Posterior nasal neurectomy for intractable rhinitis: A systematic review of the literature

Abstract

Background Rhinitis affects up to 40% of the population worldwide and can significantly reduce quality of life. Some patients remain symptomatic despite maximal medical therapy. In refractory cases, posterior nasal neurectomy (PNN—the endoscopic division of the intranasal nerve branches containing postganglionic parasympathetic fibres) is postulated to reduce symptom burden. Objectives of Review To establish whether PNN is effective and safe in the management of allergic and non‐allergic rhinitis. Type of Review Systematic review. Methods A comprehensive literature search was undertaken using PubMed, EMBASE, MEDLINE, and Cochrane. The inclusion criteria were: studies published in English, studies where PNN was performed either with or without additional procedures, and where measures of objective/subjective outcomes and/or complications were reported. Extracted data included study type, sample size, surgical technique, study population characteristics, follow‐up period, outcome measures, complications of surgery, and symptom outcomes. Results A total of 23 articles satisfied the inclusion criteria studying in total 2282 patients. Sample size ranged from 8 to 1056. There were 3 randomised controlled trials, 3 case‐control studies, and the remaining 17 were case series using both objective and subjective outcome measures. All but one study found improved patient‐reported outcomes following PNN. Complications were reported in 14 studies—epistaxis was the most common complication and was observed in 30 patients (1.5% of subjects). Conclusions PNN had a low rate of complications. Although most studies reported significant symptomatic improvement, their heterogeneity, level of evidence, study design, and/or quality was not sufficient to draw any firm conclusions on the effectiveness of the procedure. Larger, well‐designed studies are needed to clarify its role in the management of difficult‐to‐treat rhinitis.

Cadaveric analysis of autonomic nerve fiber density in posterior nasal, posterolateral nasal, and anterior ethmoid nerves

“…Previous neurectomy studies for rhinitis have largely focused on EVN and EPNN, for both AR and NAR 2,3 . EVN has been successful most consistently for rhinorrhea, with mixed results for nasal obstruction, postnasal drip, and sneezing 5 .…”

“…One point to discuss with EPNN is that studies have only reported transecting one to a few nerves traversing the sphenopalatine foramen 2,3 . Bleier et al.…”

“…When rhinitis symptoms fail to respond to appropriate medical therapy, different intranasal nerve ablations (mucosal cryoablation or radiofrequency) or neurectomies (nerve transection) have shown therapeutic promise. These procedures reduce nasal parasympathetic innervation temporarily or permanently to correct rhinorrhea and possibly nasal obstruction and sneezing 2 …”

“…Studies on surgical interventions for rhinitis have shown success with posterior nasal nerve (PNN) cryoablation, 3 radiofrequency, 4 or endoscopic posterior nasal neurectomy (EPNN) 2,3 . These interventions remove postganglionic parasympathetic nasal innervation, which helps avoid endoscopic vidian neurectomy (EVN)‐related complications like xerophthalmia and facial/palatal hypesthesia 3,5 …”

“…Regarding EPNN, published techniques have described transecting one to a few PNNs associated with the sphenopalatine neurovascular bundle 2,3 . If rhinitis patients respond to EPNN suboptimally, it would be helpful to know whether other intranasal nerves contain parasympathetic fibers that could also undergo ablation or transection.…”