Quality-of-life impact after in-office treatment of nasal valve obstruction with a radiofrequency device: 2-year results from a multicenter, prospective clinical trial

Evaluating post-rhinoplasty nasal obstruction treatment: The efficacy of VivAer radiofrequency ablation

PURPOSE

Nasal obstruction is a prevalent issue affecting up to one-third of adults, often requiring surgical intervention. Low-temperature radiofrequency (RF) treatment, specifically VivAer, has emerged as a promising alternative, especially for the treatment of nasal valve collapse (NVC). However, its efficacy in patients with a history of rhinoplasty or nasal valve repair remains unexplored.

METHODS

A single-center retrospective chart review was conducted on 37 patients with a history of rhinoplasty or nasal valve repair who underwent VivAer RF treatment. Treatment outcomes were assessed using the Nasal Obstruction Symptom Evaluation (NOSE) scale. The primary outcome was defined as a decrease in NOSE score by at least one severity category or a 20 % reduction in total NOSE score.

RESULTS

The study found a statistically significant average reduction in NOSE score of 22.4 points or 36.6 %. Among patients with a positive treatment response (21 patients or 56.8 %), the average NOSE score reduction was 34.7 points or 55.6 %. Repeat RF treatment in non-responders resulted in a 50 % response rate. No significant difference was observed in treatment outcomes based on the type of prior rhinoplasty or NVC.

CONCLUSIONS

Temperature-controlled RF treatment with VivAer can effectively alleviate nasal obstruction in patients with a history of rhinoplasty or nasal valve repair, offering a viable alternative to revision surgery. The study also highlights the potential benefit of repeat RF treatment in non-responders. Further research, including randomized controlled trials, is needed to validate these promising results and expand the treatment options for this complex patient population.

Single-arm clinical trials: design, ethics, principles

Although randomised controlled trials are considered the gold standard in clinical research, they are not always feasible due to limitations in the study population, challenges in obtaining evidence, high costs and ethical considerations. As a result, single-arm trial designs have emerged as one of the methods to address these issues. Single-arm trials are commonly applied to study advanced-stage cancer, rare diseases, emerging infectious diseases, new treatment methods and medical devices. Single-arm trials have certain ethical advantages over randomised controlled trials, such as providing equitable treatment, respecting patient preferences, addressing rare diseases and timely management of adverse events. While single-arm trials do not adhere to the principles of randomisation and blinding in terms of scientific rigour, they still incorporate principles of control, balance and replication, making the design scientifically reasonable. Compared with randomised controlled trials, single-arm trials require fewer sample sizes and have shorter trial durations, which can help save costs. Compared with cohort studies, single-arm trials involve intervention measures and reduce external interference, resulting in higher levels of evidence. However, single-arm trials also have limitations. Without a parallel control group, there may be biases in interpreting the results. In addition, single-arm trials cannot meet the requirements of randomisation and blinding, thereby limiting their evidence capacity compared with randomised controlled trials. Therefore, researchers consider using single-arm trials as a trial design method only when randomised controlled trials are not feasible.

Effectiveness of temperature-controlled radiofrequency neurolysis of the posterior nasal nerve to treat chronic rhinitis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis evaluates the effect of TRNP on rhinitis-related symptoms.

METHODS

We reviewed studies retrieved from PubMed, SCOPUS, Embase, the Web of Science, and the Cochrane database to June 2023. Studies that evaluated quality-of-life and rhinitis-related symptom scores before and after treatment were analyzed, as was one sham-treatment-controlled study.

RESULTS

In total, 406 patients evaluated in five studies were analyzed. TRNP significantly improved rhinitis-related symptoms-congestion, itching, rhinorrhea, and sneezing-for up to 12 months after treatment, compared to before treatment. The most significant symptom decreases were those of rhinorrhea and nasal congestion. Rhinitis-related symptoms had improved significantly at 3 months after TRNP, compared to sham surgery. TRNP improved disease-specific quality-of-life scores on the Rhinoconjunctivitis Quality of Life Questionnaire at 6 months after treatment, compared to before treatment. The rates of clinical improvement in terms of all nasal symptoms (reduction > 30% from baseline) and in quality of life (minimal clinically important difference > 0.4) after TRNP were 79% and 84% respectively. There was no severe adverse event associated with either device use or the overall procedure.

CONCLUSIONS

TRNP treatment improved subjective symptoms related to rhinitis, especially rhinorrhea and nasal congestion, and also improved disease-specific quality-of-life scores.

Economic impact analysis of a minimally invasive temperature-controlled radiofrequency device versus nasal surgery for the treatment of nasal airway obstruction in the United States

OBJECTIVE

To determine the economic impact of a minimally invasive temperature-controlled radiofrequency (TCRF) device for treating nasal airway obstruction (NAO).

METHODS

A budget impact model was developed for two scenarios: a reference scenario of functional rhinoplasty surgery with concomitant septoplasty and inferior turbinate reduction (ITR) performed in the hospital outpatient department where TCRF is not an available treatment option and a new scenario consisting of in-office TCRF treatment of the nasal valve and ITR. A payor perspective was adopted with a hypothetical population plan size of one million members. Costs were estimated over a time horizon of 4 years. The eligible population included patients with severe/extreme NAO and nasal valve collapse (NVC) as the primary cause or significant contributor. Data inputs were sourced from targeted literature reviews. Uncertainty within the model structure and input parameters was assessed using one-way sensitivity analysis.

RESULTS

The introduction of a TCRF device resulted in population-level cost savings of $20,015,123 and per-responder average cost savings of $3531 through a 4-year time horizon due to lower procedure costs and complication rates of the device relative to the surgical comparator. Results were robust when varying parameter values in sensitivity analyses, with cost savings being most sensitive to the prevalence of NAO and estimated response rates to functional rhinoplasty and TCRF.

CONCLUSIONS

In patients with severe/extreme NAO, with NVC as the primary or major contributor, introducing TCRF with ITR as a treatment option demonstrates the potential for significant cost savings over functional rhinoplasty with septoplasty and ITR.

Effectiveness of Radiofrequency Device Treatment for Nasal Valve Collapse in Patients With Nasal Obstruction

OBJECTIVE

Internal nasal valve dysfunction is a prevalent cause of nasal obstruction. This systematic review, along with a Meta-analysis, evaluated the efficacy of temperature-controlled radiofrequency device (RFD) treatment in alleviating nasal obstruction by rectifying nasal valve collapse.

DATA SOURCES

A comprehensive review of studies retrieved from PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases (up to December 2022) was conducted.

REVIEW METHODS

We included studies that evaluated the quality of life and nasal obstruction scores before and after RFD treatment. In addition, sham-controlled studies were analyzed.

RESULTS

In total, 451 patients across 8 studies were included in the analysis. Patients who underwent RFD treatment reported a significantly enhanced quality of life 24 months after treatment compared to pretreatment scores. The rates of clinically improved states and positive responses regarding quality of life after treatment were 82% and 91%, respectively. Moreover, the disease-specific quality of life, as assessed by the Nasal Obstruction Symptom Evaluation score, significantly improved.

CONCLUSION

RFD may help improve nasal obstruction symptoms. Further randomized clinical studies on larger cohorts are essential to substantiate its efficacy in enhancing nasal valve function.

Repairing the Nose after Failed Minimally Invasive Procedures

Minimally invasive nasal procedures can be aimed at treating both functional and cosmetic problems. These procedures include lateral nasal wall implants, dermal fillers, thread lifting, and radiofrequency ablation. Though increasingly popular, nasal surgeons have limited data to draw from when faced with operating in a nose that has been altered by these techniques. In this article, best practice recommendations are described based on the available data for each of the techniques.

Temperature-controlled radiofrequency device treatment of septal swell bodies for nasal airway obstruction: An open-label, single arm multicenter study

BACKGROUND

Nasal airway obstruction (NAO) is a highly prevalent disorder. Septal swell body (SSB) hypertrophy is an often overlooked contributor to NAO. SSB treatment may relieve symptoms of NAO. The objective of this study was to assess the clinical use of a temperature-controlled radiofrequency (TCRF) device to treat SSBs to improve symptoms in adults with NAO.

METHODS

In this prospective, multicenter, open-label, single arm study, patients with severe or extreme NAO related to SSB hypertrophy received bilateral TCRF treatment in the SSB area. The primary endpoint was improvement in Nasal Obstruction Symptom Evaluation (NOSE) Scale scores from baseline to 3 months postprocedure. A subset of study patients underwent computed tomography (CT) imaging to evaluate posttreatment changes in SSB size.

RESULTS

Mean NOSE Scale scores significantly improved from 73.5 (SD 14.2) at baseline to 27.9 (SD 17.2) at 3 months postprocedure, a reduction of -45.3 (SD 21.4, 95% confidence interval [CI]: -50.4 to -40.1; p < 0.0001); the responder rate was 95.7% (95% CI: 0.88 to 0.99; p < 0.0001). CT evaluation at 3 months showed statistically significant reductions in the SSB with the greatest reduction in the middle thickness (mean change -3.4 [SD 1.8] mL, 95% CI: -4.0 to -2.8; p < 0.0001). Minimal adverse events with any relationship to the device or procedure were reported; none were serious in nature and no septal perforations occurred.

CONCLUSIONS

This study demonstrates that TCRF treatment of SSB hypertrophy is well tolerated and effective at reducing both SSB size and symptoms of NAO at 3 months posttreatment.

Prevalence and Identification of Nasal Airway Obstruction in Patients Presenting to Otolaryngology Clinics: Results From a Large Descriptive Practice Survey

Objective: Determine the prevalence of nasal airway obstruction (NAO) in patients presenting to general otolaryngology clinics using the Nasal Obstruction Symptom Evaluation Scale (NOSE) score as a screening tool. Study Design: The clinic staff at 149 otolaryngology specialty clinics geographically distributed in the United States administered the NOSE Scale assessment to 3533 patients presenting to the clinics over a period of 1 week, regardless of the reason for the visit. All patients completed the NOSE Scale score, and additional data were collected, including the primary reason for the visit. Demographic and patient characteristics were summarized using frequencies and percentages for categorical variables. Results: The overall mean NOSE Scale score for the 3533 patients surveyed was 37.6 (SD 31.5). A total of 37.4% (1320/3533) of surveyed patients, regardless of visit reason, had severe/extreme NAO symptoms. Overall, the most common visit reason category was "Other" (61.2%, 2162/3533), followed by "NAO" (22.6%, 798/3533) and "Sinus" (16.2%, 573/3533). The mean NOSE scores for patients in each of the visit categories were 23.4 (SD 25.9), 64.7 (SD 23.3), and 53.3 (SD 28.1); for "Other," "NAO," and "Sinus," respectively. Among the patients coming in with "NAO" or "Sinus" as a primary complaint, 76.2% (608/798) and 57.2.% (328/573) had severe or extreme NOSE scores. A total of 17.8% (384/2162) of patients coming in for "Other" reasons had NOSE scores indicating severe/extreme NAO symptoms. Conclusions: The findings of this large, descriptive otolaryngology practice survey found a high prevalence of moderate to severe/extreme NAO among patients presenting to otolaryngology practices. Incorporating assessments, such as the NOSE Scale score and other diagnostic practices into the patient intake workflow and assessments, could help identify symptomatic NAO patients that might otherwise be overlooked.

Functional nasal surgery in the office-based setting

Objective

Nasal obstruction is a very common problem often addressed by functional nasal surgery. Increasingly, these procedures are being performed in the office setting secondary to decreased down time, cost, and obviation of general anesthesia. Our goal with this review is to discuss how to appropriately select patients for office-based procedures, what procedures may be considered, and current outcomes with in-office functional nasal surgery.

Data Sources

PubMed, Scopus, Google Scholar.

Methods

Research databases were searched for articles discussing techniques for performing functional nasal surgery in an office setting, and outcomes of various in-office functional nasal procedures.

Results

Studies found and included in this review discuss many aspects of office-based functional nasal surgery, including practical points on patient selection and office set-up, what procedures can safely be performed, and outcomes of different techniques to address specific problems. Broadly, procedures amenable to performance in the office address the internal and external nasal valves, the nasal septum, and the inferior turbinates.

Conclusion

A wide range of techniques to aaddress the nasal valves, septum, and inferior turbinates can be performed in a safe and effective manner without the need for an operative suite.

Two-year outcomes of temperature-controlled radiofrequency device treatment of the nasal valve for patients with nasal airway obstruction

Background

The objective of this study was to evaluate long-term symptom improvements in patients with nasal airway obstruction (NAO) secondary to nasal valve collapse (NVC) following minimally invasive temperature-controlled radiofrequency (TCRF) treatment.

Methods

A prospective, single-arm, multicenter study in patients >18 years with NAO due to NVC. Inclusion criteria were response to nasal valve dilation (e.g., modified Cottle maneuver) and baseline Nasal Obstruction Symptom Evaluation (NOSE) Scale score ≥60. Patients were treated in the nasal valve region with a TCRF device and followed through 2 years. A responder was ≥20% reduction NOSE Scale score or ≥1 reduction in severity class.

Results

A total of 122 patients were treated and 91 reached 2 years. The mean baseline NOSE Scale score was 80.3 (95% CI, 78.1-82.6). The adjusted mean change in score at 2 years was -45.8 (95% CI, -53.5 to -38.1), p < 0.001; a 57.0% improvement. The 2-year responder rate was 90.1% (95% CI, 82.3%-94.7%). Significant and sustained symptom improvement was achieved in subpopulations based on sex, age, body mass index, baseline NAO severity, nasal surgery history, NVC mechanism, septal deviation, and other anatomic contributors of NAO. No serious adverse events with a relationship to the study device and/or procedure were reported.

Conclusions

Minimally invasive TCRF device treatment of the internal nasal valve for NAO is well tolerated and leads to significant and sustained improvement in NAO symptom severity through 2 years, including in patients with both static and dynamic NVC, septal deviation, turbinate enlargement, or prior nasal surgery.

Level of Evidence

2b.

Could the use of a new novel bipolar radiofrequency device (Aerin) improve nasal valve collapse? A systematic review and meta-analysis

BACKGROUND

Surgical treatment for nasal obstruction caused by nasal valve collapse requires a significant recovery period and risks of complications, while nasal dilators are uncomfortable. Recently, radiofrequency treatment of lateral walls has been used under local anesthesia as an office base surgery. This work aims to assess the efficacy of a new radiofrequency device, the Vivaer™ System (Aerin Medical, Sunnyvale, CA), to treat nasal obstruction through a systematic review and meta-analysis.

METHODS

Two researchers independently reviewed the literature up to December 2021. Studies on patients seeking treatment for nasal obstruction due to nasal valve collapse were included in the analysis.

RESULTS

Four studies (218 patients) met the inclusion criteria and treated the nasal valve regions bilaterally with the Aerin Medical Vivaer™ System. After the treatment, the NOSE score was reduced at three months postoperatively. Minor adverse events were reported in the included studies, and two showed no complications. None of the studies reported changes in the external appearance of the nose.

CONCLUSION

The radiofrequency treatment using the Vivaer device can be useful for treating nasal valve collapse, improving significantly subjective breathing symptom scores. Further studies on a large scale are needed to confirm these results.

A Comparison of Symptom Improvement and Outcomes After Septoplasty Alone Versus Septoplasty With Turbinoplasty

Background Various causes can lead to nasal obstruction, with the most frequent anatomical cause being deviated nasal septum. It seriously affects patients' quality of life. As a result, septoplasty is performed to enhance the nasal airways. This study aimed to compare the improvement of nasal symptoms following septoplasty with or without turbinoplasty and evaluate the surgical outcomes in both different groups. Methodology A retrospective study was conducted at a tertiary hospital among patients who had undergone septoplasty with or without turbinoplasty between 2020 and 2022. Data regarding demographics, clinical features, surgical data, and complications were collected from patient files. The Nasal Obstruction Symptom Evaluation (NOSE) scale score was assessed through structured interviews. Results In our analysis of 209 patients who underwent surgery for deviated nasal septum, septoplasty was done in 110 (52.6%) patients, whereas the remaining 99 (47.4%) underwent septoplasty with turbinoplasty. The mean NOSE score was found to be 32.94 ± 35.67%. Patients who underwent septoplasty alone significantly showed higher mean scores (56.36 ± 34.62%) compared to those who underwent septoplasty with turbinoplasty (11.14 ± 18.93%) (p < 0.001). The long-term complications showed revision surgery was done in 13 patients, which was comparatively more often done in patients who underwent a septoplasty. Other long-term complications were found to be significantly higher in patients who underwent septoplasty (76.9%) compared to those who underwent septoplasty with turbinoplasty (23.1%). Conclusions Patients who underwent additional turbinoplasty experienced an improvement in nasal symptoms than those who underwent septoplasty alone. In addition, more long-term complications were noted in patients who underwent septoplasty alone.

Minimally invasive nasal valve treatment

Nasal valve insufficiency can be addressed using endonasal and open structure surgical techniques. However, some patients may prefer or be better suited for minimally invasive techniques that allow for more expedient treatment in the clinical setting. Techniques include internal dilators, external dilators, suture suspension, lateral wall implants, and radiofrequency remodeling. Understanding the indications for each technique as well as the available evidence can help facial plastic surgeons assess the role of incorporating these techniques into the care of patients with nasal valve insufficiency.

Effect of Radiofrequency Neurolysis on the Symptoms of Chronic Rhinitis: A Randomized Controlled Trial

Objective

To determine the safety and efficacy of temperature-controlled radiofrequency (RF) neurolysis of the posterior nasal nerve (PNN) area for the treatment of chronic rhinitis.

Study Design

A multicenter, prospective, single-blinded, randomized controlled trial, in which the control arm underwent a sham procedure.

Setting

Sixteen otolaryngology centers.

Methods

Patients with 24-hour reflective Total Nasal Symptom Score (rTNSS) ≥6, including moderate to severe rhinorrhea and mild to severe congestion, were randomized 2:1 to active treatment of the posterior nasal nerve area with a temperature-controlled RF device or a sham procedure, with no RF energy delivery. The stylus was applied bilaterally to nonoverlapping areas of the posterior middle meatus and posterior inferior turbinate in each nostril in the region of the PNN. The primary endpoint was responder rate at 3 months, where a response was defined as ≥30% improvement (decrease) in rTNSS from baseline.

Results

Patients had a mean baseline rTNSS of 8.3 (95% CI, 7.9-8.7) and 8.2 (95% CI, 7.6-8.8) (P = .797) in the active treatment (n = 77) and sham control (n = 39) arms, respectively. At 3 months, responder rate was significantly higher in the active treatment arm: 67.5% (95% CI, 55.9%-77.8%) vs 41.0% (95% CI, 25.6%-57.9%) (P = .009). The active treatment arm had a significantly greater decrease in rTNSS (mean, −3.6 [95% CI, −4.2 to −3.0] vs −2.2 [95% CI, −3.2 to −1.3]) (P = .013). Three adverse events related to the device/procedure were reported, and all resolved.

Conclusion

This randomized controlled trial showed temperature-controlled neurolysis of the PNN area is free from significant adverse events and superior to a sham procedure in decreasing the symptom burden of chronic rhinitis.

Temperature-controlled radiofrequency device treatment of the nasal valve for nasal airway obstruction: A randomized controlled trial

Background

Nasal valve collapse is one of several causes of nasal obstruction. The safety and efficacy of a temperature‐controlled radiofrequency (RF) device for the treatment of the nasal valve for nasal airway obstruction (NAO) has been established in single‐arm studies. The objective of this trial was to compare active device treatment against a sham procedure (control).

Methods

In a prospective, multicenter, single‐blinded, randomized controlled trial (RCT), patients were assigned to bilateral temperature‐controlled RF treatment of the nasal valve (n = 77) or a sham procedure (n = 41), in which no RF energy was transferred to the device/treatment area. The device was applied to the mucosa over the lower lateral cartilage on the lateral nasal wall. The primary endpoint was responder rate at 3 months, defined as a ≥20% reduction in Nasal Obstruction Symptom Evaluation (NOSE)‐scale score or ≥1 reduction in clinical severity category.

Results

At baseline, patients had a mean NOSE‐scale score of 76.7 (95% confidence interval [CI], 73.8 to 79.5) and 78.8 (95% CI, 74.2 to 83.3) (p = 0.424) in the active treatment and sham‐control arms, respectively. At 3 months, the responder rate was significantly higher in the active treatment arm (88.3% [95% CI, 79.2%‐93.7%] vs 42.5% [95% CI, 28.5%‐57.8%]; p < 0.001). The active treatment arm had a significantly greater decrease in NOSE‐scale score (mean, −42.3 [95% CI, −47.6 to −37.1] vs −16.8 [95% CI, −26.3 to −7.2]; p < 0.001). Three adverse events at least possibly related to the device and/or procedure were reported, and all resolved.

Conclusion

This RCT shows temperature‐controlled RF treatment of the nasal valve is safe and effective in reducing symptoms of NAO in short‐term follow‐up.

Quality-of-life impact after in-office treatment of nasal valve obstruction with a radiofrequency device: 2-year results from a multicenter, prospective clinical trial

Background

Insufficiency of the nasal valve is increasingly being recognized as a cause of nasal airway obstruction. The condition is associated with many symptoms, including nasal congestion, sleep disturbance, snoring, and an overall decline in quality of life (QoL). An in‐office, minimally invasive radiofrequency treatment of the nasal valve has been associated with improved symptoms of nasal obstruction and patients’ QoL for a 6‐month period in a noncontrolled, prospective, single‐arm study. The purpose of this study was to determine whether the results achieved with radiofrequency treatment at 6 months would be sustained through 24 months.

Methods

Thirty‐nine adult patients from an original cohort of 49 patients with severe to extreme Nasal Obstruction Symptom Evaluation (NOSE) Scale scores and dynamic or static internal nasal valve obstruction as the primary or significant contributor to obstruction were studied. Patients received intranasal bilateral radiofrequency treatment in a clinical study with a follow‐up to 6 months, and were prospectively evaluated at 12, 18, and 24 months at 8 community‐based otolaryngology practices. The patient‐reported NOSE Scale score and 21 QoL questions were assessed.

Results

Clinically significant improvement from baseline in NOSE Scale score change demonstrated at 6 months (mean, 55.9; standard deviation [SD], 23.6; p < 0.0001) was maintained through 24 months (mean, 53.5; SD, 24.6; p < 0.0001). Responders (≥15‐point improvement) consisted of 92.3% of participants at 6 months and 97.2% at 24 months. Responses to the QoL questions also showed improvement in patients’ QoL.

Conclusion

Treatment of the nasal valve with an in‐office, transnasal temperature‐controlled radiofrequency procedure was associated with stable and lasting improvement in symptoms of nasal obstruction and QoL through 24 months in this noncontrolled, single‐arm study.