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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Otolaryngology

The Biology of a Changing Nose

At a Glance

Atrophic rhinitis occurs when the nasal lining loses its tiny mucus-moving hairs and glands, making the nose dry and prone to crusting. It may be primary (ozena) or follow surgery, trauma, infection, or irritants; Empty Nose Syndrome is related but not identical.

The biology of atrophic rhinitis is a story of a specialized environment losing its ability to function. Your nasal cavity is not just a hallway for air; it is a high-tech “processing plant” lined with a delicate mucosa [1]. In atrophic rhinitis, this plant shuts down as the tissue changes from a moist, active filter into a drier, less functional lining [2].

The Biological Mechanism: Possible Changes

When atrophic rhinitis takes hold, the nasal environment can undergo structural changes that help explain your symptoms:

  1. Damage to Cilia: Normally, your nasal lining is covered in microscopic, hair-like structures called cilia that wave back and forth to move mucus toward your throat [1][3]. In this condition, these cilia may be damaged or replaced by flatter skin cells (a process called squamous metaplasia) [2][4]. Without cilia, mucus sits still, dries out, and turns into hard crusts.
  2. Glandular Atrophy: Your nose contains seromucous glands that act like built-in humidifiers [1]. As the disease progresses, these glands can shrink (atrophy) or disappear [2]. This leads to the profound dryness that characterizes the disease.
  3. Bony Resorption: In some cases, the inflammation affects the underlying bone [5]. The turbinates—the bony “shelves” that help swirl and warm air—can thin or resorb, creating an unusually wide nasal cavity [5][6]. It is important to note that bone loss is not inevitable in every patient.

Primary Atrophic Rhinitis (Ozena)

Primary atrophic rhinitis, also known as ozena, is a form that appears to start on its own, without a previous surgery or injury [7].

  • Who it affects: Historically, it is reported more frequently in certain climates and demographic groups, though researchers are still investigating exactly why [7][8].
  • The Role of Klebsiella ozaenae: This specific bacterium may be associated with cases of ozena [5][9]. While scientists debate whether the bacteria cause the initial tissue damage or simply colonize a nose that is already damaged, its presence can contribute to the characteristic fetid odor [5][10]. These bacteria can sometimes create a biofilm—a protective “shield”—that makes them difficult to clear [11].

Secondary Atrophic Rhinitis

This form is the result of an identifiable event that damaged the nasal lining [8].

  • Common Causes: The most frequent cause is extensive nasal surgery, such as the major removal of the turbinates [8][2]. Other causes include severe facial trauma, chronic infections, or long-term exposure to irritants [8][12].

Empty Nose Syndrome (ENS): A Related Paradox

Empty Nose Syndrome (ENS) is a post-surgical symptom syndrome that overlaps with secondary atrophic rhinitis, though they are not strictly synonymous [13][14]. Some patients with ENS have relatively preserved mucosa without the classic severe atrophy seen in ozena.

ENS highlights how you feel the airflow:

  • Sensory Disconnect: In ENS, emerging research proposes that the sensors that help tell your brain you are breathing (such as the TRPM8 “coolness” receptor) may be altered [4][15].
  • The “Suffocation” Feeling: Because the expected signals may be reduced or absent, patients can feel like they are suffocating despite having a completely open airway [13].
  • Altered Airflow: Removing the turbinates changes how air moves. Instead of a smooth stream, researchers propose the air may become turbulent, which might prevent it from being properly humidified and sensed by the remaining tissue [16][17].

Whether your diagnosis is primary atrophy, secondary disease, or ENS, the result is a nose that can struggle to “condition” the air you breathe, leading to dryness, crusting, and discomfort [18][19].

Common questions in this guide

What causes atrophic rhinitis?
Primary atrophic rhinitis, also called ozena, appears to begin without a previous surgery or injury. Secondary atrophic rhinitis can follow extensive nasal surgery, severe facial trauma, chronic infection, or long-term exposure to irritants.
How does atrophic rhinitis cause dryness and crusting?
Damage or loss of the tiny cilia that move mucus can leave mucus sitting in the nose, where it dries into crusts. Shrinking or disappearing nasal glands also reduces the moisture needed to humidify and clean the air.
Is ozena the same as atrophic rhinitis?
Ozena is another name for primary atrophic rhinitis, a form that appears to develop without prior surgery or injury. Secondary atrophic rhinitis has an identifiable cause, so not every case of atrophic rhinitis is ozena.
What is the connection between atrophic rhinitis and Empty Nose Syndrome?
Empty Nose Syndrome is a post-surgical symptom syndrome that can overlap with secondary atrophic rhinitis, but the two are not identical. Some people with Empty Nose Syndrome have relatively preserved nasal tissue but altered airflow or sensation, including a feeling of suffocation despite an open airway.
Does Klebsiella ozaenae cause ozena?
Klebsiella ozaenae is associated with some cases of ozena, but researchers debate whether it starts the tissue damage or mainly colonizes tissue that is already damaged. The bacteria may contribute to the characteristic odor and can form a protective biofilm that makes them harder to clear.
Does atrophic rhinitis always cause bone loss or turbinate shrinkage?
No. In some cases, inflammation affects the underlying bone and the turbinates thin or resorb, making the nasal cavity unusually wide, but bone loss is not inevitable.

Get notified when new evidence is published on atrophic rhinitis.

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References

References (19)
  1. 1

    Role of α-Tocopherol Acetate on Nasal Respiratory Functions: Mucociliary Clearance and Rhinomanometric Evaluations in Primary Atrophic Rhinitis.

    Testa D, Marcuccio G, Lombardo N, et al.

    Ear, nose, & throat journal 2021; (100(6)):NP290-NP295 doi:10.1177/0145561319870483.

    PMID: 31578104
  2. 2

    Tissue specific stem cell therapy for airway regeneration.

    Park DB, Lee JY, Kim SW, Kim DH

    Cell proliferation 2024; (57(10)):e13662 doi:10.1111/cpr.13662.

    PMID: 38803033
  3. 3

    Platelet-Rich Plasma Injection in Patients with Atrophic Rhinitis.

    Kim DH, Lee MH, Lee J, et al.

    ORL; journal for oto-rhino-laryngology and its related specialties 2021; (83(2)):104-111 doi:10.1159/000513099.

    PMID: 33561860
  4. 4

    Distinct Histopathology Characteristics in Empty Nose Syndrome.

    Wu CL, Fu CH, Lee TJ

    The Laryngoscope 2021; (131(1)):E14-E18 doi:10.1002/lary.28586.

    PMID: 32125703
  5. 5

    Therapeutic Management of Primary Atrophic Rhinitis (Ozene): About 4 Cases.

    Maalej F, Chaabouni MA, Ayadi S, et al.

    Ear, nose, & throat journal 2024; 1455613241252586 doi:10.1177/01455613241252586.

    PMID: 38742474
  6. 6

    Ozena in Immigrants of Differing Backgrounds.

    Yelenich-Huss MJ, Boyer H, Alpern JD, et al.

    The American journal of tropical medicine and hygiene 2016; (95(1)):35-7 doi:10.4269/ajtmh.15-0885.

    PMID: 27114295
  7. 7

    An Updated Review on Atrophic Rhinitis and Empty Nose Syndrome.

    Sumaily IA, Hakami NA, Almutairi AD, et al.

    Ear, nose, & throat journal 2026; (105(2)):NP150-NP161 doi:10.1177/01455613231185022.

    PMID: 37449389
  8. 8

    Serum Hormone Levels in Female Patients With Atrophic Rhinitis.

    Bhoi S, Panda S, Pradhan P, et al.

    Cureus 2025; (17(3)):e80309 doi:10.7759/cureus.80309.

    PMID: 40206888
  9. 9

    From Commensal to Pathogen: Unveiling Klebsiella pneumoniae subsp. ozaenae as a Cause of Meningitis and a Literature Review.

    Cs P, P VD, Palukuru SR, Jakkam C

    Cureus 2025; (17(11)):e96255 doi:10.7759/cureus.96255.

    PMID: 41367467
  10. 10

    Epidemiological characteristics of Klebsiella ozaenae infection and its antibiotic susceptibility: Experience of a tertiary care hospital in the Eastern Province of Saudi Arabia.

    AlJindan R

    Journal of family & community medicine 2024; (31(2)):148-152 doi:10.4103/jfcm.jfcm_280_23.

    PMID: 38800796
  11. 11

    Klebsiella pneumoniae Biofilms and Their Role in Disease Pathogenesis.

    Guerra MES, Destro G, Vieira B, et al.

    Frontiers in cellular and infection microbiology 2022; (12()):877995 doi:10.3389/fcimb.2022.877995.

    PMID: 35646720
  12. 12

    [Squamous epithelium in the nasal cytology].

    Myszkowska D, Kubicka J, Gawlik J, et al.

    Przeglad lekarski 2015; (72(12)):731-5.

    PMID: 27024949
  13. 13

    Histopathological Findings in an Unclassifiable Case of Empty Nose Syndrome with Long-term Follow-up.

    Dzhenkov DL, Stoyanov GS, Georgiev R, Sapundzhiev N

    Cureus 2018; (10(5)):e2655 doi:10.7759/cureus.2655.

    PMID: 30042906
  14. 14

    Sublabial bioactive glass implantation for the management of primary atrophic rhinitis and empty nose syndrome: Operative technique.

    Hassan CH, Malheiro E, Béquignon E, et al.

    Laryngoscope investigative otolaryngology 2022; (7(1)):6-11 doi:10.1002/lio2.713.

    PMID: 35155777
  15. 15

    Intranasal trigeminal function in patients with empty nose syndrome.

    Konstantinidis I, Tsakiropoulou E, Chatziavramidis A, et al.

    The Laryngoscope 2017; (127(6)):1263-1267 doi:10.1002/lary.26491.

    PMID: 28224626
  16. 16

    Investigation of the abnormal nasal aerodynamics and trigeminal functions among empty nose syndrome patients.

    Li C, Farag AA, Maza G, et al.

    International forum of allergy & rhinology 2018; (8(3)):444-452 doi:10.1002/alr.22045.

    PMID: 29165896
  17. 17

    Airflow Characteristics of Empty Nose Syndrome: Insights From Patient-Specific Computational Modeling of Airflow Distribution Patterns and Nasal Air-Conditioning.

    Na Y, Kwon KW, Jang YJ

    Laryngoscope investigative otolaryngology 2026; (11(5)):e70567 doi:10.1002/lio2.70567.

    PMID: 42836257
  18. 18

    The cotton test redistributes nasal airflow in patients with empty nose syndrome.

    Malik J, Thamboo A, Dholakia S, et al.

    International forum of allergy & rhinology 2020; (10(4)):539-545 doi:10.1002/alr.22489.

    PMID: 31951101
  19. 19

    The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q): a validated 6-item questionnaire as a diagnostic aid for empty nose syndrome patients.

    Velasquez N, Thamboo A, Habib AR, et al.

    International forum of allergy & rhinology 2017; (7(1)):64-71 doi:10.1002/alr.21842.

    PMID: 27557473

This page explains the biology and types of atrophic rhinitis for informational purposes only and does not constitute medical advice. An ear, nose, and throat clinician can assess your symptoms, history, and nasal examination.

Guide contents atrophic rhinitis
Research & Literature
02 Symptoms, Warning Signs, and Look-Alikes 04 Evaluating Your Nose