Empty nose syndrome: the case for “functional nasal obstruction” as a predisposing risk prior to nasal surgery

Purpose of Review: Although empty nose syndrome (ENS) is axiomatically defined post nasal surgery, these patients present to otolaryngologists with complaints of nasal airflow dysfunction preoperatively. The critical question of how to resolve ENS should be in the preoperative assessment rather than focusing on interventions post nasal surgery. There are no proven factors from surgery that predict ENS post turbinate surgery. We review the latest literature on ENS and evaluate developing trends in the understanding of its pathophysiology and associations. This review seeks to develop a modern approach to the management of this recalcitrant condition. Recent Findings: Recent literature on ENS suggests possible psychogenic etiologies and associations, providing an avenue for treatment strategies. Previous theories of ENS pathogenesis regarding extent of turbinate surgery are not supported by airflow and radiologic assessments. Premorbid neurosensory alterations may explain why some patients, often with mental health comorbidities, present for nasal surgery without significant clinical findings and is a patient population predisposed to ENS. Summary: The concept of “functional nasal obstruction” or FNO, needs to become a diagnostic option for the clinician when assessing patients for nasal surgery. Patients identifying with ENS may be a population of patients with functional nasal obstruction, unrecognized and now after surgical efforts to relieve symptoms. The disorder underlying ENS should be considered an unrecognized risk factor in patient selection “prior” to nasal surgery rather than a postoperative complication “from” nasal surgery. Identifying this risk factor preoperatively is critical in avoiding subsequent morbidity. Further research into identifying “functional nasal obstruction” prior to nasal surgery should be undertaken as a priority over interventions after the ENS condition occurs.