Empty nose syndrome

Ross Hauser, MD

I am going to start this article surrounding research and treatments of Empty nose syndrome with a patient’s story here at the Hauser Neck Center at Caring Medical. Then we will discuss how Empty nose syndrome remains a medical enigma and describe possible paths of treatments.

In this case history below, I will describe an initial teleconference I had with a patient. It will show that Empty nose syndrome is not a disorder that sits in isolation, but rather a problem that is one of many conditions many of the people we see at our center suffer from. Empty nose syndrome can be caused by many problems. In this article, I will present one possible answer.

The acrobat is grounded: His symptoms had become overwhelming and too much for him to realistically handle as a high-flying acrobat.

A well-known acrobatic master contacted us at Caring Medical because he suffered from many different “neurologic-type” symptoms, had received many different diagnoses, had many treatments, procedures, and tests, and was finally diagnosed with Empty nose syndrome amongst his other problems. He contacted us because he felt his symptoms were related to atlantoaxial instability, vagus nerve compression, and cerebrospinal venous insufficiency.

To perform the acrobatic tricks and stunts he does, our patient needs to master his skills through demanding and repetitive practice. He reported to us that he could no longer practice his routines and without the confidence and precision needed to perform at a master’s level, our patient had to ground himself.

Symptoms, conditions, and medical history

The patient suffered from shortness of breath (dyspnea) and an inability to feel the air going through his nose. He cannot breathe at times and constantly feels like he is drowning in nasal and sinus fluids. Then he begins to hyperventilate.

He was always a nose breather until the symptoms started. He has always been in master’s level/elite athletic shape and now he is practically bed-bound.

To relieve his shortness of breath and to assist his nose breathing, he has visited numerous ENTs, pulmonologists, and other specialists who have prescribed a myriad of tests and treatments including various sprays, steroids, and medications, all to no avail. He sought out alternative medicine healers who have been unable to help.

The various tests he has had, including endoscopy, MRIs, blood gas analysis, x-rays, and many others, have not been helpful in figuring out what is causing his shortness of breath and inability to breathe out of his nose.

Other symptoms include:

• loss of his sense of smell,
• disconnected feeling (head disconnected from rest of body),
• chronic head pressure,
• facial redness with changes of neck movement,
• lightheadedness and dizziness,
• stomach bloating,
• constant hiccups,
• reflux,
• swallowing difficulty, the sensation of food caught in his throat,
• inability to talk for very long,
• chest pressure,
• excessive saliva,
• tinnitus,
• hearing loss when looking left, ear fullness,
• insomnia.

It IS in his nose, BUT, it is coming from his neck?

This is just a partial list. So here we have a patient whose main complaint is the problem of being able to breathe through his nose, yet he suffers from all these other conditions. How do we treat a patient like this? Is his inability to breathe through his nose causing oxygen to shut off? His inability to breathe through his nose causing all these other problems? Is it all in his nose? In this one case we suggest, it IS in his nose, BUT, it is coming from his neck?

First, let’s explore some of the supportive research which may guide us in understanding that for many people, these symptoms including Empty Nose Syndrome can find their cause and origin in the cervical spine and neck instability causing compression on the arteries, veins, and nerves that make their way in and around the cervical spine vertebrae.

Making a connection with the trigeminal nerve

An August 2019 study in the journal Current Opinion in Otolaryngology and Head and Neck Surgery (1) comes to us from the Department of Otolaryngology-Head and Neck Surgery, University of California Davis. Here are the points:

• “Historically, Empty nose syndrome has been associated with a reduction in nasal turbinate size; new data suggest that impaired trigeminal nerve function may also play a role in the pathophysiology of the disease.”

Note: Nasal turbinate size: The nasal turbinates are mucus-covered boney structures inside the nose. They regulate airflow in and out of the nose and help warm the air you breathe in. The nasal turbinates can fluctuate in size in response to illness, allergies, and sensitivities and cause a “stuffy nose.” In many patients we see, chronic sinusitis and problems with the nasal turbinates are frequent complaints.

Clearly, someone with problems breathing in and out of their nose, where the diagnosis may be confused or hard to find may eventually wind up in a discussion about the dysfunction of the nasal turbinates.

Impaired trigeminal nerve function

Demonstration of trigeminal nerve dysfunction would be a big clue in following a path that this patient’s problems with Empty nose syndrome were being caused by nerve compression from cervical spine instability. We have two very detailed articles on our website concerning Trigeminal neuralgia: The evidence for Trigeminal Neuralgia non-surgical treatments, and, Cluster headache treatment – cervical ligament instability and the trigeminal and vagus nerves. I am going to summarize them here in regard to Empty nose syndrome.

In our many years of helping people with chronic pain of the head, neck, jaw, and face we have seen many people with a diagnosis of Trigeminal neuralgia. For some of these people, possibly including yourself, it was not easy getting this diagnosis as this problem can be confusing and frustrating to understand. Not only for the patient but the doctor alike.

When a physician and a patient believe that this nerve is being compressed, it is easy to see why surgery would be recommended.

Trigeminal neuralgia centers on what is happening to the trigeminal nerve which carries pain, feeling, and sensation from the brain to the skin of the face. In the case of trigeminal neuralgia, most medical professionals cannot find the cause for why this pain started. This is borne out by the definition of trigeminal neuralgia. Trigeminal neuralgia means that there is nerve pain in the nerve distribution of the trigeminal nerve. It actually does not tell a person what is causing the condition.

• Many people with trigeminal neuralgia initially believed they had a serious problem with their teeth. It could have started one day when they are brushing their teeth and suddenly they had shooting pain in their face/mouth.

Other related causes

Trigeminal Neuralgia can also be caused by simple daily acts.

• Washing your face, shaving, the application of makeup.
• Chewing food
• Talking
• Blowing your nose

Why do we examining the neck of a patient who comes in for a Trigeminal Neuralgia consultation?

The keyword is compression. The head and neck, as all parts of the body, live in complex relation. Something in the neck can cause problems in the jaw, face, and nose, etc.

At this point, we are going to quickly jump over to a 2017 paper that was published in the journal Laryngoscope (2). The title of this paper? “Intranasal trigeminal function in patients with empty nose syndrome.” Here are the learning points:

• The trigeminal nerve mediates the perception of nasal airflow. This study examines whether the impaired intranasal trigeminal function is a part of the paradoxical nasal obstruction sensation in patients with empty nose syndrome (ENS).

Note: Understand that the researchers are exploring that an inability to breathe is a messenger “nerve” problem. The possibility that trigeminal function is being impaired by bad messages. Where are these bad messages coming from? Let’s see if we can find out.

• Three groups of patients were examined:
  • 1) Empty nose syndrome patients with previous bilateral near-total inferior turbinectomy. NOTE: Remember we discussed above what the nasal turbinates do. A Turbinectomy is a procedure where surgeons will remove some or all of the turbinate bones in the nasal passage. The goal is to relieve nasal obstruction and make it easier to breathe through the nose.
  • 2) patients who underwent near-total inferior turbinate removal without Empty nose syndrome symptoms, and
  • 3) control participants.

Results:

• Analyses revealed that Empty nose syndrome patients had significantly lower scores on trigeminal lateralization testing (a test to assess trigeminal function in response to nasal stimulation) than the total inferior turbinate removal group and controls.
• The Empty nose syndrome group had also significantly lower scores in olfactory testing (the ability to identify odors) than controls.
• This study demonstrates significantly impaired intranasal trigeminal function in Empty nose syndrome patients.

Simply: It is a nerve compression problem. Where are the bad messages coming from? The trigeminal nerve. How? Compression of the trigeminal nerve somewhere along the line is sending out bad messages because of “compression interference.”

Mental Health Disorders

Up until this point of this article, the focus has been on the physical structure of the neck as a cause for the physical problems related to Empty Nose Syndrome. Now let’s briefly examine the mental aspects.

An October 2021 paper in the Otolaryngology–head and neck surgery (3) noted these issue in Empty Nose Syndrome patients

• ENS patients demonstrated high symptom severity.
• There is evidence of high comorbid mental health disorders in Empty Nose Syndrome patients.

Dysfunction of the Trigeminal Nerve

• Trigeminal neuralgia (nerve pain) can be caused by neck problems that lead to instability in the cervical spine, causing irritation of the trigeminal nerve.
• When you have this trigeminal nerve irritation you can get, for lack of a better word, weird swishing, a “creepy-crawlies” sensation in the face, burning in the throat, burning in the inner ear, problems with sinus and ear drainage, and the problems of Empty Nose Syndrome.

The connection of the trigeminal nerve to the cervical spine

As described above, people with Empty Nose Syndrome can suffer from many conditions simultaneously.

There are connections between the upper cervical spine and the trigeminal nerve. There is an afferent or a stimulus that comes in from your upper neck. If you have cervical spine instability if you have a terrible problem with loss of the natural curve of the neck. If you have a descending of your brainstem, anything that is a dysfunction can cause a “bad signaling” to come out of the trigeminal nerve.

• This bad signaling can cause:
  • Pain in the face.
  • Numbness in your face.
  • Burning ears.
  • Burning in the mouth.
  • Watering of the eyes.
  • Problems in the nasal and sinus cavities.

Why many treatments do not work

If we are pursuing cervical spine instability as the primary cause of the problems related to Empty nose syndrome, it is easy to see why treating many of the symptoms of this disorder are prone to failure and then surgery that may not address the true cause of the problem would be recommended.

Many patients we see with nasal breathing dysfunction often report that they have tried all the standard of care symptom alleviate treatments with limited success. These would include:

• An abundance of saline nasal spray use. Then use of antibiotic nasal sprays and irrigations because the abundance of saline usage is causing nasal infections.
• Use of humidifiers.
• Use of CPAP machines.
• Change in diet to favor hot foods and liquids.

The problems of cervical spine instability are usually not discussed.

Malalignment of C1-C2 can impact sinus drainage

We have many articles and research studies that point out the possible problems misalignment of the C1-C2 or Atlantoaxial instability can cause. As I have also pointed out, the clue to a patient’s problems may lie in the fact that they suffer from many symptoms simultaneously and not from one or two isolated symptoms.

In the story of the patient that we are covering in this article, we see that he had many symptoms. People we see with Atlantoaxial instability can also suffer from drainage problems of the sinus and associated nasal congestion, headaches, hearing problems and ear infections, vision problems, balance, vertigo, dizziness, and nausea among many symptoms. Often they suffer all at once.

When the cervical spine is involved in nasal breathing problems, we suspect that the patient is having a drainage problem. The ear and sinus are not draining. One reason that they are not draining can be a bulging or herniated disc impinging on the cervical nerves in the C1-C2 region.

The start of the chase for the root cause of the problem. The connection between the vagus nerve and the trigeminal nerve and nasal problems

The vagus nerve, as illustrated below, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglion. This disruption or herniation of the nerve can cause among the many symptoms I have listed in this article.

What are we seeing in this image?

The vagus nerve, as illustrated here, travels through the cervical spine. It travels especially close to the C1, C2, C3 vertebrae. Cervical spine instability in these regions can cause herniation or pinching of the vagus nerve, which can lead to a disruption of normal nerve communication between the vagus nerve and the trigeminal nerve and trigeminal ganglia. This disruption or herniation of the nerve can cause among the many symptoms of nasal inflammation.

This article was update 11/15/2021

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.