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Updated: Jan 18, 2026

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation
Published on: June 20, 2018
Serpentine Sign: evidence of airway compensation in patients with empty nose syndrome
1School of Medicine, Chang Gung University, Taoyuan, Taiwan;Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Taoyuan, Taiwan;Molecular Infectious Disease Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
Background:
This study aimed to evaluate the presence of Serpentine Signs on computed tomography (CT) images and its impact on the clinical symptoms in patients with empty nose syndrome (ENS).
Methods:
A retrospective study analysed patients with ENS enrolled in previous studies. The clinical characteristics and results of ENS-specific questionnaire evaluations were reviewed. The ratio of the maximal to minimal thickness (M/m ratio) of the septal mucosa was also calculated to demonstrate the degree of swelling. Mucosal swelling was defined as a thickness greater than twice that of the surrounding mucosa. A Serpentine Sign was identified by the presence of two or more mucosal swellings on one side of the central nasal septum.
Results:
Seventy-one (74.0%) of the 96 enrolled patients with ENS exhibited Serpentine Signs on CT images. Patients with the Serpentine Sign had significantly lower symptom scores on the ENS 6-item Questionnaire (ENS6Q) and 25-Item Sino-Nasal Outcome Test (SNOT-25). Regression analysis revealed that the ENS6Q, SNOT-25, sleep, psychological, and empty nose symptom domains were significantly associated with the Serpentine Sign. The M/m ratio of the nasal septal mucosa significantly decreased in 39 participants with available postoperative CT images 6 months after nasal reconstruction surgery, along with an improvement in ENS6Q and SNOT-25 scores.
Conclusion:
The Serpentine Sign was associated with fewer ENS symptoms in patients with ENS. The severity of septal mucosal swelling decreased after surgical reconstruction. These results imply a significant impact of airflow alteration due to over-reduction of the inferior turbinate on the nasal mucosa.
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