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

Efficacy of the posterior nasal nerve resection combined with hormone transnasal nebulization on difficult-to-treat rhinosinusitis: a retrospective analysis

OBJECTIVE

A retrospective analysis was performed to explore the clinical effect of the Posterior Nasal Nerve (PNN) resection combined with hormone transnasal nebulization on Difficult-to-Treat Rhinosinusitis (DTRS).

METHODS

A total of 120 DTRS patients were selected and divided into a control group (n = 60) and a study group (n = 60) according to different treatments. The control group patients were treated via PNN resection, followed by normal saline transnasal nebulization; the study group patients were given PNN resection and then treated with budesonide suspension transnasal nebulization. Subsequently, the comparison was performed between the two groups in terms of (1) Clinical baseline characteristics; (2) Sino-nasal Outcome Test (SNOT)-22 scores before treatment and after 3-months, 6-months and 12-months of treatment; (3) Lund-MacKay scores before treatment and after 10, 30, 90, and 180 days of treatment; (4) Incidence of adverse reactions during treatment.

RESULTS

There was no significant difference in SNOT-22 or Lund-Kennedy scores between the two groups before treatment (p > 0.05). After treatment, the SNOT-22 and Lund-Kennedy scores of the control and the study groups were decreased, and compared with the control group, the SNOT-22 and Lund-Kennedy scores in the study group improved more significantly (p < 0.05). In addition, the study group and the control group presented with 1 and 4 cases of nasal adhesion, 2 and 3 cases of epistaxis, 1 and 4 cases of sinus orifice obstruction, 1 and 3 cases of lacrimal duct injuries, respectively. The incidence of adverse reactions in the study group was significantly lower than that in the control group (8.3% vs. 23.3%) (p < 0.05).

CONCLUSION

PNN resection combined with hormone transnasal nebulization treatment can improve the symptoms and quality of life of DTRS patients, with good clinical efficacy but few adverse reactions. Therefore, such combination treatment deserves a promotion and application clinically.

LEVEL OF EVIDENCE

Level 3.

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.

Postnasal drip and chronic cough in patients with chronic rhinitis treated with temperature-controlled radiofrequency neurolysis

OBJECTIVE

To evaluate the contribution of postnasal drip (PND) and chronic cough (CC) to symptoms of patients with chronic rhinitis treated with temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), and correlate PND and CC scores with components of the reflective total nasal symptom score (rTNSS).

METHODS

Pooled data from three prospective studies: two single-arm studies and the index active treatment arm of a randomized controlled trial. Adult patients with baseline rTNSS ≥6 were treated with TCRF neurolysis at nonoverlapping regions of the PNN. PND and CC symptoms were evaluated on a 0 (none) to 3 (severe) scale.

RESULTS

Data from 228 patients (57.9% women, 42.1% men) were included. The mean baseline rTNSS was 8.1 (95% confidence interval [CI], 7.8-8.3), which decreased to 3.2 (95% CI, 2.9-3.5) at 6 months. At baseline, 97.4% of patients had PND and 80.3% had CC. Median baseline PND and CC symptom scores were 3 (interquartile range [IQR], 2-3) and 2 (IQR, 1-2), respectively. At 6 months, this decreased to 1 (IQR, 0-2) and 0 (IQR, 0-1), respectively, showing significant improvement from baseline (both p < 0.001). Spearman correlation coefficients with components of rTNSS (rhinorrhea, congestion, itching, sneezing) were 0.16 to 0.22 for CC and 0.19 to 0.46 for PND, indicating only a weak to moderate correlation.

CONCLUSION

PND and CC contribute to the symptomatology of chronic rhinitis and are significantly improved after TCRF neurolysis of the PNN. The inclusion of PND and CC symptoms in a chronic rhinitis assessment instrument could provide important additional information for the characterization of the disease state and outcomes after any therapeutic treatment.

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.

The Impact of Surgical Posterior Nasal Nerve Cryoablation on Symptoms and Disease-Specific Quality of Life in Patients With Chronic Rhinitis

OBJECTIVE

Preliminary data have demonstrated long-term efficacy of posterior nasal nerve (PNN) cryoablation in reducing rhinitis symptoms for patients with allergic rhinitis (AR) and nonallergic rhinitis (NAR). We sought to evaluate the impact of procedural cryoablation of the PNN on quality of life (QOL) in patients with AR and NAR.

METHODS

Adult patients undergoing PNN cryoablation for AR or NAR after appropriate medical therapy were included for analysis. Demographics, medical therapies, baseline rhinitis symptom (total nasal symptom score [TNSS]), and disease-specific QOL (mini-rhinoconjunctivitis quality of life questionnaire [mini-RQLQ]) were recorded. The Wilcoxon signed-rank test was used to test for significant changes in baseline test scores posttreatment. Absolute and relative improvement in outcomes was determined for each participant. Secondary outcomes were assessed with univariate and multivariate analyses.

RESULTS

Fourteen patients were enrolled with a mean follow-up of 16.5 weeks. The TNSS and mini-RQLQ scores significantly improved after PNN cryoablation (median δs [interquartile range]: -4 [3] and -1.61 [1.08], respectively; both P = .0002). The minimal clinically important difference for the TNSS and mini-RQLQ was obtained in 92.9% of patients in each category. Relative mean percentage (%) improvement after PNN cryoablation in the TNSS and mini-RQLQ was 40.7% and 40.5% (standard deviation = 24.9 and 29.5, respectively), respectively, for all patients. Patients with NAR (n = 10) reported mean improvement of 41.3% (29.1) as measured by the TNSS and 49.6% (25.9) by mini-RQLQ. Patients with AR reported mean percentage improvement in TNSS and mini-RQLQ scores of 39.5% (12.1) and 24.6% (28.5), respectively. Patients who had been prescribed a nasal anticholinergic for management prior to PNN cryoablation had statistically significantly increased improvement in mini-RQLQ scores from pre- to post-procedure (P = .0387).

CONCLUSION

Surgical cryoablation of the PNN significantly improves both symptoms and disease-specific QOL in majority of patients with AR and NAR.

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.

A Novel Approach to Posterior Lateral Nasal Neurectomy

Background Allergic rhinitis (AR) is a major health concern throughout the world. By severing the parasympathetic supply to the lateral wall of the nose, posterior lateral nasal neurectomy (PLNN), a form of highly selective vidian neurectomy, decreases nasal allergy symptoms. This study attempts to characterize the demographic and surgical characteristics of study participants in relation to PLNN, as well as to identify the risk factors associated with these characteristics. Methodology A five-year, cross-sectional study was undertaken among patients diagnosed with AR at a tertiary care center in Tamaka, Kolar. Case sheets accessible in the department of medical records were used to compile a list of 50 study patients. SPSS version 21 was used for data analysis (IBM Corp., Armonk, NY, USA). Results The study revealed that the average age of the sample population was 30.4 years. The majority of the study participants were less than or equal to 30 years old (54%). In our study, the majority of the participants were male (60%). This study revealed that around 46% of the surgeries were independent PLNNs and that most of them (76%) were observed to have four nerves following surgery. The average intraoperative blood loss during PLNN surgery was 43.14 mL. The mean hemoglobin levels before and after surgery were 13.11 and 12.78 g/dL, respectively. The average duration of the surgical procedure was 62 minutes. The average duration of PLNN surgery in females was 52.75 minutes, whereas the average duration in males was 68.33 minutes. According to an independent t-test (p = 0.045), this difference in mean was statistically significant. Approximately 85% of female study participants were identified with four nerves during PLNN surgery compared to 70% of male study participants. According to the chi-square test (p = 0.018), this proportional difference was statistically significant. Conclusions The majority of the participants in this study were male and younger. The typical PLNN surgical procedure lasted one hour. Males and females require different amounts of time, with females requiring less time. During PLNN surgery, most females detected four nerves, as opposed to most males.

Comparing The Effects of Botulinum toxin-A and multiple surgical parasympathectomy on treatment of allergic rhinitis

OBJECTIVE

Allergic rhinitis (AR) is a common disease with a recent increasing in prevalence. Traditional treatment strategies of AR, sometimes, show limited effectiveness and side effects. Intranasal injection of Botulinum toxin type A (BTX-A) and multiple postganglionic parasympathectomy of pterygopalatine ganglion (PPG) are among the increasingly used alternative treatment options of AR. In this study, we compared the early efficacy of BTX-A and multiple surgical parasympathectomy (MSP) on treatment of uncontrolled AR.

METHODS

Sixty patients who were diagnosed with uncontrolled AR, were recruited to the study. Participants randomly underwent either intranasal injection of BTX-A (45 IU in each nostril) (Group A) or bilateral MSP (Group B). All patients were evaluated in terms of nasal hypersecretions, congestion and sneezing with visual analogue scale prior to treatment and at weeks 1, 2, 4, 8, 12 and 6 months during the follow-up period.

RESULTS

A significant difference in the degree of nasal hypersecretions and sneezing could be identified in both groups before and after the interventions. Although the significant efficacy on sneezing was documented in group A and B only in the first 4 and 8 weeks, respectively, such efficacy on nasal hypersecretions extended for 12 weeks in group A and throughout the follow-up period in group B. Nasal congestion did not differ significantly in both groups.

CONCLUSION

Both BTX-A and MSP, in patients with uncontrolled AR, may be a long-lasting therapeutic option for the treatment of nasal hypersecretions, but not as effective as for sneezing and nasal congestion.

Posterior nasal nerve neurectomy for the treatment of chronic rhinosinusitis with nasal polyposis: a randomized controlled trial

BACKGROUND

Managing Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) is always challenging due to the chronicity of the disease and its intractable course. Posterior nasal neurectomy (PNN) can be effective in alleviating symptoms of CRSwNP.

MATERIALS AND METHODS

The study was conducted in a tertiary care referral hospital from August 2019 to April 2022. A total of 46 patients of CRSwNP were included (23 patients in the study and 23 in the control group). Patients in the study group underwent endoscopic sinus surgery (ESS) and PNN and patients in the control group with ESS. The symptoms and quality-of-life improvement were assessed at 1, 4, 12, and 24 weeks after the surgery.

RESULTS

On intragroup analysis between the preoperative and postoperative scores (SNOT-22, RSDI and LK Score), we found a significant difference for each (p < 0.05). When the improvement of outcome scores was compared between the two groups, a significant difference was obtained for SNOT-22 and RSDI scores at 1 week and 4 weeks (p < 0.05). There was no significant difference found for the duration of surgery/complications between the two groups (p = 1.00).

CONCLUSION

The PNN can be an effective add-on procedure in patients with CRSwNP in alleviating short-term control of the symptoms and the quality of life. A larger sample size with long-term follow-up may be required for a better understanding of the efficacy of the PNN in patients with CRSwNP.

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.

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.

Involvement of galanin and galanin receptor 2 in a mouse model of allergic rhinitis

BACKGROUND

Allergic rhinitis (AR) is caused by allergic reaction to allergens such as pollen. Galanin (GAL), a neuropeptide that regulates inflammatory processes, is widely expressed in the central and peripheral nervous systems. Although neuropeptides are implicated in arthritis and chemically induced ileitis, their roles in AR remain unclear.

METHODS

We developed a murine model of AR and generated control, systemic sensitization, mild AR, and severe AR groups. We examined GAL and GAL receptor (GALR) mRNA and protein levels and localization patterns in each group using reverse transcription PCR, western blotting, and immunohistochemical analyses. Additionally, we evaluated the effects of M871, a GALR2 antagonist, on mice with severe AR.

RESULTS

Gal and Galr2 are expressed in nasal mucosa and brain (control) samples from control and AR mice. GAL and GALR2 were expressed at similar levels and localized to ciliated epithelial and submucosal gland cells of the nasal mucosa in all four groups. Intranasal M871 administration significantly reduced the incidence of nose rubbing behaviors and sneezing (p < 0.001 in 30 min, respectively) in severe AR mice relative to that in controls. Mechanistically, we postulate that GALR2 is expressed in B cells, and M871 administration reduces IgE production, as well as the number of B cells in tissues.

CONCLUSIONS

GAL signaling may not change progressively with increasing nasal sensitization, suggesting that this signaling process exacerbates, rather than directly trigger, AR. GAL-GALR2 signaling likely mediates AR development, suggesting that its inhibition represents a novel therapeutic strategy for AR.

Pollen Allergy Screening with Allergen-Specific and Total Immunoglobulin E Titers

Background

Allergic rhinitis is a typical type I hypersensitivity reaction, commonly caused by inhalant allergens. Accurate identification of the causative antigen is important for rapid diagnosis and treatment initiation.

Objective

This study examined the efficiency of serum-based allergen-specific immunoglobulin E and total immunoglobulin E antibody titers in screening for pollen allergy. We also examined the effect of cross-reactive carbohydrate determinants on specific immunoglobulin E titers in screening for pollen allergy, one of the causes of false positivity in specific immunoglobulin E measurements.

Methods

A questionnaire was used to evaluate the symptoms of pollinosis among participants who underwent a medical examination. One hundred and thirty-two participants reported pollen allergy symptoms and 127 reported an absence of symptoms. Specific immunoglobulin E levels were measured using the AlaSTAT 3g Allergy method. Seventeen components, including four types of cross-reactive carbohydrate determinant-specific immunoglobulin E antibodies, were measured and evaluated comparatively.

Results

The sensitivity and specificity of the tests in predicting the presence or absence of pollen allergy were analyzed. The values of the areas under the curves for immunoglobulin E antibody levels against cedar, cypress, orchard grass, and ragweed pollen were 0.87, 0.82, 0.63, and 0.56, respectively. A cross-reactive carbohydrate determinant-related false-positive effect on the pollen specific immunoglobulin E titer was noted in pollen screening.

Conclusion

Cedar pollen-specific immunoglobulin E titers showed sufficient accuracy for use in pollen allergy screening. The study of cross-reactive carbohydrate determinants suggested that subjects who tested positive for pollen often had false-positive results due to the impact of cross-reactive carbohydrate determinants.

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.

Nanosystems as curative platforms for allergic disorder management

Allergy, IgE-mediated inflammatory disorders including allergic rhinitis, asthma, and conjunctivitis, affects billions of people worldwide. Conventional means of allergy management include allergen avoidance, pharmacotherapy, and emerging therapies. Among them, chemotherapeutant intake via oral, intravenous, and intranasal routes is always the most common mean. Although current pharmacotherapy exhibit splendid anti-allergic effects, short in situ retention, low bioavailability, and systemic side effects are inevitable. Nowadays, nanoplatforms have provided alternative therapeutic options to obviate the existing weakness via enhancing the solubility of hydrophobic therapeutic agents, achieving in situ drug accumulation, exhibiting controlled and long-time drug release at lesion areas, and providing multi-functional therapeutic strategies. Herein, we highlight the clinical therapeutic strategies and deal with characteristics of the nanoplatform design in allergy interventions via intratracheal, gastrointestinal, intravenous, and ocular paths. The promising therapeutic utilization in a variety of allergic disorders is discussed, and recent perspectives on the feasible advances of nanoplatforms in allergy management are also exploited.

Efficacy of Selective Vidian Neurectomy for Allergic Rhinitis Combined with Chronic Rhinosinusitis

OBJECTIVE

The aim of this study was to investigate the efficacy of endoscopic selective vidian neurectomy in the treatment of severe persistent allergic rhinitis (AR) combined with chronic rhinosinusitis (CRS) with nasal polyps (ARwCRSwNP).

METHODS

One hundred thirty patients with moderate to severe persistent ARwCRSwNP were enrolled at Xuanwu Hospital, Capital Medical University, from September 2015 to September 2017. Patients were divided into 2 groups. Sixty-one patients (the control group) underwent conventional surgical treatment for CRS with nasal polyps and received conservative treatment for AR. Sixty-nine patients (the experimental group) received conventional surgical treatment for CRS with nasal polyps plus endoscopic selective vidian neurectomy with amputation of the posterior nasal nerve and pharyngeal branch of the vidian nerve. Clinical parameters, including visual analog scale (VAS) score, Lund-Kennedy endoscopic mucosal morphology score, and Lund-Mackay sinus computed tomography (CT) scan lesion range score, were used to analyze and evaluate the preoperative and postoperative data. Comparisons were based on patient scores, and preoperative and postoperative scores obtained at 6, 12, and 24 months were analyzed.

RESULTS

The experimental group had higher therapeutic efficacy in nasal obstruction, nasal itching, rhinorrhea, sneezing, and general symptoms than the control group (p < 0.05). No complications such as tear-secretion disorder or atrophic rhinitis occurred in the experimental group, and no significant difference in complications incidence was observed between the 2 groups (p > 0.05).

CONCLUSION

Endoscopic selective vidian neurectomy is an effective and safe technique for the management of moderate to severe persistent ARwCRSwNP.

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.

Long-term effectiveness, safety, and quality of life outcomes following endoscopic posterior nasal neurectomy with submucosal turbinectomy for the treatment of intractable severe chronic rhinitis

OBJECTIVE

In recent decades, posterior nasal neurectomy (PNN) with submucosal inferior turbinectomy (ST) has been increasingly used for the treatment of intractable severe rhinitis; however, to the best of our knowledge, there have been few studies regarding its long-term therapeutic effects or its influence on patient quality of life (QOL). Therefore, this study examined the long-term therapeutic effects in patients who underwent PNN with ST, as well as their QOL and medication use after surgery.

METHODS

This retrospective cohort study initially included 16 consecutive patients who underwent PNN with ST from January 2010 to December 2011. Ten of the 16 patients participated in a paper-based survey questionnaire between June 2018 and November 2018; the responses of these 10 patients were used for analysis in this study. To clarify the effects of surgical treatment on symptoms, QOL, and medication status, data recorded before and 3 months after surgery were compared with data recorded at 8 years after surgery using the Japan Rhinoconjunctivitis Quality of Life Questionnaire No. 1 and Classification of the Severity of Allergic Rhinitis Symptoms I and II.

RESULTS

Nasal symptoms including runny nose and nasal congestion, medication score, respective total symptoms medication scores (i.e., combined average total symptoms score and medication score), and the scores of troubles with daily life and total QOL were significantly improved at 3 months and 8 years after surgery, compared with before surgery; scores were not significantly worsened at 8 years after surgery, compared with 3 months after surgery. In addition, there were no adverse events requiring treatment after surgery.

CONCLUSION

Our findings suggest that PNN with ST is effective and safe for long-term treatment of severe chronic rhinitis symptoms, as well as reduction of medication use and improvement of QOL.

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.

Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study

Objective

To assess the efficacy and safety of cryoablation of the posterior nasal nerve (PNN) for treatment of chronic rhinitis.

Methods

This was a prospective single‐arm trial of 98 adult patients at six U.S. centers with chronic allergic and nonallergic rhinitis. PNN cryoablation was performed in‐office under local anesthesia using a handheld device. Patients discontinued use of intranasal ipratropium 3 days prior to treatment and throughout the study period. Reflective Total Nasal Symptom Score (rTNSS) was measured at pretreatment baseline and posttreatment at 1 month, 3 months, 6 months, and 9 months. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was completed at pretreatment and 3 months posttreatment. Adverse effects and postprocedure medication usage were recorded.

Results

Ninety‐eight procedures (100%) were successfully completed. rTNSS significantly improved over pretreatment baseline (6.1 ± 1.9) at 1 month (2.9 ± 1.9, P < 0.001), 3 months (3.0 ± 2.3, P < 0.001), 6 months (3.0 ± 2.1, P < 0.001), and 9 months (3.0 ± 2.4, P < 0.001) postprocedure. Nasal congestion and rhinorrhea subscores improved significantly at all time points (P < 0.001). Both allergic and nonallergic rhinitis subcohorts showed improvement (P < 0.001), with a comparable degree of improvement between groups. RQLQ significantly improved over pretreatment baseline (3.0 ± 1.0) at 3 months (1.5 ± 1.0, P < 0.001), and all RQLQ subdomains demonstrated improvement. Of 54 patients using intranasal medication at baseline, 19 (35.2%) were able to discontinue use. Twenty‐nine adverse effects were reported, including headache, epistaxis, and sinusitis.

Conclusion

Cryoablation of the PNN for chronic rhinitis is safe and can result in relief of nasal symptoms and improvements in quality of life.

Level of Evidence

4 Laryngoscope, 130: 1877–1884, 2020

Endoscopic posterior nasal neurectomy

Background

Surgical techniques for resistant chronic rhinitis (rhinorrhoea) vary, ranging from vidian neurectomy to post-nasal neurectomy. The techniques vary mainly on the basis of instrumentation, and the avoidance of post-operative epistaxis, transient hypoesthesia of the soft palate and dryness of the eye. Endoscopic visualisation, and cauterisation or resection of posterior nasal nerve branches, can prevent such complications.

Method

The technique and surgical steps of endoscopic posterior nasal neurectomy are presented.

Results

The critical steps include: bilateral sphenopalatine nerve blocks, transnasally or transorally via the greater palatine foramen; vertical incisions made behind the posterior fontanelle; and elevation of the mucoperiosteal flap. The sphenopalatine foramen and artery is identified. The posterior nasal nerve is located 4–5 mm inferior to the sphenopalatine artery, and is resected or cauterised. The flaps are repositioned back into place. No post-operative nasal packing is required. The same procedure is performed on the opposite side for effective results.

Conclusion

This technique provides consistent, robust results, with long-term relief of allergic and vasomotor rhinitis related nasal symptoms, without risk of complication.

Gastrin-Releasing Peptide Is Involved in the Establishment of Allergic Rhinitis in Mice

OBJECTIVE

Gastrin-releasing peptide (GRP) is a neuropeptide that targets transmembrane-type receptors. Its role in allergic rhinitis (AR) has yet to be investigated. The present study utilized the nasal mucosa of AR model mice to examine GRP and GRP receptor (GRPR) expression levels, localization, and other factors to evaluate their role in AR pathology.

STUDY DESIGN

In vivo study in an animal model.

METHODS

GRP and GRPR expression levels were examined in three different AR models established in BALB/c mice. In addition, a GRPR antagonist (RC-3095) was administered to AR mice to investigate its effect. The distribution of GRPR expression on mast cells in the nasal mucosa with AR was examined. Finally, we investigated the inhibitory effect of RC-3095 on allergy symptoms induced by histamine.

RESULTS

GRP and GRPR were highly expressed in the nasal mucosal epithelium and interstitial tissues surrounding the nasal glands in AR groups according to immunostaining. GRP and GRPR expression as determined by western blotting increased in the nasal mucosa as the degree of nasal sensitization increased. In addition, the average counts of sneezing and nasal rubbing after treatment in the AR + RC-3095 group were significantly lower than those in the AR + nasal saline group. Mast cells often colocalized with GRPR around nasal glands. Moreover, RC-3095 was effective in reducing sneezing induced by histamine.

CONCLUSION

The GRP-GRPR system is likely to be involved in allergic inflammation. This system may represent a novel therapeutic target for refractory AR.

LEVEL OF EVIDENCE

NA. Laryngoscope, E377-E384, 2018.

Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis

Allergic rhinitis (AR) is a global health problem that causes major illnesses and disabilities worldwide. Epidemiologic studies have demonstrated that the prevalence of AR has increased progressively over the last few decades in more developed countries and currently affects up to 40% of the population worldwide. Likewise, a rising trend of AR has also been observed over the last 2-3 decades in developing countries including China, with the prevalence of AR varying widely in these countries. A survey of self-reported AR over a 6-year period in the general Chinese adult population reported that the standardized prevalence of adult AR increased from 11.1% in 2005 to 17.6% in 2011. An increasing number of Journal Articles and imporclinical trials on the epidemiology, pathophysiologic mechanisms, diagnosis, management and comorbidities of AR in Chinese subjects have been published in international peer-reviewed journals over the past 2 decades, and substantially added to our understanding of this disease as a global problem. Although guidelines for the diagnosis and treatment of AR in Chinese subjects have also been published, they have not been translated into English and therefore not generally accessible for reference to non-Chinese speaking international medical communities. Moreover, methods for the diagnosis and treatment of AR in China have not been standardized entirely and some patients are still treated according to regional preferences. Thus, the present guidelines have been developed by the Chinese Society of Allergy to be accessible to both national and international medical communities involved in the management of AR patients. These guidelines have been prepared in line with existing international guidelines to provide evidence-based recommendations for the diagnosis and management of AR in China.

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.

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.

A systematic review of the evidence base for vidian neurectomy in managing rhinitis

Background:

Vidian neurectomy has been proposed as a surgical option for rhinitis refractory to medical treatment. However, the evidence base for its benefit remains controversial.

Methods:

A systematic review was performed. Studies reporting original data on patients with rhinitis treated by vidian neurectomy were included. Patient-reported outcome measures were the primary outcome investigated; specific peri-operative morbidities were the secondary outcome.

Results:

A total of 1012 articles fulfilled the search criteria, 32 of which were included in the study. Patient-reported outcome measures were compared before and after surgery in eight studies. There were 529 patients represented in these trials. Significant improvement in rhinorrhoea was reported in all eight studies. Temporary dry eyes was reported in 24.63 per cent of cases (272 out of 1104 cases). There was no report of cranial nerve deficit or eye movement disturbance.

Conclusion:

Endoscopic vidian neurectomy does have a role in the surgical management of refractory rhinitis, particularly in patients with non-allergic rhinitis, but a well-designed cohort trial would be advantageous to clarify long-term outcomes.

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.

High-intensity focused ultrasound leads to histopathologic changes of the inferior turbinate mucosa with allergic inflammation

This study was aimed at understanding the histopathologic changes that occur in the nasal mucosa of patients with perennial allergic rhinitis after high-intensity focused ultrasound (HIFU) treatment. Biopsy specimens of the inferior turbinate mucosa were taken from 11 PAR patients before, immediately after and 1 y after HIFU treatment. Morphometric analysis revealed that the density of eosinophils and other inflammatory cells increased immediately after treatment and then were decreased significantly 1 y post-treatment. Submucosal glands were swollen and venous sinusoids were dilated, but there was no statistically significant change in their density, immediately after treatment. However, both glands and venous sinusoids significantly decreased in number 1 y after HIFU treatment. The ciliated epithelium or basement membrane of the nasal mucosa was well preserved at all stages. In conclusion, HIFU is a tolerable and effective treatment to reduce inflammation of the inferior turbinate mucosa in patients with perennial allergic rhinitis.

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).