International Rhinologic Society Rhinology 0300-0729 2025 11 30 Serpentine Sign: evidence of airway compensation in patients with empty nose syndrome EN P-W. WuSchool 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 F.T-N. Yu School of Medicine, Chang Gung University, Taoyuan, Taiwan T-J. LeeSchool of Medicine, Chang Gung University, Taoyuan, Taiwan Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Taoyuan, Taiwan Department of Otolaryngology, Xiamen Chang Gung Hospital, Xiamen, China C-C. HuangSchool of Medicine, Chang Gung University, Taoyuan, Taiwan Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Taoyuan, Taiwan P-H. Chang Division of Rhinology, Department of Otolaryngology, Chang Gung Memorial Hospital, Taoyuan, Taiwan C-C. HuangSchool 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 Journal Article 3349 10.4193/Rhin25.230 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.