The functional and psychological burden of empty nose syndrome
Jamil Manji, MSc
, Jayakar V. Nayak, MD, PhD
and Andrew Thamboo, MD
Background: Empty nose syndrome (ENS) is a debilitat-
ing disorder thought to arise as a postsurgical phenomenon
from excessive loss of nasal tissues. Aﬀected patients oen
report a profound impact on all aspects of life, but the ex-
tent of this burden has not been quantiﬁed. We sought to
determine the association of ENS with mental health and
Methods: A cross-sectional study was performed of indi-
viduals with ENS recruited from online ENS forums. ENS
status was validated based on a positive 6-item Empty Nose
Syndrome Questionnaire (ENS6Q) score and sinus com-
puted tomography imaging or supporting medical docu-
mentation. Subjects completed the ENS6Q, the 9-item Pa-
tient Health Questionnaire (PHQ-9) for depression, the 7-
item Generalized Anxiety Disorder questionnaire (GAD-
7), the Epworth Sleepiness Scale for daytime somnolence
(ESS), the Work Productivity and Impairment questionnaire
(WPAI), and the 5-dimension EuroQol General Health State
Survey (EQ-5D-5L). Pearson correlation analysis was per-
formed with α = 0.05 to determine signiﬁcance.
Results: Fiy-three ENS individuals were included in the
study. Overall, participants reported symptoms consistent
with moderate anxiety (μ = 12.7; standard deviation [SD],
5.9) and moderately severe depression warranting treat-
ment (μ = 17.9; SD, 6.8). Participants also noted a 62% re-
duction in productivity at work (n = 24) and 65% in all
other activities (n = 53). ENS6Q symptom severity was cor-
related with more severe depression (p < 0.001), anxiety
(p < 0.001), overall pain/discomfort (p = 0.002), and
impairment in activities of daily living (p = 0.003).
Conclusion: ENS individuals carry a clinically signiﬁcant
psychological burden and experience marked diﬃculties
with many activities of daily living. A multimodal approach
to address the tissue loss with surgery and cognitive-
behavioral therapy for the psychological burden may pro-
vide the most optimal outcome.
2018 ARS-AAOA, LLC.
anxiety; complications; depression; empty nose syndrome;
sinus surgery; symptom severity
How to Cite this Article:
Manji J, Nayak J V, Thamboo A. The functional and psycho-
logical burden of empty nose syndrome. Int Forum Allergy
mpty nose syndrome (ENS) is thought to be a post-
surgical, iatrogenic phenomenon secondary to loss of
nasal turbinate tissue.
ENS symptoms may manifest
along a spectrum of severity and include: nasal suffoca-
tion; nasal burning; nasal obstruction; crusting; nasal dry-
ness; and impaired air sensation through the nasal cavity.
Because of the severity and debilitating nature of these
St Paul’s Sinus Centre, Vancouver, BC, Canada;
Otolaryngology–Head & Neck Surgery, Stanford University School of
Medicine, Stanford, CA
Correspondence to: Andrew Thamboo, St Paul’s Sinus Centre, Room
2600-1081, Burrard Street, Vancouver, BC V6Z 1Y6, Canada; e-mail:
Potential conﬂicts of interest: None provided.
Presented at the Annual Meeting of the ARS, on September 9, 2017, in
Received: 5 August 2017; Revised: 8 January 2018; Accepted:
12 January 2018
View this article online at wileyonlinelibrary.com.
symptoms, many ENS patients also struggle with men-
tal health issues and completing activities of daily living.
Chronic, debilitating conditions such as ENS often present
with comorbid psychiatric problems. Chronic rhinosinusi-
tis (CRS) is an archetype for this phenomenon, where
the prevalence of comorbid depression approaches 25%
and signiﬁcantly reduces the effectiveness of conventional
Unfortunately, given the broad conundrum rep-
resented by ENS and relative scarcity, these atypical pa-
tients have often been shunted toward a psychiatric basis
Recent efforts to unravel the pathophysiology of ENS
suggest that quantiﬁable primary nasal parameters can be
found in these patients using computed tomography (CT)
subjective testing (the Empty Nose Syndrome 6-
and objective (nasal cotton) testing.
With development of new treatment interventions, such as
inferior turbinate augmentation, we and others have seen
signiﬁcant improvement in these outcomes.
707 International Forum of Allergy & Rhinology, Vol. 8, No. 6, June 2018