For Sinus Sufferers - The Empty Nose Syndrome

How to handle sinus pain associated with ENS

by Murray Grossan, M.D.

Dr. Eugene Krems of Mayo Clinic first coined the Empty Nose Syndrome term. He applied it to the persons complaining of pain and burning in the nose, sensation of "can't breathe" through the nose, recurrent infection, heavy crusting and sometimes depression. It is often seen when too much turbinate material has been removed.

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This was further described in the Los Angeles Times article by Aaron Zittner entitled, Sniffing on Empty Nose Idea on May 10, 01. He interviewed persons who complained of these symptoms. Many persons do develop depression because of constant symptoms and sensation of not getting enough air.

What is Empty Nose Syndrome?
There are 3 sets of turbinate or shelves in the nose. These serve to provide moisture, warmth, and direct airflow. Sometimes these are lost to disease. They shrivel and no longer function to moisten and warm the air. Sometimes they are removed by surgery. There are articles in journals recommending removal in order to provide adequate opening for breathing. When the turbinates are enlarged and block the breathing, removing them does open the airway. But now there is dryness, burning, crusting, and sometimes pain. The pain may come from the raw surface or the exposure of nerve endings or infection.

Once the turbinates can no longer provide mucus, cilia and enzymes to protect against infection, then secondary infections occur regularly and the patient may require additional surgery to clear the infection. Often these are the persons who have had 3 or 4 subsequent surgeries.

The worst symptom, in my opinion, is the feeling of not getting enough air. The nose acts like a pressure valve, like the control on the water hose. Close the opening of the hose and the stream goes 6 feet to water the petunias. Open the hose wide open, and the water dribbles at your feet. So the patient is missing the correct pressure and flow of air and feels he isn't able to breathe adequately.

All this can lead to depression. After all, you breathe 24 hours a day. With an upset stomach or broken finger, the pain is limited.

What are Turbinates?
There are 3 shelves on the side of the nose. These normally enlarge and shrink many times a day. At night they serve to prevent bedsores. You lay on your left side. The turbinates fill by gravity. They fill and push on the septum, the nasal divider in the center, and this signals you to turn on your right side. About 50 times a night this is repeated.

The inferior turbinate at the floor of the nose may be enlarged due to repeated infection. This is called hypertrophied nasal turbinate. The enlargement may be allergic, or due to an increase in circulation here such as vasomotor rhinitis. There may be huge pools of blood in the turbinate. There may be a physical swelling due to this enlargement that does block breathing.

The middle turbinate is about in the middle on the side of the nose. It is quite important as it supports the structures of drainage from most of the sinuses. In order to enlarge the opening to the maxillary sinus it may be necessary to remove part of the middle turbinate. This may loosen the entire turbinate so that it can fall forward and block the drainage of the frontal sinus. Thus it may require removal in some cases.

The superior turbinate is at the top of the side of the nose and is rarely enlarged enough to impair breathing.

The turbinates are the source of much of the mucus, the cilia action and the enzymes that fight disease such as lysozyme. If the inferior and middle are removed, the source of warming and moistening the air is gone, and then the dryness, frequent infections, crusting and local pain can result. An X ray clearly shows that the four turbinates are removed, hence the term Empty Nose Syndrome. (ENS)

With the absence of the mucus, cilia and enzymes, frequent infections of the sinuses can occur. This may lead to the need for further sinus surgery.

How do you prevent it?
Most sinus difficulties come from failure of the cilia and mucus to do their job. This is called the mucociliary system. Severe infection, toxic fumes, certain drugs - all can slow the cilia and this allows infection. If steps are taken to insure good cilia function, many sinus problems can be avoided. If irrigation is used when the cilia are slowed - with chronic pus discharge, this often helps. Extreme dryness may impair the nose so moisturizers are useful.

Sometimes the nose is blocked no matter what has been tried - allergy, irrigation, etc or X-rays indicate serious sinus blockage. If surgery is indicated, speak to your doctor about procedures that spare the cilia. These include

a. Submucus resection of the turbinate. Here only the bone is removed and the turbinate shrinks and goes to the side so it doesn't block.

b. Radiofrequency. Here a probe is used a radio wave is used to congeal the tissue under the mucosa. One such device is called Somnoplasty

c. Limited turbinate removal. Most doctors are skilled and can remove small portions of the turbinate without doing harm.

Procedures that may result in Empty Nose Syndrome when done improperly include wide chemical or electric cautery, laser cautery and of course surgical removal.

Once you have it, how do you treat Empty Nose Syndrome?
Fortunately treatment is available for this condition. For example, Dr Steven Houser of Cleveland is developing a technique of implanting tissue that has helped these patients. Instead of just narrowing the wide-open area, he directs airflow so that the pathology is reduced.

Dr Terrance Davidson of San Diego is the originator of adding antibiotics to the pulsatile irrigation for clearing infection. His clinic, The Nasal Dysfunction Clinic deals with this problem.

Since we have absence of nasal cilia here, an artificial cilia is created by pulsatile irrigation with Locke-Ringer's solution. (available as Breathe. ease) Hydro Med markets the pulsatile irrigator where the pulsation mimics the cilia action and is used for improving or replacing cilia action. The pulsatile irrigation removes crusts, bacteria and pollen, which the turbinates would dispose of if they were functional.

The pain that many persons complain of may be due to inflammation and edema of sinus membrane. Enzymes such as Clear. ease, a combination of papaya and pineapple enzymes, are very useful for reducing this inflammation. These enzymes must be taken via the buccal route - dissolve in the mouth - in order to be effective. Other anti-inflammatories such as Aleve may be helpful.

In addition to the pulsatile irrigation, patients need to use a moisturizer several times a day since the nose isn't providing moisture. Carry a one-ounce refillable spray container and spray 4 times a day.

Fortunately the effects of Locke-Ringer's in soothing the nose are quite useful for persons with this syndrome. Sometimes just this soothing action alone can reduce symptoms.

For most persons cortisone sprays should be avoided. The nose is already too open and the membranes are already too thin.

Any product with the preservative Benzalkonium and other preservatives is liable to burn and cause increased symptoms. If saline works for you, you should mix it yourself without the preservatives. The formula is one teaspoon of salt to pint of water. Add less than 1/2 teaspoon of baking soda. Change the solution once a week.

With the Empty Nose Syndrome, because there is little mucus to dilute strong odors, any strong odor can cause symptoms. Carry the spray bottle in order to wash out immediately offensive products. Even perfume in an elevator can cause symptoms! Try to use a refillable spray bottle, such as the one that comes with Breathe. ease which can be used as a spray, drops or to irrigate.

For most persons an antihistamine or decongestant may dry the nose further. But some patients do experience relief with such drugs.

Some persons have found a product that makes excess nasal mucus and they take this product to get the excess mucus condition! Perhaps if you are a person who gets mucus from drinking milk, you may want to try this if you have ENS. Some patients allergic to dogs do better around the dog when they get nasal allergy!

Warm compresses to the sinus area brings circulation to the area and this is desirable.

Skiing, winter sports are very hard for persons with ENS. The dryness of high altitude is very difficult. Dry atmosphere MUST be avoided. Moisture in the bedroom is essential.

Flying is a problem because the air is very dry. Carry tea bags and drink hot tea. Spray nose with moisturizer. When traveling, especially in the winter, moisten the bedroom by hanging wet towels in the room. If breathing cold winter air is too much for you, a piece of cotton in the nose may help warm the air and reduce symptoms.

Now that Dr Kerns has called attention to this problem, I am sure better management will result.


"The Sinus Cure" by Debra Bruce and Murray Grossan, M. D. Published 2001 by Ballantine.

Of the 7 steps for sinus cure, pulsatile irrigation to remove pus and restore the cilia is one of the most important procedures for sinus cure.

Note: Clear.ease is available at Hydromedonline.com. The Grossan Sinus Irrigator and Breathe.ease are available at AllergyBuyersClub.com.

First Published: early June 2001
Updated: April 2007

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