryngol Otol. 1998;112(6):543–6.PubMedCrossRefGoogle Scholar
  35. 35.
    el Kholy A, Habib O, Abdel-Monem MH, Abu SS. Septal mucoperichondrial flap for closure of nostril in atrophic rhinitis. Rhinology. 1998;36(4):202–3.PubMedGoogle Scholar
  36. 36.
    Rice DH, Kern EB, Marple BF, Mabry RL, Friedman WH. The turbinates in nasal and sinus surgery: a consensus statement. Ear Nose Throat J. 2003;82(2):82–4.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Edward C. Kuan
    • 1
  • Jeffrey D. Suh
    • 1
  • Marilene B. Wang
    • 1
    Email author
  1. 1.Department of Head and Neck SurgeryDavid Geffen School of Medicine at UCLALos AngelesUSA

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