Clinical Effect of Endoscopic Vidian Neurectomy on Bronchial Asthma Outcomes in Patients with Coexisting Refractory Allergic Rhinitis and Asthma

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.

The Clinical Efficacy and Safety of Endoscopic Vidian-Branch Neurectomy in Intractable Allergic Rhinitis

OBJECTIVE

Intractable allergic rhinitis (iAR) remains a clinical challenge. This study aims to evaluate the efficacy and safety of endoscopic selective vidian branch neurectomy for iAR.

STUDY DESIGN

A prospective clinical study.

SETTING

A tertiary referral center.

METHODS

A total of 205 iAR patients were initially recruited and divided into 3 groups: endoscopic vidian-branch neurectomy (EVBN), endoscopic vidian neurectomy (EVN), and conservative treatment (control). All patients were followed up for more than 2 years, and the efficacy and postoperative complications were compared.

RESULTS

After 2-year follow-up, a total of 195 patients were included, with 59 patients in EVBN group, 71 in EVN group, and 64 in control group. Post-treatment assessments at 6 months, 1 year, and 2 years revealed significant reductions in the total Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores and each domain in both EVBN and EVN groups compared to their baseline levels. However, no significant changes were observed in control group. Furthermore, the improvements in RQLQ 2 years post-treatment were higher in EVBN and EVN groups compared to control group. In EVBN group, only 3 (5.1%) patients reported mild eye dryness during the first month postoperation. However, in the EVN group, 15 (21.1%) patients experienced eye dryness, with 6 (8.5%) cases persisting for more than 1 year and remaining unresolved by the end of the 2-year follow-up.

CONCLUSION

Both EVBN and EVN were effective in iAR patients. However, EVBN appears to be a safer option, associated with fewer postoperative complications.

Long-term outcomes of functional endoscopic sinus surgery with selective vidian neurectomy for chronic rhinosinusitis with nasal polyps combined with allergic rhinitis and asthma

BACKGROUND

Patients with allergic rhinitis (AR), chronic rhinosinusitis (CRS) with nasal polyps (ARwCRSwNP), and asthma often exhibit high recurrence rates after functional endoscopic sinus surgery (FESS), sometimes requiring revision surgery. This study evaluated the long-term outcomes of combining FESS with selective vidian neurectomy in patients with ARwCRSwNP and asthma.

METHODS

Fifty-six ARwCRSwNP patients, including 27 with asthma, were divided into two groups: one received FESS with selective vidian neurectomy (group A), and the other underwent FESS alone (group B or control). Disease severity, control, and outcomes were evaluated using the Visual Analog Scale (VAS), the 22-item Sino-Nasal Outcome Test (SNOT-22), and the Lund-Kennedy score for nasal endoscopy. To assess factors influencing disease severity and treatment outcomes, we recorded allergy assessments (for mites, mold, and pollens), preoperative blood eosinophilia, and tissue eosinophil levels from histopathological examination following endoscopic surgery.

RESULTS

After three years, patients from both groups showed significant improvements in symptoms and quality of life compared to the preoperative period (p < 0.01). CRS patients with high tissue eosinophilic inflammation exhibited reduced disease control compared to those with controlled or partly controlled disease (p < 0.05). Patients in group A had better outcomes for nasal itching and sneezing compared to group B. While overall CRS control was similar between the two groups, group A demonstrated better CRS control among asthma patients (p < 0.05).

CONCLUSION

Combining FESS with selective vidian neurectomy effectively improves nasal symptoms in ARwCRSwNP patients and represents a beneficial treatment option for those with comorbid asthma.

Efficacy of vidian neurectomy in treating chronic rhinosinusitis with nasal polyps combined with allergic rhinitis: A systematic review and meta-analysis

OBJECTIVE

To evaluate the impact of additional vidian neurectomy or posterior nasal neurectomy in patients with chronic rhinosinusitis with nasal polyps (CRSwNP) and allergic rhinitis (AR), compared to the outcomes of conventional endoscopic sinus surgery alone.

METHODS

Up to May 2024, six databases were systematically searched. We evaluated studies that compared the clinical improvement of chronic sinusitis-related symptoms and endoscopic findings between the neurectomy group (endoscopic sinus surgery plus vidian neurectomy or posterior nasal neurectomy) and the control group (endoscopic sinus surgery only).

RESULTS

The neurectomy group showed a significant reduction in the Lund-Kennedy endoscopic score (SMD = -1.3163 [-1.6519; -0.9807]; I² = 53.3 %). However, this treatment did not have a significant effect on the Quality-of-life score (SMD = -0.1222 [-0.3427; 0.0983]; I² = 27.5 %) or patient-reported nasal symptom-related VAS scores (SMD = -1.6690 [-3.7062; 0.3682]; I² = 96.3 %). In the subgroup analyses of these results according to time points of measurement, the Lund-Kennedy endoscopic score was statistically lower in the treatment group during treatment periods (postop 6months, 12months, and 24months). However, there were no statistically significant differences in Quality-of-life score and VAS between the treatment and control groups during all treatment periods. There was no significant difference in the recurrent rate of CRS during the following up periods (odds ratio=0.5263 [0.1518; 1.8254], I2 = NA) between two groups. Regarding the adverse effect of neurectomy, this additional procedure did not induce the postoperative bleeding (odds ratio=0.8886 [0.3411; 2.3150]; I2 = 0.0 %) and dry eye related discomfort (odds ratio=65.3560 [0.1044; 40,908.1619]; I2 = 88.9 %) significantly compared to control group.

CONCLUSIONS

Additional neurectomy shows better efficacy in improving endoscopic findings and is safer in patients with CRSwNP combined with AR; however, more clinical studies are needed to evaluate its long-term symptomatic effects and disease recurrence.

Endoscopic vidian and vidian-branch neurectomy for refractory allergic rhinitis: A systematic review

BACKGROUND

Endoscopic vidian neurectomy is expected to provide good therapeutic relief in patients with allergic rhinitis (AR) being refractory to medication therapy or conservative surgery. However, the evidence bases for its benefit remain debatable. In this study, we conducted a systematic review and meta-analysis to clarify the therapeutic role of various forms of vidian neurectomy in refractory AR.

METHOD

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct a systematic review of primary studies that reported original patient data for endoscopic vidian neurectomy (EVN) and vidian-branch neurectomy, which includes selective vidian neurectomy (SVN) and posterior nasal neurectomy (PNN). The primary outcome was patient-reported outcome measures (PROMs), including the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Visual Analog Scale (VAS), to assess an improvement in nasal symptom severity and quality of patient's life. The incidence of surgical complications and other objective outcomes were considered secondary outcomes.

RESULTS

This review included 24 clinical studies involving 1677 patients with refractory AR, of which 510 patients in six studies had combined chronic rhinosinusitis with nasal polyps (CRSwNP) and 95 patients in one study had combined asthma. Postoperative PROMs were significantly better than preoperatively in almost all patients who underwent vidianp (RQLQ: standardized mean difference [SMD] = 2.66, 95% confidence interval [CI] = 2.40-2.92, p < 0.001; VAS: SMD = 5.15, 95% CI = 4.29-6.02, p < 0.001) or vidian-branch neurectomy (RQLQ in PNN: SMD = 3.29, 95% CI = 2.45-4.13, p < 0.001; VAS in PNN: SMD = 4.38, 95% CI = 3.41-5.34, p < 0.001), and were generally better than in the conservative treatment group. Dividing with 18 months as the cutoff point, a subgroup analysis of the follow-up period was conducted, and the results showed that both long-term and short-term postoperative patients had considerably reduced symptoms compared to the preoperative period. The two surgical procedures, SVN and PNN, attributed to vidian-branch neurectomy have extremely few complications. However, EVN is more likely to cause dry eyes and palatal numbness, with no other serious complications. In patients with AR and CRSwNP, vidian or selective vidian neurectomy combined with functional endoscopic sinus surgery (FESS) is more effective than conventional FESS (RQLQ: SMD = 2.17, 95% CI = 1.66-2.69, p < 0.001; VAS: SMD = 6.42, 95% CI = 4.78-8.06, p < 0.001). For patients who have both AR and asthma, SVN with pharyngeal branch excision is a potential treatment option.

CONCLUSION

EVN and vidian-branch neurectomy (including SVN and PNN) are effective treatments, but the former has a higher risk of complications. Additionally, vidian-branch neurectomy with FESS is beneficial for patients with mixed CRSwNP. SVN is a potential approach for patients with coexisting AR and asthma.

Neuroimmune communication in allergic rhinitis

The prevalence rate of allergic rhinitis (AR) is high worldwide. The inhalation of allergens induces AR, which is an immunoglobulin E-mediated and type 2 inflammation-driven disease. Recently, the role of neuroimmune communication in AR pathogenesis has piqued the interest of the scientific community. Various neuropeptides, such as substance P (SP), vasoactive intestinal peptide (VIP), calcitonin gene-related peptide (CGRP), nerve growth factor (NGF), and neuromedin U (NMU), released via "axon reflexes" or "central sensitization" exert regulatory effects on immune cells to elicit "neurogenic inflammation," which contributes to nasal hyperresponsiveness (NHR) in AR. Additionally, neuropeptides can be produced in immune cells. The frequent colocalization of immune and neuronal cells at certain anatomical regions promotes the establishment of neuroimmune cell units, such as nerve-mast cells, nerve-type 2 innate lymphoid cells (ILC2s), nerve-eosinophils and nerve-basophils units. Receptors expressed both on immune cells and neurons, such as TRPV1, TRPA1, and Mas-related G protein-coupled receptor X2 (MRGPRX2) mediate AR pathogenesis. This review focused on elucidating the mechanisms underlying neuroimmune communication in AR.

Surgical and instrumental options for chronic rhinitis: A systematic review and PRISMA meta-analysis

BACKGROUND

There is no consensus on the role of surgery in the treatment of chronic rhinitis (CR). Should it be considered when nasal symptoms are not controlled by medical treatment? Various targets (turbinates and secretory nerves) and techniques (surgical, laser, cryotherapy, radiofrequency and phototherapy) have been reported, but benefit varies between reports. The aim of this systematic review and meta-analysis was to evaluate results of surgical and instrumental procedures in CR care.

METHODS

Two systematic reviews of the US National Library of Medicine, Cochrane Library, Web of Science and Embase databases were conducted in October 15, 2021 (registration numbers CRD42021284257 and CRD42021295227). A database watch was performed until submission of the manuscript. The review focuses on total nasal symptom score (TNSS) and quality of life (QoL) after treatment. All controlled studies reporting nasal surgery/instrumental procedures in adult patients with CR were included.

RESULTS

The database search yielded a total of 5628 articles; after eligibility screening, 2091 patients were included from 21 studies. QoL results favored surgery/instrumental procedures over medical treatment (SMD -1.27; 95% CI [-2.38; -0.16]; I2=97%), as did TNSS (SMD -1.40; 95% CI [-2.30; -0.50]; I2=98%). The small number of studies and their heterogeneity did not allow meta-regression to be performed.

CONCLUSION

This systematic review supports the use of surgical/instrumental procedures to improve nasal symptom score and QoL of adult patients with CR poorly controlled by medical treatment.

Management of comorbidities in difficult and severe asthma

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

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.

Sixty cases of refractory allergic rhinitis treated by vidian trunk or branch neurectomy: A single-center observational study

To investigate the effect of vidian trunk neurectomy and selective vidian branch neurectomy on treating moderate-to-severe persistent allergic rhinitis. Sixty patients with moderate-to-severe persistent allergic rhinitis treated at Zhejiang Hospital of Integrative Medicine participated in this study from June 2018 to June 2020. The patients in the observation group (n = 40) underwent a vidian trunk neurectomy. The patients in the control group (n = 20) underwent a vidian branch neurectomy. The patients in both groups were followed up after 6 months, 1 year, and 2 years of surgery. The efficacy was evaluated based on the AR diagnostic and the efficacy assessment criteria. The 4 symptoms of sneezing, runny nose, nasal congestion, and nasal itch were scored as efficacy indices before and 6 months, 1 year, and 2 years after surgery. Nasal endoscopy or sinus CT was performed to assess the postoperative inferior turbinate swelling. The postoperative tear secretion was followed up in both groups, and patients with dry eyes were counted in combination with ocular symptoms. The data recorded before and after surgery and between the 2 groups were analyzed statistically. The observation group had signs of 2.73 ± 0.452 before surgery, 1.20 ± 0.405 6 months after surgery, 1.25 ± 0.494 1 year after surgery, and 1.30 ± 0.564 2 years after surgery. The control group had signs of 2.75 ± 0.444 before surgery, 1.45 ± 0.686 6 months after surgery, 1.75 ± 0.716 1 year after surgery, and 1.90 ± 0.852 2 years after surgery. The between-subjects effect test between the groups showed an overall significant difference (P < .05). The overall effective rate 2 years postoperatively was 38/40 (95.0%) in the observation group and 10/20 (50%) in the control group. Fisher's exact test showed a significant difference between the groups. No patient in either group had dry eyes 1.5 years after surgery. Both vidian trunk neurectomy and selective vidian branch neurectomy have good immediate therapeutic effects, and vidian trunk neurectomy has higher long-term efficacy than selective vidian branch neurectomy.

The long-term outcomes of posterior nasal neurectomy with or without pharyngeal neurectomy in patients with allergic rhinitis: a randomized controlled trial

INTRODUCTION

Allergic rhinitis is a form of IgE mediated inflammation of the nasal mucosa in response to specific allergens, resulting in typical symptoms.

OBJECTIVES

This study was designed with the primary goal of comparing the clinical efficacy of posterior nasal neurectomy with or without pharyngeal neurectomy for the treatment of moderate-to-severe perennial allergic rhinitis. Secondary study aims included a comparison of the severity of comorbidities, including chronic cough and asthma, between patients in these two surgical treatment groups.

METHODS

A total of 52 patients were enrolled in this randomized controlled trial and were assigned to either the control group (posterior nasal neurectomy) or the experimental group (posterior nasal neurectomy + pharyngeal neurectomy). The visual analog scale and rhinoconjunctivitis quality of life questionnaire were used to compare the differences in patient symptoms between baseline and 6-, 12-, and 24-months post-treatment. In addition, patient cough and asthma symptoms were monitored during follow-up via visual analog scale and asthma control test respectively.

RESULTS

No significant differences in preoperative scores were evident between groups (p > 0.05). At 6-months post-treatment, there were significant differences in visual analog scale, rhinoconjunctivitis quality of life questionnaire, and asthma control test scores relative to baseline values in experimental group and control group patients (p < 0.05), and this remained true upon 12- and 24-month follow-up. No significant differences in visual analog scale, rhinoconjunctivitis quality of life questionnaire, or asthma control test scores were observed between the two treatment groups at any postoperative follow-up time point (p > 0.05), while coughing severity was found to be significantly reduced in the experimental group relative to the control group (p < 0.05).

CONCLUSION

posterior nasal neurectomy can be safely implemented with or without pharyngeal neurectomy in order to effectively treat allergic rhinitis. Combined posterior nasal neurectomy and pharyngeal neurectomy treatment may offer greater value than posterior nasal neurectomy alone for the treatment of allergic rhinitis patients with chronic cough.

Identification of Novel Biomarkers for Evaluating Disease Severity in House-Dust-Mite-Induced Allergic Rhinitis by Serum Metabolomics

The aim of this study was to identify differences in serum metabolomics profiles of house-dust-mite (HDM)-induced allergic rhinitis (AR) patients compared to controls and to explore novel biomarkers reflecting disease severity. Serum samples were collected from 29 healthy controls and HDM-induced 72 AR patients, including 30 mild patients (MAR) and 42 moderate to severe AR patients (MSAR). Metabolomics detection was performed, and orthogonal partial least square discriminate analysis was applied to assess the differences between AR patients and controls and for subgroups based on disease severity. These analysis results successfully revealed distinct metabolite signatures which distinguished MAR patients and MSAR patients from controls. MSAR patients also could be discriminated from MAR patients based on their metabolic fingerprints. Most observed metabolite changes were related to glycine, serine, and threonine metabolism, pyrimidine metabolism, sphingolipid metabolism, arginine and proline metabolism, and fatty acid metabolism. Levels of sarcosine, sphingosine-1-phosphate, cytidine, and linoleic acid significantly correlated with the total nasal symptom score and visual analogue scale in AR patients. These results suggest that metabolomics profiling may provide novel insights into the pathophysiological mechanisms of HDM-induced AR and contribute to its evaluation of disease severity.

Efficacy of Selective Vidian Neurectomy for Allergic Rhinitis Combined with Chronic Rhinosinusitis

OBJECTIVE

The aim of this study was to investigate the efficacy of endoscopic selective vidian neurectomy in the treatment of severe persistent allergic rhinitis (AR) combined with chronic rhinosinusitis (CRS) with nasal polyps (ARwCRSwNP).

METHODS

One hundred thirty patients with moderate to severe persistent ARwCRSwNP were enrolled at Xuanwu Hospital, Capital Medical University, from September 2015 to September 2017. Patients were divided into 2 groups. Sixty-one patients (the control group) underwent conventional surgical treatment for CRS with nasal polyps and received conservative treatment for AR. Sixty-nine patients (the experimental group) received conventional surgical treatment for CRS with nasal polyps plus endoscopic selective vidian neurectomy with amputation of the posterior nasal nerve and pharyngeal branch of the vidian nerve. Clinical parameters, including visual analog scale (VAS) score, Lund-Kennedy endoscopic mucosal morphology score, and Lund-Mackay sinus computed tomography (CT) scan lesion range score, were used to analyze and evaluate the preoperative and postoperative data. Comparisons were based on patient scores, and preoperative and postoperative scores obtained at 6, 12, and 24 months were analyzed.

RESULTS

The experimental group had higher therapeutic efficacy in nasal obstruction, nasal itching, rhinorrhea, sneezing, and general symptoms than the control group (p < 0.05). No complications such as tear-secretion disorder or atrophic rhinitis occurred in the experimental group, and no significant difference in complications incidence was observed between the 2 groups (p > 0.05).

CONCLUSION

Endoscopic selective vidian neurectomy is an effective and safe technique for the management of moderate to severe persistent ARwCRSwNP.

Clinical Efficacy and Possible Mechanism of Endoscopic Vidian Neurectomy for House Dust Mite-Sensitive Allergic Rhinitis

BACKGROUND/AIMS

Endoscopic vidian neurectomy (EVN) for allergic rhinitis (AR) has good clinical effects. However, the pathophysiological basis of the effect of EVN on AR is still poorly understood. This study aimed to investigate the efficacy of EVN on house dust mite (HDM)-sensitive AR and the dynamic changes of serum immunoglobulin E and some immune regulatory factors.

METHODS

Twenty HDM-sensitive AR patients were treated with bilateral EVN (EVN group), 15 HDM-sensitive AR patients were treated with subcutaneous immunotherapy (SCIT group), and 15 healthy subjects served as healthy controls. Quality of daily life was assessed by the scores of the Rhinoconjunctivitis Quality of Life Questionnaire (RQLQs). The visual analog scale was used to assess clinical efficacy. Serum molecules were measured by ELISA and the UNICAP system.

RESULTS

Compared with the SCIT group, the RQLQs in the EVN group were lower 12 months after treatment (both p < 0.05). There was no significant difference in improving nasal itching and sneezing (both p > 0.05), but the clinical efficacy of bilateral EVN was greater than SCIT in improving nasal obstruction, rhinorrhea, eye itching, and lachrymation 12 months after treatment (all p < 0.05). Compared with before treatment, the serum levels of total immunoglobulin E (tIgE), Dermatophagoides pteronyssinus- and Dermatophagoides farinae-specific immunoglobulin E (sIgE), and tumor necrosis factor (TNF)-α in the EVN group and the serum levels of TNF-α and interleukin-4 in the SCIT group were lower 12 months after treatment (all p < 0.05).

CONCLUSION

The short-term efficacy of bilateral EVN is more effective than SCIT in treating HDM-sensitive AR. This may be because the surgery reduced the tIgE and sIgE levels. TNF-α may be involved in the therapeutic mechanism.

Activated leukocyte cell adhesion molecule as a biomarker for disease severity and efficacy of sublingual immunotherapy in allergic rhinitis

BACKGROUND

Activated leukocyte cell adhesion molecule (ALCAM) plays an important role in T cell activation and immune response, but the role of ALCAM in allergic rhinitis (AR) remains unclear. The objective of the current study was to validate serum ALCAM as a biomarker in assessing disease severity and predicting the efficacy of sublingual immunotherapy (SLIT) in AR patients.

METHODS

We recruited 40 healthy controls (HC group), 38 mild AR patients (MAR group) and 80 moderate-severe AR patients (MSAR group) in this study. Serum levels of ALCAM were determined by ELISA, and the association between ALCAM levels and disease severity was evaluated. In the MSAR group, 68 patients underwent and finished 3-years of SLIT, and were divided into effective group and ineffective group, the relationship between ALCAM levels and efficacy of SLIT was exampled.

RESULTS

ALCAM levels were elevated in the serum of AR patients in comparison with HC. Moreover, serum ALCAM concentrations were higher in MSAR group than in MAR group and HC group, and levels of ALCAM significantly correlated with AR total nasal symptom score (TNSS) (r = 0.330, P < 0.001), visual analogue scale (VAS) (r = 0.387, P < 0.001) and serum total IgE levels (r = 0.442, P < 0.001). In the effective group, the ALCAM levels were significantly lower than in the ineffective group. Receiver operating characteristic (ROC) curve exhibited good accuracy for predicting clinical efficacy of SLIT (area under the curve = 0.805, P < 0.001).

CONCLUSIONS

The serum ALCAM maybe a novel biomarker for assessing disease severity and predicting clinical efficacy of SLIT in AR patients.