The moment I saw my first patient with empty nose syndrome, I knew I had witnessed one of the most devastating complications in ENT surgery. 

A patient sat in my office and told me she could not breathe even though her nose felt “too open.” Her scans showed wide nasal passages. Her exam showed no obvious blockage. Yet she felt air hunger, dryness, and panic with every breath.

That paradox is what makes empty nose syndrome so frightening. People assume a bigger nasal space must mean better breathing. But the nose is not just a pipe. It is a living organ with tissue, nerves, and moisture systems that help you sense airflow and condition every breath.

Empty nose syndrome is serious and life changing. Patients deserve to understand empty nose syndrome causes and to know that many cases can be prevented. 

In my own practice, I follow strict protocols to protect nasal function, especially during turbinate surgery. I want you to breathe better after surgery, and I want you to stay safe.

What causes empty nose syndrome

Empty nose syndrome causes confusion because the problem does not always show up the way people expect. If you look only at how “open” the nose seems, you can miss what the patient is actually experiencing.

“My nose is open, but I can’t breathe”

The core symptom many people describe is paradoxical nasal obstruction. That means you feel blocked even when the nasal cavity looks wide and clear. One study describes this pattern and explain that patients may report obstruction despite broad post-surgical nasal permeability.

‍So why does that happen?

Because breathing comfort is not only about space. It is also about how air moves through the nose and how the lining of the nose senses that airflow.

What turbinates really do

Turbinates are not “extra tissue.” They are part of the nose’s working system. One study describes the nose as the main portal for air exchange and explains how the nasal cavity warms, humidifies, and filters inhaled air. 

They also describe how airflow behavior changes through the nasal valve and nasal cavity, and how contact between air and mucosa supports heat and moisture exchange.

When turbinate structures and mucosa are reduced too much, you lose surface area. That matters because mucosal surface is where conditioning happens. It is also where airflow sensation begins. 

The vestibule is a key area for sensing airflow, and the broader discussion shows how airflow patterns and mucosal contact shape breathing experience.

ENS can involve airflow changes, sensation changes, and more

One reason empty nose syndrome causes are debated is that the mechanism is complex. 

One study reviewed the pathophysiology research and found several themes. They reported that airflow measures after turbinate surgery can look similar in ENS and non-ENS patients, while some testing suggests altered sensory response. They also reported that anxiety and depression were present in over half of ENS patients and correlated with symptom severity.

It explains something important. ENS is not always a simple “too much tissue removed” story, even though tissue loss is often part of the picture. It can be multifactorial.

The role of tissue destruction after surgery

ENS is described as a rare iatrogenic disorder that results from destruction of normal nasal tissue and they urge a cautious approach to turbinate resection to help prevent it. The same study above also emphasize prevention as the most important strategy and recommend conservative techniques.

In our patient’s case, the story matched what these descriptions warn about. She had symptoms that fit ENS. Her nasal cavity was wide. Her dryness was severe. And she felt suffocation despite an apparently open airway.

When I see that pattern, I think about ENS causes in a practical way. What changed in the nose that made normal breathing feel abnormal?

The surgical decisions that lead to empty nose syndrome

When patients come to me after prior nasal surgery, they often ask a direct question. “Did my surgeon do something wrong?” That is a painful question, and the honest answer is that the problem is often linked to technique choices.

Empty nose syndrome is most often associated with turbinate surgery, especially inferior turbinate tissue loss. The AAO-HNS explains ENS as a post-surgical disorder with paradoxical obstruction in a patient whose exam shows a patent airway.

Here are the surgical patterns that raise my concern when I review revision cases.

Over-aggressive turbinate reduction or turbinectomy

The most obvious risk pattern is radical removal. 

One study explains that turbinate surgery should aim to reduce soft tissue volume while conserving as much mucosa as possible. The author warns that radical resection may lead to severe functional disturbances and describes “empty nose” as a specific entity within secondary atrophic rhinitis.

The same study above also notes that large-scale resection carries the greatest risk, although ENS has been reported after partial resection as well. That is why I do not treat turbinate surgery as a “simple trimming.”

If someone removes too much turbinate structure, the nose can lose conditioning ability. The same study describes reduced mucosal surface and explains how ENS patients can have trouble with humidification and experience dryness beyond the nose, including the throat.

Simultaneous removal of multiple nasal structures

Another pattern I see is “stacking” tissue removal. The more structures reduced in one operation, the higher the chance that airflow balance changes in a way the nose cannot regulate well.

One research studied virtual total inferior turbinectomy and compared it with actual surgical outcomes and an ENS cohort. Their conclusion was that aggressive inferior turbinate surgery alone did not recreate the airflow distortions seen in ENS, and they argued ENS is likely multifactorial. 

They also suggested that combined loss of more than one turbinate region may be involved in the airflow imbalance seen in ENS.

That fits what I see in real revision histories. Many patients with the worst symptoms describe more than one structure being altered.

Failure to preserve mucosal surface area

This is one of the biggest turbinate surgery complications that patients do not hear about clearly. Mucosa is not cosmetic lining. It is functional tissue.

Mucosa preservation is emphasized as  a core principle because the turbinates serve climate control, humidification, and cleaning of inhaled air. Experts also link reduced mucosal area to loss of humidification and conditioning functions and to disturbance of sensory receptors.

If mucosa is removed or damaged extensively, dryness, crusting, and altered sensation become much more likely.

Inadequate patient selection and planning

Prevention starts before surgery. Experts recommend confirming that nasal “dyspermeability” truly resists medical treatment before moving forward, and they recommend conservative techniques.

In real life, poor planning shows up as vague goals. I hear phrases from prior consultations like:

• “We will just open you up.”
• “Bigger airway equals better breathing.”
• “Turbinates are the problem.”

That kind of thinking can lead to overly aggressive intervention. Nasal surgery safety depends on matching the plan to your anatomy, your symptoms, and the functional role of the tissues involved.

How I protect every patient

When patients ask me about empty nose syndrome prevention, I tell them something simple first. The best treatment is avoiding the injury in the first place. Once mucosa and sensory function are disrupted, rebuilding normal function can be difficult.

Here is how I approach prevention in a way that stays consistent, case after case.

I start with a careful evaluation, not a fast decision

Before I touch a turbinate, I want clarity on what is happening in the nose. That includes:

• A detailed symptom history that separates “blockage feeling” from dryness, burning, or airflow discomfort
• Nasal endoscopy in the office to see what the lining and structures look like
• Imaging when needed so planning is based on anatomy, not guesswork

Why does this matter? 

Because ENS diagnosis itself can be difficult, and symptoms can occur even when the exam looks normal. The AAO-HNS notes the lack of reliable physical exam findings and highlights validated tools like the ENS6Q and the cotton test as adjuncts.

Even if someone is not suspected of ENS, that message still applies. Nasal function is more than “open or closed.”

I use conservative techniques that preserve critical structures

The guiding principle is mucosal preservation.

One study describes turbinate techniques as mucosal-sparing versus non-mucosal-sparing and notes that non-mucosal-sparing techniques have been associated with complications like excessive bleeding, crusting, pain, and prolonged recovery. They emphasize that the goal is to relieve obstruction while preserving function.

So what do I do in the operating room?

I choose methods that reduce volume while keeping the functional lining intact as much as possible. I avoid radical resection. I avoid “emptying” a turbinate.

I prefer submucous reduction instead of removing surface tissue

When reduction is needed, submucosal approaches matter because they aim to reduce internal volume while preserving the mucosa that conditions air.

Some experts studied a technique that preserved mucosa and submucosa while performing selective submucous resection of turbinate bone in rhinoplasty patients. They reported excellent outcomes by NOSE score and did not report specific complications such as dryness and crusting.

The same study above lists several conservative techniques recommended for prevention, including:

• Partial turbinectomy that conserves at least half of turbinate volume
• Submucosal turbinoplasty that reduces turbinate bone without resecting mucosa
• Other conservative technologies

This is the heart of my surgical philosophy. I want improvement without sacrificing the nose’s ability to do its job.

I educate patients on realistic expectations and warning signs

Patient education is a safety tool. I explain:

• Why turbinates are important
• Why “wide open” is not the goal
• What dryness, burning, or strange airflow sensations can mean after surgery
• Why follow-up matters

I also explain something many people do not expect. Even science shows ENS is not purely mechanical. 

One study reported evidence of mental health comorbidity and suggested abnormal sensory response may be present in some patients. That does not mean symptoms are “made up.” It means the experience of breathing is tied to sensation, comfort, and the brain’s processing of airflow.

So I tell patients to report symptoms early. It is safer to talk about it than to ignore it.

Patient success stories

When patients hear about ENS causes, some feel scared to do any nasal procedure at all. I understand that fear. But I also want you to know that careful nasal surgery safety practices can lead to long-term improvement.

Patients can improve with function-preserving approaches

Most patients in a study reported improvement after a technique that preserved mucosa and submucosa, with excellent postoperative function by NOSE score and no reported dryness or crusting complications.

Another one reported excellent real surgical outcomes in their obstruction patients, with large improvements in NOSE score and visual analog scores. They also concluded ENS is likely multifactorial and not solely explained by aggressive inferior turbinate reduction.

Those findings line up with what I aim for clinically. Better airflow. Better comfort. No paradox symptoms.

Long-term stability is possible

Turbinate surgery is often discussed as if it is either “perfect” or “dangerous.” Reality is more nuanced.

Some researchers performed a systematic review and meta-analysis of turbinate surgery outcomes in allergic rhinitis patients and found improvements were maintained during long-term follow-up, with a low rate of complications reported in the included studies.

That does not mean every patient has the same experience. It does show that turbinate procedures can help and can remain effective when done thoughtfully and when patients are selected appropriately.

What patients often tell me after conservative surgery

When surgery goes well, patients describe things like:

• “I can breathe through my nose again.”
• “My nose feels normal, not strange.”
• “I don’t feel dry and panicky.”
• “My sleep feels easier.”

That “normal feeling” is what I target. It is the opposite of the “too open” paradox.

Questions to ask your ENT surgeon before nasal surgery

If you are trying to prevent empty nose syndrome, you should feel comfortable asking direct questions. 

Here are questions I recommend. Bring them to your consult. Write the answers down.

Questions about technique and tissue preservation:

• How will you preserve turbinate function during surgery?
• Will you preserve mucosa, or do you remove surface tissue?
• Do you perform submucosal turbinoplasty or other mucosal-sparing techniques?
• How do you decide how much turbinate to reduce?
• Do you ever do total or near-total turbinectomy? In what situation?
• What steps do you take to avoid excessive dryness and crusting?

Questions about planning and diagnosis:

• What is the exact cause of my obstruction? Is it turbinate hypertrophy, nasal valve issues, septal deviation, inflammation, or something else?
• What does my nasal endoscopy show?
• Do I need imaging for surgical planning?
• What non-surgical options should we try first?
• If I have symptoms that seem out of proportion to exam findings, how do you evaluate that?

Questions about ENS risk and follow-up:

• How do you define empty nose syndrome?
• Have you treated ENS patients before?
• What warning signs after surgery should make me call you right away?
• How often will you see me after surgery, and what do you look for at follow-up?

Red flags I would take seriously:

• The surgeon dismisses turbinate function as unimportant
• The plan is framed as “remove more to be sure”
• You get vague answers about mucosa preservation
• Risks are minimized without a real discussion of dryness, crusting, or paradox symptoms
• The surgeon seems unwilling to explain technique choices

A surgeon should be able to explain the plan in plain language. If you leave confused, that is a signal to pause.

Final words

Empty nose syndrome causes are better understood today than they were years ago, even though there is still debate about the exact mechanism in every patient. Across the research, one theme stays consistent. ENS is strongly tied to post-surgical tissue changes, especially involving turbinates, and prevention matters. 

My approach is built around that idea. I evaluate carefully, I plan thoughtfully, and I use techniques that reduce obstruction while protecting the nose’s normal function. That is how I practice empty nose syndrome prevention and how I work to prevent empty nose syndrome in every case where turbinate surgery is involved.

Frequently Asked Questions

What causes empty nose syndrome?

Empty Nose Syndrome usually happens after nasal surgery, especially turbinate surgery. It is linked to damage or loss of normal nasal tissue, not a naturally wide nose. The problem comes from changes in airflow, moisture control, and how the nose senses breathing.

‍Is empty nose syndrome caused by having a wide nasal cavity?

No. A wide nasal cavity alone does not cause ENS. Many people with wide nasal passages breathe normally. ENS happens when surgery disrupts the tissue and sensory systems that help breathing feel comfortable.

‍Why can my nose feel “too open” but still blocked?

This is called paradoxical nasal obstruction. Your nasal passages may look open, but airflow may move in a way that feels harsh or unnatural. Changes in airflow patterns and sensation can make breathing feel difficult even without blockage.

‍Are turbinates really important for breathing?

Yes. Turbinates are essential. They help warm, humidify, and filter air. They also help your brain sense airflow. Removing or damaging them too much can make breathing feel dry, uncomfortable, or hard to sense.

‍Does removing too much turbinate tissue cause ENS?

Over-aggressive turbinate removal is a major risk factor, but it is not the only factor. ENS can involve tissue loss, airflow changes, sensory nerve changes, and how the brain processes breathing. That is why prevention matters.

‍Does mucosal damage increase ENS risk?

Yes. The nasal lining (mucosa) controls moisture and airflow sensation. If it is removed or badly damaged, dryness, crusting, and abnormal airflow awareness are more likely. Preserving mucosa is critical.

‍Does removing multiple nasal structures increase risk?

Yes. Reducing more than one turbinate or nasal structure at the same time can disrupt airflow balance. Many severe ENS cases involve combined tissue loss rather than one small change.

‍How can empty nose syndrome be prevented?

Prevention focuses on careful planning, conservative surgery, and protecting nasal tissue. Using mucosal-sparing techniques, avoiding radical removal, educating patients, and close follow-up all reduce risk. The safest surgery aims for comfort, not just a bigger airway.

Sources

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• Sahin-Yilmaz, A., & Naclerio, R. M. (2011). Anatomy and physiology of the upper airway. Proceedings of the American Thoracic Society, 8(1), 31–39. https://doi.org/10.1513/pats.201007-050RN‍
• Kanjanawasee, D., Campbell, R. G., Rimmer, J., Alvarado, R., Kanjanaumporn, J., Snidvongs, K., Kalish, L., Harvey, R. J., & Sacks, R. (2022). Empty nose syndrome pathophysiology: A systematic review. Otolaryngology–Head and Neck Surgery, 167(3), 434–451. https://doi.org/10.1177/01945998211052919‍
• Chhabra, N., & Houser, S. M. (2009). The diagnosis and management of empty nose syndrome. Otolaryngologic Clinics of North America, 42(2), 311–330. https://doi.org/10.1016/j.otc.2009.01.006‍
• Scheithauer, M. O. (2011). Surgery of the turbinates and “empty nose” syndrome. GMS Current Topics in Otorhinolaryngology – Head and Neck Surgery, 9, Doc03. https://doi.org/10.3205/cto000067‍
• Odeh, A., Wen, R., Wu, Z., Schneller, A. R., Root, Z. T., Hittle, B., Wiet, G. J., Otto, B. A., Kelly, K. M., & Zhao, K. (2024). Does total turbinectomy always lead to empty nose syndrome? A computational virtual surgery study. The Laryngoscope. Advance online publication. https://doi.org/10.1002/lary.31757‍
• Abdullah, B., & Singh, S. (2021). Surgical interventions for inferior turbinate hypertrophy: A comprehensive review of current techniques and technologies. International Journal of Environmental Research and Public Health, 18(7), 3441. https://doi.org/10.3390/ijerph18073441‍
• Kanjanawasee, D., Campbell, R. G., Rimmer, J., Alvarado, R., Kanjanaumporn, J., Snidvongs, K., Kalish, L., Harvey, R. J., & Sacks, R. (2022). Empty nose syndrome pathophysiology: A systematic review. Otolaryngology–Head and Neck Surgery, 167(3), 434–451. https://doi.org/10.1177/01945998211052919‍
• Park, S. C., Kim, D. H., Jun, Y. J., et al. (2023). Long-term outcomes of turbinate surgery in patients with allergic rhinitis: A systematic review and meta-analysis. JAMA Otolaryngology–Head & Neck Surgery, 149(1), 15–23. https://doi.org/10.1001/jamaoto.2022.3567