1. Introduction
Empty nose syndrome (ENS) is commonly evaluated using symptom quantification (ENS6Q) [1] and confirmation of symptom relief with the cotton test [2]. Nasal septal perforation (NSP) can substantially disturb anterior nasal airflow and may confound symptom attribution when it coexists with inferior turbinate (IT) loss. We observed patients with concomitant NSP and marked IT atrophy in whom the pre‐closure cotton test was negative, yet became positive after NSP closure with subsequent unmasking of ENS‐consistent symptoms. We therefore hypothesized that NSP may mask cotton‐test positivity, representing a clinically important diagnostic pitfall that could lead to under recognition of ENS. The aim of this report is to describe a consecutive 4‐patient case series and propose a staged diagnostic/treatment strategy.
Key Points
Nasal septal perforation (NSP) may mask cotton‐test positivity in suspected empty nose syndrome (ENS).
Cotton test converted positive after NSP closure in 3/4 patients; one patient remained negative.
A staged strategy (SPT→NSP closure→retest→selective) delayed augmentation may optimize care.
2. Methods
This single‐center, single‐surgeon retrospective study was IRB‐approved (Saitama Medical University Hospital, 2024‐132). We included consecutive referrals (April 2023–December 2025) with concomitant NSP and severe IT atrophy clinically suspected of ENS (n = 4). Suspected ENS was defined by prior turbinate surgery, endoscopic severe IT atrophy, and ENS‐type symptoms; ENS6Q and cotton testing were obtained in all patients. For cotton testing, cotton was placed from the nasal floor to the lateral inferior meatus at the anterior IT level and reassessed at 15 min; clinically meaningful improvement was considered positive. To assess NSP contribution, a septal patch test (SPT) was performed by covering the perforation with a thin filter‐paper patch; improvement in N‐VAS (0 best–10 worst) at 5 min defined SPT positivity [3]. NSP closure was indicated for bothersome NSP symptoms with SPT positivity. In routine office practice, any thin, readily available occlusive material that adequately covers the perforation (e.g., a trimmed adhesive bandage strip or glove wrapper paper) may be used, as the key concept is temporary occlusion rather than the specific material. Outcomes included N‐VAS and ENS6Q; ENS was operationally defined as ENS6Q > 11 with a positive cotton test on post‐closure reassessment.
Representative endoscopic images are provided in the Supporting Information Figure S1.
3. Results
Patient characteristics and longitudinal test results are summarized in Table 1. Perforation size ranged from 1.5 × 1.5 mm to 18 × 35 mm (height × length). All four patients had a negative pre‐closure cotton test. All met the prespecified indication for NSP closure. After NSP closure, the cotton test converted to positive in 3/4 patients, while one patient remained cotton‐negative. The three converters had pre‐closure ENS6Q scores above the commonly used threshold (mean 21.7; range 21–22), whereas the non‐converter had a low pre‐closure ENS6Q score [5]. In converters, NSP‐related symptoms improved after closure (N‐VAS decreased), and cotton‐test responsiveness emerged on follow‐up; at that reassessment, the mean ENS6Q was 14 (range 13–15). Staged inferior meatus augmentation procedure (IMAP) [4] was subsequently performed in all three converters, with further improvement in ENS6Q (mean 8.3; range 7–9).
TABLE 1.
Patient characteristics and longitudinal symptom/test results in patients with concomitant nasal septal perforation and severe inferior turbinate atrophy.
| Before NSP closure | After NSP closure | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| N‐VAS | ENS6Q | ||||||||||
| Age | Sex |
Size of NSP (height × length, mm) |
Before SPT | After SPT | Cotton test | ENS6Q | N‐VAS | Cotton test | Before IMAP | After IMAP | |
| 1 | 39 | M | 8 × 22 | 5 | 1 | − | 21 | 3 | + | 13 | 9 |
| 2 | 53 | F | 18 × 35 | 8 | 0 | − | 22 | 1 | + | 15 | 7 |
| 3 | 54 | M | 1.5 × 1.5 | 9 | 3 | − | 22 | 2 | + | 14 | 9 |
| 4 | 49 | M | 11 × 22 | 8 | 0 | − | 5 | 1 | − | 5 | NA |
Abbreviations: ENS6Q, Empty Nose Syndrome 6‐Item Questionnaire; IMAP, inferior meatus augmentation procedure; NA, not applicable; NSP, nasal septal perforation; N‐VAS, nasal symptom visual analog scale.
4. Discussion
Based on these observations, we propose a staged diagnostic and treatment algorithm for patients with concomitant NSP and severe IT atrophy (Figure 1). The key clinical message is that a negative cotton test in this combined phenotype should be interpreted cautiously, because NSP may mask cotton‐test responsiveness and delay recognition of ENS.
FIGURE 1.
Proposed staged diagnostic and treatment algorithm for concomitant nasal septal perforation and suspected empty nose syndrome with severe inferior turbinate atrophy. Patients undergo SPT to assess NSP contribution; if SPT‐positive with bothersome NSP symptoms, NSP closure is performed first. After healing, cotton test and ENS6Q are repeated; if cotton‐positive with ENS6Q > 11, staged IMAP is considered (typically delayed ≥ 6 months after closure). ENS, empty nose Syndrome; ENS6Q, Empty Nose Syndrome 6‐Item Questionnaire; IMAP, inferior meatus augmentation procedure; IT, inferior turbinate; NSP, nasal septal perforation; SPT, septal patch test.
A plausible mechanism is that NSP disrupts anterior nasal pressure/flow patterns to such an extent that localized “airflow‐restoration simulation” at the inferior meatus (cotton placement) provides little incremental benefit, producing a false‐negative result. After NSP closure improves anterior airflow perturbation, the contribution of IT loss to abnormal airflow perception may become more apparent, allowing the cotton test to reveal symptom reversibility. Importantly, conversion was not obviously restricted to a narrow perforation size range in this small series, suggesting that size alone may not explain the phenomenon.
We also emphasize the sequence of surgery. NSP closure often requires robust septal and/or nasal floor mucosal flaps, whereas IMAP creates a mucosal pocket in the nasal floor/lateral inferior meatus for graft placement [4]. If IMAP is performed first, the graft pocket may overlap with subsequent flap harvest sites for NSP closure, potentially necessitating graft removal or compromising flap design. For similar reasons, simultaneous NSP closure and IMAP may be technically challenging and potentially increase risk.
Mucosal donor sites on the nasal floor typically re‐epithelialize by ∼4 weeks [5], but may remain fragile early postoperatively. We therefore delay IMAP until ≥ 6 months after NSP closure to minimize flap/pocket injury, implant exposure, and infection [6].
Limitations include the retrospective single‐surgeon design, very small sample size, and subjective measures. Given the rarity of concomitant NSP with severe IT atrophy/loss, these hypothesis‐generating findings warrant multi‐center validation, but may help inform care for this uncommon, likely iatrogenic phenotype.
5. Conclusion
In patients with severe IT atrophy and concomitant NSP, NSP may mask cotton‐test positivity, creating a diagnostic pitfall for ENS. A staged strategy—SPT‐guided NSP closure followed by post‐closure reassessment and selective delayed IMAP—may be a practical approach to optimize both diagnosis and reconstruction in this challenging phenotype.
Funding
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Supplementary Figure S1. Representative left nasal endoscopic findings in a patient with a nasal septal perforation and severe inferior turbinate atrophy. (a) Pre–nasal septal perforation (NSP) closure: small NSP with severe inferior turbinate atrophy; cotton test negative. (b) Post–NSP closure: complete closure of the perforation with persistent severe inferior turbinate atrophy; cotton test positive. (c) Post‐IMAP: after inferior meatus augmentation procedure (IMAP), with improvement in empty nose syndrome‐related symptoms.
References
- 1. Velasquez N., Thamboo A., Habib A. R., Huang Z., and Nayak J. V., “The Empty Nose Syndrome 6‐Item Questionnaire (ENS6Q): A Validated 6‐Item Questionnaire as a Diagnostic Aid for Empty Nose Syndrome Patients,” International Forum of Allergy & Rhinology 7, no. 1 (2017): 64–71. [DOI] [PubMed] [Google Scholar]
- 2. Houser S. M., “Surgical Treatment for Empty Nose Syndrome,” Archives of Otolaryngology–Head and Neck Surgery 133, no. 9 (2007): 858–863. [DOI] [PubMed] [Google Scholar]
- 3. Hosokawa Y., Sawada M., and Ikezono T., “Is the Preoperative Septal Patch Test Helpful for Determining the Effects After Nasal Septal Perforation Closure?,” Plastic and Reconstructive Surgery – Global Open 13, no. 5 (2025): e6813. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Thamboo A., Dholakia S. S., Borchard N. A., et al., “Inferior Meatus Augmentation Procedure (IMAP) to Treat Empty Nose Syndrome: A Pilot Study,” Otolaryngology–Head and Neck Surgery 162, no. 3 (2020): 382–385. [DOI] [PubMed] [Google Scholar]
- 5. Pinheiro‐Neto C., Rowan N. R., Celda M. P., Mukherjee D., Gompel J. J. V., and Choby G., “Optimizing Quality of Life and Minimizing Morbidity Through Nasal Preservation in Endoscopic Skull Base Surgery: A Contemporary Review,” Journal of Neurological Surgery Part B: Skull Base 83, no. 6 (2022): 602–610. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Gwak J. W. and Jang Y. J., “Treatment Outcomes of the Inferior Meatus Augmentation Procedure With Autologous Costal Cartilage for Empty Nose Syndrome,” Clinical and Experimental Otorhinolaryngology ahead of print, June 25, 2025, 10.21053/ceo.2025-00107. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Supplementary Figure S1. Representative left nasal endoscopic findings in a patient with a nasal septal perforation and severe inferior turbinate atrophy. (a) Pre–nasal septal perforation (NSP) closure: small NSP with severe inferior turbinate atrophy; cotton test negative. (b) Post–NSP closure: complete closure of the perforation with persistent severe inferior turbinate atrophy; cotton test positive. (c) Post‐IMAP: after inferior meatus augmentation procedure (IMAP), with improvement in empty nose syndrome‐related symptoms.