Purpose of Review
The purpose of this review is to summarize the current literature regarding empty nose syndrome (ENS). This review explores the significance and role that surgery plays in the development of ENS.
ENS may occur as consequence of nasal airflow aerodynamic alterations and sensorineural dysfunction. Computational fluid dynamic (CFD) investigations in ENS patients suggest a laminar jet of airflow tunnels towards the middle meatus at the expense of the inferior and superior nasal cavity. Thermoreceptor function responsible for the sensation of nasal patency is concurrently affected. Inferior meatal augmentation procedures (IMAP) can restore pre-operative nasal airflow pathways and alleviate symptoms of ENS.
ENS is a rare debilitating condition post turbinate surgery. CFD has provided new insights into the pathogenesis of this condition and justification of surgical strategies to achieve symptom relief. The inconsistent nature in which ENS manifests among patients nonetheless requires further investigation with goals to identify the at-risk patient population pre-operatively.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Papers of particular interest, published recently, have been: • Of importance •• Of major importance
Moore EJ, Kern EB. Atrophic rhinitis: a review of 242 cases. Am J Rhinol. 2001;15(6):355–61.
Coste A. Empty nose syndrome. Eur Ann Otorhinolaryngol Head Neck Dis. 2012;129(2):93–7.
Houser SM. Surgical treatment for empty nose syndrome. Arch Otolaryngol Head Neck Surg. 2007;133(9):858–63.
Passali D, La Rosa R, Passali GC, Ciprandi G. The empty nose syndrome: a pragmatic classification in clinical practice. Acta Biomed. 2021;92(5): e2021288.
Li C, Farag AA, Leach J, Dehspande B, Jacobowitz A, Kim K, et al. Computational fluid dynamics and trigeminal sensory examinations of empty nose syndrome patients. Laryngoscope. 2017;127(6):E176–84.
Li C, Farag AA, Maza G, McGhee S, Ciccone MA, Deshpande B, et al. Investigation of the abnormal nasal aerodynamics and trigeminal functions among empty nose syndrome patients. Int Forum Allergy Rhinol. 2018;8(3):444–52.
Malik J, Li C, Maza G, Farag AA, Krebs JP, McGhee S, et al. Computational fluid dynamic analysis of aggressive turbinate reductions: is it a culprit of empty nose syndrome? Int Forum Allergy Rhinol. 2019;9(8):891–9.
Maza G, Li C, Krebs JP, Otto BA, Farag AA, Carrau RL, et al. Computational fluid dynamic safter endoscopic endonasal skull base surgery-possible empty nose syndrome in the context of middle turbinate resection. Int Forum Allergy Rhinol. 2019;9(2):204–11.
• Malik J, Dholakia S, Spector BM, Yang A, Kim D, Borchard NA, et al. Inferior meatus augmentation procedure (IMAP) normalizes nasal airflow patterns in empty nose syndrome patients via computational fluid dynamics (CFD) modeling. Int Forum Allergy Rhinol. 2021;11(5):902–9. Analysis of patients before and after IMAP with ENS6Q and CFD.
Velasquez N, Thamboo A, Habib ARR, Huang Z, Nayak JV. The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q): a validated 6-item questionnaire as a diagnostic aid for empty nose syndrome patients. Int Forum Allergy Rhinol. 2017;7(1):64–71.
Wu CL, Fu CH, Lee TJ. Distinct histopathology characteristics in empty nose syndrome. Laryngoscope. 2021;131(1):E14-18.
•• Kanjanawasee D, Campbell RG, Rimmer J, Alvarado R, Kanjanaumporn J, Snivdogs K, et al. Empty nose syndrome pathophysiology: a systematic review. Otolaryngol Head Neck Surg. 2022;167(3):434–51. Systematic review of published literature examining possible pathophysiological mechanisms in ENS.
Huang CC, Lee CC, Wei PW, Chuang CC, Lee YS, Chang PH, et al. Sleep impairment in patients with empty nose syndrome. Rhinol. 2023;61(1):47–53.
Talmadge J, Nayak JV, Yao W, Citardi MJ. Management of postsurgical empty nose syndrome. Facial Plast Surg Clin North Am. 2019;27(4):465–75.
Kim CH, Kim J, Song JA, Choi GS, Kwon JH. The degree of stress in patients with empty nose syndrome, compared with chronic rhinosinusitis and allergic rhinitis. Ear Nose Throat J. 2021;100(2):NP87–92.
Huang CC, Wu PW, Fu CH, Huang CC, Chang PH, Wu CL, et al. What drives depression in empty nose syndrome? A Sinonasal Outcome Test-25 subdomain analysis. Rhinol. 2019;57(6):469–76.
Manji J, Nayak JV, Thamboo A. The functional and psychological burden of empty nose syndrome. Int Forum Allergy Rhinol. 2018;8(6):707–12.
Huang CC, Wu PW, Lee CC, Chang PH, Huang CC, Lee TJ. Suicidal thoughts in patients with empty nose syndrome. Laryngoscope Investig Otolaryngol. 2022;7(1):22–8.
Lemogne C, Consoli SM, Limosin F, Bonfils P. Treating empty nose syndrome as a somatic symptom disorder. Genl Hosp Psychiatry. 2015;37(3):273.e9-10.
Tian P, Hu J, Ma Y, Zhou C, Liu X, Dang H, et al. The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate-sparing techniques: a prospective self-controlled study. Int Forum Allergy Rhinol. 2021;11(6):984–92.
Lamb M, Bacon DR, Zeatoun A, Onourah P, Thorp BD, Abramowitz J, et al. Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis. Int Forum Allergy Rhinol. 2022;12(11):1340–9.
Lu Y (2013) Kill the doctors. https://www.globaltimes.cn/content/827820.shtml. Accessed 31 Mar. 2023.
Lee TJ, Fu CH, Wu CL, Tam YY, Huang CC, Chang PH, et al. Evaluation of depression and anxiety in empty nose syndrome after surgical treatment. Laryngoscope. 2016;126(6):1284–9.
Mangin D, Bequignon E, Zerah-Lancner F, Isabey D, Louis B, Adnot S, et al. Investigating hyperventilation syndrome in patients suffering from empty nose syndrome. Laryngoscope. 2017;127(9):1983–8.
Hong HR, Jang YJ. Correlation between remnant inferior turbinate volume and symptom severity of empty nose syndrome. Laryngoscope. 2016;126(6):1290–5.
Dayal A, Rhee JS, Garcia GJ. Impact of middle vs. inferior total turbinectomy on nasal aerodynamics. Otolaryngol Head Neck Surg. 2016;155(3):518–25.
Ginghină C. The Coand ă effect in cardiology. J Cardiovasc Med (Hagerstown). 2007;8(6):411–3.
Hassan CH, Malheiro E, Béquignon E, Costé A, Bartier S. Sublabial bioactive glass implantation for the management of primary atrophic rhinitis and empty nose syndrome: operative technique. Laryngoscope Investig Otolaryngol. 2021;7(1):6–11.
Burrow A, Eccles R, Jones AS. The effects of camphor, eucalyptus and menthol vapour on nasal resistance to airflow and nasal sensation. Acta Otolaryngol. 1983;96(1–2):157–61.
Sozansky J, Houser SM. Pathophysiology of empty nose syndrome. Laryngoscope. 2015;125(1):70–4.
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.
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.
Freund W, Wunderlich AP, Stöcker T, Schmitz BL, Scheithauer MO. Empty nose syndrome: limbic system activation observed by functional magnetic resonance imaging. Laryngoscope. 2011;121(9):2019–25.
McKemy DD, Neuhausser WM, Julius D. Identification of a cold receptor reveals a general role for TRP channels in thermosensation. Nature. 2002;416(6876):52–8.
Law RH, Ahmed AM, Van Harn M, Craig JR. Middle turbinate resection is unlikely to cause empty nose syndrome in first year postoperatively. Am J Otolaryngol. 2021;42(4): 102931.
Houser SM. Empty nose syndrome associated with middle turbinate resection. Otolaryngol Head Neck Surg. 2006;135(6):972–3.
Tan NC, Goggin R, Psaltis AJ, Wormald PJ. Partial resection of the middle turbinate during endoscopic sinus surgery for chronic rhinosinusitis does not lead to an increased risk of empty nose syndrome: a cohort study of a tertiary practice. Int Forum Allergy Rhinol. 2018;8(8):959–63.
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.
Wong EH, Orgain CA, Sansoni ER, Alvarado R, Grayson J, Kalish L, et al. Turbinate loss from non-inflammatory sinonasal surgery does not correlate with poor sinonasal function. Am J Otolaryngol. 2020;41(1): 102316.
Sowerby LJ, Gross M, Broad R, Wright ED. Olfactory and sinonasal outcomes in endoscopic transsphenoidal skull-base surgery. Int Forum Allergy Rhinol. 2013;3(3):217–20.
Kim do H, Hong YK, Jeun SS, Park YJ, Kim SW, Cho JH, et al. Anatomic changes caused by endoscopic endonasal transsphenoidal surgery and their effects on nasal functions. Otolaryngol Head Neck Surg. 2016;154(6):1132–7.
Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ. Radical surgery: effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2007;136(2):261–7.
• Amanian A, Hari K, Habib AR, Dholakia SS, Nayak J, Thamboo A. The empty nose syndrome 6-item questionnaire (ENS6Q): a diagnostic tool to distinguish empty nose syndrome from primary nasal obstruction. Int Forum Allergy Rhinol. 202;11(7):1113–5. Comparative ENS6Q assessment of patients with ENS, primary nasal obstruction, and healthy controls.
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;127(8):1746–52.
• Malik J, Thamboo A, Dholakia S, Borchard NA, McGhee S, Li C, et al. The cotton test redistributes nasal airflow in patients with empty nose syndrome. Int Forum Allergy Rhinol. 2020;10(4):539–45. CFD analysis of ENS patients undergoing cotton testing to evaluate for nasal airflow alterations.
Thamboo A, Velasquez N, Ayoub N, Nayak JV. Distinguishing computed tomography findings in patients with empty nose syndrome. Int Forum Allergy Rhinol. 2016;6(10):1075–82.
Konstantinidis I, Tsakiropoulou E, Chatziavramidis A, Ikonomidis C, Markou K. Intranasal trigeminal function in patients with empty nose syndrome. Laryngoscope. 2017;127(6):1263–7.
Modrzvnski M. Hyaluronic acid gel in the treatment of empty nose syndrome. Am J Rhinol Allergy. 2011;25(2):103–6.
Borchard NA, Dholakia SS, Yan CH, Zarabanda D, Thamboo A, Nayak JV. Use of intranasal submucosal fillers as a transient implant to alter upper airway aerodynamics: implications for assessment of empty nose syndrome. Int Forum Allergy Rhinol. 2019;9(6):681–7.
Hosokawa Y, Miyawaki T, Omura K, Akutsu A, Kimura R, Ikezono T, Otori N. Surgical treatment for empty nose syndrome using autologous dermal fat: evaluation of symptomatic improvement. Ear Nose Throat J. 2022;1455613221130885.
Chang A, Watson D. Inferior turbinate augmentation with auricular cartilage for the treatment of empty nose syndrome. Ear Nose Throat J. 2015;94(10–11):E14–5.
• Dholakia SS, Yang A, Kim D, Borchard NA, Chang MT, Khanwalkar A, et al. Long-term outcomes of inferior meatus augmentation procedure to treat empty nose syndrome laryngoscope. 2021;131(11):E2736–41. Patient-reported outcomes (ENS6Q, SNOT-22, PHQ-9, GAD-7) in patients following IMAP at up to 12 months.
Rice DH. Rebuilding the inferior turbinate with hydroxyapatite cement. Ear Nose Throat J. 2000;79(4):276–7.
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.
Bastier P, Fierens S, Champel S, Ribadeau-Dumas A, de Gabory L. ß-Tricalcium phosphate implants in the surgical treatment of empty nose syndrome. Otolaryngol Head Neck Surg. 2016;155(3):514–7.
Lee TJ, Fu CH, Wu CL, Lee YC, Huang CC, Chang PH, et al. Surgical outcome for empty nose syndrome: impact of implantation site. Laryngoscope. 2018;128(3):554–9.
Lee DW, Kim JY, Kwon JH. Platelet-rich plasma injection for empty nose syndrome: a case report. Am J Otolaryngol. 2023;44(2): 103750.
Rhee CS, Kim DY, Won TB, et al. Changes of nasal function after temperature-controlled radiofrequency tissue volume reduction for the turbinate. Laryngoscope. 2001;111(1):153–8.
Conflict of Interest
Dakshika A. Gunaratne has no disclosures. Andrew V. Thamboo reports personal fees from Sanofi Speaker, GSK Speaker, and Stryker Speaker, outside the submitted work.
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.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Gunaratne, D.A., Thamboo, A.V. Empty Nose Syndrome as an Iatrogenic Condition from Surgery. Curr Otorhinolaryngol Rep (2023). https://doi.org/10.1007/s40136-023-00491-0