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Empty Nose Syndrome
Empty Nose Syndrome (ENS) is a complex, sometimes misunderstood, disorder often caused by
overly aggressive sinus and nasal surgery. It usually occurs when turbinates are removed from
the nasal passages. These turbinates, which warm and humidify air, project into the nose from
the nasal sidewall. There are usually three or four pairs: inferior, middle, and superio and
sometimes even a supreme turbinate. Aggressive removal of the inferior turbinate is usually the
culprit in empty nose syndrome.

The CT scan of a patient with "Empty Nose Syndrome” looks empty; this is usually secondary to
previously excised sinonasal structures. Sometimes, sufficient turbinate tissue may seem to be
present, however patients may still experience classic symptoms of this disorder.
Patients with ENS feel as though their nose is always blocked and that they cannot get in
sufficient air through their nose to breathe adequately. They can feel as though they have nasal
obstruction and sometimes even feel short of breath. Patients may also experience chronic
infections, pain, and severe nasal crusting.

Many physicians confuse ENS with Atrophic Rhinitis; some will refer to ENS as secondary
atrophic rhinitis due to the similarity. Atrophic Rhinitis is a separate disease entity with a similar
anatomic appearance to ENS. It is caused by an infection, typically Klebsiella ozenae, which
causes tissue atrophy, crusting, and terrific odor. This disease is more common in
underdeveloped countries. ENS is not atrophic rhinitis.

Diagnosing ENS
Diagnosing ENS relies upon a patient’s symptoms, along with several physician observations. A
history of nasal turbinate surgery is usually present. A CT scan or nasal endoscopy will often
reveal tissue loss. A cotton test (moist cotton placed into the nasal cavity to selectively limit and
redirect the airflow without complete obstruction) will usually improve symptoms.

Managing ENS
Saline sinonasal irrigations and humidification are paramouint to treating this difficult disorder.
Surgical options are also available. An implant of acellular dermis (Alloderm) can be placed
under the lining of the nasal cavity or septum. This implant provides additional resistance for
breathing, lessening the sensation of obstruction. The location of the implant is based upon
history, exam, CT findings, and the results of a cotton test in the office. Unfortunately relief of
pain has not been very successful with implantation.