Understanding the Cognitive and Psychological Manifestations of Empty Nose Syndrome: A Physiological Perspective

Empty nose syndrome (ENS) is recognized not only for its physical symptoms but also for the cognitive and psychological disturbances that frequently accompany it. These manifestations—ranging from anxiety and cognitive fog to depressive symptoms. Family members may struggle to comprehend the behavioral and emotional changes that occur, while primary care physicians, specialists, and mental health professionals often interpret these symptoms as evidence of a primary psychiatric disorder. Even otolaryngologists, some of whom may acknowledge ENS as a legitimate condition, may lack a clear understanding of the mechanisms by which these psychological symptoms develop.

Having lived with ENS for fifteen years, I wish to offer a perspective that challenges the prevailing assumption that these symptoms arise primarily as a psychological reaction to the distress of living with ENS. The current literature often attributes the cognitive and affective changes observed in ENS patients to coping difficulties or to comorbid psychiatric conditions.

While the emotional burden of ENS is indisputable, I propose that the cognitive and psychological sequelae are, to a significant extent, physiological responses to altered respiratory function rather than purely psychological reactions.

Proposed Physiological Drivers

1. Shallow Breathing Due to Reduced Nasal Resistance

ENS is often characterized by reduced nasal resistance, which may lead to chronically shallow breathing. This was one of the earliest symptoms I observed personally, later confirmed through objective testing at Ohio State University. Insufficient nasal resistance impairs the ability to both initiate and sustain deep inhalation. Sustained shallow breathing is known to negatively affect cerebral function and emotional regulation. This concept is consistent with the well-established use of deep breathing exercises in psychotherapy to promote calmness and stabilize mood.


2. Loss of Airflow Feedback to the Central Nervous System

Another hallmark symptom of ENS is the diminished or absent sensation of nasal airflow. Many patients describe this as a feeling of suffocation. Beyond its psychological implications, I hypothesize that the loss of airflow-related sensory feedback to the brain exerts a direct physiological impact. Nasal airflow sensation likely contributes to the neural regulation of respiration; its loss may therefore disrupt feedback mechanisms critical to respiratory control. This disruption may contribute to the limbic system activation observed in ENS patients, which could in turn underlie heightened anxiety and emotional instability.


3. Sleep Disruption and Its Secondary Effects

Sleep disturbance is frequently reported among individuals with ENS. The combination of shallow breathing, diminished sensory feedback, and limbic overactivation likely contributes to this phenomenon. In sleep medicine, it is well established that disrupted or insufficient sleep can lead to significant neurocognitive and psychological impairment. REM sleep, in particular, plays a vital role in maintaining emotional stability; chronic deprivation of this stage precipitates mood disturbances and cognitive dysfunction.

In my own case, the onset of significant ENS related sleep disturbance coincided with worsening symptoms following a nasal vestibular body reduction. My spontaneous respiratory drive diminished to the extent that I often have to consciously initiate breaths, and if not careful leading to episodes of hypoventilation. A sleep study revealed frequent unexplained arousals, though unfortunately these findings did not prompt further clinical investigation. Over time, persistent sleep disruption has contributed to measurable physiological consequences, including elevated blood pressure and other metabolic syndrome related issues. Notably, treatment with hyaluronic acid injections—intended to increase nasal resistance—produced noticable improvement in sleep quality, suggesting that reduced nasal resistance plays a causal role in these disturbances.

Conclusion

In summary, I propose that the cognitive and psychological symptoms commonly observed in empty nose syndrome are primarily physiological in origin, arising from altered respiratory mechanics and sensory disruption rather than from secondary psychological adaptation

References:

Burden

1. Association Between Autonomic Dysfunction and Empty Nose Syndrome, 2025
2. Utility of Serum Interleukine-6 Level in Empty Nose Syndrome, 2023
3. Suicidal thoughts in patients with empty nose syndrome, 2022
4. Mental health burden of empty nose syndrome compared to chronic rhinosinusitis and chronic rhinitis, 2022
5. The Degree of Stress in Patients With Empty Nose Syndrome, Compared With Chronic Rhinosinusitis and Allergic Rhinitis, 2021
6. The functional and psychological burden of empty nose syndrome, 2018

Sleep

7. Sleep impairment in patients with empty nose syndrome, 2023
8. Identifying Obstructive Sleep Apnoea in Patients with Empty Nose Syndrome, 2022
9. Impact of sleep dysfunction on psychological burden in patients with empty nose syndrome, 2022
10. Postoperative Sleep Outcomes in Empty Nose Syndrome: Associations With Psychiatric Symptomatology, 2025

Improvements after Surgery

11. Depression and anxiety in empty nose syndrome: A systematic review and Meta-analysis, 2025
12. Identifying Residual Psychological Symptoms after Nasal Reconstruction Surgery in Patients with Empty Nose Syndrome, 2023
13. Serum High-Sensitivity C-Reactive Protein Is Associated with Postoperative Psychiatric Status in Patients with Empty Nose Syndrome, 2021
14. Impact of Psychologic Burden on Surgical Outcome in Empty Nose Syndrome, 2021
15. Nasal nitric oxide in relation to psychiatric status of patients with empty nose syndrome. 2019
16. What drives depression in empty nose syndrome? A Sinonasal Outcome Test-25 subdomain analysis, 2019
17. Evaluation of depression and anxiety in empty nose syndrome after surgical treatment, 2016

Skeptics

18. The clinical effect of psychosomatic interventions on empty nose syndrome secondary to turbinate-sparing techniques: a prospective self-controlled study, 2021
19. Treating empty nose syndrome as a somatic symptom disorder, 2015
20. Empty nose syndrome: what are we really talking about?, 2009