Functional inferior turbinosurgery (FITS) for the treatment of resistant chronic rhinitis

Epidemiology of postoperative bleeding after endoscopic nasal and sinus surgery and factors associated with bleeding

PURPOSE

Endoscopic nasal and sinus surgery is a surgical procedure frequently performed by otolaryngologists. Postoperative bleeding is detrimental to both healthcare providers and patients. We investigated the epidemiology of postoperative bleeding during endoscopic nasal and sinus surgery and explored possible bleeding triggers.

METHODS

We evaluated the patients who underwent endoscopic nasal and sinus surgery. Data regarding the age, sex, presence of hypertension, and abnormal coagulability, including oral anticoagulants, diagnoses, operative procedures, intraoperative use of drills and blood loss, and postoperative antimicrobial administration of eligible patients, were extracted from medical records and retrospectively reviewed.

RESULTS

One hundred and eighty-six patients underwent endoscopic nasal or sinus surgery during the study period, and postoperative bleeding occurred in 9 patients (4.8%). Posterior nasal neurotomy (PNN) was the procedure most likely to cause postoperative bleeding (4 surgeries, 13.3%). Postoperative antimicrobial administration significantly reduced the incidence of postoperative bleeding (p = 0.04).

CONCLUSIONS

Postoperative bleeding requiring intervention occurs in 4.8% of cases, and PNN is associated with a high risk of postoperative bleeding. Wound infection is a potential cause of postoperative bleeding, and antimicrobial administration should be considered in addition to local treatment.

International consensus statement on allergy and rhinology: Allergic rhinitis - 2023

BACKGROUND

In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR-Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR-Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence-based findings and recommendation from the full document.

METHODS

ICAR-Allergic Rhinitis 2023 employed established evidence-based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work.

RESULTS

ICAR-Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost.

CONCLUSION

The ICAR-Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Posterior nasal neurectomy for intractable rhinitis: A systematic review of the literature

BACKGROUND

Rhinitis affects up to 40% of the population worldwide and can significantly reduce quality of life. Some patients remain symptomatic despite maximal medical therapy. In refractory cases, posterior nasal neurectomy (PNN-the endoscopic division of the intranasal nerve branches containing postganglionic parasympathetic fibres) is postulated to reduce symptom burden.

OBJECTIVES OF REVIEW

To establish whether PNN is effective and safe in the management of allergic and non-allergic rhinitis.

TYPE OF REVIEW

Systematic review.

METHODS

A comprehensive literature search was undertaken using PubMed, EMBASE, MEDLINE, and Cochrane. The inclusion criteria were: studies published in English, studies where PNN was performed either with or without additional procedures, and where measures of objective/subjective outcomes and/or complications were reported. Extracted data included study type, sample size, surgical technique, study population characteristics, follow-up period, outcome measures, complications of surgery, and symptom outcomes.

RESULTS

A total of 23 articles satisfied the inclusion criteria studying in total 2282 patients. Sample size ranged from 8 to 1056. There were 3 randomised controlled trials, 3 case-control studies, and the remaining 17 were case series using both objective and subjective outcome measures. All but one study found improved patient-reported outcomes following PNN. Complications were reported in 14 studies-epistaxis was the most common complication and was observed in 30 patients (1.5% of subjects).

CONCLUSIONS

PNN had a low rate of complications. Although most studies reported significant symptomatic improvement, their heterogeneity, level of evidence, study design, and/or quality was not sufficient to draw any firm conclusions on the effectiveness of the procedure. Larger, well-designed studies are needed to clarify its role in the management of difficult-to-treat rhinitis.

To Study the Long Term Outcome of Endoscopic Septoplasty with Microdebrider Assisted Inferior Turbinoplasty (MAIT) Versus Medial Flap Turbinoplasty (MFT)

To study the long term outcome of endoscopic septoplasty with microdebrider assisted inferior turbinoplasty (MAIT) versus medial flap turbinoplasty (MFT). The present study was conducted in the Department of ENT, Government Medical College, Amritsar. Patients with symptomatic persistent nasal obstruction were recruited from ENT outdoor clinics. The nasal obstruction was persistent despite medical therapy that included a minimum 4 weeks. The study was primarily a double blinded prospective randomized control study including 120 patients, where all patients enrolled at odd numbers were taken for endoscopic septoplasty with microdebrider assisted inferior turbinoplasty and all patients with even numbers were taken for endoscopic septoplasty with MFT. Patient-scored nasal obstruction (1-5) along with blindly assessed nasal airway patency ratings (1-4) was done at 3 and 24 months postoperatively. A total of 120 patients were recruited in the study. The mean ages of the MAIT and MFT groups were 28.61 ± 14.8 and 30.25 ± 8.36 years, respectively. Average follow-up period was 21.9 ± 6.3 months. Nasal obstruction was improved in both techniques at 3 months, but after long term follow up, it was highly significant for MFT along with improvement in preoperative symptoms p < 0.001. No patients complained of worsening of their obstruction. Nasal patency at 24 months, a significant proportion of patients had a greater nasal assessment by a blind assessor with 97.1% in MFT and 81.9% MAIT with mild to no obstruction. In MAIT group 16.6% had pain/discomfort, 23.6% had discharge which were the major complications, but crusting (MAIT 10% and MFT 3.3%), adhesions (MAIT 13.8% and MFT 1.6%). The medial flap inferior turbinoplasty (MFT) is technically straight forward procedure that provides long term more effective and satisfactory the patient in relieving nasal obstruction, without significant risk of complications. The long term follow up of MAIT is required as there was increase in need of decongestion and they might require second procedure as MFT.

Efficacy of Vidian Neurectomy and Posterior Nasal Neurectomy in the Management of Nonallergic Rhinitis: A Systematic Review

BACKGROUND

Nonallergic rhinitis (NAR) is characterized by rhinorrhea, nasal obstruction, and sneezing, in the absence of systemic sensitization to allergens. For cases refractory to medical therapy and conservative surgical interventions, more targeted procedures, such as endoscopic vidian neurectomy (EVN) and posterior nasal neurectomy (PNN), including surgical (SPNN) and cryoablative (CPNN) methods, may reduce symptoms of NAR.

OBJECTIVE

The purpose of this study was to compare the efficacy, side effect profile, and complication rate between EVN and PNN for NAR.

METHODS

A systematic review of primary articles that reported original patient data for either EVN or PNN was conducted using Embase, Medline, PubMed, and Cochrane databases since 2006, according to PRISMA guidelines. The primary outcome of the study was an improvement in NAR symptom severity. Secondary outcomes included the incidence of postoperative side effects or complications.

RESULTS

In total, 58 articles met the search criteria with a total of 9 studies (including 2 RCTs) eligible for inclusion. There was a pooled sample of 229 NAR patients that underwent EVN (n = 65; 28.4%), SPNN (n = 50; 21.8%), or CPNN (n = 114; 49.8%). For all 3 techniques, there was a statistically significant improvement in nasal symptoms, particularly rhinorrhea, nasal congestion, and obstruction along with quality of life. Heterogeneity in outcome reporting prevented meta-analysis and direct comparison of efficacy. The pooled incidence of postoperative complications for EVN (n = 65), SPNN (n = 50), and CPNN (n = 70) was 30.8% versus 0% versus 2.9% for dry eye, 16.9% versus 0% versus 1.4% for palatal/cheek numbness, and 0% versus 6% versus 4.3% for bleeding.

CONCLUSION

EVN, SPNN, and CPNN are similarly efficacious for patients with NAR refractory to medical management. SPNN and CPNN are associated with lower rates of complications (dry eye and palatal/cheek numbness) compared with EVN.

International consensus statement on allergy and rhinology: Olfaction

BACKGROUND

The literature regarding clinical olfaction, olfactory loss, and olfactory dysfunction has expanded rapidly over the past two decades, with an exponential rise in the past year. There is substantial variability in the quality of this literature and a need to consolidate and critically review the evidence. It is with that aim that we have gathered experts from around the world to produce this International Consensus on Allergy and Rhinology: Olfaction (ICAR:O).

METHODS

Using previously described methodology, specific topics were developed relating to olfaction. Each topic was assigned a literature review, evidence-based review, or evidence-based review with recommendations format as dictated by available evidence and scope within the ICAR:O document. Following iterative reviews of each topic, the ICAR:O document was integrated and reviewed by all authors for final consensus.

RESULTS

The ICAR:O document reviews nearly 100 separate topics within the realm of olfaction, including diagnosis, epidemiology, disease burden, diagnosis, testing, etiology, treatment, and associated pathologies.

CONCLUSION

This critical review of the existing clinical olfaction literature provides much needed insight and clarity into the evaluation, diagnosis, and treatment of patients with olfactory dysfunction, while also clearly delineating gaps in our knowledge and evidence base that we should investigate further.

Underwater posterior nasal neurectomy compared to resection of peripheral branches of posterior nerve in severe allergic rhinitis

BACKGROUND

Several surgical procedures for posterior nasal neurectomy have been reported, but no conclusion has been reached about which procedure is best.

OBJECTIVES

The aim is to evaluate the improvement in symptom medication scores for resection of the posterior nasal nerve trunk in an underwater environment, with submucous inferior turbinectomy, without injuring the sphenopalatine artery (SPA) in severe allergic rhinitis.

MATERIAL AND METHODS

Improvements in symptom medication scores were retrospectively compared between 27 consecutive cases who underwent resection of the posterior nasal nerve trunk with turbinoplasty in an underwater environment without injuring the SPA (Underwater group) and, as a historical control, 16 consecutive cases who underwent resection of peripheral branches of the posterior nasal nerve with turbinoplasty (Control group).

RESULTS

The improvements in symptom medication scores in the Underwater group were significantly better than in the Control group (3.07 vs. 1.96, p = 0.02).

CONCLUSIONS AND SIGNIFICANCE

By using underwater posterior nasal neurectomy, we can easily and safely resect the posterior nasal nerve trunk under a clear surgical view without injuring the SPA. This technique with submucous inferior turbinectomy may, more than resection of peripheral branches of the posterior nasal nerve, be able to reduce the medication score and symptom medication score.

The role of CT and endoscopy in the evaluation of patients referred for intranasal Cryoablation

BACKGROUND

Cryoablation (CA) of the posterior nasal nerves has garnered increasing interest as an office-based procedure for chronic rhinitis (CR). Standardized preoperative evaluation, specifically the role of computed tomography (CT) and nasal endoscopy, has yet to be defined. We report a series of patients who underwent CT and endoscopy as part of CR work-up in patients referred for CA.

OBJECTIVE

Highlight the importance of both nasal endoscopy and CT scan in the evaluation of CR given significant overlap of symptoms and common occurrence of related sinonasal conditions.

METHODS

Retrospective analysis of all patients referred to a single tertiary rhinology practice for CA was performed.

RESULTS

Fifteen patients were sent for CA by medical allergists. Five patients were deemed CA candidates, and 1 patient received only medical CR treatment. Four patients had evidence of incomplete prior sinus surgery and/or continued chronic rhinosinusitis on endoscopic exam. These 4 patients received a combination of medical and surgical management with either complete resolution or improvement in CR symptoms. In 3 patients, CT confirmed chronic rhinosinusitis that was not apparent on endoscopy, and received a combination of medical and surgical management with symptom improvement. In the last two patients, final diagnoses were nasal valve collapse and recurrent acute rhinosinusitis.

CONCLUSIONS

Referrals for CA are becoming more common and the optimal preoperative work up remains unclear. In this limited retrospective review, 67% of patients had diagnoses other than CR and thus were not deemed candidates for CA. Both CT and endoscopy are complementary to a detailed history and physical examination and can aid in CA candidate selection.

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 effects of resection of the peripheral branches of the posterior nasal nerves in the inferior turbinate, with special focus on olfactory dysfunction

OBJECTIVE

There are few detailed studies about peripheral branch resection of the posterior nasal nerves in the inferior turbinate; thus, this study aimed to investigate this.

METHODS

Patients who underwent submucosal turbinoplasty with or without resection of the peripheral branches of posterior nasal nerves in the inferior turbinate were included.

RESULTS

The resection of the posterior nasal nerves with turbinoplasty significantly reduced detection and recognition thresholds on olfactory testing. The rhinorrhoea severity, detection threshold and recognition threshold were significantly lower after resection of the posterior nasal nerves with turbinoplasty than after turbinoplasty alone, although there were no significant differences between the two groups before surgery.

CONCLUSION

This is the first study to show that the resection of the peripheral branches of the posterior nasal nerves in the inferior turbinate with turbinoplasty more effectively inhibits allergic symptoms compared with turbinoplasty alone. It also showed that the resection of the peripheral branches of the posterior nasal nerves can inhibit olfactory dysfunction.

Surgical Management of Nonallergic Rhinitis

Nonallergic rhinitis (NAR) describes chronic symptoms of nasal congestion, obstruction, and rhinorrhea unrelated to a specific allergen based on skin or serum testing. Vasomotor rhinitis is the most frequent subtype of NAR. Although medical management is the first-line treatment of NAR, there is a role for surgical therapy when medications fail to improve symptoms. Surgical options for NAR include inferior turbinate reduction and botulinum toxin injection as well as more directed targeting of the autonomic nerve supply to the nasal cavity through vidian neurectomy, posterior nasal neurectomy, and cryoablation of the posterior nerve.

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.

Ultrastructural regenerating features of nasal mucosa following microdebrider-assisted turbinoplasty are related to clinical recovery

BACKGROUND

The nasal mucosa plays a key role in conditioning the inhaled air and in regulating the immune response. These functions led many authors to recommend mucosal sparing techniques for the surgical management of inferior turbinate hypertrophy. However, the histological modifications of chronic diseases retain the inflammatory activity and prevent the nasal physiology restoration. It has been proved that the basal cells of the nasal mucosa are able to proliferate and to repair after cold-knife incision. The aim of this study was to demonstrate that the healing process after removal of the inferior turbinate mucosa with cold techniques results in a complete structural restoration.

METHODS

A prospective study was performed in 18 patients who underwent Microdebrider inferior turbinoplasty (cold technique). Subjective and objective improvement of nasal patency was evaluated with visual analogue scale, rhinomanometry, videoendoscopy and mucociliary transport test. Pre- and post-operative biopsy specimens were taken from 7 patients to evaluate the healing process. Two samples were taken from two healthy patients as control. The specimens were processed for transmission electron microscopy analysis.

RESULTS

Videoendoscopy showed reduction of lower turbinate after surgery. Nasal patency augmented and no adverse consequences were observed. After 4 months the nasal mucosa showed normal appearance, with restoration of the pseudostratified ciliated pattern, intercellular connections and normal cellular morphology. Fibrosis and submucosal edema disappeared. At longer time after operation (4 years) clinical improvement was confirmed.

CONCLUSIONS

The total removal of the nasal mucosa with cold techniques results in a complete restoration of the normal structure and permanent resolution of the chronic inflammation typical of hypertrophic rhinopathy.

Comparative study between partial inferior turbinotomy and microdebrider-assisted inferior turbinoplasty

PURPOSE

The purpose of our study was to compare the inferior turbinotomy and the microdebrider-assisted inferior turbinoplasty in patients with hypertrophy of the inferior turbinate.

MATERIAL AND METHODS

We carried out a retrospective review of 205 patients, 96 women and 109 men, with a mean age of 48 years, operated on for hypertrophy of the inferior turbinate between May 2005 and May 2012. Forty-seven patients were excluded from our study because in these patients, nasal obstruction was caused by a specific pathologic condition (allergy, tumors or polyps, recurrent rhinosinusitis, etc). The remaining 158 patients were randomly assigned to undergo partial inferior turbinoplasty through the use of microdebrider (group A, n = 79) or partial inferior turbinotomy (group B, n = 79). Surgical outcome was evaluated according to 4 distinct parameters: nasal endoscopic findings, nasal subjective symptoms, anterior rhinomanometry, and nasal mucociliary transport time. These evaluations were made before surgery and 1 week and 3 months after surgery. The follow-up was a minimum of 24 months and a maximum of 60 months, with a mean follow-up of 42 months.

RESULTS

Turbinate edema and secretions decreased significantly (P < 0.05) in groups A and B 3 months after surgery. In group A, crusting was not observed after surgery. In group B, crusting had increased significantly (P < 0.005) 1 week after surgery and then decreased significantly at the third month after surgery. Subjective nasal symptoms including nasal obstruction, sneezing, snoring, itchy nose, hyposmia, headache, and dryness were significantly improved in both groups from the third month after surgery (P < 0.05). Rhinomanometric measurements demonstrated a significant nasal flow increase at 3 months (P < 0.05). The mean nasal mucociliary transport time slightly increased in both groups 1 week after surgery, and then restabilized to preoperative values at the third-month follow-up in both groups (difference not significant).

CONCLUSIONS

Microdebrider-assisted inferior turbinoplasty and partial inferior turbinotomy are very effective surgical techniques for solving hypertrophy of the inferior turbinates and therefore related problems of nasal obstruction. Microdebrider-assisted inferior turbinoplasty compared to partial inferior turbinotomy ensures a greater preservation of the nasal mucosa to prevent nasal bleeding.

Olfaction in allergic rhinitis: A systematic review

Olfactory dysfunction is a key symptom in patients with allergic rhinitis (AR). Despite the implications for quality of life, relatively few articles have tested olfactory function in their investigations. The current systematic review aimed to investigate the following 2 questions: (1) What does AR do to human olfaction? (2) How effective is the treatment of AR in restoring the sense of smell? A comprehensive literature search was performed, and human studies of any design were included. A total of 420 articles were identified, and 36 articles were considered relevant. Data indicate that the frequency of olfactory dysfunction increases with the duration of the disorder, and most studies report a frequency in the range of 20% to 40%. Although olfactory dysfunction does not appear to be very severe in patients with AR, its presence seems to increase with the severity of the disease. There is very limited evidence that antihistamines improve olfactory function. In addition, there is limited evidence that topical steroids improve the sense of smell, especially in patients with seasonal AR. This is also the case for specific immunotherapy. However, many questions remain unanswered because randomized controlled trials are infrequent and only a few studies rely on quantitative measurement of olfactory function.

Surgical Management of Vasomotor Rhinitis: A Systematic Review

Background

Vasomotor rhinitis (VMR) is one of the most prevalent forms of nonallergic rhinitis. In the past, when maximal medical therapy failed, surgical options were limited. Vidian neurectomy (VN) was one option; however, it was fraught with complications and limited success. The advent of endoscopic sinus surgery revitalized interest in surgical procedures for VMR. This study was designed to review the available literature and assess the safety and efficacy of surgery on the vidian and posterior nasal nerves for treatment of VMR and when possible, compare the different approaches to one another in regard to safety and efficacy.

Methods

A systematic review was performed of English language articles using Ovid and PubMed. Search terms included “endoscopic vidian neurectomy,” “vidian neurectomy,” “endoscopic posterior nasal neurectomy” (EPNN), and “posterior nasal neurectomy.” Only clinical trials performed on humans with safety and or efficacy data were included. Independent extraction of articles by two authors using predefined data fields was performed. Safety defined by complication rates and efficacy defined as objective improvement on outcomes scores along with the overall length of benefit were the primary measures of treatment effect. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement for reporting systematic reviews was followed.

Results

In comparison with open VN, endoscopic techniques were not associated with any long-term sequelae. Rhinorrhea and nasal obstruction were shown to improve after endoscopic VN (EVN) and the benefits were maintained for several years after surgery.

Conclusion

EVN is well tolerated, safe, and effective in a majority of patients. Overall, the literature has shown that the endoscopic approach is associated with less morbidity than the traditional transantral approach. Currently, no literature exists on the effect of EPNN in patients with vasomotor rhinitis and further study is needed to elucidate the efficacy of this procedure in this subset of patients.

Nonallergic rhinitis, with a focus on vasomotor rhinitis: clinical importance, differential diagnosis, and effective treatment recommendations

The term "rhinitis" denotes nasal inflammation causing a combination of rhinorrhea, sneezing, congestion, nasal itch, and/or postnasal drainage. Allergic rhinitis is the most prevalent and most frequently recognized form of rhinitis. However, nonallergic rhinitis (NAR) is also very common, affecting millions of people. By contrast, NAR is less well understood and less often diagnosed. Nonallergic rhinitis includes a heterogeneous group of conditions, involving various triggers and distinct pathophysiologies. Nonallergic vasomo-tor rhinitis is the most common form of NAR and will be the primary focus of this review. Understanding and recognizing the presence of NAR in a patient is essential for the correct selection of medications and for successful treatment outcomes.

The accessory posterolateral nerve: an immunohistological analysis

BACKGROUND

Recent endoscopic dissection studies have redefined the postganglionic pterygopalatine autonomic pathways suggesting that neurovascular rami, termed "accessory posterolateral nerves," project directly through the palatine bone to innervate the posterolateral nasal mucosa rather than traveling with trigeminal arborizations. The goal of this study was to characterize these accessory posterolateral nerves by immunohistochemistry to determine their morphology and composition.

METHODS

This is an Institutional Review Board approved study in seven patients in whom the presence of accessory posterolateral nerves were surgically identified exiting the perpendicular plate of the palatine bone and sampled. The presence of neural tissue was confirmed by hematoxylin and eosin and S-100 protein staining. Nerves were then stained with anti-human choline acetyl-transferase (ChAT; 1:100) and anti-human dopamine beta-hydroxylase (DBH; 1:100) followed by a fluorescein isothiocyanate-labeled secondary antibody to test for the presence of peripheral parasympathetic and sympathetic fibers, respectively. Human cadaveric sensory nerves were used as a negative control.

RESULTS

All seven samples contained neural elements. Two specimens were also associated with arteries. All nerves were comprised of a single fascicle containing an approximately equal distribution of ChAT(+) and DBH(+) fibers.

CONCLUSION

This histological study supports prior descriptions defining a newly recognized neural pathway for innervation of the nasal mucosa. Our data confirm that these accessory posterolateral nerves project directly through the perpendicular plate of the palatine bone and are composed of autonomic fibers. Recognition of this pathway may be exploited in the treatment of sinonasal disease resulting from autonomic dysregulation.

Cytologic alterations in nasal mucosa after sphenopalatine artery ligation in patients with vasomotor rhinitis

BACKGROUND

Vasomotor rhinitis (VR) seems to be related to an imbalance between cholinergic and adrenergic activity in the autonomic nervous system. The nerve fibers of the sympathetic and parasympathetic nervous systems reach the nose through the posterior nasal nerve, which, after crossing the sphenopalatine foramen, distributes to the mucosa following the branches of the sphenopalatine vessels. This study was designed to evaluate the effect of sphenopalatine artery ligation on nasal function and nasal cytology in patients with VR.

METHODS

Thirty patients with VR and bilateral inferior turbinate hypertrophy (ITH) were randomly assigned to receive endoscopic inferior turbinoplasty either with or without sphenopalatine artery ligation. Pre- (baseline) and postsurgical (1-year follow-up) assessment included fiber endoscopy, active anterior rhinomanometry, measurement of mucociliary transport time (MTt), and nasal cytology examination.

RESULTS

At 1-year follow-up there was a statistically significant improvement in nasal resistances in both groups but not on intergroup comparison; MTt significantly decreased in both groups (p < 0.01) and was significantly better (p < 0.05) in the group that had undergone sphenopalatine artery ligation. Among the patients in this group, significantly fewer were found to have altered ciliated cells (p < 0.005) or a hyperchromatic supranuclear stria (p < 0.005) on nasal cytology; the differences were statistically significant also on intergroup comparison (p < 0.005 and p < 0.001, respectively).

CONCLUSION

In patients with vasomotor rhinopathy and ITH, improvement in symptoms, nasal resistance, ciliated cell trophism, and MTt was observed after sphenopalatine artery ligation.

Sphenopalatine artery ligation with nerve resection in patients with vasomotor rhinitis and polyposis: a prospective, randomized, double-blind investigation

CONCLUSIONS

Sphenopalatine artery ligation relieves symptoms of rhinorrhea, sneezing, and nasal itching in patients with vasomotor rhinitis associated with nasal polyps.

OBJECTIVES

Nasal polyps often arise in a setting of vasomotor rhinitis. Dysfunctions in nerve fiber activity of the sympathetic and parasympathetic systems are responsible for the accompanying symptoms of rhinorrhea, sneezing, and nasal itching. Sphenopalatine pedicle resection with autonomic denervation could potentially reduce related symptoms.

METHODS

In a prospective, double-blind setting, 60 patients with vasomotor rhinitis and bilateral nasal polyps randomly assigned to functional endoscopic surgery either with (group A) or without (group B) sphenopalatine artery ligation completed a 3-year follow-up. Preoperative and postoperative (at 1 and 3 years) evaluations included symptom score, fiberendoscopy, and active anterior rhinomanometry.

RESULTS

In both treatment groups nasal breathing had improved at 1-year and 3-year follow-up (p < 0.001), whereas an improvement in rhinorrhea (p < 0.001) and sneezing and itching (p < 0.01) was attained only in group A. The inter-group comparison showed that a statistically significant improvement in rhinorrhea and nasal itching (p = 0.002) and in sneezing (p < 0.001) was present in group A at both follow-up visits. Rhinomanometry improved in both treatment groups (p < 0.01). Inter-group comparison showed a significant difference only at the 3-year follow-up visit (p < 0.05).

Nonallergic rhinopathy (formerly known as vasomotor rhinitis)

This review focuses on the poorly understood condition of nonallergic rhinopathy (NAR) at a clinical level, with an eye on current optimal treatment. NAR is the new designation for the conditions formerly referred to as vasomotor rhinitis or nonallergic idiopathic rhinitis. The clinical characteristics and differential diagnosis are provided in detail in this review, and the disease should now be characterized sufficiently for clinical studies.

Effect of resection of the posterior nasal nerve on functional and morphological changes in the inferior turbinate mucosa

CONCLUSIONS

The underlying pathophysiological mechanisms of the posterior nasal nerve (PNN) resection involved the suppression of the secretogogue motor and the inhibition of neurogenic inflammation induced by parasympathetic and sensory denervation.

OBJECTIVE

The study was designed to clarify the underlying mechanisms of the resection of the PNN.

PATIENTS AND METHODS

Ten patients with allergic rhinitis and non-allergic chronic rhinitis were enrolled in the study. Clinical symptoms were evaluated before and after administration of oxitropium bromide aerosol, and after the PNN resection. Biopsy specimens from the inferior turbinate mucosa obtained from five patients before and after resection of the PNN were examined.

RESULTS

The application of oxitropium bromide resulted in a significant reduction of both watery rhinorrhea and nasal obstruction, but not sneezing or postnasal drip. Resection of the PNN also significantly improved both rhinorrhea and nasal obstruction. Morphometric analysis of the density of the nasal gland showed a significant reduction, whereas no significant change was recognized in the density of the vessels. A significant reduction in the number of infiltrating neutrophils, eosinophils, and lymphocytes was recognized.

Histomorphologic study of nasal turbinates after surgical treatment: a comparison of laser surgery and radiofrequency-induced thermotherapy effects in animals

CONCLUSIONS

From the clinical point of view, the healing process following radiofrequency-induced thermotherapy (RFITT) is faster and less painful for the patient. This corresponds with the histopathological findings, as in a case of diode laser treatment, the damage to the tissue was greater, and the regenerative and reparative processes were less prominent.

OBJECTIVE

Comparison of histopathologic changes and the healing process in the turbinate tissue regarding the kind of treatment and intensity of energy used for surgery.

MATERIALS AND METHODS

Pigs were chosen as laboratory animals for this study. The animals were divided into two groups. Two different techniques were used: treatment with diode laser fiber applied submucosally in contact mode and RFITT. The first tissue samples were taken on the third postoperative day; further sampling was done on the eight postoperative day.

RESULTS

Histological features of the specimens taken from turbinates 8 days after the surgery included necrosis and ulceration, fibrin deposition in the mucosa, necrotizing sialometaplasia, as well as proliferation of the granulation tissue. Generally, the changes found in the turbinates treated by diode laser were more severe, with more intensive tissue damage and less prominent regenerative and reparative changes.

Nonallergic rhinitis, with a focus on vasomotor rhinitis: clinical importance, differential diagnosis, and effective treatment recommendations

The term "rhinitis" denotes nasal inflammation causing a combination of rhinorrhea, sneezing, congestion, nasal itch, and/or postnasal drainage. Allergic rhinitis is the most prevalent and most frequently recognized form of rhinitis. However, nonallergic rhinitis (NAR) is also very common, affecting millions of people. By contrast, NAR is less well understood and less often diagnosed. Nonallergic rhinitis includes a heterogeneous group of conditions, involving various triggers and distinct pathophysiologies. Nonallergic vasomotor rhinitis is the most common form of NAR and will be the primary focus of this review. Understanding and recognizing the presence of NAR in a patient is essential for the correct selection of medications and for successful treatment outcomes.

Overexpression of the anaphylatoxin receptors, complement anaphylatoxin 3a receptor and complement anaphylatoxin 5a receptor, in the nasal mucosa of patients with mild and severe persistent allergic rhinitis

BACKGROUND

Although the complement anaphylatoxin peptides, complement anaphylatoxin 3a (C3a) and complement anaphylatoxin 5a (C5a), are implicated in the inflammatory process in allergic rhinitis, a direct interaction between allergic mucosa and complement receptors has not been demonstrated.

OBJECTIVE

We investigated the expressional levels and distributional patterns of the C3a receptor (C3aR) and C5a receptor (C5aR) in normal, mild, and severe persistent allergic nasal mucosa.

METHODS

Immunohistochemistry and Western blotting using C3aR and C5aR antibodies were applied to normal nasal, mild, and severe persistent allergic nasal mucosa.

RESULTS

Complement anaphylatoxin 5a receptor was detected in the inflammatory cells of normal and allergic nasal mucosa, and its expression level was significantly higher in allergic nasal mucosa than normal nasal mucosa. C3aR in normal and allergic nasal mucosa was commonly expressed in nonmyeloid cells such as epithelial cells, submucosal glands, and nerve fibers. In addition, C3aR was expressed in the endothelium of cavernous sinuses and the surrounding perivascular muscle layer in severe persistent allergic nasal mucosa, but not in normal and mild allergic nasal mucosa. Western blotting demonstrated that the expression level of C3aR was significantly increased in severe persistent allergic nasal mucosa compared with normal and mild nasal mucosa.

CONCLUSION

On the basis of the location of C3aR and C5aR, C5aR may play a role in activation of inflammatory cells, whereas C3aR may mediate mucus secretion and mucosal swelling in allergic nasal mucosa, especially severe persistent allergic nasal mucosa.

Treatment of idiopathic gustatory rhinorrhea by resection of the posterior nasal nerve

We herein describe a case of 44-year old female who presented with a chief complaint of gustatory rhinorrhea from childhood, in which gustatory stimuli caused bilateral excessive, watery nasal secretion. No abnormality of taste acuity was observed. This disorder was presumably caused by faulty regenerated parasympathetic nerve fibers reaching the nasal mucosa or possibly, by a congenital condition. Nasal pretreatment with an anti-cholinergic drug clinically blocked the positive sugar-induced rhinorrhea, thus indicating that the gustatory rhinitis in this case was produced by foods that stimulate muscarinic receptors sensitive to atropine (probably on submucosal nasal glands). Although this syndrome can be treated prophylactically by the use of topical atropine, the patient preferred to undergo radical therapy and a resection of the posterior nasal nerve was performed through the middle meatus under endoscopic control. The resection of the nerve on both sides resulted in an almost complete inhibition of the sugar-induced rhinorrhea without serious complications. Although this disease is not life-threatening, it is socially embarrassing and troublesome to patients and surgical therapy is one of the accepted modalities.