Empty Nose Syndrome (ENS) is a condition characterized by paradoxical nasal obstruction despite a widely patent nasal airway. It often results from nasal surgery involving resection of the turbinates. Diagnosis involves identifying a history of turbinate surgery and appropriate symptoms like dryness and improvement with a "cotton test" where cotton is placed in areas of deficit. Treatment planning involves using CT imaging and endoscopy to identify defects and testing placement of cotton or saline to identify locations for grafting. Surgical repair techniques involve implanting tissue like acellular dermis or autogenous tissue into locations identified as beneficial by the cotton test, such as the septum, lateral wall, or expanding the existing inferior turbinate. The

1. Empty Nose Syndrome:
Diagnosis and treatment
Steven M. Houser, MD, FAAOA
Associate Professor,
Case Western Reserve University
Cleveland Ohio, USA
5th
RMH FESS and 3rd
Rhinoplasty Course
Riyadh Military Hospital
Sunday, Nov 13, 2011

2. Sensation to Airflow
• Airflow sensation poorly understood
• Nasal vestibule most sensitive area
• IT next sensitive, and decreases above
• Clarke Clin Otolaryngol 1992;17:383–7
• Wrobel Am J Otol 2006;20:364–8
• Trial: coat vestibule with vaseline
• Feel stuffy, but can sense airflow

3. Etiology
• Nasal surgery typically involving resection of
turbinates
• or some turbinate surgery that damages the
mucosal surface, e.g., laser reduction
• Inferior turbinates most commonly involved
• Both IT & MT often involved
• Middle turbinates alone occasionally involved

4. Definition
• Paradoxical nasal obstruction
• Widely patent nasal airway
• Patient complains of a poor nasal airway
• “blocked,” “empty,” “hollow”
• Dry mucosa
• Thick mucus or possible crusts
• Poor smell
• Poor voice
• Respiratory dysfunction

5. Definition
• What is not ENS
• Pain is variable and may be concurrent, but
appears to be a separate issue from ENS
• Iatrogenic atrophic rhinitis or secondary atrophic
rhinitis
• Tissue is missing, not atrophic; no odiferous crusts
• Delayed ENS occurs – suggests atrophy or some
delayed nerve injury possible
• Hormonal issues, depression, confusion,…
• Depression over symptoms is possible

6. ENS physiology
• Airflow easily diverts toward “empty” space
• Mucosa surrounding the “empty” space
appears to have lost some sensitivity to
airflow
• Normal mucosa has been robbed of airflow
• Conflicting messages to brain
• Nose says “I’m suffocating”
• Lungs/diaphragm says breathing fine

7. How common is ENS?
• 22.2% incidence of “atrophy” (likely ENS)
following total inferior turbinectomy
• 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;108(6):569-575.
• 8% of partial turbinectomy patients developed
a dry nose
• Courtiss EH, Goldwyn RM. Resection of obstructing inferior nasal
turbinates: a 10-year follow-up. Plast Reconstr Surg. 1990;86(1):152-
154.

8. Definition
• ENS-IT
• Inferior turbinate significantly resected
• ENS-MT
• Middle turbinate significantly resected
• ENS-both
• Both IT & MT significantly resected
• ENS-type symptoms
• Appear to have adequate tissue, but symptoms
and cotton test suggest ENS is present

9. ENS-IT
right
left

10. ENS-MT

11. ENS-both

12. ENS-type

13. Diagnosis
• History of surgical intervention with turbinate
resection/surgery
• Appropriate symptoms
• Suffocation, dryness
• Improvement with “Cotton test”
• Cotton placed into area of deficit to obstruct
airflow leads to a subjective improvement in nasal
patency and moisturization

14. Planning
• Review CT & nasal endoscopy to identify
defect
• Cotton placed at selected area(s) to simulate
graft
• Air shifted away from empty area, toward
unoperated area
• Assess patient’s subjective sensation of nasal
breathing
• Alternatively, site infiltrated with saline to swell
the site (e.g., IT injection)

15. Cotton Test
• Requires that NO
anesthetic agent be
applied
• Takes time for patient
to assess benefit
• Move cotton into
different locations
• Alter size of cotton
• Record findings as
surgical plan

16. Surgical Repair Technique
• Implant tissue into location(s) identified per
cotton test
• Allogenic acellular dermis or autogenous tissue
• Septum
• Lateral wall
• Direct expansion of existing inferior turbinate
• “Spear” technique
• Need sufficient volume

17. Septal Implantation

18. Lateral Wall Implant

19. IT augment “spear” technique

20. ENS grafted

21. ENS implantation: my volume
• 67 cases performed on 44 different patients
• Ranging from 1 to 5 case per patient
• Performed from 2003 to 2011
• ENS-IT 22, -both 10, -type 9, -MT 3
• Locations (may be >1 location/case)
• Septum: 36
• Lateral wall: 26
• Inferior turbinate (spear): 17

22. Conclusion
• ENS is often a severly debilitating process
• Poorly understood
• Not accepted/believed by all ENT’s
• These patients can be made more comfortable
and they tend to be very grateful

23. • New launch by AAOA and ARS
• Only journal to combine allergy
and rhinology
• Largest circulation of any
rhinology title
• First print issue Feb. 2011
• Free color for authors
• Top Editor-in-Chief and
International Editorial Board