- Orthopedics

Five Signs of Empty Nose Syndrome

Persons with empty nose syndrome have a difficult time in getting a proper diagnosis. Yet, correct diagnosis and management make a huge difference in symptom relief.

In a typical scenario, a patient presents to the doctor and explains she can’t breathe through her nose. Then, the doctor looks in the nose and sees it is wide open. He doesn’t see any blockage to breathing. He may measure the blood oxygen and sees that it is normal. If he orders a blood count, that is normal too. He may decide to “humor” the patient and give her a sample of a nasal spray. Then this patient leaves the office unhappy that she was essentially ignored.

The main sign of empty nose syndrome is the complaint of not getting enough air from the nose.

In ENS the turbinates have been removed or severely reduced. Instead of a blockage, the nose is actually excessively wide open. But, like a garden hose, when the hose opening is wide open, the water has very little pressure and comes out only inches. In the hose, when the opening is made smaller, the water will project several feet.

Because the nose is now wide open, the sensors for air pressure don’t get notified that there is air coming in. That much lowered air pressure “feels wrong” and so the patient feels like he isn’t getting any air. Unless your doctor understands this, he will be confused.

The second sign of ENS is a history of nasal turbinate surgery. There are various procedures that doctors do to open a narrowed airway. These include Laser Turbinectomy, Somnoplasty, Coblation, Microdebridement, and Turbinectomy. Despite care, sometimes too much nasal turbinate tissue is removed or destroyed.

A third sign of ENS is unusual pain. Because the airflow is severely changed, certain nerve endings may be stimulated. Because the pain is very difficult to pinpoint, the accompanying anxiety is made much worse.

A fourth positive sign of ENS is frequent or constant nasal/sinus infection. There may be thick postnasal drainage and a constant sore throat. This is due to the absence of nasal cilia that are no longer there to move bacteria out of the nose, and to help moisten the air to the throat and lungs.

A fifth indicator that this is ENS is a reduced sense of smell and taste. The sense of smell is critical to life’s pleasures. Sometimes the poor smell is the primary complaint of the ENS patient. When smell sense is reduced, that also affects the sense of taste. You enjoy a steak because you can smell the cooked meat. The altered air currents don’t bring the odor particles to the organ of smell in the roof of the nose, plus the excessive dryness are both factors in causing the hyposmia.

Which comes first, the lack of sleep causing fatigue, or the fatigue from constant infection that causes poor sleep? Fatigue and overall reduction of quality of life can be significant.

For many ENS patients, a CT Scan of the sinuses taken before turnbinate surgery may not even show sinus disease, yet for many ENS patients the CT Scan taken a year later does show sinus disease!

Differential Diagnosis:

The doctor needs to make a differential diagnosis here. Chronic sinus infection can also cause fatigue, poor sleep, and reduced sense of smell. The difference is that in chronic sinusitis, the airway is seen by the doctor to be swollen and partially obstructed.

Atrophic rhinitis is also called Ozena. Here there is severe nasal crusting, a bad smell from the nose, and the internal nose is wider. This condition runs in families. There is a blockage of the blood supply to the nasal tissue, causing the underlying bones, particularly the turbinates, to shrink. Present mostly in females. The main difference between Ozena and ENS is that with Ozena, you don’t have a history of nasal surgery. Ozena shows much more foul smelling crusts.

Sjogren’s Syndrome is characterized by dryness of the nose, mouth and eyes. It is an autoimmune disease that involves the glands that moisten the mouth and eyes, as well as the mucus secretions of the nose and throat. In Sjogren’s, the primary complaint is the dry mouth and eye, there is no history of nasal surgery and the nose shows ordinary turbinate tissue.


For ENS the primary problem is lack of nasal cilia and decreased mucus. It is this absence that allows bacteria to grow and penetrate the nasal tissue and cause sinus disease. Therefore the best therapy is pulsatile irrigation because the pulsing saline going through the nose and sinuses, pulsaing at a rate analogous to the normal pulse rate of the cilia, performs like regular cilia action. This pulsing action with enhanced saline used early will prevent the significant sinus infections that often accompany ENS. Pulsatile irrigation for ENS also helps to massage the nasal tissue and bring more circulation to nasal tissue. If biofilm forms in ENS, pulsatile irrigation is an effective means of removing these organized bacterial colonies. Later, if sinus disease has developed as a result of ENS, pulsatile irrigation is effective in clearing the sinus disease. Of particular value is the fact that you can add your prescribed antibiotic to the pulsatile irrigation solution and avoid the systemic antibiotic effects.

For Atrophic Rhinitis pulsatile nasal/sinus irrigation has the advantage of being the best means of removing the thick heavy crusts. In orthopedics they reported that pulsatile irrigation is 100x more effective for removing bacteria and crusts than simple wash.

In ENS, measures to improve immune factors are important. Take iron if your hemoglobin is low, take Probiotic or yogurt to aid the production of immune factors. CQ 10 can be a help. Depending on what the doctor finds, he may ask you to use Premarin vaginal cream in the nose to build up membrane thickness.

Avoid cortisone nasal sprays as these will thin the nasal tissue. ENS patients are especially sensitive to saline spays that contain preservatives such as benzalkonium, so these should be avoided. Products like Atrovent or Afrin don’t improve ENS symptoms.

Anxiety is often seen in ENS, especially when the diagnosis is not well established. I hope this presentation will clarify many of the concerns of ENS patients and serve to reduce that anxiety.