Romanian Journal of Rhinology, Vol. 7, No. 27, July - September 2017 DOI: 10.

1515/rjr-2017-0015

LITERATURE REVIEW
Empty nose syndrome
Vasile Cabac, Veronica Polovei, Ala Istratenco
Department of Otorhinolaryngology, SUMPh “Nicolae Testemitanu”, Chisinau, Republic of Moldova
ENT Department, MCH “Sfanta Treime”, Chisinau, Republic of Moldova

ABSTRACT

Empty nose syndrome (ENS) is a clinical entity lacking consensual meaning, illustrating a rare nose surgery complication, par-
ticularly of nasal conchae surgery, which results in the destruction of the normal nasal tissue. In severe forms it may become de-
bilitating; the inability in identification and appreciation of this syndrome turns detrimental to the patient. Physiopathology
remains controversial, which probably implies disorders caused by excessive nasal permeability, affecting neurosensory receptors
as well as the humidification functions and conditioning of inhaled air. Neuropsychological involvement is being suspected.
Symptomatology is both variable and changeable, the most evident sign outlining paradoxical nasal obstruction. The diagnosis is
based on a series of symptoms that need to be collected precisely, the objective examination that highlights the permeability of
nasal fossae.
The management is problematic; there are implemented a complete range of simple hygiene and humidification techniques of
the nasal cavity and, for more severe cases, surgery is provided, regardless of technique, the surgery targeting partial filling of the
nasal airways. Prevention is the most essential strategy along with basic conservative surgical techniques.
KEYWORDS: empty nose syndrome, nasal obstruction, turbinoplasty.

INTRODUCTION not known since there were not published detailed

studies, but some authors assume that approximately
Empty nose syndrome (ENS) is a clinical entity 20% of patients who suffered turbinoplasties develop
poorly recognized, but undoubtedly destructive, pre- ENS2. It is difficult to set a diagnosis, as exact objective
senting surgical complication of the nasal conchae. tests for this do not exist; so, the subjective symptoms
The term appears described for the first time in the of the patient are considered.
specialty literature in 1994 by Dr. Eugene Kern from
Minessota, as being an empty space, which is outlined
within the coronary section on CT image, in the con- ETIOLOGY OF ENS
chae region, in certain patients who underwent sur-
gery on inferior or middle nasal conchae1. These pa- Chronic nasal obstruction, although not being a pa-
tients complained about dryness and crusts at the level thology with vital risk, may affect patient’s quality of
of nasal mucosa, paradoxical nasal obstruction, the life. Patients who do not respond to the medical treat-
feeeling of obstructed breathing, significant nasal ment may benefit from a surgical one. The most im-
breathing difficulty, feeling of excessive airflow, dis- portant thing to consider in the surgery of nasal con-
comfort while breathing, irritability, anxiety, asthenia. chae is the fact that a wider nasal cavity does not neces-
ENS so far remains a controversial disorder regarding sarily imply a better functioning as such. The aim of
symptomatology, because the majority of patients that the surgery is to decrease patient’s complaints, keep-
undergo surgery on nasal conchae experience an im- ing organ functionality and the volume reduction of
provement in nasal breathing. The disease may outset the conchae, considering individual anatomical fea-
from several months to years after the surgery at the tures, preserving at the same time the nasal mucosa as
nasal conchae level. The incidence of the disease is much as possible. There exists a multitude of surgical

Corresponding author: Vasile Cabac

e-mail: [email protected]
136 Romanian Journal of Rhinology, Vol. 7, No. 27, July - Septembe 2017

methods used in the volume reduction of the nasal covered with mucosa and submucosa. Inferior nasal
conchae. As far as the inferior nasal conchae are in- conchae direct the airflow toward the middle meatus,
volved, surgery is applied in the treatment of compen- acquiring the capacity to modify its size, as well as the
satory hypertrophy, protrusion of concha bone, iso- airflow. The middle nasal concha has minimum tissue
lated hyperplasia of the anterior or posterior part of capacity, but it has mucous glands and a small quantity
the nasal conchae (e.g. lateroposition, resection pro- of olfactory nerve endings; in addition to this, it pro-
cedures, clotting procedures, cryotherapy, radiofre- tects the sphenopalatine area.
quency laser surgery, ultrasound). According to some authors, ENS denotes a combi-
Concha bulosa, polypoid degeneration of the mu- nation between structural changes and physiological
cosal middle nasal concha, paradoxical curved middle ones, as a result of surgeries at this level. This combi-
nasal concha represent pathologies that require surgi- nation in structural and physiological changes impacts
cal treatment through the following methods: tempo- each other and interferes amongst them leading to:
rary septum medialization by means of a suture; vol- decrease in nasal resistance, a nonphysiological and
ume reduction of the middle nasal concha; resection unnatural airflow, absence of functional mucosa in
of the middle nasal concha. certain areas and also simultaneous widening of the
Surgical techniques on nasal conchae are very dif- nasal cavity, temporary contact reduction between air
ferent; nevertheless, till now, none of these techniques and mucosa5.
embody the ideal standard.
I. Functional composition of the syndrome may be
expressed either by one of the following, or a combi-
CLASSIFICATION nation of:
Nerve damage (neuropathy) and mucosa atrophy. Often,
Two types of ENS are described: with and without ENS patients do not feel the airflow through the nasal
nasal conchae mucosa defect. cavity. The nasal mucosa is richly innervated by multi-
The first type, empty nose syndrome with conchae ple sympathetic and parasympathetic nerve fibers (au-
mucosa defect, is represented by three subtypes: tonomic nervous system), nociceptive fibers that can
1. ENS of the inferior nasal concha is most com- be damaged during surgery, resulting in insensitivity
monly met and paradoxical nasal obstruction and atrophy. Through its sympathetic and parasympa-
stands for the most frequent symptom. thetic fibers, the autonomic nervous system controls
2. ENS of the middle nasal concha is rarely met; several involuntary functions in the body, such as
beside nasal obstruction, pain persists during res- blood pressure, heart rate, breathing frequency. At
piration, induced by the cold airflow that, at its the nose level, the autonomic nervous system controls
turn, hits the area of the sphenopalatine gan- the conditioning of inhaled air, nasal resistance,
glion, which is no more protected by the middle mucus secretion, cilia function and mucus layer, hav-
concha as it was before surgery. ing an important vascular and glandular role6. Sur-
3. Common ENS, which refers to the resection of gery often unbalances the autonomic nervous system,
both inferior and middle nasal conchae. in some cases causing neuropathy; certain areas of the
The second type is characterized by the presence of mucosa change their sensitivity to airflow, and the pa-
seemingly enough healthy tissue at the nasal conchae tient may experience pain or burning sensation that
level, but the patient suffers from ENS as a result of may occur in response to stimuli that normally do not
nasal conchae surgery3. cause pain.
Cold thermoreceptors. According to Zhao et al.7, the pri-
mary physiological mechanism that explains the pro-
ENS PHYSIOPATHOLOGY duction of nasal airflow sensation is the activation of
cold thermoreceptors, TRPM8, located at the level of
Physiopathology of the syndrome stays incompletely the inferior nasal conchae mucosa. These receptors
elucidated, but in the specialty literature, certain hy- are activated by the airflow, which moves rapidly as it
potheses may be found. It is well known the fact that penetrates through the nostril and induces water evap-
the nose represents a lot more than the pathway for oration from the fluid that covers the epithelium. The
the inhaled air. It also serves as air conditioner before remaining fluid has a lower temperature, which leads
it gets to the lungs through filtration, thermal adjust- to a decrease in the fluidity of the phospholipid mem-
ment, as well as humidification4. The nose offers more brane. This change in membrane rigidity is perceived
than 50% resistance toward the airflow, and it has the by TRPM8 receptors, causing neuron depolarization
role of air and odor passage to the olfactory grooves. that contacts the respiratory center7. The cold message
Nasal conchae play a very important role, presenting is interpreted as nostril permeability and open airway,
bony structures from the sidewall of the nasal fossae, leading to a decrease in the activity of intercostal and
Cabac et al Empty nose syndrome 137

accessory respiratory muscles. The lack of stimulation ively cause changes in breathing, bronchomotor tone,
is interpreted by the brain as uncool signal and causes mucus secretion, laryngeal caliber, spinal reflexes.
apnea, increases the activity of respiratory muscles or
falsely increases the sensations, which is interpreted II. Structural modifications
as nasal obstruction. In response, thickening of the Nasal resistance. Nasal conchae have an important
nasal mucosa or excessive production of mucus can role in nasal breathing. The nasal meatuses being the
also occur, which may also partially occlude the air- spaces through which the airflow passes, formed be-
ways and limit evaporation; thereby, the degree of tween the nasal conchae, the nasal septum and the
mucosal cooling is reduced, which consequently re- floor of the nasal cavity are very narrow and create
duces the feeling of permeability. The permeability airflow resistance. Normally, nasal airway resistance
sensation is dependent on adequate mucosal cooling constitutes more than 50% of the total respiratory
as well as a sufficient number of TRPM8 receptors tract resistance. This resistance offers an average veloc-
that function properly. ity of nasal flow, still laminar. As a result, there is a
Poor nerve regeneration. Importantly, the nasal con- mucosal air-conducting interface that provides the
chae are a source of nerve growth factor8. However, it right breathing sensation. Additionally, the nasal valve
is known that sensory nerves regenerate poorly. redirects the flow of air coming from the front and the
Therefore, damage to nasal conchae or the removal sides to create a laminar airflow, thus prolonging its
of any part of them, the surface of which is rich in contact with the nasal mucosa, appropriately achiev-
receptors, can cause poor nerve regeneration. It can ing olfaction, retaining foreign particles, humidifying
induce a feeling of insufficient airflow, a general im- and heating the inhaled air10. Tissue loss of nasal con-
pediment to the nasal function, significant distur- chae destroys and damages meatus structures causing
bances in the perception of nasal signals, the trans- airflow disruption. This airflow transformation from
mission of contradictory information at the brain laminar to turbulent decreases the velocity of the in-
level and the autonomic nervous system, with a suc- haled air, facilitating at the same time the heat and the
cessive incorrect system response9. evaporation transfer. Moreover, a significant decrease
Atrophy and destruction of the mucosa. Atrophy of the in nasal resistance can substantially affect the balance
nasal mucosa is a common sign in patients suffering of resistance required for deep pulmonary inspiration
from ENS. Often, the mucosa of these patients is pale, and may lead to breathlessness. In order to apprehend
dry due to nerve damage; scarring, deterioration of a sufficient airflow, the nasal mucosa must experience
nasal air conditioning function, lack of mucosal stimu- aerodynamics.
lation and blood flow changes, caused by surgery, may In the ENS patient, the nasal cavity becomes un-
be also present. Deterioration of mucosal regenera- physiological and abnormally wide, leading to stress
tion due to atrophy and mucosal dysfunction leads to reduction over the nasal mechanoreceptors and thus
the increase in nasal epithelium vulnerability and reducing the sensation of airflow and nasal regulation
damage of the mucociliary transport mechanism. mechanisms5.
Shortage of muciparous glands produces a humidity Air conditioning. During inspiration, the air is fil-
decrease in the nasal cavity and a decline in nasal se- tered, heated and humidified. The air conditioning
cretions. Moreover, the nasal mucosa contains mecha- function is mainly performed by the nasal airways. The
noreceptors, proprioceptors and thermoreceptors of healthy nose provides about 90% of the humidity and
the nasopulmonary reflex. Additionally, there exist heating required for conditioning the surrounding air.
pulmonary C-fiber receptors and quickly adapting re- To carry out this task properly, the anatomical and
ceptors located on the bronchial wall, the larynx and morphological conditions must operate in an equiva-
the nasal cavity, multimodal responsiveness to me- lent way; the geometry of the nasal structures and the
chanical stimuli, chemical stimuli, and to the inflam- sufficient quantity of the functional mucosa must be
matory and immunological mediators responsible for kept intact5. Fulfillment of the nasal air conditioning
the secretion of mucus at the level of the respiratory function is required for the exchange of undiluted al-
tract and cardiovascular reflex. It is discussed the pos- veolar gas to avoid dehydration and adhesion of the
sible existence of a reflex arc between the lungs and alveolar capillary bed11. The mucociliary nasal clear-
the capacity of the blood from the nose vessels that ance is very important for nasal drainage. Extracellu-
come from extensive pulmonary receptors. The reflex lar nucleotides (adenosine and uridine) can stimulate
arc starts from the extensive pulmonary receptors in the mucociliary clearance in several ways. These nu-
the vagus nerve to the central nervous system and con- cleotides are released by the local epithelium and act
tacts the blood from the vessels of the nasal mucosa in a paracrine way. Furthermore, an altered histologi-
through the efferent nerves of the vidian one. Finally, cal structure, such as cilia loss after surgery on nasal
studies have demonstrated that the absence, inappro- conchae, disturbs the normal mucociliary flow in the
priate stimulation of any receptor group can reflex- anterior sinuses (the frontal, anterior ethmoid, and
138 Romanian Journal of Rhinology, Vol. 7, No. 27, July - Septembe 2017

the maxillary sinuses), which occur along the uncinate dyspnea. Because of the subjective absence of airflow,
process and the inferior nasal conchae toward the na- these patients tend to become tachypneic and often
sopharynx in the posterior. Thus, nasal secretions are slip into hyperventilation because they feel a relentless
accompanied by insufficient mucociliary clearance in feeling of dyspnea. Dyspnea may be accompanied by
ENS patients due to deteriorated and reduced inferior compensatory hyperventilation. Although the air that
conchae tissue. enters the nose in ENS patients fails to stimulate the
Cognitive function. After nasal conchae resection, the thermoreceptors of the nasal mucous membrane, the
nasal passage becomes much wider than it should air gets into the lungs and activates the pulmonary tis-
physiologically be. Intranasal pressure decreases, the sue stretching receptors, indicating the brain that a
airflow rate diminishes during inspiration and expira- proper ventilation is taking place. The possibility of
tion. However, because of a low airflow rate (within this conflicting message could explain the stress asso-
the same inspiring effort) as well as a lack of airflow ciated with breathing in ENS patients. This condition
sensation, an ENS patient begins to experience a feel- is probably the most severe form of paradoxical ob-
ing of suffocation and other physical and cognitive struction and can aggravate patient’s physical activity.
symptoms, forcing the activation of the sympathetic Nasal symptoms can be represented by nasal dry-
nervous system, anxiety and forced breakout of breath- ness, facial and nasal pain, sneezing, anosmia/hypos-
ing, which becomes unstable. This leads to the inabil- mia, hoarseness and cough (due to inadequate air
ity to relax, concentrate or think clearly (nasal apo- purification and humidification. A healthy nose can
plexy)4. provide 90% of the heat and water flows necessary to
condition the inspired air in a constantly changing en-
vironment. After conchae reduction surgery, a rela-
POSITIVE AND DIFFERENTIAL DIAGNOSIS tively large volume of inspired air passes through a
OF THE EMPTY NOSE SYNDROME wide pathway without any chance for a proper condi-
tioned air. Naftali et al.13 have demonstrated that the
The diagnosis is difficult to assess because of the middle and inferior conchae control up to 90% of the
lack of a precise clinical definition, symptom variability total nasal conditioned air, its efficacy being reduced
and psychological stress that gets associated frequently. by almost 23% without an adequate conchae surface
Ultimately, a number of ENS patients are not diag- (resection of both inferior and middle turbinates).
nosed, as most often the physicians search for physical The performed studies have shown a correlation
signs of dryness and atrophy - a result of turbinoplasties between turbinoplasties and dryness sensation. Ac-
as long-term complications. The subjective complaints cording to the histological structure of glands at the
of nasal obstruction or the breathing difficulty get to level of inferior conchae, the acini of the mucous
be ignored as much as many other otolaryngological glands are most often embedded deep in the lamina
disorders (e.g. tinnitus, throat lumps), since the symp- propria, and these glands grow progressively in num-
toms are subjective and cannot be objectively kept ber from the anterior region to the posterior one of
under control. And yet the diagnosis is based on the the inferior conchae. Thus, 70% of the mucous mem-
patient’s complaints and the objective clinical exami- branes are found in the posterior portion. Hence, it is
nation performed during consultation. easy to attest that after conchae reduction surgery, es-
The signs and the symptoms of the empty nose syn- pecially on the posterior part of the inferior nasal con-
drome may be structured into several categories: res- cha, the number of mucous glands is reduced, result-
piratory, nasal, cognitive, emotional, sleep disorders. ing in nasal dryness. Difficulties in thickened mucus
The respiratory signs and symptoms can be repre- removal, evident crusts on clinical examination, are
sented by paradoxical nasal obstruction, empty nose the result of insufficient mucociliary clearance due to
sensation, shortness of breath, tachypnea or dyspnea. deterioration and reduction of the inferior conchae
The paradoxical nasal obstruction is the most com- tissue.
mon complaint, a subjective feeling of nasal “stuffi- It is not known exactly the pathophysiology that
ness”; during physical examination of the nasal fossae, would explain the facial and nasal pain, but it was
the permeability of the nasal fossae is noted because speculated that increased pain in ENS patients may be
of the nasal conchae tissue absence12. The feeling of related to the disturbances of the sensory innervation
nasal obstruction may be associated with the feeling of of the anterior nasal cavity. The general sensory nasal
‘’emptiness’’, patients refering to this term to depict innervation is provided by trigeminal nerve branches
the subjective incapacity to perceive the airflow, mainly (V1 and V2). In particular, the internal lateral branch
noted due to total inferior turbinectomy. The exces- of the anterior ethmoid nerve feeds the anterior end
sive flow of air, the lack of nasal resistance and the of the inferior nasal concha, which deals with pressure
difficulty in complete breathing can lead to breathing and pain. Nasal sensory receptors are responsible for
difficulties like shortness of breath, tachypnea and the airflow sensation, and these receptors are sensitive
Cabac et al Empty nose syndrome 139

to temperature. We suspect that more sensory defects bility because it only focuses on the obstruction at-
will occur if several anterior conchae tissues are dam- tributed to certain anatomical factors. However, the
aged. If there is no nerve and receptor regeneration, test can objectively demonstrate a difference between
the nose could present hypersensitivity responses to the subjective perception of nasal patency and the ob-
the inhaled air; moreover, this response is more likely jective air resistance, results that can deter the ENT
to be worsened by the uncontrolled and disrupted air- surgeon in performing other resections of the nasal
flow caused by the reduced nasal conchae. conchae.
From the cognitive point of view, ENS patients pre- Many studies have presented the feeling of obstruc-
sent a loss of concentration because they find them- tion without any proven anatomical cause; for exam-
selves in a permanent state of dyspnea, become very ple, local application of an anesthetic in the nasal cav-
concerned about their breathing, which has a bad im- ity produces an artificial sensation of nasal obstruction
pact on productivity. This phenomenon is known as with unchanged permeability measured objectively,
“nasal apoplexy”. while topical application of menthol produces a feel-
The emotional status can be characterized by irrita- ing of decongestion without altering the current nasal
bility, frustration, depression, panic attacks, anxiety or morphology16.
chronic asthenia. The differential diagnosis of the empty nose syn-
All the above symptoms can lead to sleep disorders, drome is done primarily with atrophic rhinitis. It is
like: sleeping difficulties, nocturnal awakenings, in- important to note that the two distinct conditions
somnia, general asthenia. were widely highlighted in the specialty literature: pri-
SNOT-20 (Sino-Nasal Outcome Test 20) question- mary and secondary atrophic rhinitis. Primary atrophic
naires or the modified version, customized with 5 ad- rhinitis is often spontaneous at onset and, of course,
ditional questions that relate directly to ENS (SNOT- slowly progressively debilitating. Often, no distinct eti-
25), are the most used tools in assessing the quality of ology is identified, although the causes of successive or
life in patients with nasopharyngeal problems, in ENS infectious diseases are proposed. Although spontane-
diagnosis and appreciation of subsequent treatment. ous at onset, primary atrophic rhinitis reflects an insig-
It encloses 25 questions marked from 0 to 5, divided nificant blood flow disorder at microvascular level,
into 4 subscales - rhinologic, otological-facial, sleep which continues for a prolonged period of time. Sec-
and cognitive disturbances14. ondary atrophic rhinitis is more commonly encoun-
The clinical and paraclinical examination are also tered and specifically after proper injuries, such as
an important step in diagnosing an empty nose syn- traumas, irradiation, reductive rhinosinusal surgery or
drome. Nasal endoscopy can reveal large nasal cavi- granulomatous pathology in secondary entities. The
ties, with the lack or considerable reduction of the clinical examination reveals nasal crusts, enlarged
inferior nasal conchae and / or post-surgery mediums. nasal cavities, conchae resorption, mucosal atrophy
The mucous membrane is pale, dry, presenting crusts and paradoxical nasal congestion. Less frequent re-
at the mucosa level. ported symptoms include facial pain and pressure,
Objective tests, like the cotton bud test, can validate anosmia and intermittent epistaxis17.
an empty nose symdrome. During the cotton bud test,
a piece of cotton wool moistened in isotonic solution
is inserted in the nasal cavity for 20-30 minutes; if TREATMENT STRATEGIES IN THE EMPTY
symptoms improvement is recorded, the test is consid- NOSE SYNDROME
ered positive for ENS (because the symptomatology is
associated with excessive lumen enlargement)9. Prevention can be the first step to take into consid-
Usually, the diagnosis is clinically established, but it eration. As the nasal mucosa is the functional entity
can be supplemented with a few signs that can be ob- involved in the conditioning of the inhaled air, the
served on CT images (but not pathognomonic): thick- minimal invasive surgical procedure of the nasal con-
ening of the sinus mucosa, clarity loss of the os- chae with maximum preservation of the mucosa and
teomeatal complex secondary to damaging the thermoreceptors is the key to obtaining the optimal
ethmoidal bubble and the uncinate process, opacity of outcome and reducing the risk of ENS development.
the maxillary sinus, enlargement of the nasal fossae, Drug treatment includes nasal hygiene with regular
osteodistruction of the inferior and middle nasal con- intranasal irrigations, which remains the standard con-
chae15. servative therapy to minimize crust formation and re-
There are authors who state that rhinomanometry storing nasal hydration; one can also use vitamin ther-
is not useful for the diagnose approval of ENS, the test apy associated with vitamin A and E topically applied,
confirming the absence of any anatomical obstruc- oils locally, aerosols and corticosteroids applied locally
tion4. Rhinomanometry results cannot be correlated as well. The addition of methol activates thermorecep-
with the subjective sensation of the patient’s permea- tors at the conchae mucosa level, those responsible for
140 Romanian Journal of Rhinology, Vol. 7, No. 27, July - Septembe 2017

inspiration; thus, without causing morphological REFERENCES

changes, they transmit the brain a permiability airway
signal; hyaluronic acid injected locally produces an 1. Sozansky J., Houser S.M. - Pathophysiology of empty nose syndrome.
increased thickness in the conchae mucosa, but the Laryngoscope, 2015;125(1):70–74. doi: 10.1002/lary.24813. Epub 2014
Jun 30.
symptoms return after various periods of time; “dispos-
2. Chhabra N., Houser S.M. - The diagnosis and management of empty
able silicone” prostheses to redirect the airflow are
nose syndrome. Otolaryngol Clin North Am., 2009;42(2):311–330, ix.
also used.
doi: 10.1016/j.otc.2009.02.001.
Surgical treatment includes reconstruction of the nasal 3. Coste A., Dessi P., Serrano E. - Empty nose syndrome. Eur Ann
conchae. However, before performing a nasal conchae Otorhinolaryngol Head Neck Dis., 2012;129(2):93–97. doi: 10.1016/j.
implant, it must be determined whether the lumen anorl.2012.02.001. Epub 2012 Apr 16.
reduction of the nasal fossae would be beneficial to 4. Freund W., Wunderlich A.P., Stöcker T., Schmitz B.L., Scheithauer M.O.
the patient. By cotton wool testing or local injections - Empty nose syndrome: limbic system activation observed by functional
of hyaluronic acid, the need for a transplant can be magnetic resonance imaging. Laryngoscope, 2011;121(9):2019–2025.
determined if the patient responds positively to them. doi: 10.1002/mary.21903. Epub 2011 Aug 16.
The surgical technique involves the transnasal ap- 5. Scheithauer M.O. - Surgery of the turbinates and “empty nose” syn-
drome. GMS Curr Top Otorhinolaryngol Head Neck Surg., 2010;9:Doc03.
proach, with implant material fixed in a submucosa
doi: 10.3205/cto000067.
pocket. The amount and thickness of the implant ma-
6. Baraniuk J.N., Merck S.J. - Neuroregulation of human nasal mucosa. Ann
terial is arbitrarily determined depending on how the
N Y Acad Sci., 2009;1170:604–609. doi: 10.1111/j.1749-6632.2009.04481.x.
reconstruction of the inferior conchae was required 7. Zhao K., Blacker K., Luo Y., Bryant B., Jiang J. - Perceiving nasal patency
during surgery. Implant locations are multiple – on through mucosal cooling rather than air temperature or nasal resistance.
the lateral nasal wall, at the level of the inferior con- PLoS One, 2011;6:e24618.
chae remains or the septal area adjacent to the re- 8. Wu X., Myers A.C., Goldstone A.C., Togias A., Sanico A.M. - Localization
sected concha –, normally performed to restrict the of nerve growth factor and its receptors in the human nasal mucosa. J
region of the nasal valve. Materials of different origins Allergy Clin Immunol., 2006;118(2):428–433. Epub 2006 Jun 6.
may be used: biological – cartilage graft at the auricu- 9. Houser S.M. - Surgical treatment for empty nose syndrome. Arch
lar pavillion or costal level, bone graft, muscle or adi- Otolaryngol Head Neck Surg., 2007;133(9):858-863.
10. Elad D., Naftali S., Rosenfeld M., Wolf M. - Physical stresses at the air-wall
pose tissue; synthetic – teflon, hydroxyapatite (mineral
interface of the human nasal cavity during breathing. J Appl Physiol
from bones and teeth), acellular dermis.
(1985), 2006;100(3):1003–1010. Epub 2005 Nov 3.
11. Lindemann J., Keck T., Wiesmiller K.M., Rettinger G., Brambs H.J., Pless
D. - Numerical simulation of intranasal air flow and temperature after
CONCLUSIONS resection of the turbinates. Rhinology, 2005;43(1):24-28.
12. Baraniuk J.N. - Subjective nasal fullness and objective congestion. Proc
The empty nose syndrome may emerge as a result Am Thorac Soc., 2011;8(1):62–69. doi: 10.1513/pats.201006-042RN.
of surgery on nasal conchae, but can still occur on 13. Naftali S., Rosenfeld M., Wolf M., Elad D. – The air – conditioning capac-
conchae with normal morphological structure. It is ity of human nose. Ann Biomed Eng., 2005;33:545-553.
not clear why some patients develop this syndrome 14. Piccirillo J.F., Merritt M.G. Jr, Richards M.L. - Psychometric and clinimet-
and others do not. In a sense, it is often associated with ric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20).
Otolaryngol Head Neck Surg., 2002;126(1):41–47.
psychiatric disturbances and psychosomatic patholo-
15. Jang Y.J., Kim J.H., Song H.Y. - Empty nose syndrome: radiologic findings
gies that indicate the role of psychosocial stress in
and treatment outcomes of endonasal microplasty using cartilage im-
some patients. The most striking symptom is the para-
plants. Laryngoscope, 2011;121(6):1308–1312. doi: 10.1002/lary.21734.
doxical nasal obstruction. Patients are preoccupied Epub 2011 May 6.
with their breathing and nasal sensations, leading to 16. Eccles R., Morris S., Tolley N.S. - The effects of nasal anaesthesia upon
the inability to concentrate, chronic fatigue, irritabil- nasal sensation of airflow. Acta Otolaryngol., 1988;106(1-2):152–155.
ity, anxiety, depression, associated with a major impact 17. Houser S.M. - Empty nose syndrome associated with middle turbinate
on the patient’s quality of life. Diagnosis is based on resection. Otolaryngol Head Neck Surg., 2006;135(6):972–973.
patient’s complaints and clinical examination. ENS
measures of prevention are very important by keeping
as much as possible the mucosa of the middle and in-
ferior nasal conchae. Patient’s life quality suffering
from this syndrome can be improved by restoring the
nasal volume.

Conflict of interest: The authors have no conflict of

interest.
Contribution of authors: All authors have equally
contributed to this work.