the diagnosis of ENS and many ENTs will wait a year before diagnosing in hopes the patient accepts the new airflow; it is typically diagnosed by ruling out other conditions, with ENS remaining the likely diagnosis if the signs and symptoms are present. A "cotton test" has been proposed, in which moist cotton is held where a turbinate should be or in various locations in the nasal passages, to see if it provides relief and an airflow pattern that allows for natural breathing; while this has not been validated nor is it widely accepted, it may be useful to identify which people may benefit from surgery. As of 2015, protocols for using rhinomanometry to diagnose ENS and measure response to surgery were under development, as was a standardized clinical instrument (a well defined and validated questionnaire) to obtain more useful reporting of symptoms. A validated ENS-specific, 6-item questionnaire called the Empty Nose Syndrome 6-item Questionnaire (ENS6Q) was developed as an adjunct to the standard Sino-Nasal Outcome Test 22 (SNOT-22). The ENS6Q is the first validated, specific, adjunct questionnaire to the SNOT-22. It can more reliably identify patients suspected of ENS. The ENS6Q is gaining usage in studies on ENS. Classification Four types have been proposed: ENS-IT: Inferior turbinate (IT) was fully or partially resected ENS-MT: Middle turbinate (MT) was fully or partially resected ENS-both: Both the IT and MT were both at least partially resected ENS-type: Patient appears to have adequate turbinate tissue but suffers ENS symptoms due to damage to the mucosal surface of the turbinates. Prevention Attempt non surgical methods for an extended period of time prior to surgical intervention. Avoid any unnecessary nasal surgery, avoid any surgical treatment to the turbinates and septum, seek multiple consults for any nasal surgery, conduct imagery on the nasal passages prior to any surgical treatment, seek opinions from surgeons familiar with ENS. Many surgeons will tell patients that ENS is only seen in patients that have excessive turbinate reduction, but studies have shown that any surgery/procedure involving the nasal turbinates can potentially lead to ENS. For this reason it is critical that anyone planning any surgery to the nose for function or appearance should be aware of the high risk of ENS developing if the body does not accept the new airflow and exchange of gasses. Treatment Treatment of ENS by many ENTs is extremely limited with very marginal success rates