Bradley Rhoton’s ordeal began with something most of us would ignore—a whistling sound in his nose while carving pumpkins for Halloween. But what started as harmless soon spiraled into a debilitating mystery. As The Washington Post recently reported, Rhoton, a Boston-based software marketer, underwent standard nasal surgery to correct a deviated septum and reduce the size of his nasal turbinates. Instead of breathing easy, he was left with crushing fatigue, constant congestion, sleep disturbances, anxiety, and a haze of brain fog that persisted for years. His frustrating journey through the healthcare system, marked by dismissals from multiple specialists, ultimately led to the little-known diagnosis of “empty nose syndrome” (ENS)—a rare but potentially devastating condition that paradoxically leaves patients feeling suffocated despite wide-open nasal passages (Washington Post; MSN News).
For Thai readers, this case holds an important lesson: even “routine” medical procedures carry risks that are all too easy to overlook, and rare complications can be devastating, both physically and psychologically. In Thailand—where nasal and sinus problems are common due to allergies, pollution, and urban living—turbinate reduction surgery is widely offered as a solution for chronic nasal congestion. However, the international experience, including emerging research, highlights that more education is needed among both patients and healthcare providers to recognize and address rare post-surgical syndromes like ENS (Wikipedia).
Empty nose syndrome arises most commonly after surgical reduction or removal of the inferior turbinates, the curved structures inside the nose that humidify and filter the air. While these procedures are usually performed to improve airflow for people with chronic nasal blockage, in ENS something goes terribly wrong. Instead of relief, sufferers experience persistent nasal dryness, crusting, a paradoxical sense of suffocation, and symptoms like insomnia, fatigue, and anxiety. Medical experts believe that ENS results from the loss of crucial tissue receptors within the turbinates; without these, the nose no longer senses airflow properly, tricking the brain into feeling that it cannot breathe (PubMed; Wikipedia).
The statistics are telling yet incomplete—no exact figures exist for ENS prevalence, likely because it is underdiagnosed, misattributed to psychological causes, or dismissed altogether by unwary clinicians (Wikipedia). Recent studies indicate that only a minority of patients develop ENS after turbinate surgery, but those who do can be profoundly affected. For example, a 2025 investigation published in the European Archives of Oto-Rhino-Laryngology used computational fluid dynamics to show how disrupted airflow patterns relate to ENS symptoms, emphasizing that both anatomical and subjective factors must be considered in diagnosing and managing the disease (Springer Link).
Further, diagnostic tools are improving. The Empty Nose Syndrome 6-item Questionnaire (ENS6Q), validated in 2025, helps clinicians systematically identify ENS, while a modified “cotton test” has been developed to reduce false positives by providing stepwise confirmation of the diagnosis (PubMed). Traditionally, the main line of treatment was symptomatic—saline irrigations, nasal gels—as there is no way to truly replace lost neural tissue. Recently, innovative therapies, such as injectable gels to temporarily restore nasal volume and surgical implantation of rib cartilage, show promise for restoring some function and reducing symptoms, as highlighted by Stanford ENT experts working with patients like Rhoton (Washington Post).
Expert commentary underlines the need for caution and awareness. Dr. Jayakar Nayak, a leading ENS researcher at Stanford University, told the Post, “Inferior turbinate reduction for abnormally enlarged and obstructing turbinate tissue is a remarkably safe and effective procedure to help patients to breathe and sleep better… We don’t know why ENS happens in a small group and not in others. I’ve seen similar levels of tissue loss in other patients who don’t have symptoms and are so happy with their breathing.” Dr. Eugene Kern of SUNY Buffalo, who first coined the term ENS in 1994, observed that, “It’s easy to diagnose when you know what you are looking for. You can’t miss it,” but he acknowledges that awareness is still sorely lacking among nose specialists worldwide (Wikipedia).
In a Thai context, where allergies (โรคภูมิแพ้จมูก), sinus infections, and air pollution-related nasal problems are on the rise, the story of ENS should serve as both a warning and a call for more rigorous patient counseling before nasal surgeries. While most turbinate reductions are safe and improve quality of life, Thai ENT surgeons should discuss with patients, in plain language, the very small but real risk of ENS and how symptoms might present, especially for those with a history of multiple nasal procedures.
Thailand’s robust medical tourism sector and reputation for excellent ENT care mean many patients, Thai and foreign, come seeking relief from chronic nasal congestion. However, there may be pressure—especially in busy urban clinics—to prioritize quick surgical solutions for non-urgent nasal issues. The experience from international centers shows that careful patient selection, less aggressive surgical techniques, and thorough postoperative follow-up are key to minimizing the risk of ENS (PubMed; Springer Link).
Empty nose syndrome also exposes a broader issue—a gap in how rare complications are recognized, reported, and managed in the healthcare system. The psychological toll of feeling dismissed or “gaslighted” by multiple doctors, as Rhoton described, is a global problem—for Thais as well, who may feel reluctant to challenge doctor’s opinions or seek second opinions. Medical education and hospital policies should encourage physicians to listen closely to patient experiences, even when objective tests appear normal, and to refer complex cases to specialized centers when ENS or other rare syndromes are suspected.
Historically, the understanding of turbinate function in modern Thai healthcare has evolved—previously, the structures were regarded as insignificant “obstructions,” but now most ENT specialists (แพทย์หูคอจมูก) recognize their vital role in humidifying and filtering Thailand’s hot, dusty air. ENS research underscores why preservation, rather than removal, should be the guiding philosophy in most non-life-threatening cases.
Looking ahead, ongoing research—some of it published in 2025—aims to refine diagnostic approaches and offer hope for those affected by ENS. The use of computational fluid dynamics to simulate airflow patterns and individualize surgeries, the development of animal models to better understand underlying mechanisms (bioRxiv PDF), and innovative treatments like injectable fillers or cartilage implants all point to a future where ENS may become less feared and more manageable (Wiley Online Library). For now, preventing ENS through careful surgery and patient selection remains paramount.
For Thai readers considering or recovering from turbinate or nasal surgeries, the practical takeaway is clear: ask your doctor about the risks of ENS, no matter how rare. Report persistent symptoms of nasal dryness, crusting, or breathlessness, even if your nose “looks open.” If you are uncomfortable or feel unheard, don’t hesitate to seek a referral to a specialist familiar with ENS and its diagnosis. And remember, most people do brilliantly after turbinate surgery—แต่ความเสี่ยงเล็กน้อยต้องแจ้งผู้ป่วยก่อน (even small risks must be explained to patients in advance).
For healthcare professionals, continued education about ENS, use of standardized diagnostic tools like the ENS6Q, and a patient-centered approach will help bridge the gap in rare complication recognition. As our understanding of the nose’s delicate balance deepens, the Thai medical community can ensure that both common and uncommon post-surgical outcomes are managed with the compassion and competence that every patient deserves.
Sources:
- Washington Post: It started with a whistling sound in his nose. Then things got much worse. (2025)
- Empty nose syndrome: new insights from a CFD approach (Springer Link, 2025)
- Empty nose syndrome: new insights from a CFD approach (PubMed, 2025)
- Wikipedia: Empty nose syndrome
- Does Total Turbinectomy Always Lead to Empty Nose Syndrome? (Wiley, 2025)
- How Nasal Cavity Structure Influences ENS Severity (bioRxiv, 2025)