Historical, pathophysiological, and therapeutic aspects of vidian neurectomy

Temperature-controlled radiofrequency ablation for the treatment of chronic rhinitis: Two-year outcomes from a prospective multicenter trial

BACKGROUND

Minimally invasive temperature-controlled radiofrequency (TCRF) ablation of the posterior nasal nerve (PNN) demonstrated a significant larger treatment effect on the symptom burden of chronic rhinitis patients than a sham control (no energy delivery) at the 3-month primary endpoint of this trial.

METHODS

Two-year posttreatment outcomes for patients treated in a prospective, multicenter, patient-blinded randomized controlled trial were determined by combining the index active treatment-arm and index control-arm crossover patients into a single group (after the primary endpoint) to evaluate the treatment effect durability and long-term effects on concomitant chronic rhinitis medication usage.

RESULTS

The mean baseline reflective total nasal symptom score (rTNSS) was 8.2 (95% confidence interval [CI], 7.9-8.6; N = 104). At 2 years (N = 79), the mean change in rTNSS was -5.3 (95% CI, -5.8 to -4.8; p < 0.001; 64.6% improvement). The 2-year responder rate (≥30% improvement in rTNSS) was 87.3% (95% CI, 78.0-93.8). All four components of the rTNSS (rhinorrhea, congestion, sneezing, and nasal itching) showed significant improvement over baseline, with rhinorrhea and congestion showing the most improvement. Postnasal drip and cough symptoms were also significantly improved. At 2 years, 81.0% (95% CI, 70.6-89.0) reported a minimal clinically important difference of ≥0.4-point improvement in the mini-rhinoconjunctivitis quality of life questionnaire score. Of 56 patients using chronic rhinitis medications at baseline, 25 of 56 (44.6%) either stopped all medication use (7/56 [12.5%]) or stopped/decreased (18/56 [32.1%]) use of ≥1 medication class at 2 years. No serious adverse events related to the device/procedure were reported over 2 years. To determine the potential effect of patients who left the trial over 2 years on the responder rate, the responder statuses of the 14 patients with follow-up data who were lost to follow-up/withdrew/died were imputed by the last observation carried forward and the responder statuses of all nine patients who had an additional nasal procedure were imputed to nonresponder, resulting in a 2-year responder rate of 79.4% (95% CI, 70.3-86.8).

CONCLUSION

TCRF ablation of the PNN is safe and resulted in a significant and sustained reduction in chronic rhinitis symptom burden through 2 years and a substantial reduction in concomitant medication burden.

An indirect comparative analysis of two posterior nasal nerve ablation techniques for treating chronic rhinitis: A systemic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis evaluates and compares the effects of two treatments that ablate the posterior nasal nerves for rhinitis-related symptoms: cryotherapy and radiofrequency neurolysis.

METHODS

We reviewed studies retrieved from PubMed, SCOPUS, Embase, the Web of Science and the Cochrane database up to June 2023. Papers reporting quality-of-life and rhinitis-related symptom scores before and after cryotherapy, and sham-controlled studies, were analyzed.

RESULTS

In total, 738 patients enrolled in 10 studies were evaluated. Both cryotherapy and radiofrequency neurolysis significantly improved rhinitis-related symptoms including congestion, itching, rhinorrhea, and sneezing, and quality of life during 12 months of follow-up. Radiofrequency neurolysis was significantly more effective than cryotherapy in terms of reducing total nasal symptom scores at up to 12 months postoperatively. In terms of individual symptoms, itching, rhinorrhea, and congestion were significantly alleviated or tended to be reduced more by radiofrequency neurolysis than by cryotherapy. The improvements in the minimal clinically important difference in total nasal symptom scores (1.0 point) after 3 months of cryotherapy and radiofrequency therapy were 81.8 % and 92.7 %, respectively.

CONCLUSIONS

Cryotherapy and radiofrequency neurolysis both improved rhinitis-symptom and quality-of-life scores. Especially, radiofrequency neurolysis showed the better effectiveness for improving the nasal symptoms related to the rhinitis than cryotherapy.

Effectiveness of temperature-controlled radiofrequency neurolysis of the posterior nasal nerve to treat chronic rhinitis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis evaluates the effect of TRNP on rhinitis-related symptoms.

METHODS

We reviewed studies retrieved from PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database to June 2023. Studies that evaluated quality-of-life and rhinitis-related symptom scores before and after treatment were analyzed, as was one sham-treatment-controlled study.

RESULTS

In total, 406 patients evaluated in five studies were analyzed. TRNP significantly improved rhinitis-related symptoms-congestion, itching, rhinorrhea, and sneezing-for up to 12 months after treatment, compared to before treatment. The most significant symptom decreases were those of rhinorrhea and nasal congestion. Rhinitis-related symptoms had improved significantly at 3 months after TRNP, compared to sham surgery. TRNP improved disease-specific quality-of-life scores on the Rhinoconjunctivitis Quality of Life Questionnaire at 6 months after treatment, compared to before treatment. The rates of clinical improvement in terms of all nasal symptoms (reduction > 30% from baseline) and in quality of life (minimal clinically important difference > 0.4) after TRNP were 79% and 84% respectively. There was no severe adverse event associated with either device use or the overall procedure.

CONCLUSIONS

TRNP treatment improved subjective symptoms related to rhinitis, especially rhinorrhea and nasal congestion, and also improved disease-specific quality-of-life scores.

Comparative Effectiveness of Cryotherapy and Radiofrequency Ablation for Chronic Rhinitis: A Systematic Review and Meta-analysis

OBJECTIVES

Multiple minimally invasive techniques for chronic rhinitis treatment focus on posterior nasal nerve ablation. We conducted a systematic review and meta-analysis to evaluate the efficacy of cryotherapy and radiofrequency ablation for alleviating symptoms in patients with allergic and nonallergic rhinitis.

METHODS

We retrieved studies from PubMed, Scopus, Embase, Web of Science, and Cochrane Database up to July 2023. Data on the impact of cryotherapy and radiofrequency ablation on quality of life and symptom ratings of rhinitis were extracted and evaluated.

RESULTS

An analysis of 12 studies involving 788 patients demonstrated significant improvements in quality of life and rhinitis-related symptoms (nasal obstruction, itching, rhinorrhea, and sneezing) in patients treated with cryotherapy or radiofrequency ablation (symptom score at 24 months and quality of life score at 3 months). However, radiofrequency ablation had a more positive effect on nasal symptoms after 3 months than cryotherapy. Nonallergic rhinitis patients responded more favorably to posterior nerve ablation than patients with allergic rhinitis. Both techniques enhanced disease-specific quality of life during the initial 3 months of treatment (cryotherapy, 84.6%; radiofrequency, 81.6%; P=0.564). After 3 months of treatment, a clinical improvement in all nasal symptoms (minimal clinically important difference in the total nasal symptom score: >1.0 points) was seen in 81.8% and 91.9% of patients who underwent cryotherapy and radiofrequency ablation, respectively (P=0.005), suggesting that radiofrequency is more likely to lead to clinical improvement.

CONCLUSION

Rhinitis-associated subjective symptom scores and quality of life may be improved by both cryotherapy and radiofrequency ablation. Ablation was more efficacious than cryotherapy for nasal symptoms in patients with nonallergic rhinitis. To corroborate these findings, further randomized controlled studies directly comparing these two techniques are warranted.

Improvement in Nasal Symptoms of Chronic Rhinitis after Cryoablation of the Posterior Nasal Nerve

Objective

To determine the efficacy of posterior nasal nerve (PNN) cryoablation for improving the symptoms of chronic rhinitis.

Study Design

Retrospective cohort study.

Setting

A private practice.

Methods

This study evaluated medication usage and adverse effects of in-office PNN cryoablation with a handheld device in patients > 18 years with chronic (>6 months) allergic or nonallergic rhinitis for whom medical management failed. The total nasal symptom score (TNSS) and mini rhinoconjunctivitis quality of life questionnaire (mRQLQ) scores were compared before and after treatment.

Results

This study included 127 patients with a mean age of 52.4 ± 16.9 years; 60.6% of patients were female and 49.6% had allergic rhinitis. Mean symptom scores decreased from 5.94 (95% confidence interval [CI], 5.51-6.43) to 3.44 (95% CI, 2.97-3.81, P < .001) after the procedure, with clinically important decreases in 75 (59.1%) patients. For patients with baseline TNSS values of ≥4, 63.5% (66/104) had a clinically important decrease, whereas only 39.1% (9/23) of those with the lower baseline did (P = .04). Mean mRQLQ scores also decreased from 2.51 (95% CI, 2.29-2.72) to 1.28 (95% CI, 1.20-1.47, P < .001) after the procedure. Seventy-eight of 273 (28.6%) medications were discontinued after the procedure. Adverse effects occurred in 18.1% (23/127) of patients with headache as the most common.

Conclusion

PNN cryoablation improves nasal symptoms and quality of life in patients with chronic rhinitis. Patients with a higher baseline TNSS are more likely to experience significant symptomatic improvement.

Temperature-controlled radiofrequency neurolysis for treatment of chronic rhinitis: 12-month outcomes after treatment in a randomized controlled trial

BACKGROUND

Temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic rhinitis was previously reported as superior to a sham-control procedure at 3 months postprocedure in a randomized controlled trial (RCT). The primary endpoint was a responder rate of ≥30% improvement (decrease) for 24-hour reflective total nasal symptom score (rTNSS) compared with baseline. Herein, 12-month outcomes after active treatment are reported.

METHODS

In this prospective, multicenter, patient-blinded RCT, patients in the index active treatment arm were unblinded at 3 months and followed through 12 months. At 3 months, eligible patients from the sham-control arm of the study were invited to crossover to active treatment. Eligibility criteria included rTNSS ≥6, with moderate-severe rhinorrhea and mild-severe congestion. The TCRF stylus was applied bilaterally to nonoverlapping areas in the region of the PNN.

RESULTS

Patients in the index active treatment arm (n = 77) had a mean baseline rTNSS of 8.3 (95% confidence interval [CI], 7.9-8.7). At 12 months, the responder rate was 80.6% (n = 67) (95% CI, 69.1%-89.2%). At 12 months, the mean change in rTNSS was -4.8 (95% CI, -5.5 to -4.1; p < 0.001), a 57.8% improvement. The available initial rTNSS-based outcomes in the crossover active treatment arm (n = 27) were following the same course as the index treatment arm. No serious adverse events and 8 adverse events related to the device/procedure were reported in the trial to date.

CONCLUSION

TCRF neurolysis of the PNN area is safe and the symptom burden improvement that was superior to a sham procedure at 3 months was sustained through 12 months.

Efficacy of various surgical methods in the treatment of allergic rhinitis: A network meta-analysis

OBJECTIVE

We often use surgery to treat allergic rhinitis (AR) patients who have failed drug treatment, but there is currently no clear gold standard for the treatment of allergic rhinitis. Using network meta-analysis, we evaluated the efficacy of different surgical methods in the treatment of AR.

METHODS

PubMed, Embase, The Cochrane Library, Web of Science, CBM, Wan Fang Data, and CNKI databases were searched to collect clinical randomized controlled trials of AR with different surgical methods that met the inclusion criteria. After two investigators independently screened literature, extracted data, and assessed the risk of bias of included studies, R software was used to evaluate inconsistency using the node splitting method, and Stata15.1 was used to estimate the ranking probability of treatment.

RESULTS

A total of 47 randomized control studies involving 17 surgical schemes and 4144 participants were included. The results showed that after excluding surgical methods that did not form a closed loop, in AR patients without chronic rhinosinusitis and nasal polyps, surgical efficiency and symptom score ranked the same, which were posterior nasal neurectomy (PNN), Vidian neurectomy (VN), anterior ethmoid neurectomy (AEN), nasal septal reconstruction (NSR), and bilateral inferior turbinoplasty (BIT). In AR patients with chronic rhinosinusitis with nasal polyps, the effective rate (OR = 5.06; 95% CI = 2.75-9.32) and symptom and sign scores (MD = -3.80; 95% CI = -6.50-1.09) of PNN + FESS (functional endoscopic sinusitis surgery) were higher than FESS, and there was a significant difference.

CONCLUSION

Our findings suggest that PNN is the best single operation for patients with AR and without chronic rhinosinusitis and nasal polyps, and the combination of multiple procedures may be better than a single operation. FESS + PNN is more effectual in AR patients with chronic rhinosinusitis with nasal polyps.

Is Posterior Nasal Nerve Neurectomy Really a Ray of Hope for the Patients of Allergic Rhinitis

Allergic rhinitis significantly affects the quality of life, it contributes to missed or unproductive time at school or work, disturbed sleep pattern and day time somnolence. Rhinitis is defined clinically as having two or more symptoms of anterior or posterior rhinorrhoea, sneezing, nasal blockage and/or itching of the nose during two or more consecutive days for more than 1 h on most days (International rhinitis management working group, 1994). Allergic rhinitis is diagnosed when these symptoms are caused by allergen exposure leading to an IgE mediated reaction. Nerve irritation causes sneezing and itching, the loss of mucosal integrity causes causes rhinorrhoea and the vascular engrogment leads to nasal blockage. Medical modalities are symptomatically effective in mild cases, with temporary relief and addressable adverse effects. Prolonged treatment with allergy immunotherapy causes a sustainable financial burden while remaining inaccessible at smaller towns. Posterior nasal nerve neurectomy is short, easy and effective alternative. The basic procedure is to selectively cut nerve bundles at the level of the sphenopalatine foramen (SPF) with a trans nasal approach. By denervating the nasal mucosa one renders it unresponsive to any sorts of allergen or allergic reaction. The aim of the study was to evaluate the outcome of posterior nasal nerve neurectomy in cases of severe allergic rhinitis by assessing its impact on the total nasal symptom score. The study is a hospital based prospective study, conducted on 15 patients who presented to the ENT department of Mahatma Gandhi Hospital from march 2021 to October 2021 (6 months) suffering from allergic rhinitis and did not show any satisfactory improvement even after 1 year of medical treatment. Adult patients in the age group of 20-45 yrs. diagnosed with allergic rhinitis were enrolled into the study after obtaining a due written consent. These included patients having 2 or more symptoms of allergic rhinitis and refractoriness to medical therapy for > 1 year along with significantly affected quality of life and elevated IgE level. Patients with drug induced & hormonal causes of rhinitis, chronic rhinosinusitis and any anatomical feature which precipitates to rhinitis such as deviated nasal septum, hypertrophied turbinates, blocked osteomeatal unit, polypoidal nasal mucosa and sinonasal polyposis were excluded from the study. During our study period from march 2021-September 2021, 15 patients were enrolled in the study. All the patients were followed up at 2nd and 6th month postoperatively. Amongst these patients, there were 11 females (73.34%) and 4 were male (26.67%)The mean age of patients was 35.2 years. Subjective nasal symptoms of all 15 patients improved over the period of 6 months. The mean TNSS improved from 12.067 preoperatively to 8.66 at the end of 2nd month, i.e., 23.1% improvement. By the end of the 6th postoperative month there was a consistent reduction in the tnss, which further reduced to a mean of 3.4 (70.2% reduction) indicating a further improvement in symptoms with time. With the advancement & popularity of endoscopic sinus surgery in the past decade, endoscopic resection of the posterior nasal nerve is emerging as a safe and less invasive technique with long standing results. Medical treatment usually provides mild and symptomatic relief with long duration of treatment period. Thus, PNN is safer, economical & easier alternative to current trend of treatment of allergic rhinitis, proving to be highly efficient in cases of intractable allergic rhinitis.

Long-term Outcomes Following Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Chronic Rhinitis

Background

Temperature-controlled radiofrequency neurolysis of the posterior nasal nerve has been shown to reduce the symptom burden of patients with chronic rhinitis.

Objectives

To evaluate the long-term safety and effectiveness of temperature-controlled radiofrequency neurolysis of the posterior nasal nerve for the treatment of chronic rhinitis.

Methods

A prospective extension of a 12-month single-arm study, where reflective total nasal symptom score (rTNSS) and the responses to a study-specific quality of life questionnaire and patient satisfaction survey were collected at 24 months.

Results

Forty-seven patients completed initial 12-month follow-up after treatment with the study device, of which 34 patients were reconsented and completed 24-month follow-up. The mean rTNSS of the long-term follow-up patients improved from 8.4 (95% confidence interval (CI), 7.7 to 9.0) at baseline to 2.9 (95% CI, 2.1 to 3.6), P < .001 at 24 months, a 65.5% improvement. On a 6-point scale (0-5), postnasal drip improved from a mean of 4.1 (95% CI, 3.6 to 4.6) to 2.1 (95% CI, 1.7 to 2.5) and chronic cough improved from 3.2 (95% CI, 2.7 to 3.6) to 0.9 (95% CI, 0.5 to 1.3) from baseline through 24 months; P < .001 for both measures. The proportion of patients achieving a minimal clinically important difference of 30% improvement from baseline at 24 months was 88.2% (95% CI, 73.4%-95.3%). At 24 months, 24% of patients were taking overall fewer and 15% taking overall more rhinitis medication classes than at baseline. Patients reported a higher quality of life in terms of sleep, well-being, and lower oral medication/nasal spray use at 24 months. There were no serious adverse events considered related to the procedure in the 12-24-month period.

Conclusion

Temperature-controlled radiofrequency neurolysis results in a significant and durable reduction in the symptom burden of chronic rhinitis and patients reported improved quality of life through 24 months postprocedure.

Effect of Radiofrequency Neurolysis on the Symptoms of Chronic Rhinitis: A Randomized Controlled Trial

Objective

To determine the safety and efficacy of temperature-controlled radiofrequency (RF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic rhinitis.

Study Design

A multicenter, prospective, single-blinded, randomized controlled trial, in which the control arm underwent a sham procedure.

Setting

Sixteen otolaryngology centers.

Methods

Patients with 24-hour reflective Total Nasal Symptom Score (rTNSS) ≥6, including moderate to severe rhinorrhea and mild to severe congestion, were randomized 2:1 to active treatment of the posterior nasal nerve area with a temperature-controlled RF device or a sham procedure, with no RF energy delivery. The stylus was applied bilaterally to nonoverlapping areas of the posterior middle meatus and posterior inferior turbinate in each nostril in the region of the PNN. The primary endpoint was responder rate at 3 months, where a response was defined as ≥30% improvement (decrease) in rTNSS from baseline.

Results

Patients had a mean baseline rTNSS of 8.3 (95% CI, 7.9-8.7) and 8.2 (95% CI, 7.6-8.8) (P = .797) in the active treatment (n = 77) and sham control (n = 39) arms, respectively. At 3 months, responder rate was significantly higher in the active treatment arm: 67.5% (95% CI, 55.9%-77.8%) vs 41.0% (95% CI, 25.6%-57.9%) (P = .009). The active treatment arm had a significantly greater decrease in rTNSS (mean, −3.6 [95% CI, −4.2 to −3.0] vs −2.2 [95% CI, −3.2 to −1.3]) (P = .013). Three adverse events related to the device/procedure were reported, and all resolved.

Conclusion

This randomized controlled trial showed temperature-controlled neurolysis of the PNN area is free from significant adverse events and superior to a sham procedure in decreasing the symptom burden of chronic rhinitis.

Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Rhinitis

Background

Chronic rhinitis is a prevalent condition with a significant impact on quality of life. Posterior nasal nerve and vidian neurectomy are surgical options for treating the symptoms of chronic rhinitis but are invasive procedures.

Objective

To determine the outcomes of patients diagnosed with refractory chronic rhinitis and treated with temperature-controlled radiofrequency neurolysis of the posterior nasal nerve area in a minimally invasive procedure.

Methods

A prospective, single-arm multicenter study with follow-up through 52 weeks. Eligible adult patients had chronic rhinitis symptoms of at least 6 months duration with inadequate response to at least 4 weeks usage of intranasal steroids and an overall 12-h reflective total nasal symptom score (rTNSS) ≥ 6 with subscores 2 to 3 for rhinorrhea, 1 to 3 for nasal congestion, and 0 to 3 for each of nasal itching and sneezing. Temperature-controlled radiofrequency energy was delivered to the nasal cavity mucosa overlying the posterior nasal nerve region with a novel single-use, disposable, handheld device.

Results

A total of 50 patients were treated (42.0% male; mean age 57.9 ± 11.9 years), and 47 completed the study through 52 weeks. Mean rTNSS significantly improved from 8.5 (95% CI 8.0, 9.0) at baseline to 3.6 (95% CI 3.0, 4.3) at 52 weeks (P < .001), a 57.6% improvement. Similar trends in improvement were noted for rTNSS subscores (rhinorrhea, nasal congestion, itching, sneezing), postnasal drip scores, and chronic cough scores. Subgroup analysis demonstrated the treatment was effective regardless of rhinitis classification (allergic or nonallergic). No serious adverse events with a relationship to the device/procedure occurred.

Conclusions

Temperature-controlled radiofrequency neurolysis of the posterior nasal nerve area for the treatment of chronic rhinitis is safe and resulted in a durable improvement in the symptoms of chronic rhinitis through a 52-week follow-up. Data suggest that this novel device could be considered a minimally invasive option in the otolaryngologist's armamentarium for the treatment of chronic rhinitis.

The long-term outcomes of posterior nasal neurectomy with or without pharyngeal neurectomy in patients with allergic rhinitis: a randomized controlled trial

INTRODUCTION

Allergic rhinitis is a form of IgE mediated inflammation of the nasal mucosa in response to specific allergens, resulting in typical symptoms.

OBJECTIVES

This study was designed with the primary goal of comparing the clinical efficacy of posterior nasal neurectomy with or without pharyngeal neurectomy for the treatment of moderate-to-severe perennial allergic rhinitis. Secondary study aims included a comparison of the severity of comorbidities, including chronic cough and asthma, between patients in these two surgical treatment groups.

METHODS

A total of 52 patients were enrolled in this randomized controlled trial and were assigned to either the control group (posterior nasal neurectomy) or the experimental group (posterior nasal neurectomy + pharyngeal neurectomy). The visual analog scale and rhinoconjunctivitis quality of life questionnaire were used to compare the differences in patient symptoms between baseline and 6-, 12-, and 24-months post-treatment. In addition, patient cough and asthma symptoms were monitored during follow-up via visual analog scale and asthma control test respectively.

RESULTS

No significant differences in preoperative scores were evident between groups (p > 0.05). At 6-months post-treatment, there were significant differences in visual analog scale, rhinoconjunctivitis quality of life questionnaire, and asthma control test scores relative to baseline values in experimental group and control group patients (p < 0.05), and this remained true upon 12- and 24-month follow-up. No significant differences in visual analog scale, rhinoconjunctivitis quality of life questionnaire, or asthma control test scores were observed between the two treatment groups at any postoperative follow-up time point (p > 0.05), while coughing severity was found to be significantly reduced in the experimental group relative to the control group (p < 0.05).

CONCLUSION

posterior nasal neurectomy can be safely implemented with or without pharyngeal neurectomy in order to effectively treat allergic rhinitis. Combined posterior nasal neurectomy and pharyngeal neurectomy treatment may offer greater value than posterior nasal neurectomy alone for the treatment of allergic rhinitis patients with chronic cough.

Adverse Events Associated With ClariFix Posterior Nasal Nerve Cryoablation: A MAUDE Database Analysis

Posterior nasal nerve (PNN) cryoablation is a novel surgical technique used to address chronic rhinitis. The purpose of this study is to review the medical device reports (MDRs) submitted to the Food and Drug Administration's (FDA) Manufacturer and User Device Facility Experience (MAUDE) database to identify adverse events related to the use of ClariFix, a device designed for office-based cryosurgical ablation of the PNN. A total of 12 adverse events associated with ClariFix from January 2017 to August 2020 were identified and analyzed. The most common adverse events associated with ClariFix PNN cryoablation include epistaxis and nasal swelling. Further studies are needed to clarify whether PNN cryoablation is associated with epistaxis in certain populations.

Clinical Efficacy and Possible Mechanism of Endoscopic Vidian Neurectomy for House Dust Mite-Sensitive Allergic Rhinitis

BACKGROUND/AIMS

Endoscopic vidian neurectomy (EVN) for allergic rhinitis (AR) has good clinical effects. However, the pathophysiological basis of the effect of EVN on AR is still poorly understood. This study aimed to investigate the efficacy of EVN on house dust mite (HDM)-sensitive AR and the dynamic changes of serum immunoglobulin E and some immune regulatory factors.

METHODS

Twenty HDM-sensitive AR patients were treated with bilateral EVN (EVN group), 15 HDM-sensitive AR patients were treated with subcutaneous immunotherapy (SCIT group), and 15 healthy subjects served as healthy controls. Quality of daily life was assessed by the scores of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQs). The visual analog scale was used to assess clinical efficacy. Serum molecules were measured by ELISA and the UNICAP system.

RESULTS

Compared with the SCIT group, the RQLQs in the EVN group were lower 12 months after treatment (both p < 0.05). There was no significant difference in improving nasal itching and sneezing (both p > 0.05), but the clinical efficacy of bilateral EVN was greater than SCIT in improving nasal obstruction, rhinorrhea, eye itching, and lachrymation 12 months after treatment (all p < 0.05). Compared with before treatment, the serum levels of total immunoglobulin E (tIgE), Dermatophagoides pteronyssinus- and Dermatophagoides farinae-specific immunoglobulin E (sIgE), and tumor necrosis factor (TNF)-α in the EVN group and the serum levels of TNF-α and interleukin-4 in the SCIT group were lower 12 months after treatment (all p < 0.05).

CONCLUSION

The short-term efficacy of bilateral EVN is more effective than SCIT in treating HDM-sensitive AR. This may be because the surgery reduced the tIgE and sIgE levels. TNF-α may be involved in the therapeutic mechanism.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

The anatomical and radiological evaluation of the Vidian canal on cone-beam computed tomography images

INTRODUCTION

The aim of this study is to explore the anatomy of the Vidian nerve to elucidate the appropriate surgical approach based on preoperative cone-beam computed tomography (CBCT) images.

MATERIALS AND METHODS

The Vidian canal and its surrounding structures were morphometrically evaluated retrospectively in CBCT images of 400 cases by the Planmeca Romexis program. The types of the Vidian canal were determined and seven parameters were measured from the images.

RESULTS

Three types of the Vidian canal according to the relationship with the sphenoid bone were found as follows: the Vidian canal totally protruded into the sphenoid sinus (19.75%), partially protruded into sphenoid sinus (44.37%) and embedded inside bony tissue of the body of sphenoid bone (35.87%). The position of the Vidian canal was medial (34.62%), on the same line (55.12%) and lateral (10.25%) to the medial plate of the pterygoid process. The distance between the Vidian canal and the vomerine crest, the mid-sagittal plane, the round foramen, the palatovaginal canal, and the superior wall of the sphenoid sinus, the length of the Vidian canal and the angle between the Vidian canal and the sagittal plane was found to be 16.69 ± 2.14, 13.80 ± 2.00, 8.88 ± 1.60, 5.83 ± 1.37, 23.98 ± 2.68, 13.29 ± 1.71 mm and 25.78° ± 3.68° in males, 14.62 ± 1.66, 11.43 ± 1.28, 8.51 ± 1.63, 5.78 ± 0.57, 22.37 ± 2.07, 12.91 ± 1.26 mm and 23.43° ± 3.07° in females, respectively.

CONCLUSIONS

Our results may assist with proper treatment for surgical procedures around the Vidian canal with a high success rate and minimal complications. Therefore, the results obtained in this study contribute to the literature.

Regulation of Interaction between the Upper and Lower Airways in United Airway Disease

The concept of united airway disease comprises allergic rhinitis (AR) with asthma, and eosinophilic chronic rhinosinusitis (ECRS) with asthma. It embodies a comprehensive approach to the treatment of upper and lower airway inflammation. The treatment of upper airway inflammation reduces asthma symptoms and decreases the dose of inhaled corticosteroids (ICS) necessary to treat asthma. However, little is known about the mechanisms of interaction between upper and lower airway inflammation. Here we review these mechanisms, focusing on neural modulation and introduce a novel therapeutic approach to united airway disease using a fine-particle ICS. Our understanding of the relationship between the upper and lower airways and its contribution to T helper 2 (Th2)-skewed disease, such as AR and/or ECRS with asthma, has led us to this novel therapeutic strategy for a comprehensive approach to the treatment of upper airway inflammation with asthma.

Management of Intractable Nasal Hyperreactivity by Selective Resection of Posterior Nasal Nerve Branches

The posterior nasal nerves emerge from the sphenopalatine foramen and contain sensory and autonomic nerve components. Posterior nasal neurectomy is an effective method to remove pathological neural networks surrounding the inferior turbinate that cause unregulated nasal hypersensitivity with excess secretion in patients with severe allergic rhinitis (AR). We describe the sophisticated endoscopic surgical procedure that allows feasible access to the confined area and selective resection of the nerve branches with the preservation of the sphenopalatine artery (SPA). We retrospectively analyzed the cases of 23 symptomatic severe AR patients who failed to respond to standard medical treatment and underwent surgery. There have been no major complications after surgery including nasal bleeding or transient numbness of the upper teeth. The mean total nasal symptom scores (TNSS) were decreased by 70.2% at 12 months after the procedure. Our comparison of the clinical effectiveness based on the number of severed nerve branches revealed that the improvement of the TNSS was significantly higher in patients with >2 branches. We conclude that this minimally invasive technique that preserves the SPA is clinically useful and decreases the rate of postoperative complications. This trial is registered with UMIN000029025.

Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis

Background

Endoscopic posterior nasal nerve (PNN) resection has been described as an efficacious surgical treatment of allergic and nonallergic rhinitis, but the requirement for surgery under general anesthesia has limited its acceptance. We report the first series of patients treated for chronic rhinitis using a novel device designed for office‐based cryosurgical ablation of the PNN.

Methods

Twenty‐seven patients with chronic rhinorrhea and/or nasal congestion for >3 months were recruited (allergic or nonallergic rhinitis), with minimum rhinorrhea and/or congestion subscores of 2 as part of the Total Nasal Symptom Score [TNSS]). Under local anesthesia, the cryotherapy device was applied endoscopically to the posterior middle meatus and was used to freeze the PNN region bilaterally. Patients were followed up after 7, 30, 90, 180, and 365 days to assess TNSS.

Results

The procedure was successfully completed in 100% of patients, with no complications; 74% reported no or mild discomfort by the first postprocedure day. TNSS was reduced significantly at 30 days (mean ± standard deviation: 6.2 ± 0.5 at baseline, 2.6 ± 0.3 at 30 days, n = 27, p < 0.001), with continued reduction at 90 (2.7 ± 0.4, n = 24, p < 0.001), 180 (2.3 ± 0.5, n = 21, p < 0.001), and 365 days (1.9 ± 0.3, n = 15, p < 0.001). Both rhinorrhea and congestion subscores decreased significantly at 30, 90, 180, and 365 days compared to baseline (p < 0.001). Allergic and nonallergic subcohorts both appeared to benefit from treatment.

Conclusion

Office‐based cryotherapy of the PNN region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days.

Original study. Effectiveness of endoscopic posterior nasal neurectomy for the treatment of intractable rhinitis

BACKGROUND. Chronic rhinitis is a clinical condition affecting more than 20% of the world population. The standard treatment strategy is medical. Surgical management can be considered in patients with intractable rhinitis. Various surgical techniques have been documented with varying success rates, but none of them is considered as a gold standard. Hence, we are studying the effectiveness of posterior nasal neurectomy (PNN) in patients who have intractable rhinitis, refractory to maximum medical therapy.

MATERIAL AND METHODS. A prospective study was conducted in the ENT Department, Padmavathy Medical Foundation, Kollam, Kerala, India, from January 2015 to February 2016. Adult patients, in the age group of 20 to 60 years, diagnosed with chronic rhinitis, presenting two or more symptoms of rhinitis, refractory to maximum medical therapy for a period of at least 3 or more years and whose quality of life was significantly affected were enrolled and PNN was done for them.

RESULTS. We observed a statistically significant improvement in subjective symptoms and patient quality of life at the end of 6 months post-operatively.

CONCLUSION. PNN is a safe and less invasive procedure, which can provide a significant relief in symptoms of intractable rhinitis. Fewer complications and better results make it superior over vidian neurectomy.

Denervation of nasal mucosa induced by posterior nasal neurectomy suppresses nasal secretion, not hypersensitivity, in an allergic rhinitis rat model

The posterior nasal nerve is the dominant source of the parasympathetic, sympathetic, and sensory fibers that innervate the nasal respiratory mucosa. Therefore, a posterior nasal neurectomy (PNN) is thought to induce denervation of the nasal mucosa and relieve the nasal symptoms of allergic rhinitis. However, the underlying mechanisms and therapeutic action of PNN remain unknown. To investigate the impact of PNN-induced denervation of the nasal mucosa on allergic rhinitis, we developed a rat model of PNN and examined the effects of PNN on allergic rhinitis in ovalbumin-sensitized rats. This rat model of PNN was characterized by the depletion of nerve fibers, choline acetyltransferase, and neuropeptides (eg, substance P, calcitonin gene-related peptide, vasoactive intestinal peptide, and neuropeptide Y) in the nasal respiratory mucosa. These animals exhibited nasal gland and goblet cell hypertrophy in the septal mucosa and atrophy of the submucosal gland in the lateral nasal wall, as well as reduced nasal secretion due to deficient acetylcholine synthesis. In an ovalbumin-sensitized model of allergic rhinitis, PNN also induced the depletion of nerve fibers, choline acetyltransferase, and neuropeptides in the nasal mucosa and suppressed nasal secretion. However, PNN did not affect mucosal thickening, eosinophil and mast cell infiltration, interleukin-4 and interferon-γ mRNA expression, and allergic symptoms (ie, sneezing and nasal scratching). These results suggest that the peripheral nerves and corresponding neuropeptides regulate nasal secretion, but not hypersensitivity, in allergic rhinitis, and that allergic rhinitis-related mucosal reactions occur in a highly denervated mucosa after PNN. Posterior nasal neurectomy may be a therapeutic option for the treatment of hyperrhinorrhea, but not allergic rhinitis hypersensitivity.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Aberrant facial flushing following monobloc fronto-facial distraction

BACKGROUND

Patients with syndromic forms of craniosynostosis may experience functional problems such as raised intracranial pressure, proptosis, obstructive sleep apnoea and failure to thrive. The monobloc fronto-facial advancement with osteogenic distraction is increasingly used to correct these functional problems in one procedure as well as improve appearance. The authors report the phenomenon of post operative aberrant facial flushing - an unusual and previously unreported complication of the procedure.

METHODS

The case notes of 80 consecutive patients undergoing fronto-facial advancement by distraction using the rigid external distraction device (RED) were reviewed for features of aberrant facial flushing.

RESULTS

Four out of eighty individuals developed facial flushing after monobloc fronto-facial distraction using the rigid external distractor (RED) frame. All were female with Crouzon or Pfeiffer syndromes causing the severe functional problems for which they underwent the surgery. They were aged 6-8 years. Following removal of the frame, they developed intermittent but severe facial flushing. The flushing spontaneously settled in three patients after up to four years but persists in the other child seven years after her surgery.

CONCLUSION

Aberrant facial flushing is a rare but significant complication of monobloc fronto-facial surgery. It occurred in 4 of our 80 (5%) patients. The skull base osteotomies essential for the procedure are made anterior to the pterygopalatine ganglion and it is our contention that damage from these was responsible for a neuropraxia of its efferent nerve branches. A review of the autonomic control of the facial vascular system suggests that the phenomenon is due to an unequal process of recovery that leaves the cutaneous vasodilating parasympathetic or beta-adrenergic innervation relatively unopposed - a situation that persists until with time a normal balance of autonomic input is achieved.

A Rare Finding of Schwannoma of the Vidian Canal: A Case Report

Background Schwannomas of the vidian canal are an extremely rare type of intracranial tumor that can have variable clinical presentations including headache, facial pain, facial muscle paralysis, decreased lacrimation, or nasal dryness. We present an atypical case of an incidentally identified asymptomatic vidian canal schwannoma.

Case Description A 49-year-old woman with a history of multiple sclerosis presented for routine surveillance magnetic resonance imaging that detected an ovoid mass originating in the vidian canal. Given the unusual location of the lesion, an endoscopic endonasal biopsy was performed and confirmed the diagnosis of a vidian canal schwannoma, for which the patient chose to receive fractionated radiation therapy.

Conclusion When a vidian canal tumor is identified, endoscopic endonasal biopsy can be used to confirm the diagnosis before pursuing either surgical or radiotherapy treatment. In particular, fractionated radiation therapy offers a radiobiologically safe means of delivering radiation when there is concern for late radiation-related side effects following treatment completion.

Surgical options for the allergic rhinitis patient

PURPOSE OF REVIEW

Allergic rhinitis is a very common disorder that affects millions of patients annually and the hallmark complaint of nasal obstruction significantly impacts the quality of life. Many surgical options exist for the treatment of allergic rhinitis, directed primarily at the underlying nasal obstructive component. The purpose of this review is to highlight and discuss the various surgical modalities and their historical efficacy.

RECENT FINDINGS

Much of the literature has focused on reduction of the inferior turbinate for symptomatic improvement in patients afflicted with allergic rhinitis. Endoscopic sinus surgery and septoplasty play little role in the management of allergic rhinitis, unless when seen in conjunction with other conditions such as rhinosinusitis.

SUMMARY

Although no single modality has evolved as the gold standard for the treatment of allergic rhinitis, the mainstay of surgical intervention targets the inferior turbinate. It is very important for the otolaryngologist to be familiar with an armamentarium of surgical techniques.

The surgical management of allergic rhinitis

In their discussion of the treatment of allergic rhinitis, the authors present key features of the disease and its management, allergen responses, the role of the inferior turbinate, and reviews of outcomes with submucosal resection, total inferior turbinectomy, cryosurgery, laser cautery, radical turbinectomy, submucous turbinectomy, submucous electrocautery, and microdebriber turbinoplasty. The authors discuss radiofrequency ablation and coblation outcomes and complications, along with the role of endoscopic sinus surgery in allergic rhinitis and emphasize the need for Otolaryngologists to be facile with a variety of procedures for best outcomes.

Desmoplastic fibroma of the vidian canal in a child: case report

INTRODUCTION

To present a case of a child with a desmoplastic fibroma of the vidian canal, compressing the vidian nerve.

CASE REPORT

A 12-year-old girl with several years' history of right-sided facial pain was referred to our institution. Magnetic resonance imaging and computed tomography scans showed an expansile mass involving the right vidian canal. The patient underwent a complete endoscopic surgical resection aided by the FusionTM ENT navigation system. This was performed through a transnasal, trans-septal, trans-sphenoidal route via the right nostril, and achieved macroscopic clearance with minimal peri-operative morbidity. A biopsy of the lesion showed a fibro-osseous lesion consistent with desmoplastic fibroma.

CONCLUSION

Diagnosis and resection of this rare lesion at an earlier stage would have avoided delays in resolving the child's disabling pain. This emphasises the importance of early referral of unusual cases to tertiary centres.

Evaluation of the feasibility of the vidian neurectomy using computed tomography

For around 50 years, various approaches to the vidian neurectomy have been advocated. This indicates that there is no single surgical technique that is superior to all others. In this report, we analyze the included angle between the posterior end of middle turbinate and the anterior opening of the vidian canal. The aim of this paper is to use preoperative CT scanning to find a key anatomical structure to predict the feasibility of the vidian neurectomy. A retrospective research was performed. A total of 63 patients with 106 endoscopic vidian neurectomies between September 2006 and April 2010 were selected. The study population included 50 men and 13 women, with a mean age of 28. A paranasal sinus CT scan was obtained and analyzed. The included angle was measured and compared to the operating success rates. In the successful group (78 sides, 73.58%), the included angle from axial and coronal CT imaging was 30.2 ± 4.9° and 26.4 ± 9.1°, respectively. In the 28 failed sides (26.42%), the value was 33.8 ± 4.8° and 44.3 ± 8.1°, respectively. Statistical analysis confirmed that the difference between those two groups was significant (P < 0.05). The present study reports the relationship between the vidian canal and the middle turbinate, which is represented by their included angle. The findings support the decision to intervene the surgical side with a smaller angle, because of the significantly higher success rate.