Last updated:
07/17/2025
Years published: 2025
NORD gratefully acknowledges Gioconda Alyea, MD (FMG), MS, National Organization for Rare Disorders, for the preparation of this report.
Summary
Empty nose syndrome (ENS) is a rare and complex nasal condition that most often develops as a complication of sinus or nasal surgeries, particularly those involving the reduction or removal of turbinates, the structures within the nose responsible for regulating air flow and humidification. Although their nasal passages appear wide open, people with ENS often have a sensation of congestion, a persistent feeling of nasal blockage or difficulty breathing through the nose. This disconnect between physical appearance and perceived airflow can lead to significant physical discomfort and psychological distress.1
The diagnosis of ENS is based on the signs and symptoms, medical history, specialized questionnaires like ENS6Q and physical tests like the cotton test.1,2
Treatments range from conservative therapies (like nasal humidification) to reconstructive surgery. A multidisciplinary care approach is often essential for successful management.1,2
Introduction
The term “empty nose syndrome” (ENS) was introduced into medical practice in 1994 to describe empty space in the place of inferior and middle turbinate on computed tomography (CT) in people who had partial or total turbinectomy.3
People with ENS may have a wide range of symptoms that can severely impact quality of life:1,4,5
ENS is iatrogenic, meaning it is caused by medical treatment, in this case, nasal surgery. The most frequent cause is over-resection of the inferior and/or middle turbinates during procedures meant to alleviate chronic nasal obstruction.1,4
The nasal cavity has three pairs of turbinates on each side: inferior, middle and superior. They are bony shelves that extend from the lateral (side) walls of the nasal cavity. They are covered by a layer of soft tissue (mucosa) and play a crucial role in respiratory health helping to warm, humidify and filter the air we breathe.
There are three main factors involved in the development of this condition:3,4
The trigeminal nerve (cranial nerve V) provides sensation to the face, including touch, pain and temperature and relays sensory information from the sinuses, mucous membranes of the nose and mouth and the cornea of the eye.
There are a few types of ENS depending on which turbinate was affected during the surgery:1
ENS is a rare condition, but its true incidence is not well defined due to underdiagnosis. It typically presents months to years after nasal surgery, though it can occur sooner.5 Several studies reported about 8%-22% ENS occurrence rate in people who had undergone turbinate resection surgery.
Diagnosis of ENS is primarily clinical, supported by tools designed to determine symptom severity and confirm diagnosis:1,5,6
Examination of tissue under a microscope (histopathology), if performed, may show submucosal fibrosis, loss of submucosal glands and decreased TRPM8 receptors. TRPM8 receptor changes have been associated with airflow sensation impairment ⁴
Treatment
Treatment includes conservative management and surgery:1,4,5,6
Initial treatment focuses on symptom relief and mental health support and may include:
These measures aim to maintain moisture, support mucosal healing and address associated anxiety or depression.
Surgery is usually attempted only after an adequate trial of medical management, counseling and education for a period of 6 to 12 months. Surgery includes several options aimed at reconstructing nasal tissue and restoring airflow dynamics.
Ideally, people with this condition should be seen by several specialists, including ear, nose, and throat surgeons, allergists and psychiatrists. The specialists should work together as a team in a coordinated manner.
Many people benefit most from a combination of both medical and surgical treatments tailored to their specific symptoms and anatomy. Surgical success is best achieved with careful pre-operative evaluation, including cotton test responsiveness and appropriate material selection based on anatomy and severity of the condition. Most studies show improvement in symptom scores after treatment, but psychological improvement sometimes takes longer than physical recovery.³
Prevention of iatrogenic ENS through avoidance of excessive turbinate reduction is very important in preventing the feeling of nasal obstruction.1,2
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. Government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
TTY: (866) 411-1010
Email: [email protected]
Some current clinical trials also are posted on the following page on the NORD website: https://rarediseases.org/living-with-a-rare-disease/find-clinical-trials/
For information about clinical trials sponsored by private sources, contact: www.centerwatch.com
For information about clinical trials conducted in Europe, contact:
https://www.clinicaltrialsregister.eu/
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