More than a decade ago, rhinologist Jayakar V. Nayak, MD, PhD, a head and neck surgeon, rhinologist, otolaryngologist, and associate professor of otolaryngology–head and neck surgery at Stanford Medicine in Palo Alto, Calif., saw a teenager in his clinic who’d had septoplasty and three revision turbinate reductions. In the aftermath, she complained of “breathing funny, air hunger, and sleep issues” as a result. Her mother had brought her in to see Dr. Nayak, and both were desperate for a solution.
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August 2025“When I examined her, I saw that her inferior turbinates had been completely excised,” Dr. Nayak said. Although it was early in his practice, he remembered reading about a ‘cotton test’ for a situation like this. He placed some plugs of dry cotton inside the patient’s nose where her turbinates used to exist and left the room to do a quick online search. When he returned, he and the patient began having a normal conversation, free of the young woman’s labored breathing and pressured speech. “I don’t know what you just did,” she said, “but my nose and my breathing feel really good right now.”
This case introduced Dr. Nayak to empty nose syndrome (ENS), a condition that would become a major clinical and research focus of his. His findings would also challenge conventional thinking about post-surgical nasal complications and their unexpected ramifications.
A Complex and Controversial Condition
ENS represents one of the more complex conditions in otolaryngology, characterized by the paradoxical feeling of nasal obstruction despite objectively patent airways. In addition to the feeling of severe nasal obstruction—one patient called it “suffocating with every breath”—patients also report dryness, burning, and crusting. The quality-of-life impact can be so great that some patients travel the world seeking multiple consultations and revision surgeries. Dr. Nayak has seen ENS patients from 37 states and 20 countries. Some patients experience suicidal ideation from symptoms that feel relentless and interminable. And some surgeons have received threats, due to their research on the psychological aspects that may inform ENS, from self-identifying patients who believe their very real symptoms are being dismissed as being all in their heads.
Just because ENS patients may have some somatic symptoms that stem from a psychological origin, it doesn’t make their suffering any less real.” —John R. Craig, MD
According to John R. Craig, MD, division chief of rhinology in the department of otolaryngology and co-director of the Skull Base Pituitary and Endoscopy Center at Henry Ford Health in Detroit, one of the problems with the stigma of a psychological component to ENS is that often when surgeons try to explain this to the afflicted patient, the patient interprets it as, “You’re saying I’m crazy and I’m not experiencing this.” “Just because ENS patients may have some somatic symptoms that stem from a psychological origin, it doesn’t make their suffering any less real,” Dr. Craig said.
Brent A. Senior, MD, vice chair of academics and outreach, the Nathaniel and Sheila Harris Distinguished Professor, and chief of the division of rhinology, allergy, and endoscopic skull base surgery at the University of North Carolina at Chapel Hill, concurs. “Whatever is happening is very much a real phenomenon. It’s just that there can be a lot more to it than simply the physical structure in the nose. It’s a disservice to patients not to introduce the mental health aspect as particularly important in terms of how this needs to be treated.”
In his clinical practice, Dr. Senior witnessed what he called remarkable results involving cognitive behavioral therapy (CBT) in the case of a North Carolina State University student whom he saw for ENS-like symptoms. The patient in this case had never undergone surgery but was experiencing nasal breathing difficulties so severe that he was considering dropping out of school. “He just couldn’t function,” Dr. Senior said. After being prescribed standard medical therapy, the patient returned months later for a follow-up appointment, completely transformed. He told Dr. Senior he felt amazing and was doing great in school. When Dr. Senior asked if the medication he had prescribed did the trick, the patient said he hadn’t taken any of it. Someone had told him about CBT, and he had pursued it on his own. “That was my ‘aha’ moment,” Dr. Senior said.
Another concerning consequence of defining ENS as an iatrogenic condition is that it vilifies the surgeon, which can influence surgical decision making. “Due to concerns of causing ENS, some surgeons will either not perform turbinate surgery, or they will err on the side of performing the least invasive option possible because they’re worried about causing the condition and possibly being sued,” Dr. Craig said. This reluctance to perform indicated procedures may paradoxically harm patients who could benefit from more complete nasal airway surgery.
Whatever is happening is very much a real phenomenon. It’s just that there can be a lot more to it than simply the physical structure in the nose. It’s a disservice to patients not to introduce the mental health aspect as particularly important in terms of how this needs to be treated.” — Brent A. Senior, MD
The good news about ENS is that it’s very rare in both inferior and middle turbinate surgeries. Dr. Craig showed that in 100 consecutive patients who underwent medial flap turbinoplasties (reduction of the inferior turbinate bone, with or without soft tissue reduction), none developed ENS. Additionally, he worked with seven other institutions in a prospective multicenter study to show that of 110 patients who underwent subtotal middle turbinate resection, none developed ENS. He added that while these studies are too small to suggest that no one will ever develop ENS after nasal surgery, he believes they help to show that ENS is very unlikely to be caused by these appropriately indicated surgeries.
“The overwhelming majority of people do fantastically following appropriately indicated and performed nasal airway surgeries,” Dr. Craig said. “Unfortunately, some patients will develop ENS, so what we really need is to develop screening measures to predict those at risk for ENS pre-operatively. Then we can appropriately counsel patients and develop the most appropriate treatment plans.”
That doesn’t necessarily mean that ENS isn’t being caused by surgery in some cases. Dr. Nayak notes the enormous variability in both noses and respiration when comparing one human to the next, from nostril size and nasal shape to lung capacity, along with rate and volume of breathing.
“What I consider comfortable breathing isn’t necessarily what you consider comfortable breathing,” Dr. Nayak said. “There is likely variability in pressure receptors, receptor density, and nerve endings in the turbinate between patients. So, a given patient may have one to 100 more nerve endings in their turbinates than another patient, but to surgeons, the turbinates look identical. As such, if a given patient relies on these nerves and receptors to detect airflow, those who may eventually develop ENS will always be hard to predict.”
Prevention
Ways to prevent an ENS case before it even happens can range from taking surgical precautions before doing any type of nasal surgery to counseling or screening out certain types of patients pre-surgically, as psychological aspects of ENS have been extensively documented, with specialists observing strong correlations between the condition and certain types of mental health disorders.
Dr. Senior has conducted research revealing patterns among patients who develop ENS symptoms and has found that there seems to be a type of patient who is more likely to develop these symptoms. “Patients may have an underlying anxiety disorder, or perhaps an element of obsessive–compulsive disorder, and with the change of sensation in the nose after an operation, patients may hyperfocus on that,” he said. He added that his clinical experience with ENS has revealed an interesting pattern of patients who are overachievers, including several university professors, department heads, and deans. “These are highly focused, super successful people,” he said.
Edward D. McCoul, MD, MPH, vice chair, department of otorhinolaryngology, and professor of ENT at the University of Queensland Medical School–Ochsner Health in New Orleans, has had ENS patients whom he describes as experiencing their symptoms in ways that differ markedly from typical nasal obstruction cases and points to discussion in the literature about ENS being associated with clinical anxiety and depression.
“The number one reason people come to see me is that they can’t breathe through their noses, it bothers them, and they’ve been dealing with it for years,” Dr. McCoul said. “Most of them have found a way to manage that to some extent, however. The handful of people I see with ENS say they can’t breathe, they can’t focus, and they become obsessed by their symptoms to the extent that they are having difficulty functioning.”
Dr. McCoul found himself wondering if these patients became anxious and depressed by the functional symptoms of ENS, or whether they had preexisting anxiety and depression that affected their post-operative experience.
Dr. Senior said he is considering incorporating screening questionnaires for certain mental health disorders into his practice before performing certain nasal procedures. “If a patient has obsessive–compulsive disorder, for example, that’s not to say that we wouldn’t do the procedure, but we would want to be rigorous in terms of pre-operative counseling about what to expect, as well as perhaps being very minimalistic in terms of the procedure we perform.”
According to Chadi A. Makary, MD, associate professor, vice chair of clinical services, medical director, chief of rhinology, and director of quality improvement and safety at West Virginia University School of Medicine in Morgantown, W.Va., up to 77% of ENS patients exhibit features of hyperventilation syndrome, characterized by deep rapid breathing in stressful circumstances, and many meet the criteria for Somatic Symptom Disorder, which comprises excessive thoughts, feelings, and behaviors related to physical symptoms that cause significant distress.
“The key is a comprehensive evaluation incorporating objective findings, validated symptom questionnaires, and mental health screening tools like the PHQ-9 [Patient Health Questionnaire-9] and GAD-7 [Generalized Anxiety Disorder-7 questionnaire] ,” he said. He added that when a patient comes in with symptoms that align with ENS, one of the most important things an ENT can do is to validate their experience. “Many ENS patients have seen multiple providers and felt dismissed,” Dr. Makary said. “Taking time to listen and involve them in care decisions builds trust and improves adherence.”
Accurate Diagnosis
Diagnosis can be extremely difficult when it comes to ENS. The biggest challenge, said Dr. Makary, is the lack of standardized diagnostic criteria and objective biomarkers. “Many surgical interventions lack control groups and are influenced by placebo effects. The psychological overlay further complicates the interpretation of outcomes,” he said.
Additionally, a true ENS diagnosis is rare, and most ENTs have had little to no clinical experience with it. “Whenever we have situations where the objective and the subjective don’t correlate, it becomes very difficult for us to help manage those patients,” said Dr. Senior.
Accurately diagnosing ENS begins with ruling out other causes of nasal obstruction. “ENS is a diagnosis of exclusion,” Dr. Makary said. Before considering ENS, he evaluates for allergic rhinitis, chronic rhinosinusitis, turbinate hypertrophy, nasal valve collapse, septal deviation, and mucosal disorders such as atrophic rhinitis. “Structural integrity and mucosal health must be assessed to rule out reversible causes. If the objective findings don’t match the symptom burden, the possibility of functional nasal obstruction (FNO) should be considered,” he said.
A recent review recommended that FNO become a diagnostic option for otolaryngologists assessing patients for nasal surgery, since the disorder underlying ENS should be considered a risk factor in patient selection prior to nasal surgery rather than a complication from the surgery itself (Curr Otorhinolaryngol Rep. doi.org/10.1007/s40136-023-00487-w).
Dr. Nayak’s perspective that ENS may be a manifestation of individual physiological differences that surgery can unmask or exacerbate is a fundamentally new way of looking at the condition. “If you reduce a turbinate, a minority of people might have more nerve endings than other people,” he said. “And after surgery, those same patients may not be able to sense the airflow, or find that it feels very different, even disturbingly so.” Dr. Nayak’s clinical experience supports this theory. He estimates that of the 1,500 patients on whom he has performed turbinate reductions (3,000 turbinates total), “1,497 are extremely happy with the outcome,” while three experienced issues that led to ENS-like symptoms. He recalls that two of those three had spontaneous resolution of their suspected ENS issues over a year, leaving one patient whom Dr. Nayak had to implant on one side for ongoing symptoms. Dr. Nayak emphasized that he believes this low rate of 1/1000 is due to the principle of anatomic preservation during tuboplasty—maintaining the tubular shape and contour of the native turbinate—and simply trying to reduce turbinate caliber via submucosal bone and soft tissue reduction. Despite this, his practice is not immune to its patients developing post-operative ENS, due to the variances in post-operative healing that can occur in any given patient.
Dr. Nayak believes nearly all practitioners who perform turbinate surgery, including himself, may eventually have one or more patients who develop ENS even after following best practices. He has been referred patients from primary and specialist otolaryngologists from around the U.S. and the world, and says it is likely becoming increasingly important to acknowledge this (rare) possibility with patients ahead of surgery, and to consider supporting/assisting patients with some of the tools now available, such as using Empty Nose Syndrome 6-item Questionnaire (ENS6Q) testing, encouraging use of a variety of topical emollients, and perhaps even using gel filler augmentation to guide patients who may have post-operative concerns.
Through his research, and especially the experiences shared by patients, Dr. Nayak has developed a systematic approach to understanding ENS symptoms, identifying six “cardinal symptoms”:
- Nasal suffocation (“the sense that there’s a pillow over your nose”);
- Nasal dryness;
- Nasal burning or pain;
- Nasal crusting;
- Nasal congestion or inability to feel airflow; and
- Too much nasal airflow (“nose feels too open”).
“Some patients will say they know air is passing through the nose, but there’s ebb and flow to the beginning or end of a breath,” Dr. Nayak said. “These patients say that air just rushes through the nose without feeling any resistance, and that this feeling is really unnerving.”
One of the most challenging aspects of ENS is its delayed presentation, which research by Dr. Nayak and others has documented. “The time between surgery and reporting of symptoms is, on average, six years. Three months is the minimum given time for post-op healing, but the average is six years based on the literature,” he said. “This delay creates a complex diagnostic puzzle and complicates the understanding of causality.”
Another big challenge can be the high placebo effect involved in the classic cotton test. Dr. Nayak and his colleagues addressed this by developing the SENSE—Stepwise Empty Nose Syndrome Evaluation (Int Forum Allergy Rhinol. doi:10.1002/alr.23442), a four-step blinded assessment that evaluates nasal breathing in the absence of topical anesthesia or decongestants based on the following conditions:
- Placebo/no cotton placed in the nasal cavity;
- Complete cotton blockade of the nasal cavity;
- Cotton placed medially against the nasal septum; and
- Cotton placed laterally in the site of inferior turbinate tissue loss.
With each condition, patients complete an ENS six-item questionnaire. The group found that the placebo effect for the cotton test in the study was 29%, akin to many other tests in medicine. Patients could also readily discriminate minor changes in cotton placement, and the majority had the most benefit with cotton placed in the inferior meatus/site of highest tissue loss.
Dr. Nayak also uses temporary gel fillers as both a diagnostic tool and a temporary treatment option. “Similar to temporary vocal cord injections, we theorized that transient restoration of turbinate volume using submucosal gel filler injections might help patients and provide both physician and patient confidence in the diagnosis. We have published our findings of significant improvement in symptoms over one week to two months, with return to baseline ENS symptoms by three months.”
Perhaps the most compelling evidence for the physiological basis of ENS, Dr. Nayak believes, comes from computational fluid dynamics (CFD) analysis. Kai Zhao, PhD, a professor who studies nasal physiology at The Ohio State University in Columbus, has conducted this research independently and in collaboration with Dr. Nayak. Using CT scans, a computer algorithm creates three-dimensional reconstructions of the nasal airways and models airflow patterns.
“Dr. Zhao has discovered a very characteristic and aberrant airflow pattern that only exists in ENS patients,” Dr. Nayak said, adding that after ENS surgery, that pattern changes significantly and trends towards normal nasal aerodynamics.
Symptom scores from patients are subjective, but Dr. Zhao rarely meets the patients; his objective analysis is based solely on CT scans and simulated airflow patterns. These consistent findings from numerous patients suggest that ENS patients have measurably different airflow dynamics, independent of their subjective symptom reports.
For patients who do well with the cotton test and/or gel filler and meet additional strict criteria, Dr. Nayak offers an implant procedure using cadaveric rib cartilage to restore the inferior turbinate structure. His inferior meatus augmentation procedure (IMAP) outcomes show significant long-term improvement in both ENS6Q symptoms and Sino-Nasal Outcome Test (SNOT-22) scores (Laryngoscope. doi:10.1002/lary.29593).
“In our experience, we also see reduced metrics for anxiety and depression, the features that are often associated with empty nose syndrome. In my opinion, if this were strictly a psychiatric disorder, nasal implant surgery shouldn’t have produced lasting control of psychiatric symptoms. It seems that by restoring a semblance of normal nasal anatomy, airflow parameters also improve, and psychological well-being can naturally follow as a result.”
While some skepticism remains, Dr. Makary said most rhinologists now recognize ENS as legitimate. “We need to shift from viewing ENS as a complication of surgery to a manifestation of a preexisting functional problem,” he said. “This shift reduces stigma, avoids unfair blame on surgical technique, and better aligns with the evidence. Recognizing ENS as a functional disorder with neuropsychological underpinnings brings clarity and compassion to the conversation.”
While that conversation and Dr. Nayak’s research have attracted patients to his practice from around the world, he emphasizes that surgical intervention is reserved for carefully selected cases. Of the 400 patients referred to him for suspected ENS, only half have been diagnosed with the condition based on his testing protocols.
The future of understanding ENS likely lies in abandoning the either/or debate between physical and psychological causes in favor of a more integrated approach. As the field advances, the combination of sophisticated diagnostic tools, objective airflow analysis, and careful patient selection offers hope for better outcomes.
“The most effective strategy is prevention,” said Dr. Makary. “A major advancement is not procedural, but diagnostic. This means recognizing [that] the pre-operative functional and psychological predisposition is key. Conservative turbinate surgery that preserves mucosa, selective tissue-sparing techniques, and the use of powered instrumentation with endoscopic guidance all help minimize risk.”
Renée Bacher is a freelance medical writer based in Louisiana.
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