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[Table 1]. The questionnaire is then scored from 0 (no issues) to 30 (extremely severe). ENS6Q was found to
reliably discriminate between ENS vs. control patients and ENS vs. chronic rhinosinusitis without polyposis
[27]
patients . The questionnaire can also distinguish ENS from patients with primary nasal obstruction (i.e.,
[28]
septal deviation, inferior turbinate hypertrophy) .

A thorough history and physical examination is necessary when evaluating patients with suspicion of ENS
including comprehensive ear, nose, and throat examination with nasal endoscopy. Another physical exam
maneuver that is commonly used to assess patients is the cotton test, which involves the placement of dry
cottonoids along the area of missing inferior turbinate in the non-anesthetized nose. The test is positive if
the patient reports an improvement in symptoms with cotton in place. In a case-control study comparing 15
patients with ENS and 18 controls, nearly all baseline differences in ENS6Q scores equalized after the
cottonoids were placed in the ENS patients, demonstrating that cotton testing is a validated office test [29,30] .
The minimal clinically important difference for ENS6Q was found to be 7, suggesting that the ENS6Q score
needs to change by at least 7 to represent a clinically meaningful change experienced by the patient. The
monofilament test is another assessment that utilizes monofilaments of variable diameters applied to the
patient turbinate; the sensitivity threshold is recorded as the minimum monofilament size that patients can
detect sensation .
[31]

The use of computed tomography (CT) in ENS patients has not been well studied in the literature. One
study comparing patients with ENS with patients who had undergone inferior turbinate resection but
without ENS found that ENS patients had increased central (> 2.64 mm) and posterior (> 1.32 mm) septal
[32]
mucosal thickness compared to the septum in inferior turbinate reduction patients without ENS . As these
patients often undergo CT sinus imaging as part of their workup, measuring mucosal thickening may serve
as an adjunct to the other diagnostic modalities discussed above in the appropriate patient.

There are a variety of patient-reported outcome measures and testing available to help diagnose patients
with suspected ENS. The ENS6Q and cotton test are now the standardized first-line modalities, with CT
sinus, computational fluid dynamics, and intranasal trigeminal nerve testing as useful but lacking sufficient
[30]
evidence for routine use . Due to high psychiatric comorbidity, patients with elevated suspicion of ENS
should also undergo anxiety and depression screening.

MANAGEMENT
Non-surgical approaches
Conservative management is based on symptomatic relief by optimizing topical moisturization and treating
any other comorbid psychiatric illnesses by obtaining a behavioral assessment. Strategies such as saline
sprays, topical emollients, nasal lavage, and lubricant drops can be utilized to increase local humidification
of the nasal cavity . Regular use of a humidifier in the environment may also help alleviate symptoms .
[33]
[12]
While there are no original research studies assessing the efficacy of these conservative measures, they are
low-risk and should be aimed at alleviating specific patient symptoms. As psychiatric comorbidities are
common among patients with ENS, mental health specialists can be valuable to help diagnose and treat any
underlying conditions. As a provider, an empathetic and honest discussion on the underlying cause and
possible treatment options for ENS is crucial.

Surgical techniques
Should patients fail conservative treatments, a plethora of surgical approaches have been reported in the
literature. In one systematic review, the most common technique involved a transnasal approach with
submucosal implants in multiple strategic areas to ultimately narrow the nasal valve region or reconstruct