The Suffocating Truth Behind Empty Nose Syndrome

Take a deep breath in through your nose for a time. Feel the chilly resistance in your mucous membranes as air flows through your nose, warming and moistening your breath. Consider the same nasal inhalation without the pleasurable sensation of inhaling oxygen. Instead, it feels like you're sucking air through a skinny cocktail straw. Or you have the impression that you are inhaling too much air. Or the air you breathe in is excessively dry or frigid, making even inhaling through your nose uncomfortable. These unpleasant symptoms become so unbearable that you begin to feel suffocated. You get headaches and dizziness, get nosebleeds, and occasionally wake up in the middle of the night gasping for oxygen. However, when you see a doctor, he looks deep into your nasal passages and finds no medical basis for your symptoms. Your nose is not impeded or disfigured in any way. Even your respiration appears to be normal. Perhaps the problem is all in your brain, he believes. Is it possible that you have empty nose syndrome?

Let Us Define Empty Nose Syndrome

"Empty nose syndrome is a paradoxical impression of nasal blockage," explains Dr. Spencer C. Payne, associate professor of otolaryngology at the University of Virginia. "Paradoxical because, by all appearances, the nose appears to be very open, but the person suffering from it feels as if they can't breathe or as if air isn't passing through the nose. And because the physics of airflow via the nose is tricky," he explains, "it's difficult to discern if they're actually suffering nasal obstruction or if they're simply not detecting the flow of air through the nose."

According to some estimates, one in every 1,000 patients who have certain types of nasal surgery develop empty nose syndrome, or ENS. Nobody knows how many patients who did not have surgery developed the ailment. To complicate matters further, many doctors do not accept ENS as a medical illness at all. Suffocation can be debilitating for those who suffer it, interfering with their employment, leisure activities, and quality of life. Many patients expressed concern that they would never enjoy the satisfaction of taking a regular breath of air again. They get anxious and depressed because there is no medical professional to support their symptoms.

Causes of Empty Nose Syndrome

It is widely assumed that empty nose syndrome is an iatrogenic disorder, meaning that it is caused by medical therapy, in this case nasal surgery, such as septoplasty to fix a deviated septum, cosmetic or functional rhinoplasty, or sinus surgery. All or some of the nose's turbinates are removed or decreased during these treatments. Turbinates are bony, mucous membrane-covered structures placed along the sides of the nasal cavities inside the nose. Turbinates control airflow and warm and moisturize the air you breathe in.

However, Payne believes that even this is a doubtful cause of ENS. Some patients never develop ENS after having some or all of their turbinates removed. "Although the statistics and study haven't really been looked at from a comprehensive causative perspective, the issue is that most people who present with [ENS] have had surgery because they had a nasal obstruction or a perception of a clogged nose," he says. Following surgery, the patient may claim that their nasal obstruction is worse than before. "It's difficult to say whether the surgery caused or exacerbated this failing to effectively perceive airflow via the nose," he says.

"The truth is, we don't fully understand why some individuals get it and others don't, which is why I personally believe it's a combination of some underlying nerve issue."

Is There A Scientific Basis About Empty Nose Syndrome?

Payne was assigned to write a response concerning the occurrence of empty nose syndrome for the journal Otolaryngologic Clinics of North America in 2009. He wasn't really an expert in the subject of ENS. However, he had studied it sufficiently to deliver instructional speeches on the disorder and had encountered a few patients with symptoms suggestive of ENS in his own practice. He delved into research, hoping to support the common thinking of other otolaryngologists at the time, which held that empty nose syndrome was more of a symptom of mental illnesses. Instead, he came to a completely different conclusion: "The problem with empty nose syndrome is probably not that it does not exist," he said in the essay, "but that we cannot adequately explain its existence by what we now know about the nose."

Because not everyone who undergoes turbinectomy develops ENS, he concluded, "it behooves us to evaluate this latter entity with a more critical eye, so that we can avoid creating future sufferers and provide relief to those who have already been afflicted." Since then, otolaryngologists, according to Payne, have become more open-minded about empty nose syndrome. But there are still doubters. "There are parts of the world where they don't normally see empty nose syndrome, and it's considered much more problematic," he explains. He thinks it's because of the weather.

Then there's the anxiety and melancholy that commonly follow an ENS diagnosis, "compounding by the idea that you'll never get well and no one will ever believe you," he says. "It would drive anyone insane," he says, adding that anxiety and depression are seen in patients with chronic disease "all the time." Regardless, the symptoms of ENS can be so debilitating and negatively impacting on quality of life that a small number of people, particularly those with underlying psychiatric problems, have committed suicide.

How Is Empty Nose Syndrome Detected?

Diagnosis of ENS is also difficult because there are frequently no clinical symptoms that can be discovered during a physical examination or a scan. A "cotton test" for ENS was devised, which includes inserting cotton into the nasal cavity. The cotton was found to enhance nasal resistance, correct airflow distribution, and give relief from ENS symptoms in some individuals within minutes, according to the researchers. Some patients are evaluated using the Sino-Nasal Outcome Test 22 (SNOT-22), which evaluates nasal symptoms using 22 symptoms. Recently, the ENS6Q, a six-item questionnaire, was developed as an auxiliary to the SNOT-22 test to better identify patients with empty nose syndrome. However, Payne claims that these tests just scratch the surface. "There are people with empty nose syndrome who still have normal appearing turbinates and don't seem to have a decrease in air flow over the turbinates, so there's really no great way to diagnose individuals by any objective measure other than trying to say, 'Well, based on what the nose looks like and what you're complaining about, then you must have empty nose syndrome."

Is There A Cure?

It is one thing to be diagnosed with ENS. However, people who receive a definitive diagnosis have a variety of therapy alternatives. These are some examples:

• To moisturize the nose, use saline nasal sprays or gels. The evaporation of the fluid creates the illusion of wind.
• To stimulate the cold receptors in the nose, use menthol products or essential oils such as rosemary, mint, and eucalyptus.
• Surgeries that use implants to reconstruct the turbinates or enhance nasal resistance are uncommon and do not replicate the humidification and immune protection of the original turbinate mucosa.
• Some researchers have used platelet-rich plasma in conjunction with implants to treat ENS.
• Injections of stem cells into the nose lining to promote regeneration have also been explored.

Another method is to treat not just the symptoms of empty nose syndrome, but also the psycho-social discomfort that is a fundamental component of it. "Because you can't heal the sickness, I think it's vital to recognize that these problems put stress and strain on the body and mind," Payne adds. "I also recommend those with ENS to seek mental counseling to supplement their entire treatment strategy."