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

Innovative surgical approaches for chronic rhinitis: nasal neurectomy mechanisms, techniques, and clinical outcomes

INTRODUCTION

Chronic rhinitis (CR) represents a prevalent, persistent inflammatory condition of the nasal mucosa, substantially impacting patients' quality of life. Despite standard pharmacotherapy, many patients with refractory symptoms do not achieve adequate relief, highlighting the need for alternative interventions such as nasal neurectomy.

AREAS COVERED

Literature was reviewed on the PubMed, EMBASE, and Web of Science databases published from March 1961 to April 2025. Our review discusses the underlying mechanisms, surgical techniques, and clinical outcomes of different nasal neurectomy approaches, including vidian neurectomy, vidian-branch neurectomy, and anterior ethmoidal neurectomy, as well as recent advancements in endoscopic and minimally invasive methods.

EXPERT OPINION

Nasal neurectomy presents a promising alternative for managing refractory CR by directly targeting the neuro-immune pathways that drive symptoms. Understanding the mechanisms, techniques, and clinical outcomes in nasal neurectomy will not only advance our insight into CR pathophysiology but also guide the development of refined, patient-specific surgical strategies for optimal outcomes.

Anatomy and Physiology of the Nasal Valves

The nasal valves are not simple, 2-dimensional cross-sections but rather a complex, 3-dimensional, collapsible, and heterogeneous structure. Historically, the internal nasal valve (INV) is defined by the septum medially, the caudal margin of the upper lateral cartilage laterally, and the inferior turbinate inferiorly. Typically located 1.3 cm deep into the nasal cavity, the INV angle delineated by the upper lateral cartilage and septum typically measures 10° to 15° in the Caucasian population. As computational methods reveal new insights into nasal valve function, a new conceptual framework is needed to guide rhinoplasty surgical decision-making.

In-office Posterior Nasal Nerve Ablation

Chronic rhinitis is a common condition affecting up to 60 million Americans each year. Posterior nasal nerve ablation has been shown to be an effective and safe treatment option for patients refractory to medical management for both allergic and nonallergic rhinitis. Currently, there are 3 commercially available devices, including 1 cryoablation and 2 radiofrequency ablation appliances that are all equally effective at decreasing symptoms and improving quality of life.

Posterior Nasal Nerve Neurolysis in Addition to Radiofrequency Ablation of the Inferior Turbinates for Patients with Chronic Rhinitis

INTRODUCTION

This study aimed to evaluate the outcome of radiofrequency ablation of the inferior turbinates (RFITs) combined with posterior nasal nerve neurolysis (RPN3) in comparison with RFIT alone in the treatment of patients with chronic rhinitis unresponsive to pharmacological therapy.

METHODS

A retrospective cohort study was conducted on adult and adolescent patients with chronic rhinitis who demonstrated a poor response to medication. Patients with a total 24-h reflective total nasal symptom score (rTNSS) of ≥5, rhinorrhea score of ≥2, and congestion score of ≥2 were included. The treatment outcomes of patients who underwent RPN3 and RFIT alone were assessed. The primary endpoint was the change from baseline in 24-h rTNSS, Nasal Obstruction Symptom Evaluation (NOSE) scores, and the response rate defined as rTNSS improved by ≧30% during follow-ups.

RESULTS

A total of 64 patients were included (45 males, 70.3%). Overall, 49 patients underwent RPN3, and 15 patients underwent RFIT alone. The rTNSS had improved by 78.4% and 65.8% in RPN3 and RFIT groups, respectively (both p < 0.001). The NOSE score had improved by 92.89% and 86.81% in the RPN3 and RFIT groups (both p < 0.001), respectively. Patients in the RPN3 group demonstrated statistically significantly better results after 3 months than patients in the RFIT alone group (p < 0.05). The response rate was 98% in the RPN3 group after 3 months.

CONCLUSIONS

The proposed RPN3 alleviated rhinitis symptoms, which demonstrated a high response rate with a superior symptom control rate than RFIT alone in chronic rhinitis with severe rhinorrhea and nasal congestion cases.

Clinical Outcomes of a Modified Technique Combining Submucosal Turbinectomy and Extended Neural Targeting in Chronic Rhinitis Management

BACKGROUND/AIM

This study evaluated the outcomes of combining submucosal turbinectomy with extensive disruption of the pterygopalatine ganglionic efferent nerve fibers through a minimucosal incision in patients with intractable rhinitis, irrespective of their dependency on the posterior nasal nerve.

PATIENTS AND METHODS

We describe an endoscopic extended neurectomy procedure performed via a minimucosal pocket. The primary outcome measures included the Total Nasal Symptom Score (TNSS), Visual Analog Scale (VAS) score, and runny nose and nasal obstruction subdomains of the Sino-Nasal Outcome Test-22 (SNOT-22), which were assessed pre-procedure and at 3 and 6 months post-procedure. The secondary outcomes included the incidence of adverse events and medication dependency.

RESULTS

Six patients with rhinitis [66.7% female, 66.7% allergic rhinitis, average age: 48.17 (26-69) years] received treatment and completed a 6-month evaluation, with a mean follow-up period of 16.5 (8-30) months. The modified technique significantly reduced VAS scores from 8.67±1.21 to 0.50±0.55 (p=0.035) and TNSS from 8.83±2.40 to 1.17±0.75 (p=0.031) at three months compared to baseline. These effects were sustained at six months (p=0.0335 and p=0.0355, respectively). The severity and frequency of rhinorrhea and nasal congestion showed marked improvement, as assessed by the TNSS and SNOT-22. None of the patients experienced severe post-procedural adverse events, and all ceased medication use at the last follow-up visit.

CONCLUSION

Transturbinectomy extended neurectomy based on surgical dissection is a feasible technique and could be considered as a potential alternative to standard treatments for patients with intractable rhinitis.

Clinical Outcomes After Innovative Multipoint Impedance-Controlled Radiofrequency Ablation of the Posterior Nasal Nerve for Treatment of Chronic Rhinitis

Objective: Chronic rhinitis substantially impacts a person's quality of life. We evaluated a novel, multipoint, impedance-controlled, radiofrequency ablation device for the treatment of chronic rhinitis. Methods: This was a prospective, multicenter, single-arm clinical study of posterior nasal nerve ablation in adults with chronic rhinitis. The primary efficacy endpoint was the change in reflective Total Nasal Symptom Score (rTNSS) at 6-month follow-up. Additional assessments included the Eustachian Tube Dysfunction Questionnaire (ETDQ-7), Nasal Obstruction Symptom Evaluation (NOSE), and mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini-RQLQ). The primary safety endpoint was the incidence of related serious adverse events. Results: Seventy-nine of 80 enrolled participants completed 6-month follow-up. Statistically significant improvements were observed for mean change in rTNSS (-4.2), ETDQ-7 (-1.2), NOSE (-33.5), and mini-RQLQ (-1.8; P < .0001 for all). Allergic and nonallergic rhinitis subgroups demonstrated significant improvement in all assessments (P < .0001) with no significant differences between subgroups. Higher baseline rTNSS was associated with greater improvements at follow-up. One serious adverse event of epistaxis was reported. Conclusions: The results of this study demonstrate the efficacy and safety of a multipoint, impedance-controlled, radiofrequency ablation device for the treatment of chronic rhinitis. Significant improvements were observed in rTNSS, ETDQ-7, NOSE, and mini-RQLQ assessments.Study registration: www.clinicaltrials.gov. Unique identifier NCT05591989.

Temperature-controlled radiofrequency ablation for the treatment of chronic rhinitis: Two-year outcomes from a prospective multicenter trial

BACKGROUND

Minimally invasive temperature-controlled radiofrequency (TCRF) ablation of the posterior nasal nerve (PNN) demonstrated a significant larger treatment effect on the symptom burden of chronic rhinitis patients than a sham control (no energy delivery) at the 3-month primary endpoint of this trial.

METHODS

Two-year posttreatment outcomes for patients treated in a prospective, multicenter, patient-blinded randomized controlled trial were determined by combining the index active treatment-arm and index control-arm crossover patients into a single group (after the primary endpoint) to evaluate the treatment effect durability and long-term effects on concomitant chronic rhinitis medication usage.

RESULTS

The mean baseline reflective total nasal symptom score (rTNSS) was 8.2 (95% confidence interval [CI], 7.9-8.6; N = 104). At 2 years (N = 79), the mean change in rTNSS was -5.3 (95% CI, -5.8 to -4.8; p < 0.001; 64.6% improvement). The 2-year responder rate (≥30% improvement in rTNSS) was 87.3% (95% CI, 78.0-93.8). All four components of the rTNSS (rhinorrhea, congestion, sneezing, and nasal itching) showed significant improvement over baseline, with rhinorrhea and congestion showing the most improvement. Postnasal drip and cough symptoms were also significantly improved. At 2 years, 81.0% (95% CI, 70.6-89.0) reported a minimal clinically important difference of ≥0.4-point improvement in the mini-rhinoconjunctivitis quality of life questionnaire score. Of 56 patients using chronic rhinitis medications at baseline, 25 of 56 (44.6%) either stopped all medication use (7/56 [12.5%]) or stopped/decreased (18/56 [32.1%]) use of ≥1 medication class at 2 years. No serious adverse events related to the device/procedure were reported over 2 years. To determine the potential effect of patients who left the trial over 2 years on the responder rate, the responder statuses of the 14 patients with follow-up data who were lost to follow-up/withdrew/died were imputed by the last observation carried forward and the responder statuses of all nine patients who had an additional nasal procedure were imputed to nonresponder, resulting in a 2-year responder rate of 79.4% (95% CI, 70.3-86.8).

CONCLUSION

TCRF ablation of the PNN is safe and resulted in a significant and sustained reduction in chronic rhinitis symptom burden through 2 years and a substantial reduction in concomitant medication burden.

Posterior Nasal Nerve Ablation as a Viable Treatment Option for the Primary Symptom of Postnasal Drip

BACKGROUND

Postnasal drip (PND) syndrome is a prevalent complaint encountered in otolaryngology practices. PND may be refractory to medical therapy, and surgical treatments are complicated by side effects.

OBJECTIVE

While posterior nasal nerve (PNN) ablation has demonstrated efficacy for chronic rhinitis overall, we sought to examine the effect of PNN ablation for patients with PND as their primary complaint.

METHODS

This is a retrospective case series study of 40 chronic rhinitis (CR) patients with a primary complaint of PND. Included patients had to have failed medical therapy such as anti-cholinergic nasal sprays, reflux treatments, and/or nasal steroids. Primary outcome measures included 22 item Sino-Nasal Outcome Test (SNOT-22) PND component and Total Nasal Symptom Score. Secondary outcome measure was subjective improvement, defined as a  > 30% improvement in PND symptoms.

RESULTS

Median follow-up was 138 days (interquartile range: 72-193). 72.5% (29/40) of patients reported at least a 30% improvement in PND symptoms. Mean PND SNOT-22 scores were 4.2/5 (SD = 0.8) pre-procedure versus 1.9/5 (SD = 1.3) post-procedure (P = .001). PNN ablation response did not correlate to ipratropium bromide nasal spray response, although younger and non-smoker patients had better response rates.

CONCLUSION

This exploratory study of PNN ablation for the primary symptom of PND demonstrates efficacy as assessed by the PND component of SNOT-22 and subjective improvement. These results can be useful in guiding physician-patient discussions in determining treatment options for medically refractory PND.

Long-term outcomes following impedance-controlled radiofrequency ablation for the treatment of chronic rhinitis

Objective

To assess long-term safety and effectiveness of a multipoint, impedance-controlled, RF ablation device for treatment of chronic rhinitis through 12-month follow-up.

Methods

A prospective, multicenter study. Bilateral posterior nasal nerve (PNN) ablation was performed on all participants. Assessments at 6-, 9-, and 12-month visits included Visual Analog Scale Nasal Symptom Score (VAS NSS), reflective Total Nasal Symptom Score (rTNSS), mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini RQLQ), and adverse events.

Results

Thirty-six participants were enrolled and 35 completed the 12-month follow-up. All 5 VAS NSS items demonstrated statistically significant improvement (p < .0001) over baseline at all 3 time points. The total rTNSS improved from 7.9 ± 1.8 at baseline to 4.3 ± 2.1 at 6-months, 3.8 ± 2.4 at 9-months, and 4.0 ± 2.1 at 12-months (all p < .0001). At 12-months, 91% (31/35) of participants had achieved the minimum clinically important difference (MCID) of a reduction from baseline of ≥1 point and 80% (28/35) of the participants met the responder criteria of ≥30% reduction from baseline. The total mean mini RQLQ was reduced from 3.0 ± 1.0 at baseline to 1.4 ± 0.8 at 6-months, 1.4 ± 1.0 at 9-months, and 1.3 ± 0.8 at 12-months (all p < .0001). At 12-months, 86% (30/35) of participants achieved the MCID of a reduction from baseline of ≥0.4 points for the mini RQLQ. No related serious adverse events occurred during the study.

Conclusions

Impedance-controlled RF ablation of the PNN is safe and resulted in durable, significant improvement in rhinitis symptoms and quality of life through 12-month follow-up.

Trial Registration

The study is registered at www.clinicaltrials.gov with the unique identifier of NCT05324397.

Level of Evidence

4.