Safety and efficacy of cryotherapy on chronic rhinitis: a systematic review and meta-analysis

BACKGROUND

Chronic rhinitis is when the nasal passages become inflamed and irritated, causing symptoms like nasal congestion, runny nose, sneezing, and postnasal drip that last for at least 12 weeks. While various medical treatments are available for chronic rhinitis, studies have shown that patients often do not comply with the treatment or report that it is ineffective. Cryotherapy for the nasal mucosa is a surgical option that has shown promise for these patients, with acceptable side effects.

AIM

Our goal is to evaluate the existing literature regarding the effectiveness and safety of cryotherapy as a treatment for chronic rhinitis.

METHODS

We searched four electronic databases for relevant studies. Data were extracted from the included studies after screening procedures. Using the random effect model, we calculated the pooled mean difference (MD) for our continuous outcomes and pooled proportions for categorical outcomes. The I2 test was used to detect heterogenicity. Randomized controlled trials (RCTs) were assessed for methodological quality using the Cochrane risk of bias assessment tool 2, while observational studies and single-arm studies were assessed using the National Institutes of Health's tools.

RESULTS

Our study comprised 21 studies; eighteen were eligible for analysis, with 1663 patients with chronic rhinitis. All of our assessed outcomes showed improvement with cryotherapy from their baseline status. Our pooled MDs for Total Nasal Symptom Score (rTNSS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Nasal Obstruction Symptom Evaluation (NOSE) scores were as follows: ( - 3.58, 95% CI [ - 3.80,  - 3.37], p < 0.001), ( - 1.48, 95% CI [ - 1.68,  - 1.27], p < 0.001), and ( - 26.65, 95% CI [ - 33.98,  - 19.31], p < 0.001), respectively. Regarding nasal obstruction and rhinorrhea, cryotherapy showed effectiveness in 61% and 52% of patients in the complete relief subgroup and 26% and 34% in the < 50%-relief subgroup, respectively.

CONCLUSION

We observed significant improvement in our measured outcomes as rTNSS, RQLQ, and NOSE scores compared to the baseline state, demonstrating the cryotherapy's efficacy. This improvement was consistent in all subsequent follow-up periods. However, we need more high-quality RCTs for stronger evidence to be generalized.

Nonallergic Rhinopathy: A Comprehensive Review of Classification, Diagnosis, and Treatment

Chronic nonallergic rhinitis syndromes encompass various conditions, of which vasomotor rhinitis is the most common form, representing approximately 80% of patients, also referred to as nonallergic rhinopathy (NAR), nasal hyperreactivity, neurogenic rhinitis, or idiopathic rhinitis. Expert panels have recommended replacing vasomotor rhinitis terminology because it is more descriptive of this condition that is characterized by symptoms triggered by chemical irritants and weather changes through chemosensors, mechanosensors, thermosensors, and/or osmosensors activated through different transient receptor potential calcium ion channels. Elucidating the specific role of transient receptor potential vanilloid 1, triggered by capsaicin, has been an important advancement in better understanding the pathophysiology of NAR because it has now been shown that downregulation of transient receptor potential vanilloid 1 receptors by several therapeutic compounds provides symptomatic relief for this condition. The classification of NAR is further complicated by its association with allergic rhinitis referred to as mixed rhinitis, which involves both immunoglobulin E-mediated and neurogenic mechanistic pathways. Comorbidities associated with NAR, including rhinosinusitis, headaches, asthma, chronic cough, and sleep disturbances, underscore the need for comprehensive management. Treatment options for NAR include environmental interventions, pharmacotherapy, and in refractory cases, surgical options, emphasizing the need for a tailored approach for each patient. Thus, it is extremely important to accurately diagnose NAR because inappropriate therapies lead to poor clinical outcomes and unnecessary health care and economic burdens for these patients. This review provides a comprehensive overview of NAR subtypes, focusing on classification, diagnosis, and treatment approaches for NAR.

Radiofrequency Neurolysis of the Posterior Nasal Nerve: A Systematic Review and Meta-Analysis

OBJECTIVE

Temperature-controlled radiofrequency neurolysis of the posterior nasal nerve (PNN) has been approved for use since 2020. This review synthesized the published data to assess its efficacy for treatment of chronic rhinitis.

DATA SOURCES

Pubmed/Medline, Embase, Scopus, Web of Science.

REVIEW METHODS

A systematic search was conducted with no restrictions on publication years in April 2023. RCTs and prospective investigations that reported the reflective Total Nasal Symptom Score (rTNSS) outcome of radiofrequency neurolysis as a single procedure in chronic rhinitis patients were included. Pooled estimates for change in rTNSS from baseline at 3 months and responder rates (≥30% reduction in baseline rTNSS) at 3 and 6 months were obtained. Other outcomes, such as postnasal drip and cough scores, quality of life (QoL) measures, and adverse events were included for qualitative review.

RESULTS

Five studies were included in the systematic review, of which four were included in the meta-analysis. A total of 284 participants underwent treatment. The pooled change in rTNSS score at 3 months was -4.28 (95% CI, -5.10 to -3.46). The pooled responder rate at 3 months was 77.11% (95% CI, 68.21%-86.01%) and at 6 months 80.80% (95% CI, 70.85%-90.76%). Postnasal drip and cough scores and QoL also improved significantly at follow up. A total of 36 adverse events were reported in 21 (7.4%) patients.

CONCLUSIONS

The findings from this review suggest that temperature-controlled radiofrequency neurolysis of the PNN is effective at treating chronic rhinitis symptoms and that it has an overall favorable safety profile. Laryngoscope, 134:507-516, 2024.

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.

Research Progress of Hydrogen on Chronic Nasal Inflammation

Chronic nasal mucosal inflammatory disease is a common nasal disease, which is involved by inflammatory cells and a variety of cytokines. Its main pathological features are inflammatory reaction, increased secretion, mucosal swelling and thickening of nasal cavity or paranasal sinuses.It mainly includes chronic rhinitis (divided into allergic rhinitis, non-allergic rhinitis), chronic sinusitis (divided into with nasal polyps, without nasal polyps type), etc.The main symptoms of chronic rhinitis are nasal itching, sneezing, runny nose, and nasal congestion. The main symptoms of chronic sinusitis are nasal congestion, purulent or sticky nasal discharge, headache, and reduced sense of smell. They are a type of disease with a high incidence rate and seriously affect the quality of human life.Although the etiology and treatment of this type of disease have been extensively studied, there are still many aspects that are unclear.Currently, oxidative stress is believed to be an important link in the pathogenesis of chronic inflammatory diseases of the nasal mucosa. Therefore, anti-oxidative stress is a direction of research for the treatment of chronic nasal mucosal inflammatory diseases.Hydrogen, as a medically therapeutic gas, has been extensively studied for its antioxidant, anti-inflammatory, and anti-damage properties, and has been used in the treatment of various diseases.Although there are relatively few studies on the use of hydrogen for nasal inflammation, its positive effects have also been found. This article systematically summarizes the relevant research on the use of hydrogen to improve chronic nasal mucosal inflammation, with the aim of clarifying the ideas and indicating the direction for further research in the future.

The Impact of Spray Cryotherapy on Lesion-Induced Osteitis in a New Murine Experimental Model

Background and Objectives: Endoscopic sinus surgery is considered the gold management strategy for difficult-to-treat chronic rhinosinusitis. The inflammatory bony process is incriminated as being involved in the unfavorable evolution and recurrence of the disease. Osteitis is significantly increased in patients that have been previously submitted to surgery, and it is more often present in patients with extended radiological disease and in patients undergoing revision surgery. The aim of the research is to demonstrate the presence of inflammations and neo-osteogenesis associated with nasal mucosal surgical injury and the correlation between their severity and to evaluate the efficacy of low-pressure spray cryotherapy in reducing inflammation and bone remodeling. Materials and Methods: The experimental murine model was conducted over a period of 80 days and included a total of 60 adult female Wistar rats, with three periods of withdrawal of 20 individuals each from the experiment. After inducing a bilateral mechanical injury by brushing, low-pressure spray cryotherapy application was performed unilaterally, and tissue samples were prepared specifically for histological analysis. The scores for inflammation and osteitis were compared over time and between the two nasal fossae. Results: Osteitis and inflammation were induced by a simple mucosal brushing lesion, similar to surgical injury. We identified the presence of inflammation in 95% of the specimens, and it was present over time. Moreover, criteria for bone remodeling were clearly highlighted in a percentage of 72% of the specimens. There was a direct correlation between the severity of inflammation and neo-osteogenesis, with a statistical significance of p = 0.050. Low-pressure spray cryotherapy was safe and effective in reducing inflammation (p = 0.020) and osteitis (p = 0.000) with a safety profile. Conclusions: Low-pressure cryotherapy reduces the severity of mucosal inflammation and osteitis in lesion-induced neo-osteogenesis.

Cryoablation for the treatment of chronic rhinitis: a systematic review

BACKGROUND

ClariFix is a novel intranasal cryotherapy device developed for clinic-based cryosurgical ablation of the posterior nasal nerves region. As a relatively new technology, there is a paucity of studies within the literature assessing the efficacy and safety profile of ClariFix for chronic rhinitis.

METHODS

A systematic review was completed in accordance with PRISMA guidelines. Databases searched included: Ovid Medline, Ovid EMBASE, Pubmed, Cochrane and Web of Science. Inclusion criteria consisted of studies investigating the use of ClariFix in chronic rhinitis (i.e., allergic and non-allergic rhinitis) in patients of all ages.

RESULTS

The initial search identified 1110 studies. Final analysis consisted of 8 articles, evaluating a total of 472 patients. The data showed a significant reduction in scores post-treatment across all studies based on validated outcome measures. In all studies, at all time intervals, there was a significant improvement in outcome scores from baseline. Minor adverse effects included post-procedural pain and discomfort, headache and palate numbness. No major adverse events were identified.

CONCLUSION

ClariFix is a novel intranasal cryotherapy device that was introduced in Canada in 2021. This is the first systematic review evaluating its efficacy and safety profile. Across all studies, there was a significant reduction in validated outcome scores at multiple time intervals. Further, the treatment is safe with only minor adverse effects reported by patients. Overall, the consensus from this study highlights an apparent benefit in using this intervention for chronic rhinitis that is refractory to medical management.

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.

Nasal nerve ablation, nasal swell body and inferior turbinate reduction for nasal obstruction and congestion relief

OBJECTIVE

Nasal obstruction and congestion can occur because of turbinate and septal variations with or without rhinitis. A combined treatment for nasal obstruction and congestion was examined retrospectively in cases where the nasal swell body was addressed with inferior turbinectomy, with or without posterior nasal nerve ablation.

METHODS

A 940 nm laser was utilised for contact (nasal swell body, septum and inferior turbinate) and non-contact (posterior nasal nerve) ablation. Total Nasal Symptoms Score, visual analogue scale pain score, complications and procedure location (office vs operating theatre) were recorded.

RESULTS

All 242 patients underwent nasal swell body reduction with inferior turbinate reduction, and 150 had posterior nasal nerve ablation also. No laser complications were observed. An 80 per cent reduction in medication usage was noted. Total Nasal Symptoms Score decreased by 73 per cent; rhinorrhoea and congestion scores decreased by 54 per cent and 81 per cent respectively. Crusting, epistaxis and infections were minimal, and resolved within two weeks.

CONCLUSION

Nasal swell body with inferior turbinate reduction, with or without posterior nasal nerve ablation, is a new method of treating nasal obstruction and congestion. Laser posterior nasal nerve ablation can be utilised as a complementary tool to deliver anatomical obstruction relief.

Efficacy of Cryoablation on Chronic Rhinitis Management: A Systematic Review and Meta-Analysis

BACKGROUND

ClariFix for posterior nasal nerve ablation has been approved for use since 2017, and this is the first study attempting to synthesize and assess the efficacy of this new device on the management of chronic rhinitis.

OBJECTIVE

The primary objective of this meta-analysis is to assess the efficacy of ClariFix in the symptomatic management of patients with chronic rhinitis. The main outcome measure is the mean difference in the reflective total nasal symptom score (rTNSS).

METHODS

A systematic search of Pubmed/Medline, Web of Science, and EBSCOhost was conducted from inception to May 2022. Peer-reviewed clinical trials reporting postcryotherapy rTNSS at both 1- and 3-month intervals for patients with chronic rhinitis were included. A random-effects model was utilized for meta-analysis. Study heterogeneity, bias, and overall quality were all assessed. The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The primary outcome measures included mean differences in rTNSS from baseline to both 1- and 3-month postoperative time points. Secondary measures included other questionnaires including the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ).

RESULTS

There were 5 studies that met the criteria (247 individuals). The pooled rTNSS mean difference from baseline to 1 and 3 months postoperatively was found to be -3.48 points (95% CI: -3.73 to -3.23, I² = 0.13). and -3.50 (95% CI: -3.71 to -3.29, I² = 0.00), respectively. The mean difference from baseline to 3 months postoperatively regarding the RQLQ was found to be -1.53 (95% CI: -1.74 to -1.31, I² = 0.00). The most common adverse effects included facial or surgical site pain (40.4%), followed by headache (18.2%), oral numbness (11.1%), and sinusitis (4.0%).

CONCLUSIONS

The findings of this systematic review suggest that cryoablation with Clarifix is an effective treatment modality for chronic rhinitis. However, higher-quality randomized controlled trials will need to be performed to affirm the findings of this study.

Prevalence of Rhinorrhea in Parkinson Disease: A Systematic Review and Meta-analysis

Purpose of Review

To perform a systematic review and determine the prevalence of rhinorrhea in Parkinson disease (PD).

Recent Findings

Of 451 patients with PD and 233 controls, the pooled prevalence of rhinorrhea in patients with PD was 45.0% (95% confidence interval 33.94-56.40), which was significantly greater than that in controls (p < 0.001). The prevalence of self-reported olfactory dysfunction was greater in patients with PD; however, a pooled analysis of studies using objective scores showed no difference. The mean age of patients with PD was greater than that of controls (p = 0.002). The mean age of patients with PD with rhinorrhea was also greater than that of patients with PD without rhinorrhea (p < 0.001), but disease characteristics did not differ.

Summary

There is a high prevalence of rhinorrhea in patients with PD; therefore, providers should query for rhinorrhea during visits and understand the treatment options available. Future studies should explore the pathophysiology of rhinorrhea in PD and the relationship between rhinorrhea and disease severity and duration, as well as determine whether treatment-specific outcomes differ in patients with PD.

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.

Cryotherapy for treatment of chronic rhinitis: 3-month outcomes of a randomized, sham-controlled trial

Background

The purpose of this study was to test whether cryotherapy is superior to a sham procedure for reducing symptoms of chronic rhinitis.

Methods

This study was a prospective, multicenter, 1:1 randomized, sham‐controlled, patient‐blinded trial. The predetermined sample size was 61 participants per arm. Adults with moderate/severe symptoms of chronic rhinitis who were candidates for cryotherapy under local anesthesia were enrolled. Participants were required to have minimum reflective Total Nasal Symptom Scores (rTNSSs) of 4 for total, 2 for rhinorrhea, and 1 for nasal congestion. Follow‐up visits occurred at 30 and 90 days postprocedure. Patient‐reported outcome measures included the rTNSS, standardized Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ(S)], and Nasal Obstruction Symptom Evaluation (NOSE) questionnaires. Adverse events were also recorded. The primary endpoint was the comparison between the treatment and sham arms for the percentage of responders at 90 days. Responders were defined as participants with a 30% or greater reduction in rTNSS relative to baseline.

Results

Twelve US investigational centers enrolled 133 participants. The primary endpoint analysis included 127 participants (64 active, 63 sham) with 90‐day results. The treatment arm was superior at the 90‐day follow‐up with 73.4% (47 of 64) responders compared with 36.5% (23 of 63) in the sham arm (p < 0.001). There were greater improvements in the rTNSS, RQLQ(S), and NOSE scores for the active arm over the sham arm at the 90‐day follow‐up (p < 0.001). One serious procedure‐related adverse event of anxiety/panic attack was reported.

Conclusion

Cryotherapy is superior to a sham procedure for improving chronic rhinitis symptoms and patient quality of life.

Cryosurgical Ablation for Treatment of Rhinitis: Two-Year Results of a Prospective Multicenter Study

Objectives/Hypothesis

To assess the long‐term (12–24 months) safety and effectiveness of cryoablation of the posterior nasal nerve as treatment for chronic rhinitis.

Study Design

A multicenter, prospective, single‐arm clinical study.

Methods

The study was conducted from February 2017 to April 2020. Study endpoints included change from baseline in the reflective Total Nasal Symptom Score (rTNSS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), physician assessment of improvement using the Clinical Global Impression–Improvement (CGI–I), and the incidence of treatment‐related adverse events.

Results

Ninety‐one participants completed the study through the initial 12‐month study period. Sixty‐two participants consented to the long‐term follow‐up with 57 completing the 24‐month follow‐up. Significant improvements in the total rTNSS were reflected in a median change from baseline of −3.0 or −4.0 at all timepoints (P < .001). Greater than 80.0% of participants achieved the minimum clinically important difference (MCID) of improvement by ≥1 point on the rTNSS at all follow‐ups. Total RQLQ scores indicated significant improvement (P < .0001) in quality of life. Over 77% of participants achieved the MCID (≥0.5 points) for the total RQLQ score. According to the CGI–I, ≥83.0% experienced improvement at all but the 12‐month visit (61.9%). One participant experienced two treatment‐related serious adverse events (epistaxis and retained pledget). A total of 29 nonserious treatment‐related AEs were reported in 23 participants; most events were transient and resolved with little to no intervention.

Conclusions

Cryotherapy significantly and clinically improves rhinitis symptoms and quality of life with outcomes that are durable through 24 months after treatment.

Level of Evidence

4 Laryngoscope, 131:1952–1957, 2021

Acute effects of ambient air pollution on outpatients with chronic rhinitis in Xinxiang, China

Air pollution exposure leads to increased mortality and morbidity rates of respiratory diseases. Most of the evidence was founded on acute diseases such as acute lower respiratory diseases. However, limited studies have been conducted to evaluate the effects of air pollution on chronic respiratory diseases. This time-series study was conducted to examine the acute effects of 6 criteria ambient air pollutants on hospital outpatients with chronic rhinitis (CR) in Xinxiang, China. We retrieved 223,826 outpatient records of patients with respiratory diseases, of which 62,901 were those of patients with CR. Results showed that the current 10-μg/m³ increase in fine particulate matter (PM_2.5), inhalable particulate matter (PM₁₀), sulfur dioxide (SO₂), nitrogen dioxide (NO₂), and carbon monoxide (CO) corresponds to 0.67% (95% confidence interval [CI]: 0.15-1.18%), 0.58% (95% CI: 0.24-0.92%), 1.89% (95% CI: 0.52-3.27%), 3.01% (95% CI: 1.66-4.35%), and 0.06% (95% CI: 0.03-0.10%) increments in outpatients with CR, respectively. In addition, the effects in the male were stronger than those in the female. Higher effect estimates were observed in the old (≥ 65 years of age) and younger (< 15 years of age) groups. Our study confirmed the association between air pollution and outpatients with CR in Xinxiang, China. More stringent air pollution control measures must be implemented.

Evaluation of In-Office Cryoablation of Posterior Nasal Nerves for the Treatment of Rhinitis

Background

Chronic rhinitis is a common condition generally treated with medical therapies. However, 10-22% of patients are refractory to medical therapies. A cryotherapy handheld device targeting the postganglionic nerve fibers of the posterior nasal nerve (PNN) now serves as an additional option for therapy. This study evaluates the efficacy of the cryosurgical ablation device of the PNN in the clinic setting.

Methods

This was a prospective single-arm trial of 24 adult patients at seven locations within a large health maintenance organization. Patients with chronic rhinitis that failed medical therapy were offered an in-office cryoablation of PNN. Patients completed the Total Nasal Symptom Score (TNSS) questionnaire consisting of 5 items reported based on the previous 12 hours and 2 weeks at the following time points: pre-treatment, 30 days, 90 days and 1 year post-treatment.

Results

Following cryoablation of the PNN, the TNSS 12-hour symptom score improved from 6.92 (±2.9) to 3.17 (±2.4, P < 0.001) at 30 days, 2.92 (±1.4, P < 0.001) at 90 days and 3.08 (±2.6, P < 0.001) at 1 year post treatment. Similar results were noted for the 2 weeks scores improving from 7.75 (±3.1) to 3.79 (±2.1, P < 0.001) at 30 days, 3.88 (±1.9, P < 0.001) at 90 days and 3.76 (±2.1, P < 0.001) at 1 year post-treatment. 64.7% of respondents stated the procedure decreased or eliminated nasal sprays.

Conclusions

Our independent evaluation of cryoablation of the PNN shows improvement in nasal symptoms over a 1 year period and is consistent with other published data.

Hyperbaric CO2 Cryotherapy for Managing Swelling After Mandibular Angle Ostectomy

ABSTRACT

Postoperative facial swelling after mandibular angle ostectomy is a concern for patients as it affects their quality of life. This study aimed to evaluate the effect of hyperbaric CO2 cryotherapy in relieving postoperative swelling. Thirty-seven patients (mean age: 22.95 ± 3.49 years) who underwent bilateral mandibular angle ostectomy from April to October 2019, were included in this study. A split-mouth design was adopted and through a random sequence, either side of the face was designated as the experimental side. Both received routine nursing care, while the experimental side underwent an additional hyperbaric CO2 cryotherapy treatment. The facial structure was recorded by a 3-dimensional laser scanner pre- and postoperatively. Geomagic Studio was used for alignment, visualization, and quantification of the swelling. The largest deviation value on each side was adopted to assess the overall swelling. Parameters were compared using the paired t-test, and P<0.05 was considered statistically significant. No necrosis of the skin and adjacent structures or other complications occurred in these patients. After the first day of cryotherapy, the deviation in the experimental and the control groups was (8.40 ± 1.95) mm and (10.42 ± 2.03) mm, respectively. The next day, after cryotherapy, the value further reduced to (5.42 ± 1.36) mm and (8.24 ± 2.22) mm for the experimental and control groups, respectively. And the effect remained till the seventh day. No difference was observed in terms of volume of drainage. Hyperbaric CO2 cryotherapy is safe and effective in relieving postoperative swelling and seems to be more effective than the traditional cold-pack treatment after mandibular angle ostectomy.

Multiple Site Cryoablation Treatment of the Posterior Nasal Nerve for Treatment of Chronic Rhinitis: An Observational Feasibility Study

Background

Cryoablation of the posterior nasal nerve at the middle meatus has been shown to successfully treat nasal obstruction and symptoms of chronic rhinitis. Cryoablation of both the middle and inferior meatus has not yet been studied.

Objectives

To evaluate the safety and feasibility of cryoablation of the posterior nasal nerve at both the middle and inferior meatus locations to treat chronic rhinitis.

Methods

Participants underwent bilateral cryoablation of the posterior nasal nerve at both the middle meatus and inferior meatus and were assessed through 3 months post treatment. The primary endpoint is the change from baseline to 3-month follow-up in the reflective Total Nasal Symptom Score (rTNSS). Other assessments include additional patient-reported outcomes, physician assessment, and independent review and scoring of imaging.

Results

Thirty participants were enrolled at 3 US centers. There was a significant improvement from baseline in the median rTNSS (-4.0, P < .001) at 3 months. Statistically significant improvements from baseline (P < .001) were also observed with the Nasal Obstruction Symptom Score (NOSE), nasal symptom visual analog scale (VAS), Sino-Nasal Outcomes Score (SNOT-22), and mini Rhinoconjunctivitis Quality of Life Questionnaire (mini RQLQ). Clinical Global Impression - Improvement (CGI-I) indicated that 89.7% (26/29) of participants experienced improvement at 3 months. No serious adverse events were reported.

Conclusion

Cryoablation at both the middle meatus and inferior meatus appears to be a safe and feasible option for treatment of chronic rhinitis. In this feasibility study, there is significant improvement in symptoms post treatment. Adverse events are minor and transient.

Predictors of rhinorrhea response after posterior nasal nerve cryoablation for chronic rhinitis

BACKGROUND

Posterior nasal nerve (PNN) cryoablation has shown promise in improving rhinorrhea due to allergic and nonallergic rhinitis (NAR). Early case series have shown meaningful clinical improvement in 75-80% of patients, but variables predicting PNN cryoablation success have not been studied. The purpose of this study was to evaluate whether disease features and ipratropium nasal spray response predicted rhinorrhea response after PNN cryoablation.

METHODS

A multi-institutional retrospective case-control study of 55 patients who underwent PNN cryoablation for bilateral rhinorrhea due to allergic, nonallergic, or mixed rhinitis was conducted at 3 tertiary medical centers. Patients received a 1-month trial of ipratropium spray. Runny Nose Scores (RNSs) of 0-5 from the 22-item Sino-Nasal Outcome Test were collected prospectively, before and after PNN cryoablation.

RESULTS

The mean age of subjects was 55.3 years and 54.6% were women. Mean follow-up was 170 days. NAR comprised 62% of patients. Of the 48 patients who trialed ipratropium spray, 33 (69%) had some response and 15 (31%) had no response. Mean overall preprocedural RNS was 4.2 ± 1.0. After PNN cryoablation, there was a ≥1-point decrease in RNS in 39 patients (71%). Only ipratropium spray (INS) response predicted cryoablation success. For ipratropium spray responders, 28 of 33 (85%) had improved RNS after cryoablation, whereas 5 of 15 (33%) nonresponders improved (p = 0.001).

CONCLUSION

In chronic rhinitis patients, rhinorrhea response to ipratropium was predictive of rhinorrhea improvement after PNN cryoablation. This study has important implications for preoperative counseling and guiding patient expectations when considering PNN cryoablation.

Laser ablation of posterior nasal nerves for rhinitis

BACKGROUND

Posterior nasal nerve (PNN) surgery, Radiofrequency (RF), and cryoablation have been described as alternative treatments for allergic and vasomotor rhinitis. We hypothesize that endoscopic (diode) laser ablation (ELA) is effective and less invasive than previously described methods.

METHODS

An IRB approved prospective study was performed. Thirty-two patients with chronic rhinitis and nasal congestion resistant to medical management were recruited. Total Nasal Symptom Score (TNSS) measurements were used to assess symptom severity and treatment outcomes. ELA was performed bilaterally in the clinic with a 940 nm diode laser with CW 5 W output, under topical/local anesthesia in 21 patients, while the remaining 11 were treated under sedation in the operating room. The 400-micron uninitiated diode laser fiber tip with a malleable protective shaft was specially designed for PNN ablation. The fiber was pre-shaped according to the intranasal anatomy and endoscopically advanced toward the posterior middle meatus. Patients were followed up for the first 90 days after treatment.

RESULTS

ELA was successfully completed in 97% of patients. No crusting, epistaxis, or other complications were observed. One patient could not be treated in the office due to limited endoscopic access. TNSS was reduced significantly after30 and 90 days (mean ± SD: 6.0 ± 0.7 prior to ablation, 2.3 ± 0.4 at 90 days, p < .001). Rhinitis and congestion scores decreased at 30 and 90 days after treatment compared to the baseline (p < .001).

CONCLUSION

ELA of the PNN region is safe and well tolerated both in the office and ambulatory settings. Symptom scores were significantly decreased after 30 and 90 days. This new minimally invasive method appears to be a promising treatment method.

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