Abstract
Allergic rhinitis significantly affects the quality of life, it contributes to missed or unproductive time at school or work, disturbed sleep pattern and day time somnolence. Rhinitis is defined clinically as having two or more symptoms of anterior or posterior rhinorrhoea, sneezing, nasal blockage and/or itching of the nose during two or more consecutive days for more than 1 h on most days (International rhinitis management working group, 1994). Allergic rhinitis is diagnosed when these symptoms are caused by allergen exposure leading to an IgE mediated reaction. Nerve irritation causes sneezing and itching, the loss of mucosal integrity causes causes rhinorrhoea and the vascular engrogment leads to nasal blockage. Medical modalities are symptomatically effective in mild cases, with temporary relief and addressable adverse effects. Prolonged treatment with allergy immunotherapy causes a sustainable financial burden while remaining inaccessible at smaller towns. Posterior nasal nerve neurectomy is short, easy and effective alternative. The basic procedure is to selectively cut nerve bundles at the level of the sphenopalatine foramen (SPF) with a trans nasal approach. By denervating the nasal mucosa one renders it unresponsive to any sorts of allergen or allergic reaction. The aim of the study was to evaluate the outcome of posterior nasal nerve neurectomy in cases of severe allergic rhinitis by assessing its impact on the total nasal symptom score. The study is a hospital based prospective study, conducted on 15 patients who presented to the ENT department of Mahatma Gandhi Hospital from march 2021 to October 2021 (6 months) suffering from allergic rhinitis and did not show any satisfactory improvement even after 1 year of medical treatment. Adult patients in the age group of 20–45 yrs. diagnosed with allergic rhinitis were enrolled into the study after obtaining a due written consent. These included patients having 2 or more symptoms of allergic rhinitis and refractoriness to medical therapy for > 1 year along with significantly affected quality of life and elevated IgE level. Patients with drug induced & hormonal causes of rhinitis, chronic rhinosinusitis and any anatomical feature which precipitates to rhinitis such as deviated nasal septum, hypertrophied turbinates, blocked osteomeatal unit, polypoidal nasal mucosa and sinonasal polyposis were excluded from the study. During our study period from march 2021-September 2021, 15 patients were enrolled in the study. All the patients were followed up at 2nd and 6th month postoperatively. Amongst these patients, there were 11 females (73.34%) and 4 were male (26.67%)The mean age of patients was 35.2 years. Subjective nasal symptoms of all 15 patients improved over the period of 6 months. The mean TNSS improved from 12.067 preoperatively to 8.66 at the end of 2nd month, i.e., 23.1% improvement. By the end of the 6th postoperative month there was a consistent reduction in the tnss, which further reduced to a mean of 3.4 (70.2% reduction) indicating a further improvement in symptoms with time. With the advancement & popularity of endoscopic sinus surgery in the past decade, endoscopic resection of the posterior nasal nerve is emerging as a safe and less invasive technique with long standing results. Medical treatment usually provides mild and symptomatic relief with long duration of treatment period. Thus, PNN is safer, economical & easier alternative to current trend of treatment of allergic rhinitis, proving to be highly efficient in cases of intractable allergic rhinitis.
Keywords: Allergic rhinitis, Posterior nasal nerve neurectomy, Total nasal symptom score
Introduction
Rhinitis is defined clinically as having two or more symptoms of anterior or posterior rhinorrhoea, sneezing, nasal blockage and/or itching of the nose during two or more consecutive days for more than 1 h on most days [1].
Allergic rhinitis is diagnosed when these symptoms are caused by allergen exposure leading to an IgE mediated reaction.
The inflammatory mediators produced as a result of this IgE mediated reaction causes the classical symptoms of allergic rhinitis.
Nerve irritation causes sneezing and itching, the loss of mucosal integrity causes causes rhinorrhoea and the vascular engrogment leads to nasal blockage.
Based on the nasal symptoms the prevalence of allergic rhinitis in the Indian population is 20–30% [2].
Allergic rhinitis significantly affects the quality of life, it contributes to missed or unproductive time at school or work, disturbed sleep pattern and day time somnolence.
The most popular and widely accepted treatment strategy for allergic rhinitis is pharmacotherapy, this includes antihistamines, leukotriene receptor antagonist and intranasal corticosteroids.
These medical modalities are symptomatically effective in mild cases, with temporary relief and addressable adverse effects.
Prolonged treatment with allergy immunotherapy causes a sustainable financial burden while remaining inaccessible at smaller towns.
Posterior nasal nerve neurectomy is short, easy and effective alternative. The basic procedure is to selectively cut nerve bundles at the level of the sphenopalatine foramen (SPF) with a trans nasal approach [1–3]. The nerve bundles consist of parasympathetic and sympathetic components of the vidian nerve and somatosensory fibers from the maxillary branch of the trigeminal nerve and they are distributed in the nasal mucosa following the branches of the sphenopalatine vessels [4].
By denervating the nasal mucosa one renders it unresponsive to any sorts of allergen or allergic reaction.
The aim of the study was to evaluate the outcome of posterior nasal nerve neurectomy in cases of severe allergic rhinitis by assessing its impact on the total nasal symptom score.
Materials and Method
The study is a hospital based prospective study, conducted on 15 patients who presented to the ENT department of Mahatma Gandhi Hospital from March 2021 to October 2021 (6 months) suffering from allergic rhinitis and did not show any satisfactory improvement even after 1 year of medical treatment.
Inclusion and Exclusion Criteria
Adult patients in the age group of 20–45 years. diagnosed with allergic rhinitis were enrolled into the study after obtaining a due written consent.
These included patients having 2 or more symptoms of allergic rhinitis and refractoriness to medical therapy for > 1 year along with significantly affected quality of life and elevated IgE level.
Patients with drug induced & hormonal causes of rhinitis, chronic rhinosinusitis and any anatomical feature which precipitates to rhinitis such as deviated nasal septum, hypertrophied turbinates, blocked osteomeatal unit, polypoidal nasal mucosa and sino-nasal polyposis were excluded from the study.
A pre-operative nasal endoscopy and a non-contrast computed tomographic scan of the nose and the paranasal sinus was done to identify and exclude such patients from the study.
Those patients who satisfied the inclusion and exclusion criteria and gave the consent to participate in the study were selected for the operative procedure.
Surgical Procedure
Under hypotensive general anaesthesia, with a mean arterial blood pressure of 55–60 mm of hg, the patient was placed in a reverse Trendelenburg position. To achieve nasal decongestion, pre operatively the nasal cavity was packed with cotton pellets soaked in 4% xylocaine, oxymetazoline and adrenaline solution.
A zero degree, 4 mm rigid nasal endoscope with a high-definition camera was used.
After the induction of anaesthesia and oral intubation, 0.5–1 ml of 1:20,0000 lignocaine with adrenaline was injected into the lateral nasal wall, along the posterior end of the inferior turbinate. Alternatively, the middle meatus area can be packed with a merocele soaked in a solution of 4% xylocaine and oxymetazoline.
Using a flag knife, a semilunar bone deep incision was made at the level of the posterior fontanelle, in the lateral nasal wall. This was extended till the attachment of inferior turbinate.
A mucoperiosteal flap was elevated off the lateral nasal wall till the posterior end of middle meatus, fibro neurovascular bundle comprising of the sphenopalatine artery and the posterior nasal nerve was identified.
Identification of the Nerve
Arising from the sphenopalatine foramen, the posterior nasal nerve which is a branch of vidian nerve, is further composed of 2–4 branches.
In most cases 2 major branches are always present. The first branch goes antero-inferior towards the inferior turbinate, the second travel postero-superior towards the middle meatus.
All branches that were endoscopically visible were severed.
After the nerve was sectioned a malleable cauterizing microprobe was used to achieve capillary haemostasis and to avoid any possible reinnervation.
The elevated mucoperiosteum was repositioned, anterior nasal packing was done and retained for 1 day.
Patients are given 2 days of IV antibiotics followed by 5 days of oral antibiotics. Oral analgesics and oral antihistamines were also given for 7 days.
Follow up
The patients were pre operatively evaluated 1 week before the surgery and followed up at 2nd and 6th post operative months.
The patients were graded as per TNSS both pre and post-operatively.
Subjective evaluation was done using the total nasal symptom score, where 5 nasal symptoms
rhinorrhoea.
nasal obstruction.
sneezing.
itching.
anosmia.
Were scored on a scale of 0–3, where 0 is none, symptoms completely absent, 1 = mild, symptoms present but bothersome, 2 = moderate, bothersome symptoms but tolerable, 3 = severe, symptoms tolerable but desiring treatment.
The total TNSS along with improvement in each symptom was evaluated.
Statistical Analysis
The data obtained was put into a master chart and was statistically analysed. Continuous data was represented as mean and standard deviation. Paired t test was used as test of significance to identify the mean difference between more than two quantitative variables. P value (Probability that the result is true) of < 0.001 was considered as statistically significant after assuming all the rules of statistical tests.
Results
During our study period from March 2021-September 2021, 15 patients were enrolled in the study. All the patients were followed up at 2nd and 6th month postoperatively.
Amongst these patients, there were 11 females (73.34%) and 4 were male (26.67%).
The mean age of patients was 35.2 years.
Subjective nasal symptoms of all 15 patients improved over the period of 6 months.
The mean TNSS improved from 12.067 preoperatively to 8.66 at the end of 2nd month, i.e., 23.1% improvement.
By the end of the 6th postoperative month there was a consistent reduction in the TNSS, which further reduced to a mean of 3.4 (70.2% reduction) indicating a further improvement in symptoms with time.
Individual symptoms of rhinorrhoea, sneezing and itching showed the maximum improvement after the 2nd post-operative month, the mean values for these symptoms further reduced by the end of 6th postoperative month.
The P values for these were statistically significant < 0.001.
Anosmia and Nasal obstruction showed improvement as well.
The improvement in TNSS & individual nasal symptom score at the end of the 2nd and the 6th postoperative month is shown in Table 1
Table 1.
Subjective nasal symptom score evaluated using TNSS scale
| Time period | Rhinorhhoea | Sneezing | Itching | Nasal obstruction | Anosmia | TNSS |
|---|---|---|---|---|---|---|
| Pre-op | 2.67 ± 0.61 | 2.8 ± 0.494 | 2.6 ± 0.632 | 2.4 ± 0.828 | 1.86 ± 1.1 | 12.06 + 1.79 |
| 2nd post op month | 1.93 + 0.63 | 1.63 ± 0.38 | 1.76 ± 0.57 | 1.65 ± 0.765 | 1.34 ± 0.92 | 8.68 + 1.56 |
| 6th post op month | 0.46 ± 0.5 | 0.6 ± 0.5 | 0.6 ± 0.507 | 0.86 ± 0.352 | 0.67 ± 0.4 | 3.4 + 0.91 |
| Pre-op vs 6th post op month | 0.000002 | 0.000025 | 0.00003 | 0.0000264 | 0.0008 | 0.0000002 |
There were no major complications in the immediate or late post-operative period. No bleeding from the sphenopalatine artery or its branches, no severe postoperative pain, dry eyes, dry mouth, numbness of cheek or palate related to the procedure were noted. Crusting or atrophy of the turbinates was not seen in any of the patients 3 patients presented to us with adhesions which were released during the follow up (Fig. 1).
Fig. 1.
Sex ratio
Discussions
Over the past years, the prevalence of allergic rhinitis has increased in India. Surgical management is indicated as a successful alternative strategy when patients fail to respond to a standard combination of medical treatments.
Resection of the posterior nasal nerve is especially effective for severe rhinorrhoea because the interruption of parasympathetic nerve fibres suppresses nasal secretion. As it contains afferent sensory fiber supplying the posterior half of the mucosa in the nasal cavity, sneezing can be reduced, thus making this procedure superior to Vidian neurectomy [5].
The posterior nasal nerve emerges from the SPF and is distributed to the inferior turbinate mucosa following the branches of the sphenopalatine vessels. Innervation of the parasympathetic component increases the secretomotor function, and innervation of the sensory component regulates the sensitivity of the nasal mucosa [6, 7]. By resection of the posterior nasal nerve at this point, we can expect modifying the hyperreactivity of the neural network that augments the allergic reaction. In addition, this technique causes partial denervation of the middle turbinate and septum submucosal glands based on anatomical innervation [8].
Our results confirm the desired efficacy of over 90% of cases for a follow-up period of 6 months to 2 years reported by Kikawada particularly in reducing nasal symptoms of rhinitis such as nasal discharge, nasal congestion, sneezing and post-nasal discharge significantly. Kikawada also reported more than 80% efficacy in 94 patients after 2 years of surgery which are similar to our findings. Our most significant findings at 2 months were for nasal discharge and nasal congestion with p < 0.001 although symptoms of postnasal discharge and sneezing also improved significantly with p < 0.001. These findings are similar to previously published papers [9].
Ogawa et al. [10] found out that PNN in allergic rhinitis patients significantly reduce levels of IL-5, eotaxin protein in nasal secretions. They also observed reduction of infiltrated immuno-component cells in the subepithelial mucous layer, which are major sources of cytokine release.
Mori et al. [11], Kobayashi et al. [12] also reported similar patient benefits following posterior nasal neurectomy. They concluded that selective resection of peripheral branches of the posterior nerve could reduce allergic symptoms.
Kawamura et al. [13], in their study of PNN with harmonic scalpel among 20 patients, observed subjective improvement in nasal obstruction, sneezing and nasal discharge in 100%, 90 and 75% patients respectively. They reported no surgical complications.
Cassano et al. attributes the reduction in sneezing and nasal pruritis following posterior nasal nerve transection to the resection of posterior inferior nasal nerve fibres [14]. In our study, there was substantial reduction in TNSS which continued to reduce 6 months following surgery, showing significant reduction in parasympathetic supply.
In our study, we found that the mean score for each nasal symptom of all patients was statistically decreased from pre-operative levels at the 6-month follow-up without any major complications.
Endoscopic endonasal surgery’s development replaced the classic Vidian neurectomy with posterior nasal nerve neurectomy (PNN). This surgery overcame the complications of Vidian neurectomy and is minimally invasive [13].
Conclusions
With the advancement & popularity of endoscopic sinus surgery in the past decade, endoscopic resection of the posterior nasal nerve is emerging as a safe and less invasive technique with long standing results. Medical treatment usually provides mild and symptomatic relief with long duration of treatment period. Thus, PNN is safer, economical & easier alternative to current trend of treatment of allergic rhinitis, proving to be highly efficient in cases of intractable allergic rhinitis.
Funding
No funding sources.
Declarations
Conflict of interest
None declared.
Human or Animal Participants
The research involved human participants, an informed consent was obtained from all participants before enrolling them into the study.
Ethical Approval
The study was approved by the Institutional Ethics Committee.
Footnotes
Publisher's Note
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Contributor Information
Bhargavi Trivedi, Email: Bhargavi0794@gmail.com.
Pratibha Vyas, Email: drprathibhaent@gmail.com.
Nikhil Kumar Soni, Email: Nikhils523523@gmail.com.
Priyanshi Gupta, Email: priyanshi728@gmail.com.
Rajendra Kumar Dabaria, Email: dr.r.dabaria@gmail.com.
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