Q: What is Empty Nose Syndrome?
A: Empty nose syndrome is a very unpleasant condition characterized by a wide open, dry nose that drips and feels blocked. Patients complain bitterly of nasal blockage while their physician insists that it is wide open. The nose appears dry and crusty on examination, but drains constantly. Typically the inferior turbinates are small, atrophic, or surgically absent.
Turbinates are soft, vascular structures within the nose that warm and humidify the air before it reaches the lungs. Healthy turbinates will swell when the ear is cold and secrete more water when the air is dry. The turbinates will shrink if the air is warm and secrete less mucus if the air is moist. The image to the right shows a nose with healthy turbinates. They appear as the curly grey structures on both sides of the midline nasal septum. The air spaces appear black on CT scans. In this patient, the air spaces around the turbinates are a healthy 2-3 mm wide throughout, which allows a large surface area for the nose to warm and humidify the air.
If the inferior turbinates are surgically removed, the air flows freely through cavernous nasal passages, evaporating the mucus from the limited surface area. The nasal mucosa senses the cold, dry air and attempts to swell and secrete more mucus. If the turbinates are absent or nonfunctional, then they never achieve the goal of warming and humidifying the air. The remaining nasal tissue continues to swell and to secrete more and more fluid until it begins to drip and drain. The patient experiences the perception of swelling, which he or she describes as nasal congestion, even though the air is moving. The mucus eventually drips from the nose and drains into the throat even though the nasal cavity is dry and crusty.
The patient image shown to the right had a septoplasty with aggressive turbinate resection in the 1980s. This was a popular procedure at that time, but was abandoned in the 1990s because of the high incidence of empty nose syndrome. The inferior turbinates are absent, and the middle turbinates are swollen, contributing to a wide open, dry nose, that feels stuffy and drips constantly.
Aging is a natural cause of Empty Nose Syndrome. If the turbinates begin to lose volume, or if the mucous glands secrete poorly, then the nose again becomes dry and drippy as if the turbinates had been surgically trimmed. This is called “atrophic rhinitis.”
Treatment of Empty Nose Syndrome is difficult, because the missing tissue is not easily replaced. Salt water (saline) rinses and petroleum jelly (e.g. Vaseline) can help protect the lining of the lower nose from drying, while nasal steroid sprays can reduce the swelling in other parts of the nose. Sometimes, a drying agent such as ipratropium bromide nasal spray can reduce excess dripping.
Nasal turbinates may be overgrown on the side opposite a nasal septal deviation, or they may be so large that they block drainage from or surgical access to the sinuses. If turbinate reductions are necessary with septoplasty or sinus surgery, the surgery should be as conservative as possible to reduce the risk of empty nose. The surgeon should also attempt medical management and consider allergy before surgically reducing swollen turbinates. It is far better to correct the cause of the swelling than to amputate the swollen body part.