I might have found out some really important stuff for getting ENS recognized. It might be a bit complex, but please bear with me. Ask your questions, I will try to edit the post to make it more understandable.
I saw a new doctor. He diagnosed that everyday activities give me very high lactate level (700% higher than normal), which explain exhaustion. And also that when breathing with my "naked" nose, I am able to use only 50% of my lung volume. There is also a tendency towards hyperventilation, which can easily turn chronic if you dont work against it, which I do. I will outline the diagnostic tests, everyone can repeat with their doctors and potentially have an easier time, getting their suffering recognized by medical personnel and friends&family alike.
***** Please note *****
This is only the report of one single patient with ENS. It could be different for all of you, or just a subset of you. As we all know, ENS has many forms. Breathing was always my main issue with all of this.
Two weeks ago, I went to see a new doctor in Mannheim, Germany, Dr. Weiss, who specializes in breathing and the mind-body connection. He has a YouTube channel with many videos explaining stuff. It's all in Germany, but has really good automated English subtitles. Video link
We did two seperate tests, which I am showing in the attached image. Please dont get confused, they are completely seperate from each other. The top test A, and the bottom test B.
This test is also called spiro-ergometry (roughly translates to: "breathing test on a bicycle"), dont confuse it with the other test, called spirometry ("breathing measurement").
We did this one first. It is a standardized test many doctors will be able to perform. If you want to repeat it, I would look for a lung or heart doctor, or maybe someone specialized in athletes.
The test setup went like this:
The result was as ayou can see in the picutures. I started out with already elevated blood lactate levels of 4 (where 0-2 is normal). In the past I have had BGA which showed normal values, I can only speculate why it was elevated that day. The bike ride was not very stressful for my muscles (I used to do functional fitness training several times weekly), but very stressful for my mind and breathing. Afterwards, I felt a bit dizzy and slightly nauseous.
After the bike ride, the measurements showed low CO2 (medical term: hypocapnia, hyperventilation/overbreathing) in blood (pCO2) and breathing gas (EtCO2). And also lactic acidosis, meaning very high lactate in combination with lowered/acidic blood pH levels.
The doctor does this kind of testing many times per week, and he says the highet values he ever sees are in the 6-8 range, never 14mmol/L as in my case.
What does this mean? Lactate is produced when your cells trying to produce energy, but are not getting enough oxygen. This indicates my oxygen supply of cells in my body is limited. Please note, that blood oxygen measurements (SpO2) mean nothing in this regard. It is at for me 99% anyways.
So this was the first test, and I was really happy to finally see such an unmistakeable result. Lactic acidosis has symptoms of exhaustion and fatigue - this is an established fact, and my values are very high (as indicated by the machine adding a double 
next to the measurement). You can read more about it here.
Dont be confused by the name, spirometry means "breathing measurement", and is the standard test many people have already done at a lung doctor's office. It is used to determine maximum lung volume and some other values. It is usually done via the mouth, as you can see in the bkack&white-photo above. I have done this kind of measurement in the past, and I had healthy, strong values while mouth-breathing. But since we are looking at ENS, we tried something different.
My main issue has always been: During regular nose breathing, I feel that I cannot draw a satisfying breath. So we decided to modify the measurement apparatus for nasal measurement. I have attached a photo I took myself, where you can see it.
The standard procedure for this test is this:
This is repeated three times to get good measurements.
We did this set-up two times. Once with a normal, "naked"/empty nose. And a second time with all the tools I know that improve my breathing: synthetic cotton inserts, nose clip and VICKS menthol inhaler stick. Read more here: www.enstips.com/guide It was a bit tricky, but I was able to fit the nasal clip under the mask. I inhaled from the menthol before each of the three rounds of measurement.
When we got the results, the doctor and I were both really surprised. Read carefully: With my naked nose, I was able to breathe THREE liters of air into my lungs. When using cotton+clip+menthol, I was able to breathe SIX liters of air into my lungs. Double the amount!
We were both astonished and decided to repeat the test (another 3 rounds of naked nose, and 3 rounds of "assisted" nose). And the result was almost the same. TWO liters naked, and FOUR liters with cotton etc. Not sure why the numbers were different, it was with a different technician who instructed me a little differently. But the doctor said, it's not important, because the relation between the two values is again 2x.
He also looked at the other values and told me, I am basically only breathing from my chest. And when I use menthol etc, I am able to properly belly breathe.
This felt like finally confirming, what I had been describing all the time. I usually cannot take a satisfying breath, but when the cotton is just in the right place during cotton test, or with menthol inhalation, it suddenly feels like I can breathe deep into my stomach. It's like I can feel the resistance of the diaphragm, and sometimes even some tingling.
I had already stayed at the doctor's office for more than 4 hours, which is why we couldnt continue with more testing. I would be interested in isolating, which of my tools played the biggest role, cotton, clip or menthol. But I am already amazed to see such a clear result!
The measurement technique was a bit experimental, I know that. But there are also more formal ways to do "nasal spirometry", if you google it. So this is not completely novel. But as far as I know, I have not seen this be measured in ENS patients.
Now everyone is probably wondering, what might be the explanation. There is such a thing called the "nasopulmonary reflex", which has been mentioned by Scheithauer and Houser in their papers. Basically, the nose is effectively connected to the lungs through the trigeminus nerve - this is a known fact since the 1960s. For example, it has been tested, that when you spray ice water on the nasal mucosa, the lungs/bronchiae contract as aprotective mechanism.
There also seems to be an effect on CO2 tolerance, which is our main driver of breathing reflex. This paper has been mentioned by Houser in his paper.
For me, I will hand these results to my other doctors and discuss them with them. They might also come in handy when trying to apply for disability or in other situations, where I have to prove, that my suffering is real! I can finally show that there is indeed a severe issue with my breathing, causing lots of lactate buildup, lactic acidosis and hyperventilation.
For you, I hope you can feel inspired and motivated by my case to go out and try to get the same testing done by your doctor. Hopefully, you will see similarly results. It might help you greatly to prove your condition to doctors, in court, or just to your family, who doesnt understand.
If you want an indication of this might be relevant for you, try the CP-test to test yourself for low CO2-tolerance, which might indicate you have the same problems. I usually score only around 14 seconds during daytime, but feel much better when I sometimes score 25+ in the mornings. Video link
The best way to increase CO2-tolerance and breathing in general for me, has been using synthetic cotton inserts, as described in www.enstips.com/guide
If you suspect your lactate is high, one clinically proven way to improve the processing of it, is to use Gelum, which is available from German pharmacies. I have been using it for months. It can give me real boost sometimes, but be aware, it will only ever be a support, never a solution.
I value this doctor very much. He was very kind and understanding. One of the few doctors, who understand that psychosomatic means mind->body and body->mind, and that the body can cause symptoms far stronger than pure willpower could ever control. He is an expert on all things breathing, and also understands the nervous system very well.
He has heard about ENS, but didnt know much about it. But seemd genuinely interested. It seems that it is really his passion and he made it his mission in life to help people with breathing issues.
His testing was partially covered by my German public health insurance, but I had to pay for some measurements myself. They were very transparent about this: The first thing they handed to me was price list which listed every single measurement. The bike test for example cost 80€, blood gas analysis 30€.
You can make appointments there in person or also for a videocall. I was able to get an appointment within 1-2 months. https://www.weiss.de/en/
They are also running a clinic, where you can treat breathing dysfunctions like chronic hyperventilation. There you will learn for example Buteyko exercises and train with an EtCO2 capnometer. But they will also do much more, which I havent deeply looked into. They offered this to me as well. One week would be 1,500€. They were not trying to push this on me in any way.
I dont think, this will be effective in treating my case, because I have already studied Buteyko etc extensively. But for people with chronic hyperventilation, this might be really helpful though. Alternatively, you can do a much cheaper online programme, where they send you a capnometer device.
I am still considering organizing a stay at their clinic in the future, to see if we can improve my symptoms sometwhat, or be it, just to do more measurements and discuss them with a genuinely interested doctor.
I know one other German ENS patient who already went to see him and was also diagnosed with hyperventilation, chronic in their case. I will ask them to comment under this post to confirm and tell their story.
⚠️ DISCLAIMER: I am not a medical professional. Everything here is based on my own experience and you should consult with your doctor before trying these methods.
This guide is aimed at patients, who have been diagnosed with Empty Nose Syndrome by a qualified doctor. Everything in this guide has been tested by me personally and at least a handful of other patients. The symptoms of ENS patients vary widely. You might get the most benefit from this guide, if these symptoms apply to you:
You might benefit less, if you have these symptoms:
Not sure if you have Empty Nose Syndrome? Read here: Do I Have Empty Nose Syndrome?
The methods are ranked with 1-5 stars according to their effectiveness.
Let's start the with the most important and effective method first. If you only do one thing, do this!
Using synthetic cotton strips has been a complete game-changer for my symptoms. It is the single most effective treatment I have encountered. It gives me almost the same great effect as a cotton-test performed by my ENT. In my personal opinion, you should make it a priority to try out this method, since it can alleviate your symptoms to a degree, that no other treatmenrs are necessary anymore.
It was developed by my German ENT. He used "Hartmann Rolta soft" polyester cotton, which has two huge advantages over rolled-up cotton pads: Because of the special material, they adhere/stick to the mucosa and do not get soaked! This means they mostly stay in place, don't move around in the nose, and you are not at risk of swallowing them (as long as you let them stick out a bit). I have been wearing these 24/7 for over a year.
The only downside is, that it is a bit more complicated to apply. You need to buy some special products and need to learn the technique. If this seems daunting to you, you can make an appointment with your ENT and show them the video. They can help you learn how to apply the strips to the nose and safely use the bayonet tweezers.
The strips are applied in a way that they augment the natural shape of the inferior turbinate. You might need to experiment a bit with the dimensions of the strips. I would start with a width of 7-10mm and a length of 40-60mm. If your nose is really tight, you can also try a strip of only 30mm length, just in the front part of the nose.
Here are some links so you can buy the products:
This is a lower effort, more accessible variant for the synthetic cotton inserts - but it is WAY less effective. Rolta soft should be your number one priority, even if it's not readily available where you live.
Cotton pad rolls were the first treatment I tried for my ENS. They were a signifcant improvement for me and should be easy and cheap to try out for most people. The main drawback is, that the cotton gets soaked and moves around in the nose. It might also happen that you swallow it by accident. Always be careful when wearing this and don't wear it during sleep.
Some patients experience relief by changing the airflow at the point of the outer nose. You can try this very easily by carefully pinching the bridge of your nose. You want to change the flow of air, not cutting it off. Try to find find the upper bony part of your nose, the cartilageous area you are looking for is right under there. Use only the tips of your fingers to apply pressure. The idea is to direct the airflow downwards. If this works for you, you can also buy a swimmer's nose clip for a hands-free solution. I have tried half a dozen products and this one was significantly better than the others. The pressure can be adjusted precisely and it stays in place better than other models.
Menthol has been shown in a study to ease the feeling of suffocation and calm the overexcited nervous system in ENS patients. It stimulates the TRPM8 nerve receptors in the nose, which signal your brain that you are breathing. You can try products like VICKS inhaler sticks or VapoRub (called WICK in Germany), Tiger Balm White, or menthol oil.
As you can probably tell from the picture, I always carry one of those inhaler sticks around with me and have several scattered around my apartment, so they are always at hand. Just be careful to not over-use them, or you might lightly irritate your nasal mucosa. If it gets uncomfortable, just take a break for a few minutes.
ENS patients have been shown in a study to have lowered nasal nitric oxide (NO). Not to be confused with nitrous oxide (N2O).
For instant suffocation relief, you can increase nasal nitric oxide with a nasal spray called SaNOtize Enovid ("VirX" in Germany). It is avaliable for prescription-free for purchase in Israel and Germany. But you can order it from international sellers on eBay for around $30.
Be careful: This spray contains the preservative benzalkonium chloride, which can cause a rebound effect of rhinitis medicamentosa, if used too much. I personally have not yet experienced this after 1-2 daily use for a few weeks.
Scientific study on Enovid
Here are some reports from other users
Gelum-drops reduce lactate levels in the body. Lactate is connected with anxiety and known to be elevated in people with breathing issues like obstructive sleep apnea or (chronic) hyperventilation. Hyperventilation is a common symptom in ENS patients.
Effects: I have been taking them for six weeks now as prescribed, 3x daily 1ml. The effect has been noticeable immediately for me. I feel more relaxed, more focussed, have better mood. There have been no changes in breathing, dryness or sleep so far. But I am really amazed, this is one of the most effective things I have taken so far. It basically saved Christmas for me, because for the last weeks I had been suffering really badly, as every year during wintertime. My family also noticed the change immediately.
I also spoke to a doctor about it, who knew these drops. Told him how after taking it for the first time, my tense back muscles started tingling and after some stretching I felt relaxed and clear-minded again for the first time in weeks. And he confirmed for me, that this is an expected effect when lactate gets removed.
Side effects: They list gastrointestinal discomfort as a possible side effect. I have noticed a bit of bloating and gas maybe, but not a huge issue.
How they work: The drops contain a "potassium-iron-phosphate-citrate complex" and are usually used for people who are suffering from liver issues. The aim is to ease the burden on the liver, by binding ammonium in the gastrointentinal tract. This frees up capacity in the liver to process more lactate and turn it into glucose, which gives us new energy. And if you have heard about lactate before you probably know, that it is produced in the cells, when not enoug oxygen is present. This is a well-known phenomenon in patients with sleep apnea or hyperventilation and connected with anxiety/panic.
One study showed it helps in liver disease and how it improves symptoms of exhaustion and depression in liver patients.
And one German study about how they achieved to improve the lactate curve of healthy athletes (PDF auto-translated).
Where to get them: They are prescription-free in Germany. A small bottle of 30ml to try it out costs 8€. There are also international sellers.
Pregabalin/Lyrica is the prescription medication that has helped me best so far. It is usually prescribed for anxiety, restless legs or nerve pain. From taking it for the first time, I had the experience "I finally feel like myself again!". I have been taking it for several months, at a low dose of 3x50mg daily.
It clears my mind, calms my body (no more restless legs!), takes me from irritable to more social, and also allows me to breathe a little deeper. My diaphragm relaxes a little bit.
It works by targetting GABA receptors in the brain, which cause calm and relaxation. Those are the receptors that are also targetted by alcohol or benzodiazepines. So far, at this dosage, I have not experienced any side effects.
It is non-addictive, but needs to be tapered off if taken at higher doses. I felt the effects immediately after the first dosage, others have reported feeling the effects after one week. Please consult with your doctor.
Triptans are usually prescribed as migraine medication. Since I got ENS in 2019, I have developed migraines myself and started taking triptans. One thing I noticed was, that it does not only cure my headache, but also allows me to breathe easier and deeper. They also help my body relax and calm down, but it might take 2-3 hours for the effect to fully develop. I don't understand how this effect is created, but sometimes the inside of my nose starts tingling when taking them, as if it increases blood flow in there.
Watch out: Triptans are very potent and one of the most effective treatments I have found, but they should be taken very carefully. Migraine patients are told to take at most 10 doses per month.
Nara-Triptan is prescription-free in Germany, other triptans need to be prescribed by your doctor. I have also tried Riza-Triptan, which seems to have a stronger, more short-lasting effect, wheres I feel the effect of Nara-Triptan for about 24 hours.
Medical Cannabis through a vaporizer has been effective for me personally. It allowed me to breathe depper. Especially the long inhalation draws on the vaporizer felt very comfortable. I could breathe really deep again.
The overall effect was very calming, felt a little bit "stoned". It did not help me sleep. But I would definitely recommend it, when you are suffering and are looking for relief.
I have used this strain: IMC THC17 T01 HK Hindu Kush (Indica) at 0.15g per dose in a vaporizer.
DO NOT SMOKE IT!
Cartilage implants are often considered the most promising long-term solution to rebuild turbinates. These implants can use your cartilage from the ear or rib or donor cartilage. While other materials are used, they may be absorbed over time. Scientific study on cartilage implants
For a less invasive but more experimental approach, consider adipose-derived stem cell (ADSC) injections. Although only one study has been conducted, it shows promise in treating ENS. Clinics offering ADSC injections are located in San Marino (Italy) and Kyiv, Ukraine. Scientific study on ADSC treatment
Please report back if you try any of the methods here, whether successful or not. Your feedback can be valuable to others dealing with ENS.
We get many questions of people asking whether they have ENS.
That being said, if you are asking yourself, if you should go see an ENT, please take the ENS6Q:
The "The Empty Nose Syndrome 6-Item Questionnaire (ENS6Q)" is a scientifically validated diagnostic aid and checks for the symptoms that makes ENS distinct from others nose diseases. Rate each symptom from 0 (No problem/Not applicable) to 5 (Extremely severe).
Then add up the scores, the sum should be between 0 and 30. If you have a score of 11 or higher, you should consider seeing an ENT for proper diagnosis. Please be aware, that you might score unusually high in the early days and weeks after surgery. This is normal and expected, and will most likely disappear again after some times has passed and healing has progressed further.
Many doctors wait 6-12 months till making an official ENS diagnosis, because so much healing can still potentially happen during this time.
Please also check yourself for chronic overbreathing (the correct medical term is chronic hyperventilation). You can try the so called CP-test to check yourself. A healthy result would be 40 seconds or higher, below 20 seconds usually presents as noticeable health difficulties.
There is a study which showed that 77% out of 22 ENT patients were suffering from hyperventilation. But there are also anecdotal reports of ENS patients experiencing the opposite symptom of hypoventilation ("under-breathing"). Those might experience almost forgetting to breathe, for example.
If you have a low score and want to raise it, there are breathing exercises which can help you improve it. health difficulties. This video explains the concept and shows an exercise. Please try the exercise for a full 10 minutes and see if it improves your symptoms. It should provide relief for many nasal and breathing conditions. You can also check your CP score again afterwards and see if it is higher now. The exercise should provide relief for many people, whether they have ENS or not. The main difference is, that ENS patients will only have immediate, but not lasting effects from this.
If you suspect, that you might be suffering from ENS, then please make an appointment with an ENT to get diagnosed. We have a list of doctors around the world which might be able to help you.
You might also want to take a look at our Self-Help Guide, to find something to give you relief in the meantime.
