Why spend time on this website?
You needn’t spend time on this website, unless you are curious about one of the most important changes in our understanding of nasal breathing in past decades. Recent discoveries recognized by the 2021 Nobel Prize in Physiology or Medicine are changing how we think about nasal physiology, contemporary turbinate surgery, and the Empty Nose Syndrome.
For more than sixty years I have pursued one question: “How do we really breathe?” This website is the story of that search. A quiet scientific revolution is underway in rhinology. New discoveries in sensory neuroscience are changing how we understand nasal breathing, how we perform turbinate surgery, and why some patients continue to feel breathless despite anatomically widely open nasal passages.
Welcome
My professional career has been devoted to understanding not only the anatomy of the human nose, but also the physiology of breathing and to improving the care of patients with nasal disorders. This website shares that work, including research, lectures, historical perspectives, and current investigations into the physiology of nasal breathing and the Empty Nose Syndrome.
“The nose is not merely an airway to the lungs. It is a sensory organ whose neural signals allow us to perceive the sense of breathing.”
Current Scientific Focus “What I’m working on today.”
1. The Paradox of Patency
Most people think breathing through the nose depends only on how open the airway is. Surprisingly, that is not always true. Some people have a nose that looks wide open on examination and CT scans, yet they feel they cannot breathe. Others have a narrowed airway but still feel they breathe comfortably.
This difference is called the Paradox of Patency, meaning, despite a widely open nose, the patient is unable to sense breathing and often has a sense of suffocation. For many years, doctors focused mainly on the anatomy of the nose. Today, new discoveries show that anatomy is only part of the story.
2. What is Empty Nose Syndrome (ENS)?
Empty Nose Syndrome (ENS) is a condition that may develop when the nose is injured by disease or altered during surgery. Patients often describe a frightening feeling that they cannot get enough air, even though the nasal passages appear open.
Many also experience dryness, burning, crusting, disturbed sleep, difficulty concentrating, anxiety and depressed feelings caused by the constant sensation of air hunger or difficulty breathing.
3. Why Anatomy Alone Cannot Explain It
CT scans, nasal endoscopy, and airflow measurements often show that the airway is open. Yet many patients continue to feel severe shortness of breath. This tells us that breathing depends on more than anatomy alone.
4. Airflow Is Only the Beginning
Air moving through the nose is not the final goal. Airflow is only the beginning. It is the stimulus that activates the nose’s sensory system. As cool air passes over the lining of the nose, it activates tiny sensory nerve endings. Without those signals, the brain may not recognize that normal breathing is taking place.
5. The Sensory Pathway
Tiny sensory receptors in the nasal lining—called the TRPM8 receptors, which detect cooling, and called the PIEZO receptors, which detect mechanical forces—send information through the trigeminal nerve to the brain.
The brain combines these signals into what we experience as the sense of breathing. When this pathway is injured, disrupted or removed by disease of surgery patients may feel they cannot breathe even when plenty of air is passing through the nose.
6. Why Can Someone Feel Short of Breath with an Open Airway?
This question puzzled physicians for many years. The answer lies not simply in moving air, but in sensing (feeling) that movement. If the brain receives weak or abnormal signals from the nose, breathing can feel incomplete despite a normal open airway. This helps explain the paradox that has challenged rhinologists for decades.
7. What This Means for Diagnosis
Diagnosis should include more than imaging CT scan studies, measurements of airflow, measurements of both airflow and pressure as in rhinomanometry. Listening carefully to the patient’s symptoms remains essential. Future diagnostic tests may also evaluate how well the nasal sensory system is functioning which we do not have presently.
8. What This Means for Prevention and Performing Contemporary Turbinate Surgery
The best treatment is prevention. Whenever possible, nasal surgery should preserve the tissues, nerves, and blood supply that help create the normal sense of breathing. Specifically, the goal for contemporary turbinate surgery, is not simply to create a larger airway. The goal is to preserve normal nasal physiology, saving as much normal functional tissue as possible.
9. Looking to the Future
Rapid advances in neuroscience are opening exciting new possibilities. Future treatments may include regeneration of sensory nerves, tissue engineering, neurostimulation and other approaches that restore the normal sensory pathway rather than simply changing the size of the airway.
Our understanding of Empty Nose Syndrome continues to evolve, but one principle has become increasingly clear:
“The sense of breathing is determined by the amount of air that passes through the nose and on the receptors and how the brain senses that airflow to give you the sense of breathing.” EBK
Physiology Diagrams
Airflow stimulates specialized sensory receptors (TRPM8 and PIEZO) within the nasal lining. These signals travel through the trigeminal nerve to the brain, where they create the conscious perception, the sense of breathing.