Rhinitis medicamentosa: therapeutic effect of diode laser inferior turbinate reduction on nasal obstruction and decongestant abuse

Office-based blue laser therapy for inferior turbinate hypertrophy: a pilot study

PURPOSE

To investigate the subjective effect of office-based blue laser therapy for inferior turbinate hypertrophy in patients with nasal obstruction.

METHODS

Patients with nasal obstruction who underwent office-based blue laser for the inferior turbinate hypertrophy between October 2022 and December 2023 were included in the study. The two outcome measures used to gauge the improvement in nasal obstruction and success of surgery were the Nasal Obstruction Symptom Evaluation (NOSE) scale and the Visual Analogue Scale (VAS). Patient's level of comfort during the procedure was also rated using a 10-point VAS scale.

RESULTS

A total of 14 patients were included in this study. The mean age of the study group was 41.47 ± 18.52 and the F/M ratio was 4.67. All patients reported significant improvement in nasal breathing. The mean NOSE score decreased significantly from 13.07 ± 3.89 pre-operatively to 2.64 ± 2.43 post-operatively (p = 0.002). Similarly, the mean VAS score decreased from 7.43 ± 0.85 to 2.0 ± 1.57 (p = 0.002) following surgery. The procedure was well-tolerated by all participants and the mean total score ranged from 6 to 9 with an average of 7.59 ± 1.34.

CONCLUSION

Office-based blue laser therapy for inferior turbinate hypertrophy may be an effective treatment modality for nasal obstruction from the patient's perspective. Although the procedures were tolerated well with no complications noted, these results should be cautiously interpreted until studies using objective measures are conducted.

Long-term treatment outcomes in refractory rhinitis medicamentosa managed with nasal surgery

BACKGROUND

Limited treatment options exist for refractory Rhinitis Medicamentosa (RM). The role of surgery after failed medical management is not well defined. Mucosal contact points and restricted airflow often perpetuate decongestant use. This study assessed the long-term outcomes of nasal surgery in patients with refractory RM.

METHODS

A prospective cohort study of refractory RM treated with nasal surgery was performed with ≥12 months follow-up. Refractory RM was defined as nasal decongestant use once per day continuously for ≥4 weeks despite medical therapy. Patients with concomitant sinus disease and nonrhinitis conditions were excluded. Sinonasal Outcome Test (SNOT22), Nasal Symptom Score (NSS), and nasal medication use were assessed. Patients who ceased decongestants were compared with ongoing users.

RESULTS

A total of 56 patients (age 48.4 [5.0] years, 50% female) were assessed. Median follow-up was 3.4(1.6-6.2) years. Total cessation of decongestants was achieved in 91.1%, while 5.4% had intermittent use, and 3.6% reported daily use. Ongoing users had higher odds of concomitant asthma (40.0% vs. 3.9%; odds ratio [OR], 16.33 [1.7-159.75]; p = 0.036), reduced symptom improvement (ΔSNOT22, -4.6 [15.7] vs. 27.1 [17], p = 0.009 and ΔNSS, -1.0 [4.2] vs. -6.6 [5.1], p = 0.025), and greater ongoing use of nasal corticosteroid (60.0% vs. 5.9%; OR 24.0 [2.8-203.1]) and saline sprays (40% vs. 3.9%; OR 16.3 [1.7-159.8]) but showed no difference in allergy status (OR, 0.7[0.1-7.1]), previous surgery (OR, 1.0[0.1-10.2]), gastroesophageal reflux (OR 1.0[0.1-10.2], or underlying anxiety/depression (OR 6.1[0.8-45.9]) compared with those who ceased.

CONCLUSION

Surgically re-establishing a nasal airway was associated with long-term decongestant cessation and symptom improvement in medically refractory RM.

Rhinitis medicamentosa - comparing two treatment strategies: a retrospective analysis

OBJECTIVE

Rhinitis medicamentosa poses a therapeutic challenge for both patients and physicians. Treatment strategies vary, starting with avoidance of decongestants, followed by medications or surgical intervention. This study aimed to compare two treatment strategies for this condition.

METHODS

A review was conducted of patients diagnosed with rhinitis medicamentosa from 2013 to 2021, who were managed conservatively with medications or surgically by inferior turbinate reduction.

RESULTS

Forty-seven patients were included: 21 patients were treated conservatively and 26 underwent turbinate reduction. Following surgical therapy, the frequency of using decongestants was significantly reduced (p < 0.001), with a significant improvement in Sino-Nasal Outcome Test-22 scores (p < 0.001). The conservative treatment group was significantly older with more co-morbidities. Following medical therapy, the conservative treatment group had a significant decrease in the frequency of decongestant use, but there was no significant improvement in their Sino-Nasal Outcome Test-22 scores.

CONCLUSION

Compared to conservative treatment, inferior turbinate reduction for rhinitis medicamentosa resulted in reduced decongestant use and improved quality of life.

Comparison of efficacy of potassium titanyl phosphate laser & diode laser in the management of inferior turbinate hypertrophy: A randomized controlled trial

Background & objectives:

Inferior turbinate hypertrophy (ITH) is a common condition causing nasal obstruction. This study was undertaken to compare the efficacy of potassium titanyl phosphate (KTP) laser and diode laser in the reduction of the turbinate size.

Methods:

This randomized controlled trial included 209 patients with ITH. Pre-operative symptoms were assessed based on the Nasal Obstruction Symptom Evaluation (NOSE) score. Diagnostic nasal endoscopy was done to rule out other nasal sinuses. Nasal mucociliary clearance was measured by saccharin transit time (STT). Postoperatively, the NOSE score, STT and complications were assessed at days one and two, at one week, one month and three months.

Results:

Of the 209 patients analyzed at day one, the median NOSE score was 50 in the diode group and 40 in the KTP group, and at three months, 15 in the diode group and five in the KTP group. KTP laser showed a 93 per cent improvement in the NOSE score as compared to 77 per cent improvement shown by diode laser group. Among the intra-operative complications, of the 104 patients in the diode group, 6.73 per cent had burning sensation and 91.43 per cent had bleeding, and of 105 patients in the KTP group, 54.29 per cent had burning sensation and 36.54 per cent had bleeding. Among the post-operative complications in the KTP group, 32 and 34 per cent had bloody nasal discharge on days one and two, compared to 12 and 14 per cent in diode group. Crusting was present in 61 and 49 per cent on days one and two in KTP group as compared to 9 and 15 per cent in diode group, respectively. In the KTP group 30 per cent had synechiae as compared to 10 per cent in diode group.

Interpretation & conclusions:

KTP laser was more efficacious than diode laser in improving the NOSE scores but with slightly increased rate of complications in early post-operative period. Both the lasers impaired the mucociliary clearance mechanism of the nose till three months of post-operative follow up.

Surgical Treatment for the Refractory Allergic Rhinitis: State of the Art

Nasal obstruction is a frequent disorder that interferes with the daily patient’s quality of life. The key element in the pathophysiology of the disorder is the inferior turbinate hypertrophy related to multiple conditions such as allergic rhinitis (AR). Many patients are managed using conventional drug therapies such as antihistamines, decongestants, and intranasal steroid sprays, anticholinergic agents, mast cell stabilizers, and desensitizing vaccines. When traditional therapy failed to relieve AR symptoms, surgical inferior turbinate reduction (ITR) is indicated. A vast variety of surgical techniques have been reported in the literature for AR such as resectioning, coagulating, and laser procedures. We aimed to revise all surgical options in AR management. We confirm that no ideal standard technique for turbinate reduction has been developed so far regarding the multitude of different surgical procedures. Furthermore, no prospective and comparable long-term studies are present in the literature; it is challenging to recommend evidence-based surgical techniques.

[Rhinitis medicamentosa]

One type of non-allergic non-infectious rhinitis is represented by a heterogeneous group of rhinitis medicamentosa, which can be divided into several pathogenetic types. The most common rebound nasal congestion associated with the use of topical decongestants. Excessive use of intranasal decongestants leads to a decrease in the number of alpha-adrenoreceptors on the surface of cell membranes and uncoupling their connection with the G-protein and the development of tachyphylaxis. To prevent the development of rebound nasal congestion caused by topical decongestants, it is important to limit the frequency of their use. In most cases, the duration of the use of vasoconstrictor drugs should be limited to 5-7 days, according to Patient information leaflets for the drugs. However, in patients who have had a history of episodes of rebound nasal congestion, which develops including the previously indicated periods, the duration of decongestant therapy should be limited to 3 days. Rhinitis associated with local inflammation is caused by the intake of acetylsalicylic acid (ASA) or other non-steroidal anti-inflammatory drugs. Currently, the so-called "aspirin triad" is well known - a combination of bronchial asthma, rhinosinusitis (often polyposis) and intolerance to ASA. Neurogenic rhinitis develops due to the use of drugs that violate vascular tone, for example, antihypertensive drugs or type 5 phosphodiesterase inhibitors. Drug-induced rhinitis has a significant impact on the patient's quality of life: nasal congestion, rhinorrhea, secondary night apnea, insomnia as a result of nasal breathing disturbances, headaches, irritability, weakness after sleepless nights disturb patients to a large extent. Timely diagnosis and withdrawal of a provocative drug, the use of topical corticosteroids in case of severe rhinitis are the basis of the treatment of rhinitis medicamentosa. In severe cases, there is a need, including surgical treatment, such as, for example, submucosal laser destruction of the lower nasal concha.

Rhinitis medicamentosa: a nationwide survey of Canadian otolaryngologists

Background

Rhinitis medicamentosa is a non-allergic form of rhinitis that is typically caused by prolonged use of topical nasal decongestants. This condition commonly affects young adults and treatment is not trivial. We aimed to survey Canadian Otolaryngologists to determine practice patterns and their opinions regarding this under-studied condition.

Methods

An electronic survey was sent to practicing Otolaryngologists within the Canadian Society of Otolaryngology – Head and Neck Surgery. The survey contained 16 questions pertaining to the diagnosis and treatment of rhinitis medicamentosa, as well as opinions on public and primary care awareness of proper use of nasal decongestants.

Results

The survey was distributed to 533 Otolaryngologists and 69 surveys were returned (response rate of 13%). Cessation and weaning of decongestant (96%), and intranasal steroids (94%) were the most common methods for treating RM. Intranasal saline rinses (55%) and oral steroids (25%) were also supported by some respondents. For those who recommended cessation/weaning, 61% also concurrently introduced an intranasal steroid during this process. The majority responded that current warnings on nasal decongestants were inadequate (75%), and were not visible enough (79%).

Conclusions

Rhinitis medicamentosa is a common, and very preventable condition. Although the literature lacks a standardized approach to RM, our survey has shown that many Otolaryngologists diagnose and treat RM in a similar manner. Treatment tends to focus on decongestant cessation, often with concurrent introduction of intranasal steroids. It was felt the warning labels on the topical medications are not currently satisfactory.

Management of Rhinitis Medicamentosa: A Systematic Review

OBJECTIVE

Rhinitis medicamentosa (RM) is a common condition resulting from overuse of topical nasal decongestants. Despite the prevalence in otolaryngologic practice, a clear treatment protocol has not been established. Our objective was to review the current published literature pertaining to the treatment of RM with the possibility of finding data that support one treatment over another.

DATA SOURCES

PubMed, Embase, Cochrane, and Web of Science databases were examined for patients diagnosed with RM resulting from chronic use of topical nasal decongestants.

REVIEW METHODS

The PRISMA standard (Preferred Reporting Items for Systematic Reviews and Meta-analyses) was utilized to identify English-language studies reporting treatment of patients with the primary diagnosis of RM after chronic use of a topical decongestant. Outcome measures of interest included patient-reported symptom relief and objective parameters. MINORS criteria (methodological index for nonrandomized studies) were used to assess the quality of articles.

RESULTS

A total of 350 articles were identified, 9 of which met final inclusion criteria for qualitative analysis. Outcomes defined in each publication were highly varied and relied on several unstandardized measures. The most commonly reported treatment option was topical nasal steroids, although overall there was limited evidence on which to base treatment recommendation.

CONCLUSIONS

There is not adequate evidence to develop a standardized treatment protocol for RM. The development of a uniform questionnaire, standard outcomes to be measured, and a method of assessing such outcomes is necessary. Prospective randomized controlled studies are warranted to determine the optimal treatment regimen following diagnosis of RM.

Three different turbinoplasty techniques combined with septoplasty: Prospective randomized trial

OBJECTIVES/HYPOTHESIS

Septal deviation and hypertrophic inferior turbinates are a frequent cause of nasal breathing disorders. The goal of this study was to prove the effectiveness and safety of three current turbinoplasty techniques.

STUDY DESIGN

This is a prospective, three-arm, single-blinded, single-center, randomized controlled trial.

METHODS

Sixty patients were randomly assigned to either anterior turbinoplasty (ATP) (n = 20), radiofrequency ablation (RFA) (n = 19; Celon Pro Breath), or novel submucous radial diode laser ablation (DLA) (n = 21; ELVeS Radial PainLess, wavelength = 1,470 nm), each in combination with standard septoplasty. Acoustic rhinometry, rhinomanometry, subjective nose questionnaire, and saccharin test served as outcome parameters for preoperative and 3-month, 1-year, and 2-year postoperative examinations.

RESULTS

After 3 months 47/60 patients were evaluated, 28/60 patients were evaluated after 1 year, and 26/60 patients were evaluated in the 2-year follow-up visit. An improvement of nasal breathing was observed in all three groups in all follow-up visits. The increase of endonasal volume 2 (volume between the nasal valve and body of the inferior turbinate) was statistically significant in the ATP and RFA group after 3 months and 2 years, and in the RFA group also after 1 year. The DLA group failed to reach significance level in all follow-up visits. Subjective evaluation of nasal breathing improved in all three groups.

CONCLUSIONS

In this trial, three different current techniques of turbinate surgery in combination with standard septoplasty were effective for the improvement of nasal breathing. The ATP and RFA techniques were more effective in the long term than DLA.

LEVEL OF EVIDENCE

1b. Laryngoscope, 2016 127:303-308, 2017.

Low level laser therapy for patients with cervical disk hernia

BACKGROUND AND AIMS

In previous studies we have reported the benefits of low level laser therapy (LLLT) for chronic shoulder joint pain, elbow, hand and finger pain, and low back pain. The present study is a report on the effects of LLLT for chronic neck pain.

MATERIALS AND METHODS

Over a 3 year period, 26 rehabilitation department outpatients with chronic neck pain, diagnosed as being caused by cervical disk hernia, underwent treatment applied to the painful area with a 1000 mW semi-conductor laser device delivering at 830 nm in continuous wave, 20.1 J/cm(2)/point, and three shots were given per session (1 treatment) with twice a week for 4 weeks.

RESULTS

1. A visual analogue scale (VAS) was used to determine the effects of LLLT for chronic pain and after the end of the treatment regimen a significant improvement was observed (p<0.001). 2. After treatment, no significant differences in cervical spine range of motion were observed. 3. Discussions with the patients revealed that in order to receive continued benefits from treatment, it was important for them to be taught how to avoid postures that would cause them neck pain in everyday life.

CONCLUSION

The present study demonstrates that LLLT was an effective form of treatment for neck and back pain caused by cervical disk hernia, reinforced by postural training.

Diode laser treatment of hypertrophic inferior turbinates and evaluation of the results with acoustic rhinometry

Inferior turbinate hypertrophy is the most common cause of chronic nasal obstruction. When conservative medical treatment options fail in patients with inferior turbinate hypertrophy, reduction of the inferior turbinate can be performed using surgical techniques. Laser-assisted turbinate surgery has the advantages of limited tissue trauma and reduced bleeding. We evaluated the effectiveness and outcomes of using a diode laser (λ = 980 nm) in turbinate reduction. Our study included 62 patients with symptoms of nasal obstruction due to hypertrophic inferior turbinates, who did not respond to medical treatment (≥ 1 year). Patients were treated with diode laser between January 2009 and December 2010 in our ENT (ear, nose, and throat) department. Subjective outcome of severity of nasal obstruction was assessed on a standard 10-cm visual analog scale (VAS). Acoustic rhinometry was used to measure nasal patency. The cross-sectional areas 1, 2, and 3 and the volumes between 2.5 and 5.5 cm were measured. VAS scores and acoustic rhinometry measurements were performed preoperatively and 1, 6, and 12 months after surgery. The mean follow-up was 13.1 ± 1 months. The mean operation time was 3 min per turbinate; no nasal packing was necessary. We did not observe any major complications. Both subjective and objective evaluations showed significant improvement. VAS scores improved, the mean MCA2, MCA3, and V2-5 measurements increased significantly 1 year after surgery. In the first year after surgery, 53 of 62 (85.4%) patients reported marked improvements in nasal breathing. Our results showed that, objectively and subjectively, the success rates in diode laser-assisted turbinate reduction were satisfactory. The diode laser, being one of the most portable and least expensive of the lasers available for turbinate surgery, makes it possible for turbinate reduction to be performed under topical anesthesia within a short period of time with excellent patient acceptance.

Effect of laser treatment on olfactory dysfunction

Olfactory disorders are not rare and affect quality of life in patients. The purpose of our study was to evaluate the outcomes of an outpatient-based diode laser inferior turbinate reduction (ITR) in otherwise therapy-refractory olfactory disorder. In a prospective clinical investigation, 20 patients (7 male, 13 female, mean age 53.2 ± 15.34) with olfactory disorder and 10 patients (8 male, 2 female, mean age 52.5 ± 17.55) without olfactory disorder underwent ITR under videoendoscopic control with a continuous diode laser in "contact" mode after topical anesthetic preparation. Treatment efficiency was assessed before and 2 months after surgery. Subjective nasal airflow (NA) and the olfactory function were rated by means of visual analogue scales (VAS). Olfactory function was assessed using the "Sniffin' Sticks" test battery. VAS showed very low median values for intraoperative pain (0) [0-1.20] and high postoperative patient satisfaction (8) [5-9]. After 2 months there was no significant improvement of objective olfactory function as measured by the TDI score (threshold, discrimination and identification). The VAS displayed a slight significant improvement in the group of patients with olfactory disorder from 2.95 to 3.65 (P = 0.04). After 2 months, NA data revealed a statistically significant improvement of subjective VAS from 5.05 to 6.25 (P < 0.0005) and of objective NA from 353.77 to 443.50 (P = 0.007) as measured by rhinomanometry in both groups. Outpatient diode laser ITR represents an effective option providing recovery by NA improvement but not a significant improvement of the olfactory function.

Surgery of the turbinates and "empty nose" syndrome

Surgical therapy of the inferior and/or middle turbinate is indicated when conservative treatment options have failed. The desired goal is a reduction of the soft tissue volume of the turbinates regarding the individual anatomic findings, whilst simultaneously conserving as much mucosa as possible. As the turbinates serve as a functional entity within the nose, they ensure climatisation, humidification and cleaning of the inhaled air. Thus free nasal breathing means a decent quality of life, as well.Regarding the multitude of different surgical techniques, we confirm that no ideal standard technique for turbinate reduction has been developed so far. Moreover, there is a lack of prospective and comparable long-term studies, which makes it difficult to recommend evidence-based surgical techniques. However, the anterior turbinoplasty seems to fulfil the preconditions of limited tissue reduction and mucosa-preservation, and therefore it is the method of choice today.Radical resection of the turbinates may lead to severe functional disturbances developing a secondary atrophic rhinitis. The "empty nose" syndrome is a specific entity within the secondary atrophic rhinitis where intranasal changes in airflow result in disturbed climatisation and also interfere with pulmonary function. Results deriving from an actual in vivo study of climatisation and airflow in "empty nose" patients are presented.

Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses

In this review, anatomy and physiology of the respiratory mucosa of nose and paranasal sinuses are summarized under the aspect of its clinical significance. Basics of endonasal cleaning including mucociliary clearance and nasal reflexes, as well as defence mechanisms are explained. Physiological wound healing, aspects of endonasal topical medical therapy and typical diagnostic procedures to evaluate the respiratory functions are presented. Finally, the pathophysiologies of different subtypes of non-allergic rhinitis are outlined together with treatment recommendations.

Endoscopic diode laser polypectomy and high-dose intranasal steroids in recurrent nasal polyposis

BACKGROUND

The aim of this clinical investigation was to determine the outcomes of an outpatient videoendoscopic diode laser polypectomy (DLPE) and subsequent topical high-dose corticosteroid application in chronic rhinosinusitis with recurrent nasal polyposis (NP).

METHODS

After ineffective revision sinus surgery and prolonged mometasone furoate application, 19 consecutive mild and moderate NP patients suffering from nasal obstruction (NO) and olfactory dysfunction (OD) were prospectively entered into the study to undergo DLPE under topical anesthesia. Beginning 1 week postoperatively, 250 microg of beclomethasone dipropionate aerosol spray (BDPAS) was self-administered into each nostril twice a day. Treatment efficacy was assessed after 1, 6, and 12 weeks and at quarterly long-term follow-ups based on objective parameters (videoendoscopic photodocumentation and rhinomanometry) and subjective evaluation of NO, OD, and satisfaction (visual analog scales [VASs]).

RESULTS

VASs indicated very low values for intraoperative pain and discomfort and high postoperative satisfaction. After 6 weeks, subjective and objective data revealed a significant improvement of NO and OD (p < 0.0005). Topical BDPAS application was well tolerated. At a median follow-up of 32 months (range, 1-4 years), 21% of the patients developed NP disappearance, 53% had a stable disease, and 26% had a progressive disease.

CONCLUSION

In therapy-refractory NP, endonasal DLPE represents a minimally invasive, symptom-oriented, safe and easily reapplicable outpatient treatment option that provides effective improvement of NO and OD. Compared with the pre-DLPE period, the proposed long-term quarterly follow-up combined with high-dose topical BDPAS application might reduce or delay the need for major surgery and appears to be suitable for disease control.