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PubMed This is a summary of 22 peer-reviewed journal articles Updated
Otolaryngology

Surgical Options and Advanced Interventions

At a Glance

For atrophic rhinitis or Empty Nose Syndrome that does not improve with medical care, surgery can narrow the nasal cavity using grafts, implants, fillers, or Young’s procedures. It may reduce crusting and improve airflow sensation, but complications occur and smell may not return.

When conservative treatments like saline rinses and lubricants are not enough to manage atrophic rhinitis or Empty Nose Syndrome (ENS), surgery may be considered [1][2]. Because these conditions are often caused by having “too much space” in the nose, surgical goals focus on narrowing the nasal cavity to restore normal airflow patterns and humidity [3][4].

The Surgical Context

It is important to recognize that many cases of secondary atrophic rhinitis and ENS are associated with previous nasal surgeries [5].

  • Total or Subtotal Turbinectomy: This is the most common surgical trigger. The inferior turbinates are responsible for most of the nose’s ability to warm and moisten air [6]. If too much of this tissue is removed during a surgery to “improve breathing,” the nose can become too open, leading to the dry, crusty environment of atrophic rhinitis [7][1].
  • Aggressive Septoplasty: In some cases, extensive work on the septum or the removal of other internal structures can contribute to the “empty” sensation [8][9].

Reconstruction and Augmentation

A common modern surgical approach for these conditions is augmentation, where a surgeon places an implant or graft under the lining of the nose to “rebuild” the missing bulk [3][10]. Before considering permanent implants, a doctor may perform a ‘cotton test’ during an office visit—placing moist cotton in the widened area of your nose to temporarily simulate a narrowed cavity.

What Materials are Used?

Surgeons use a variety of materials to narrow the nasal cavity:

  • Autologous Grafts: This uses your own tissue, most commonly cartilage taken from your ear or rib [11][12]. This is often preferred because your body is unlikely to reject it, though it requires a second surgical site [13].
  • Homologous (Donor) Grafts: Cartilage taken from a cadaver/donor. This avoids the need for a second surgery on your own body [14][15].
  • Synthetic Implants: Materials like Medpor (porous polyethylene) or hydroxyapatite (a ceramic) are designed to stay in place permanently and allow your own tissue to grow into them [10][16].
  • Injectable Fillers: In some cases, temporary gels or fillers may be injected into the nasal wall to see if narrowing the cavity provides relief before committing to a permanent implant [17].

Surgical Procedures

Meatus and Lateral Wall Augmentation

This is a common approach for ENS, though evidence remains limited. The surgeon creates a “pocket” under the lining of the side wall of the nose and inserts the chosen material [3]. This helps slow down the air as it enters, allowing the remaining sensors to feel it more effectively [18].

Young’s and Modified Young’s Procedures

For severe, primary atrophic rhinitis (ozena), a surgeon may perform Young’s procedure, which involves surgically sewing the nostrils shut for several months [19]. This total lack of airflow allows the nasal lining time to heal and “re-moisturize” [19]. A Modified Young’s procedure narrows the nostril without closing it completely [20].

Risks and Complications

While surgery can be life-changing, it carries specific risks that you should discuss with your surgeon:

  • Implant Complications: In one review, about 4.7% of implants pushed through the thin nasal lining (extrusion), though rates vary by material and procedure. Implants can also migrate or resorb [3].
  • Infection: Bacteria, especially the Klebsiella species common in atrophic rhinitis, can infect the implant site [3].
  • Nasal Obstruction: Sometimes the cavity is narrowed “too much,” making it difficult to breathe physically (unlike the paradoxical sensation) [12].
  • Limited Olfactory Recovery: While surgery often improves the sensation of breathing and reduces crusting, it may not restore a lost sense of smell (anosmia) [21].
  • Other Risks: Anesthesia risks, donor-site morbidity (if your own cartilage is used), scarring, and the potential need for revision surgery.

Measuring Success

To determine if you are a good candidate for surgery, many doctors use the ENS6Q questionnaire or the SNOT-25 (Sino-Nasal Outcome Test) [22][3]. An ENS6Q score of 11 or higher is often used as a screening aid for ENS, though it does not reliably predict who will benefit from surgery [14]. Research shows that many patients see significant improvements in their scores, as well as reduced anxiety and depression, for at least a year following these procedures [1][3].

Common questions in this guide

When is surgery considered for atrophic rhinitis or Empty Nose Syndrome?
Surgery may be considered when saline rinses, lubricants, and other medical treatments do not provide enough relief. The goal is usually to narrow an overly open nasal cavity to improve airflow sensation and moisture, but results vary and surgery is not guaranteed to restore smell.
What does a cotton test show before Empty Nose Syndrome surgery?
During a cotton test, a clinician places moist cotton in a widened part of the nose to temporarily simulate a narrower cavity. If you notice a genuine improvement in airflow sensation, the result can help you and your surgeon discuss whether augmentation is appropriate.
What materials are used to narrow the nasal cavity?
Options include cartilage from your ear or rib, donor cartilage, synthetic implants such as Medpor or hydroxyapatite, and temporary injectable fillers. Your surgeon can compare the need for a second surgical site, how permanent the material is, and the risks of movement, infection, or extrusion.
What are the risks of surgery for Empty Nose Syndrome?
Possible risks include implant extrusion through the nasal lining, migration, resorption, infection, scarring, and physical blockage if the cavity becomes too narrow. Surgery may also fail to restore smell, and some people may need revision surgery or implant removal.
What is Young’s procedure for atrophic rhinitis?
Young’s procedure temporarily closes the nostrils for several months in severe primary atrophic rhinitis, also called ozena, so the lining has time to heal and regain moisture. A modified version narrows the nostrils without closing them completely.
How do doctors measure whether Empty Nose Syndrome surgery worked?
Doctors may track symptoms with questionnaires such as the ENS6Q and Sino-Nasal Outcome Test and compare them before and after treatment. An ENS6Q score of 11 or higher can support screening for Empty Nose Syndrome, but it does not reliably predict who will benefit from surgery.

Get notified when new evidence is published on atrophic rhinitis.

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References

References (22)
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    A Systematic Review and Meta-Analysis of Management Options for Empty Nose Syndrome: A Proposed Management Algorithm.

    Hussain S, Hayat J, Almhanedi H, et al.

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    Update on empty nose syndrome: disease mechanisms, diagnostic tools, and treatment strategies.

    Gill AS, Said M, Tollefson TT, Steele TO

    Current opinion in otolaryngology & head and neck surgery 2019; (27(4)):237-242 doi:10.1097/MOO.0000000000000544.

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    The clinical efficacy of surgical interventions for empty nose syndrome: A systematic review.

    Leong SC

    The Laryngoscope 2015; (125(7)):1557-62 doi:10.1002/lary.25170.

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    Computational fluid dynamics and trigeminal sensory examinations of empty nose syndrome patients.

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    Serum Hormone Levels in Female Patients With Atrophic Rhinitis.

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    Treatment Outcomes of the Inferior Meatus Augmentation Procedure With Autologous Costal Cartilage for Empty Nose Syndrome.

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This page is for informational purposes only and does not constitute medical advice. An otolaryngologist or rhinologist should assess your symptoms, prior surgery, and surgical risks before you consider treatment.

Guide contents atrophic rhinitis
Research & Literature
05 Daily Care and Medical Management 07 Living With and Monitoring Your Condition