Efficacy of Cryoablation on Chronic Rhinitis Management: A Systematic Review and Meta-Analysis

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.

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.

Posterior nasal nerve surgical neurectomy versus ablation for chronic rhinitis

INTRODUCTION

For chronic rhinitis (CR) refractory to medical management, several ablative procedures exist that target the posterior nasal nerve (PNN). Here we compare outcomes of PNN surgical neurectomy to in-office ablative procedures.

METHODS

We retrospectively reviewed patients with CR who trialed ipratropium at our center from 2013 to 2024 and received PNN ablation (cryoablation or radiofrequency) or neurectomy. We used the SNOT-22 questionnaire to assess outcomes, specifically evaluating the rhinologic subdomain: need to blow nose, sneezing, runny nose, nasal obstruction, loss of smell, cough, post-nasal discharge, and thick nasal discharge.

RESULTS

Our cohort consisted of 55 patients, 34 receiving PNN ablation and 26 receiving surgical neurectomy (9 receiving both). Mean follow-up time was 243 ± 353 days. Surgical neurectomy (18.6 ± 5.5 to 14.9 ± 5.9, p = 0.02) were associated with significant SNOT-22 rhinologic domain improvements, and neurectomy was associated with significant rhinorrhea improvement (3.4 ± 1.6 to 2.4 ± 1.7, p = 0.04). Surgical neurectomy was associated with a greater decrease in sneezing (p = 0.04) scores than ablation, although there were no significant differences in total or rhinologic subdomain SNOT-22 scores between ablation and neurectomy. No clear improvements were observed in patients undergoing a neurectomy following ablation. Multivariable logistic regression analysis did not reveal any predictors of post-procedure improvement.

CONCLUSION

Both surgical neurectomy and in-office ablation were associated with improvements in rhinologic symptoms for patients with CR, although neurectomy may have increased benefit for specific symptoms like sneezing. There is limited evidence that secondary procedure after an initial ablation is beneficial.

Neurectomy for allergic rhinitis in Japan: Increasing trends and surgeon preferences

OBJECTIVE

There is no consensus on the optimal surgical technique for allergic rhinitis (AR). Furthermore, the appropriateness of surgical intervention in children and older individuals remains debatable. This study aimed to analyze trends and patterns in the surgical management of AR in Japan, focusing on parasympathetic neurectomy.

METHODS

Using the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB), we conducted a comprehensive review of procedures performed between April 2014 and March 2022. In addition, a cross-sectional survey targeting otolaryngologists across Japan was conducted to gather insights into surgical preferences and practices.

RESULTS

The NDB data showed an increasing trend in neurectomies, with the most frequent age group being 25-29 years; the procedure was also performed in pediatric and older patients. The survey among otolaryngologists indicated that 58.2 % of surgeons preferred peripheral branch neurectomy of the posterior nasal nerve. The findings of this study also indicated a cautious approach toward conducting these procedures in children, with 51.2 % of surgeons considering patients less than 18 years of age unsuitable for the procedure.

CONCLUSION

This study highlighted a shift toward simple and minimally invasive surgical methods, such as peripheral branch neurectomy, in Japan. However, further research is needed to understand the long-term outcomes and refine the surgical techniques. The findings of this study also emphasized the need for age-specific considerations when treating pediatric and older patients with AR.

Safety and efficacy of cryotherapy on chronic rhinitis: a systematic review and meta-analysis

BACKGROUND

Chronic rhinitis is when the nasal passages become inflamed and irritated, causing symptoms like nasal congestion, runny nose, sneezing, and postnasal drip that last for at least 12 weeks. While various medical treatments are available for chronic rhinitis, studies have shown that patients often do not comply with the treatment or report that it is ineffective. Cryotherapy for the nasal mucosa is a surgical option that has shown promise for these patients, with acceptable side effects.

AIM

Our goal is to evaluate the existing literature regarding the effectiveness and safety of cryotherapy as a treatment for chronic rhinitis.

METHODS

We searched four electronic databases for relevant studies. Data were extracted from the included studies after screening procedures. Using the random effect model, we calculated the pooled mean difference (MD) for our continuous outcomes and pooled proportions for categorical outcomes. The I2 test was used to detect heterogenicity. Randomized controlled trials (RCTs) were assessed for methodological quality using the Cochrane risk of bias assessment tool 2, while observational studies and single-arm studies were assessed using the National Institutes of Health's tools.

RESULTS

Our study comprised 21 studies; eighteen were eligible for analysis, with 1663 patients with chronic rhinitis. All of our assessed outcomes showed improvement with cryotherapy from their baseline status. Our pooled MDs for Total Nasal Symptom Score (rTNSS), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ), and Nasal Obstruction Symptom Evaluation (NOSE) scores were as follows: ( - 3.58, 95% CI [ - 3.80,  - 3.37], p < 0.001), ( - 1.48, 95% CI [ - 1.68,  - 1.27], p < 0.001), and ( - 26.65, 95% CI [ - 33.98,  - 19.31], p < 0.001), respectively. Regarding nasal obstruction and rhinorrhea, cryotherapy showed effectiveness in 61% and 52% of patients in the complete relief subgroup and 26% and 34% in the < 50%-relief subgroup, respectively.

CONCLUSION

We observed significant improvement in our measured outcomes as rTNSS, RQLQ, and NOSE scores compared to the baseline state, demonstrating the cryotherapy's efficacy. This improvement was consistent in all subsequent follow-up periods. However, we need more high-quality RCTs for stronger evidence to be generalized.

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.

Severe epistaxis after posterior nasal nerve ablation requiring surgical intervention: A multi-center case series

KEY POINTS

Severe epistaxis occurs in 2% of PNN ablation cases, independent of method or device type. Major epistaxis requiring intervention after PNN ablation can occur on average 20 days post-procedure.

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.

Effectiveness of the Posterior Nasal Nerve Cryoablation in Allergic and Non-Allergic Rhinitis

OBJECTIVES

This study assessed the impact of cryoablation of the posterior nasal nerve on symptoms of rhinitis in individuals with allergic rhinitis (AR) and non-allergic rhinitis (NAR).

DATA SOURCES

PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases for studies published up to June 2023.

REVIEW METHODS

Studies that evaluated the quality of life and rhinitis-related symptom scores before and after cryotherapy treatment, as well as sham-controlled studies, were included.

RESULTS

In total, 368 patients from seven studies were analyzed. Patients who underwent cryoablation showed a significant improvement in rhinitis-related symptoms in both NAR and AR. In particular, the most significant improvement was observed in symptoms of rhinorrhea and congestion. Furthermore, cryoablation improved the disease-specific quality of life evaluated using the Rhinoconjunctivitis Quality of Life Questionnaire. The rate of clinical improvement in the total nasal symptom score (total nasal symptom score [TNSS]; >30% reduction from baseline) after cryotherapy was 74%. The change in TNSS score significantly increased over time in NAR patients (p = 0.0041). Therefore, changes in the TNSS score after 12 months of cryotherapy treatment were greater in the NAR group than in the AR group (p = 0.0020), indicating that cryoablation is effective for both types of rhinitis and has better long-term efficacy in NAR than in AR.

CONCLUSIONS

Subjective symptom scores related to rhinitis, particularly for rhinorrhea and congestion, decrease after cryoablation of the posterior nasal nerve. Furthermore, the symptom improvement was greater in NAR than AR. Laryngoscope, 134:2502-2512, 2024.

Rhinitis Disease Burden and the Impact of Social Determinants of Health

Social determinants of health (SDHs) have a substantial impact on patient care and outcomes globally, both in low- to middle-income countries and in high-income countries. In the clinic, lack of availability of diagnostic tools, inequities in access to care, and challenges obtaining and adhering to prescribed treatment plans may further compound these issues. This article addresses a case of rhinitis in the context of SDHs and inequities in care that may affect various communities and populations around the world. SDHs may include various aspects of one's financial means, education, access to medical care, environment and living situation, and community factors, each of which could play a role in the rhinitis disease manifestations, diagnosis, and management. Allergic and nonallergic rhinitis are considered from this perspective. Rhinitis epidemiology, disease burden, and risk factors are broadly addressed. Patient evaluation, diagnostic tests, and management options are also reviewed, and issues related to SDHs are noted. Finally, inequities in care, knowledge gaps, and unmet needs are highlighted. It is critical to consider SDHs and care inequities when evaluating and treating patients for rhinitis and other allergic conditions.

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.