Abstract
To study the efficacy of endoscopic resection of posterior nasal nerves in the treatment of chronic Allergic rhinitis that has not benefitted from medical therapy. Ours was a prospective study that included 20 patients with diagnosed allergic rhinitis with unsatisfactory response to medical therapy who opted for surgical management. Pre-operatively Computed tomography of the nose and paranasal sinuses was done. Also, preoperative nasal symptom assessment was done using a 5-point visual analog scale (VAS) and Lund-Mackay score. Endoscopic resection of posterior nasal nerves under local anesthesia was done for all patients following which VAS and Lund-Mackay scores at 1 month, 3 months, 1 year, and 2 years postoperatively were recorded. The mean age in our study was 26.45 years with most of them being females. The VAS scores pre-operatively were higher (5.00 for nasal congestion, discharge, and sneezing, 4.00 for itching) with a drastic reduction at 1 month and 3 months post operatively (scores ranging from 0 to 1). However, at 1st and 2nd year of follow up there seemed to be a slight increase in the scores (average of 2.00) which was statistically significant (p < 0.001). Lund Mackay score from the pre-operative to post-operative period improved with a mean score of 1.50 to 1.00 at the end of 2 years (p = 0.022). Posterior nasal nerves resection in the management of chronic allergic rhinitis helps to alleviate symptoms. However, there is a need for long-term studies to site the persistence of the effects of this procedure. Treatment of chronic allergic rhinitis should include posterior nasal neurectomy in refractory cases.
Keywords: Chronic allergic rhinitis, Posterior nasal neurectomy, Nasal allergic symptoms, Intractable rhinitis
Introduction
Allergic rhinitis is a troublesome disorder of the nose affecting the day-to-day activities of the patients which occurs due to inflammatory changes in nasal mucosa on exposure to allergens.
Definition of Rhinitis
It is defined as having 2 or more of the following symptoms: Rhinorrhoea (anterior or posterior), Sneezing, Nasal blockage, and/or Nasal Itching for more than one hour on most days for two or more consecutive days [1].
Allergic rhinitis occurs due to nasal hypersensitivity and refractory symptoms may be seen due to abnormal functioning of a plexus of nerves surrounding the inferior turbinate [2]. These nerves contain sensory and autonomic fibers. Hence in patients with severe allergic rhinitis not responding to medical treatment, an alternative therapy i.e., surgical resection of these nerves may be considered.
Several surgical treatment modalities have been implemented to alleviate symptoms of nasal hypersensitivity thereby reducing the effects of allergic rhinitis. One of the effective procedures is the resection of the neural network of nerves surrounding the inferior turbinate called posterior nasal neurectomy. Hence nasal hypersensitivity and excessive nasal secretions can be controlled. The procedure involves trans nasal approach by cutting out the nerve bundles selectively at the level of the sphenopalatine foramen [3–5].
As there are not many studies in Indian literature on the role of endoscopic posterior nasal nerves resection in the management of chronic allergic rhinitis, we conducted this study to assess the efficiency of posterior nasal neurectomy that allowed feasible access to the confined area and selective resection of the nerve branches with the preservation of the sphenopalatine artery (SPA).
Materials and Methods
This was a prospective study conducted at the Department of Otorhinolaryngology, Lok Nayak Hospital, over a period of two years on 20 patients diagnosed with chronic allergic rhinitis.
Inclusion Criteria
Patients attending our ENT OPD with a clinical diagnosis of perennial allergic rhinitis whose symptoms were moderate to severe grade and not controlled by two years of standard medical therapy are opting for surgery.
Age ranging from 18 to 65 years.
Exclusion Criteria
Patients with any serious medical disease like uncontrolled diabetes mellitus, hypertension, chronic heart disease, and systemic causes of rhinitis (hormonal, drug-induced).
Patients with bacterial sinusitis.
Sinonasal malignancy.
All cases of sinonasal polyposis.
Patients with significant anatomical variations (deviated nasal septum, hypertrophied turbinates, medialized uncinate process) as diagnosed on CT scan which can hinder our endoscopic procedure.
Patients with previous sinonasal surgeries.
All patients with perennial allergic rhinitis attending our OPD presenting with the four nasal symptoms lasting for more than 2 consecutive years with no good response to medical treatment (including antihistamines, decongestants, oral and topical steroids) and opting for surgery were included in the study.
After obtaining informed consent, patients were enrolled in the study and kept drug-free for 15 days. A non-contrast CT scan of the nose and PNS was done for all patients to exclude any structural pathology.
A detailed history regarding the symptoms was taken and a clinical examination was done. Preoperatively a 5-point visual analog scale (VAS) was used for scoring the symptoms and an objective scoring using the Lund-Mackay scoring scale was done.
Endoscopic resection of posterior nasal nerves was done under local anesthesia by the same surgeon for all patients. In the procedure, sphenopalatine vessels along with the posterior superior nasal nerve were identified coming out of the sphenopalatine foramen (Fig. 1). The posterior nasal nerve located 4–5 mm inferior to the sphenopalatine artery was identified and cauterized (Fig. 2). The same procedure was performed on the opposite side for effective results. Post-operative Merocel standard nasal dressing was applied bilaterally, and patients were monitored for 24 h, and the nasal dressing was removed before discharge.
Fig. 1.
Shows posterior superior nasal nerves coming out of the sphenopalatine foramen
Fig. 2.
Shows cauterised posterior superior nasal nerves
Postoperatively the VAS and Lund-Mackay scores were noted at 1 month, 3 months, 1 year, and 2 years of follow-up.
Statistical Analysis
The collected data was analyzed and evaluated using the SPSS 25 version. Descriptive data were presented as mean ± SD. All the collected symptoms were explored for normality by the Shapiro-Wilk test. The paired t-test was used to compare pre-and post-operative subjective (VAS) and objective (Lund-Mackay score) scores. The Spearman correlation coefficient was used to explore the correlation between subjective (VAS) and objective scores. Differences were considered significant when the p-value was < 0.05.
Results
In our study consisting of 20 patients the mean age was 26.45 years, with the youngest patient being 19 years old, and the eldest patient 46 years. More than half of the study group was aged less than 25 years. 75% of the patients were females and 25% were males.
Preoperatively the median VAS score for nasal congestion, discharge, and sneezing was 5.00, while for itching it was 4.00. However, at 1 month and 3 months of follow-up, there was a drastic reduction in scores indicating improvement in the symptoms The median VAS score for nasal congestion after the procedure had decreased from 5.00 to 0.50 (at 1 month) and 1.00 (at 3 months). Additionally, the median VAS scores for sneezing decreased from 5.00 to 0 (at 1 and 3 months) and 0 & 0.50 at 1 month and 3 months respectively while for itching, the median VAS score decreased from 4.00 to 0 (at 1 and 3 months). Furthermore, the VAS scores for all symptoms increased to 2.00 at 1 year and 2 years of follow-up (Table 1). These values were statistically significant with a p-value of < 0.001.
Table 1.
Comparison of change in symptomatic VAS scores from pre-operative to post-operative period (N = 20)
| Median (IQR) | p-value | |||||
|---|---|---|---|---|---|---|
| Pre-operative period | Post-operative period | After 3 months | After one year | After two year | ||
| Nasal congestion |
5.00 (4.00–5.00) |
0.50 (0–1.75) |
1.00 (0–1.00) |
2.00 (2.00–3.00) |
2.00 (2.00– 3.00) |
< 0.001 |
| Nasal discharge |
5.00 (4.00–5.00) |
0 (0–1.00) |
0.50 (0–1.00) |
2.00 (2.00–3.00) |
2.00 (2.00– 3.00) |
< 0.001 |
| Sneezing |
5.00 (4.00–5.00) |
0 (0–1.00) |
0 (0–1.00) |
2.00 (1.00–2.00) |
2.00 (2.00– 3.00) |
< 0.001 |
| Itching |
4.00 (4.00–4.00) |
0 (0–0.75) |
0 (0–1.00) |
2.00 (2.00–3.00) |
2.00 (2.00– 3.00) |
< 0.001 |
Lund Mackay rhinosinusitis score from the pre-operative to postoperative period showed a decrease from 1.50 to 1.00 indicating improvement. This change in the score was statistically significant (p = 0.022) (Table 2).
Table 2.
Comparison of Lund Mackay rhinosinusitis score from pre-operative to post-operative period (N = 20)
| Lund Mackay rhinosinusitis | Median (IQR) | p-value | |||
|---|---|---|---|---|---|
| Pre-operative period | Post-operative period after three months | Post-operative period after one year | Post-operative period after two year | ||
| 1.50 (0–3.75) | 1.00 (0–3.00) | 1.00 (0–2.00) | 1.00 (0–2.00) | 0.022 | |
Discussion
Allergic rhinitis is a type of atopic condition that causes troublesome symptoms like sneezing, nasal discharge, and itching accounting for approximately 55% of all allergies. Various modalities of treatment available are pharmacotherapy, allergen avoidance, allergen immunotherapy, and surgical management. Surgical therapy has been implicated in patients who are refractory to medical management. The various surgical options available are vidian neurectomy, posterior nasal neurectomy, and inferior turbinate reduction which have been described in the literature [6–10].
As there have been a few complications associated with procedures like vidian neurectomy, it is rarely recommended for the treatment of allergic rhinitis. However posterior nasal neurectomy does not carry much risk of complications and is an easy-to-perform surgery, hence it has been described as an effective surgical treatment for allergic rhinitis.
Most of the studies in the literature have a higher female preponderance as seen in our study with a male-to-female ratio of 1:3. Pinart et al., Hwang et al. and Nagalingeswaran et al. too reported a higher female preponderance [11–13].
The mean age in studies by Hwang et al. and Nagalingeswaran et al. was 53.3 ± 3.3 years and 36.24 ± 7.93 respectively which was higher when compared to our study [12–13].
There have been few studies on posterior nasal neurectomy as early as 1983 where Terao et al. conducted a study that described cryosurgery on the posterior superior nasal nerve near the sphenopalatine foramen and submucosal resection of the posterior superior nasal nerve and sphenopalatine artery using ultrasonic coagulation. However, in this procedure, as the sphenopalatine artery is not under direct vision it could be a potential cause of intraoperative bleeding from the sphenopalatine foramen [14].
Another study by Kikawada et al. in 1997 described endoscopic posterior nasal resection wherein the sphenopalatine artery at the sphenopalatine foramen is under direct vision and intraoperative bleeding if any can be controlled. Therefore, this procedure gives better results and avoids complications when compared to vidian neurectomy [5].
Another study on endoscopic posterior nasal nerve resection using a cryosurgery device for allergic rhinitis was conducted by Hwang et al. in 2017. 27 patients with symptoms for more than 3 months were included. A Total nasal symptom score (TNSS) was compared pre-operatively and postoperatively at 7, 30, 90, 180, and 365 days. They had a 100% success rate with no complications. Symptoms significantly reduced from the pre-operative period up to 365 days of follow-up post-operatively as reflected by the improvement in the TNSS indicating the effectiveness of surgery [12].
Similarly, Arun et al. in 2017 in their study on intractable rhinitis reported that endoscopic resection of the posterior nasal nerve alleviated the symptoms of intractable rhinitis mainly nasal obstruction and discharge. It is a safe, less invasive, and low-risk procedure effective in the treatment of chronic intractable rhinitis. Patients reported significant improvement in symptoms and quality of life on postoperative follow-up of 6 months. Hence this procedure is more effective than vidian neurectomy and is associated with lesser complications [15].
Nagalingeswaran et al. in 2020 studied the various surgical options for nasal allergy. Although they found no single modality to be most efficacious, a combination of endoscopic posterior nasal neurectomy with inferior turbinoplasty seems to be very effective with a 60–70% improvement in symptoms. Parasympathetic activity by the posterior nasal nerve supplying the inferior turbinate can cause rhinorrhoea when excessively stimulated. Hence, this nerve has been targeted for surgical resection. This combination has given high success rates with long-term relief of symptoms [13].
Therefore, we see that posterior nasal neurectomy has its advantages and is effective in the management of refractory allergic rhinitis. Although there has not been much research in the area all the studies done so far indicate a positive response. Our study too showed an efficacy of around 90% on follow-up. The VAS scores showed a drastic improvement within the first 3 months, with a gradual slight increase at 2 years of follow-up. However, the symptoms were not as worse as the pre-operative period. The Lund Mackay scores showed a constant reduction indicating better control of the disease. Overall, to summarize our study states that posterior nasal neurectomy is an effective procedure in the surgical management of chronic allergic rhinitis. However longer studies with higher sample sizes are required to establish a conclusion on the long-term effects of posterior nasal neurectomy.
Conclusion
Posterior nasal neurectomy has been an underutilized surgical procedure in the management of allergic rhinitis so far. Although there have been a few studies in literature, there are not many from India. Hence our study which was conducted in the Indian population found it to be a safe, affordable, reliable, and effective treatment modality that drastically reduced the symptoms of allergy i.e., nasal congestion, discharge, itching, and sneezing in patients who did not respond to medical therapy.
Clinical Significance
Chronic allergic rhinitis and its treatment by posterior nasal neurectomy is an upcoming surgical modality. It is easy to do, safe, and associated with lesser complications but is not being routinely used. Ideally, intractable allergic rhinitis cases can be considered for posterior nasal neurectomy. This can help allergic patients have a good quality of life and be symptom-free. Hence to summarize, considering posterior nasal neurectomy in allergic rhinitis is a good choice.
Declarations
Ethical Approval
The study was approved by the Institutional Ethics Committee.
Conflict of Interest
The authors have no competing interests to declare.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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