Empty nose syndrome (ENS) is a complex condition in which a person can feel obstructed, dry or unable to sense normal nasal airflow despite having an objectively open nasal airway. Modern rhinology therefore needs a balanced approach: take symptoms seriously, preserve normal nasal function, identify the real cause of obstruction and align patient expectations with what surgery can realistically achieve.
Rethinking Empty Nose Syndrome Without Dismissing It
A recent professional discussion between rhinologists raised an important question: can fear of empty nose syndrome sometimes make surgeons too cautious during primary nasal surgery, leaving unresolved problems that later require revision?
Mr Hassan Elhassan has commented that concern about ENS can influence surgical decision-making and that, in his revision practice, overly conservative primary surgery may sometimes contribute to persistent symptoms. That is a clinical observation rather than evidence that a defined proportion of revision surgery is caused by fear of ENS.
The important point is not that surgeons should become more aggressive. The better question is how to preserve normal nasal physiology while still treating genuine obstruction effectively.
That requires a proportionate plan: protect healthy turbinate tissue, avoid unnecessary resection, identify the true source of obstruction and make sure the patient’s goals match what the proposed operation can reasonably deliver.
What Is Empty Nose Syndrome?
ENS is usually described after previous nasal surgery involving loss or reduction of turbinate tissue, particularly the inferior turbinates. Symptoms can include paradoxical nasal obstruction, excessive openness, dryness, burning, crusting, impaired airflow sensation and a feeling of suffocation or inadequate breathing.
Paradoxical Obstruction
The nose may appear widely open on examination while the patient still experiences a powerful sensation that nasal breathing is inadequate.
Altered Air Sensation
Research suggests that altered airflow distribution and trigeminal sensory function may contribute to abnormal perception of nasal breathing in some patients.
Dryness & Crusting
Turbinates help warm, humidify and condition inspired air. Disruption of those functions can contribute to dryness, crusting and irritation.
Quality-of-Life Impact
ENS can be associated with poor sleep, anxiety, depression and major disruption to daily life.
A systematic review of ENS pathophysiology found that anatomy alone does not explain why some patients develop severe symptoms while others with similar postoperative structural changes do not. Altered nasal aerodynamics, sensory dysfunction, mucosal changes and psychological burden may all be relevant, but the underlying mechanisms remain incompletely understood.
ENS Should Not Be Diagnosed From an “Open” Nose Alone
Assessment begins with the history. The surgeon needs to understand what operation was performed, when symptoms started, what the patient feels when breathing, whether symptoms change with humidity or position, and what other nasal or general health problems may be present.
Detailed History
The timing of symptoms, previous surgery, dryness, crusting, airflow sensation, sleep, breathing distress and original treatment expectations all matter.
Nasal Examination & Endoscopy
Endoscopy helps assess remaining turbinate tissue, mucosal health, the septum, nasal valve, crusting, scarring and alternative causes of obstruction.
ENS6Q
The Empty Nose Syndrome 6-Item Questionnaire is a validated symptom tool used as an aid in identifying patients with a symptom pattern consistent with ENS. It supports specialist assessment rather than replacing it.
Cotton Testing
Temporary placement of cotton in the inferior meatus can change airflow and may improve symptoms in selected patients. Newer work also highlights the value of controlling for placebo and position effects during testing.
Published work commonly uses an ENS6Q score of 11 or more as part of specialist assessment. Symptoms such as blockage, dryness or breathing discomfort can also occur with nasal valve problems, residual septal deviation, rhinitis, crusting, sinus disease and other conditions.
Preventing ENS Does Not Mean Leaving Every Turbinate Untouched
The turbinates are functional structures involved in humidification, filtration, temperature regulation and sensory feedback. Modern turbinate surgery therefore aims to preserve useful mucosa and avoid unnecessary tissue loss.
Preserve Function
Mucosa-preserving and tissue-sparing techniques aim to improve airflow while maintaining as much normal turbinate function as possible.
Treat Real Obstruction
Excessive caution is not automatically safer if a significant anatomical problem remains untreated and the patient is still obstructed.
Identify the Correct Structure
Nasal blockage may come from the septum, nasal valve, turbinate hypertrophy, inflammation, scarring or a combination of factors.
Avoid One-Size-Fits-All Rules
“Never touch the turbinates” and “remove enough tissue to make the airway very open” are both oversimplifications. Surgical planning should be individual.
Reviews of turbinate surgery consistently emphasise preservation of functional mucosa and avoidance of radical tissue loss. Recent literature also supports submucosal and mucosa-preserving approaches when turbinate reduction is clinically required.
Why Patient Goals Need to Be Discussed Before Surgery
A technically successful operation and a satisfied patient are not always the same thing. Before surgery, surgeon and patient need a shared understanding of the symptoms being treated and the limits of what surgery is expected to change.
- Which symptom is the main problem: blockage, pressure, dryness, sleep disturbance or altered airflow sensation?
- Is there an anatomical finding that reasonably explains that symptom?
- What improvement is realistic, and which symptoms may remain despite technically successful surgery?
- Has appropriate medical treatment been tried before another operation is considered?
- If previous surgery did not give the expected result, is revision addressing a demonstrable problem or simply repeating an assumption?
If the patient’s symptoms, examination findings and expectations do not fit together, further investigation, medical treatment, observation or input from another specialty may be more appropriate than immediately planning another operation.
Psychological Distress Is Important — but It Should Not Be Used to Dismiss Symptoms
Mental health is an important part of ENS care because the condition can be profoundly distressing. A 2025 systematic review and meta-analysis found high rates of depression and anxiety among published ENS cohorts.
That does not establish that ENS is “caused by anxiety” or that symptoms are imaginary. The direction of the relationship remains uncertain: psychological symptoms may develop because of persistent breathing distress, may amplify symptom perception, may pre-date surgery in some patients, or may interact with physical mechanisms in different ways.
Where anxiety, depression, panic, health-related fear or severe distress are present, treating them is part of good care. Psychological or psychiatric support can sit alongside ENT assessment rather than replacing it.
If nasal symptoms are accompanied by a mental-health crisis, thoughts of self-harm or an immediate risk to safety, seek urgent help. In England, NHS 111 can provide urgent mental-health support; if there is an immediate danger to life, call 999 or attend A&E.
Revision Nasal Surgery Should Start With Re-Diagnosis
A patient who remains blocked or uncomfortable after nasal surgery does not automatically need “more of the same”. Revision assessment should begin again with the diagnosis.
Residual Septal Deviation
A persistent or recurrent deviation can remain an important source of airflow limitation.
Nasal Valve Dysfunction
Internal or external valve narrowing or collapse can produce major obstruction even when the septum looks relatively straight.
Turbinate Problems
Ongoing hypertrophy, asymmetry, scarring or excessive previous tissue loss can each require a different approach.
ENS-Type Symptoms
Paradoxical obstruction, excessive openness, dryness or impaired airflow sensation may justify ENS-specific assessment.
How Is Empty Nose Syndrome Managed?
Treatment is individual and usually begins conservatively. The evidence base remains limited, and there is no single treatment that works for every patient.
Moisturisation & Humidification
Saline, nasal moisturisation and environmental humidification may reduce dryness and crusting in some patients.
Treat Coexisting Conditions
Rhinitis, sinus disease, sleep problems, anxiety, depression and other contributors should be identified and treated where appropriate.
Temporary Augmentation Testing
Cotton testing or other temporary measures can help explore whether changing intranasal volume or airflow improves symptoms.
Reconstructive / Augmentation Procedures
Selected patients with persistent symptoms may be considered for specialist augmentation techniques, but outcomes remain variable and the evidence is heterogeneous.
Recent systematic reviews report improvement in ENS symptom and quality-of-life measures after selected interventions, but much of the literature consists of observational studies, case series and varied techniques. Larger controlled studies are still needed.
Before Primary or Revision Nasal Surgery
- What exactly is causing my nasal obstruction?
- Does my operation involve the inferior or middle turbinates?
- If turbinate reduction is required, how will healthy mucosa and useful tissue be preserved?
- What symptoms is the operation expected to improve — and which may not change?
- What alternatives are available if my symptoms and the examination findings do not match?
- If this is revision surgery, what is different about the diagnosis or plan compared with my previous operation?
The Aim Is Functional, Proportionate Nasal Surgery
ENS is real, complex and potentially life-changing. At the same time, fear of ENS should not turn nasal surgery into a choice between “remove nothing” and “remove too much”.
The more useful approach is careful diagnosis, tissue preservation, proportionate surgery, endoscopic assessment, realistic expectation-setting and appropriate multidisciplinary support. For patients with persistent symptoms after surgery, the priority should be to understand the mechanism of those symptoms before deciding whether another procedure is likely to help.
Evidence Used in This Article
- Velasquez N, Thamboo A, Habib AR, Huang Z, Nayak JV. The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q): a validated 6-item questionnaire as a diagnostic aid for empty nose syndrome patients.
- Thamboo A, Velasquez N, Habib AR, et al. Defining surgical criteria for empty nose syndrome: validation of the office-based cotton test and clinical interpretability of the ENS6Q. The Laryngoscope. 2017.
- Empty Nose Syndrome Pathophysiology: A Systematic Review.
- Stepwise Empty Nose Syndrome Evaluation (SENSE) test — a modified cotton test for reduced bias in office diagnosis.
- Hussain S, et al. A Systematic Review and Meta-Analysis of Management Options for Empty Nose Syndrome: A Proposed Management Algorithm.
- Surgical and Regenerative Treatment Options for Empty Nose Syndrome: A Systematic Review. Clinical and Experimental Otorhinolaryngology. 2024.
- Depression and anxiety in empty nose syndrome: a systematic review and meta-analysis. 2025.
- Surgical interventions for empty nose syndrome: a meta-analysis of meta-analyses. 2025.
- Guerrero-García T, Cárdenas-Camarena L, Ceballos MA. Inferior Turbinate Preservation Surgery: Surgical Strategies to Prevent Empty Nose Syndrome. 2026.
- NHS. Urgent support for mental health.