Two-Year Outcomes After Radiofrequency Neurolysis of Posterior Nasal Nerve in Chronic Rhinitis

OBJECTIVE

To assess the long-term safety and effectiveness of temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN), a minimally invasive treatment for chronic rhinitis.

METHODS

A prospective, single-arm study of 129 patients at 16 centers (United States, Germany) was conducted. Patient-reported outcome measures were the 24-h reflective total nasal symptom score (rTNSS) and mini rhinoconjunctivitis quality of life questionnaire (MiniRQLQ). Postnasal drip and cough symptoms were assessed using a 4-point scale.

RESULTS

The mean pretreatment rTNSS was 7.8 (95% CI, 7.5-8.1). The significant rTNSS treatment effect at 3 months (-4.2 [95% CI, -4.6 to -3.8]; p < 0.001) was sustained through 2 years (-4.5 [95% CI, -5.0 to -3.9]; p < 0.001), a 57.7% improvement. At 2 years, the proportion of patients with a minimal clinically important difference (MCID) of ≥30% improvement in rTNSS from baseline was 80.0% (95% CI, 71.4%-86.5%). Individual postnasal drip and cough symptom scores were significantly improved from baseline through 2 years. The proportion of patients who reached the MCID for the MiniRQLQ (≥0.4-point improvement) at 2 years was 77.4% (95% CI, 68.5%-84.3%). Of 81 patients using chronic rhinitis medications at baseline, 61.7% either stopped all medication use (28.4%) or stopped or decreased (33.3%) use of ≥1 medication class at 2 years. No device/procedure-related serious adverse events were reported throughout 2 years.

CONCLUSION

TCRF neurolysis of the PNN resulted in sustained improvements in chronic rhinitis symptom burden and quality of life through 2 years, accompanied by a substantial decrease in medication burden.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:2077-2084, 2024.

Sleep Subdomain of the Sinonasal Outcome Test as a Potential Screening Tool for Sleep Apnea in Chronic Rhinosinusitis

OBJECTIVES

Approximately 20% of patients with chronic rhinosinusitis (CRS) have comorbid obstructive sleep apnea (OSA). Patients with undiagnosed OSA are at high risk for perioperative complications. The Sinonasal Outcomes Test (SNOT-22) Questionnaire is commonly administered to CRS patients, whereas OSA screening tools are less routinely employed. This study compared SNOT-22 sleep subdomain (Sleep-SNOT) scores among non-OSA CRS versus OSA-CRS patients undergoing ESS, and assessed sensitivity, specificity, and diagnostic accuracy of the Sleep-SNOT for OSA screening.

METHODS

Retrospective review of patients that underwent endoscopic sinus surgery (ESS) for CRS from 2012 to 2021. Patients either carried a reported OSA diagnosis and completed the SNOT-22, or had undocumented OSA status and completed both STOP-BANG and SNOT-22. Demographics, questionnaire scores, and OSA status were collected. A receiver operating characteristic (ROC) curve assessed cutoff scores, sensitivity, and specificity of the Sleep-SNOT for OSA screening.

RESULTS

Of 600 patients reviewed, 109 were included. 41% had comorbid OSA. OSA patients had a higher BMI (32.1 ± 7.7 vs. 28.35 ± 6.7 kg/m² ; p = 0.02), Sleep-SNOT (21.96 ± 12.1 vs. 16.8 ± 11.2; p = 0.021) and STOP-BANG (3.1 ± 1.44 vs. 2.06 ± 1.27; p = 0.038) scores. A Sleep-SNOT score of 17.5 had a sensitivity of 68.9%, specificity of 55.7%, and diagnostic accuracy of 63% for OSA detection (p = 0.022).

CONCLUSIONS

Sleep-SNOT scores are greater for CRS-OSA patients. The Sleep-SNOT ROC curve demonstrates a high sensitivity, specificity, and accuracy for OSA screening in CRS patients. A Sleep-SNOT score of ≥17.5 should prompt further OSA evaluation. The Sleep-SNOT may be considered as a surrogate OSA screening tool when other validated tools are not employed.

LEVEL OF EVIDENCE

Retrospective chart review, Level 3 Laryngoscope, 2023.

Clinical and Quality of Life Outcomes Following Temperature-Controlled Radiofrequency Neurolysis of the Posterior Nasal Nerve (RhinAer) for Treatment of Chronic Rhinitis

Background

Temperature-controlled radiofrequency (TCRF) neurolysis of the posterior nasal nerve (PNN; RhinAer) is a minimally invasive treatment option for patients with chronic rhinitis.

Objective

To determine clinical outcomes and quality of life (QoL) following TCRF neurolysis of the PNN.

Methods

A prospective single-arm study of 129 patients with chronic rhinitis at 16 medical centers in the United States and Germany.

Results

The mean 24-h reflective total nasal symptom score (rTNSS) improved from 7.8 (95% CI, 7.5-8.1) at baseline to 3.6 (95% CI, 3.2-4.0) at 3 months and continued to improve to 2.9 (95% CI, 2.5-3.3) at 6 months (p < .001 comparing follow-up to baseline and p = .002 comparing 3 and 6 months). This represents 53.8% improvement over baseline at 3 months and 62.8% improvement at 6 months. Rhinorrhea, congestion, sneezing, and itching subscores and postnasal drip and cough scores were all significantly improved over baseline at both timepoints. At 3 months, 76.2% (95% CI, 68.1%-82.8%) of patients achieved a minimal clinically important difference of ≥30% improvement in rTNSS over baseline and the percentage was higher at 6 months (83.5% [95% CI, 75.8%-89.0%]). At 3 months, 80.3% (95% CI, 72.6%-86.3%) reported a minimal clinically important difference of ≥0.4-point improvement in the mini rhinoconjunctivitis quality of life questionnaire score, and the percentage was higher at 6 months; 87.7% (95% CI, 80.7%-92.4%). There were no serious adverse events with a relationship to the device/procedure reported through 6 months.

Conclusion

In this large, multicenter study, TCRF neurolysis of the PNN was safe and resulted in a significant reduction in rhinitis symptom burden at 3 months that was sustained/improved through 6 months. The majority of patients reported a clinically relevant improvement in QoL at 3 and 6 months postprocedure.

The association of asthma, nasal allergies, and positive skin prick tests with obesity, leptin, and adiponectin

BACKGROUND

Cross-sectional and longitudinal reports show that obese adults have more asthma than non-obese adults. A proposed mechanism is via effects of adipokines (leptin and adiponectin) on the immune system.

OBJECTIVE

We wished to measure the associations of asthma and other atopic diseases with serum adipokine levels and to find whether the associations with asthma were strong enough to rule out the possibility that they are secondary to the association of fatness measures with asthma.

METHODS

The Global Asthma and Allergy Network of Excellence (GA(2) LEN) clinical follow-up survey is a clinical survey, embedded in a larger multi-centre cross-sectional postal survey, involving, with a case/control design, enrichment of the sample with subjects with asthma and chronic rhinosinusitis (CRS). We recorded serum leptin or adiponectin in 845 men and 1110 women in 15 centres and also anthropometric measures of fatness including body mass index and waist/hip ratio, current asthma, and specific skin prick and IgE sensitisation. We used inverse sampling-probability-weighted rank and regression statistics to measure population associations of disease outcomes with adipokines in males and females, adjusting for confounders (area, age, smoking history, and number of elder siblings) and also mutually adjusting associations with adipokines and fatness measures.

RESULTS

One thousand nine hundred and fifty-five subjects aged 16-77 years had information on leptin or adiponectin levels. Leptin and leptin/adiponectin ratio were positively associated with the level of asthma, especially in females (Somers' D of leptin by asthma score, 0.20; 95% CI, 0.08-0.30; P = 0.00079). These associations were attenuated after adjusting for confounders and became non-significant after additionally adjusting for fatness measures and multiple comparisons.

CONCLUSIONS AND CLINICAL RELEVANCE

Asthma levels are positively associated with serum leptin. However, we cannot rule out the possibility that this association is secondary to associations of both with fatness measures.

Nonallergic Rhinitis: Diagnosis and Management

Program Description:

Patients with nonallergic rhinitis (NAR) are commonly seen in an otolaryngologist’s practice. These patients may have no allergic triggers, may be negative to routine allergy testing, and are therefore diagnosed with NAR. Recent workgroups both in the United States and internationally have attempted to better classify the pathophysiology and phenotype of patients with NAR, with the goal of facilitating more accurate diagnosis and improved treatment. This panel will review, through brief didactic discussions and case presentations, recent knowledge and current understanding of NAR and will highlight methods to improve the management of these frequently challenging patients.

Educational Objectives:

(1) Discuss the various pathophysiologies and presentations that are grouped under the diagnostic category of nonallergic rhinitis. (2) Review important elements of the diagnostic workup in evaluating the patient with nonallergic rhinitis. (3) Implement treatment strategies for patients diagnosed with nonallergic rhinitis.

Facts and Fictions about Non-allergic Rhinitis

Program Description: Background: AAAAI set up a working group for non-allergic rhinitis (NAR) 2 years ago to describe established facts about NAR with the purpose of identifying gaps in our knowledge based on a comprehensive review of existing literature. Dr Toskala is a member of this working group and most of the review data is now available. Methods: A literature search spanning the years 1960-2010 was performed and articles relevant to NAR were assigned into 7 categories. Information from each article was extracted into category-specific databases. Descriptive analyses were conducted. Results: A total of 2000 articles were reviewed out of which 40% were deemed relevant for data extraction. Reviews were excluded. The majority of articles described prospective, controlled studies. Very few articles offered epidemiologic information. The lack of universal terminology and of NAR phenotyping using objective criteria were the most striking knowledge gaps. Pathophysiology research covered areas of nasal hyperreactivity and autonomic nerve dysfunction, but the evidence was inconclusive. The presence of mucosal inflammation may identify distinct NAR syndromes such as local allergy with local IgE production in the absence of systemic sensitization. Medical management studies suggest that intranasal steroids and topical antihistamines are useful in some patients with NAR, but the responder phenotype is unclear. In patients with excessive rhinorrhea, anticholinergic treatment is effective. The use of capsaicin is supported by one randomized, placebo-controlled trial. Few combination trials were found. Many surgical procedures were reviewed, but there are no randomized controlled trials comparing medical versus surgical treatments.

Educational Objectives: 1) Recognize, diagnosed and treat patients with NAR according to the evidence-based data. 2) Give a comprehensive review of published data about NAR with classification of the evidence. 3) Identify the gaps in our knowledge about NAR.

Inhalation challenge test in the diagnosis of occupational rhinitis

BACKGROUND

Evaluations of rhinitis reactions in inhalation challenges (ICs) are sparse compared with research on nasal challenges. This study evaluates the outcome of IC tests in assessing occupational rhinitis (OR). It presents the largest rhinologic IC data in the literature, analyzing the exposure method of various agents causing OR and their relation to asthma.

METHODS

Challenge tests performed on 829 individuals with suspected cases of OR were reviewed. Results from both exposures with occupational agents (n = 1229) and placebo (n = 838) were evaluated.

RESULTS

A total of 10% of the occupational ICs (n = 123) were positive, suggesting OR, and 13% (n = 161) showed asthmatic reaction in the same challenge. In control challenges 2% showed rhinitis and 6% showed asthma symptoms. The most common agents tested were molds (160 tests), flours, and animal fodders (115 tests) and formaldehyde (122 tests). Obeche wood dust and latex produced positive nasal reactions the most frequently, followed by acid anhydrides.

CONCLUSION

Although IC is a resource-intensive methodology, the evaluation of nasal symptoms and signs together with bronchial reactions saves time and expense compared with the organization of multiple individual challenges. We encourage the simultaneous evaluation of both nasal and bronchial reactions in IC tests.