Received: 13 November 2023 Revised: 30 January 2024 Accepted: 3 March 2024

DOI: 10.1002/lio2.1238

ORIGINAL RESEARCH

Modified technique improves efficacy for in-office posterior

nasal nerve ablation

Daniel Gorelik MD, MPH 1 | Aatin K. Dhanda BA 2 | Alexander Choi MD 3 |

1 1 4
Masayoshi Takashima MD | Najm S. Khan MBS | Nicholas R. Rowan MD |
5 1
Aria Jafari MD | Tariq Syed MS | Omar G. Ahmed MD 1
1
Division of Rhinology and Skull Base Surgery, Department of Otolaryngology-Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, USA
2
Rutgers New Jersey Medical School, Newark, New Jersey, USA
3
Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA

Division of Rhinology and Skull Base Surgery, Department of Otolaryngology – Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore,
4

Maryland, USA
5
Division of Rhinology and Endoscopic Skull Base Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle,
Washington, USA

Correspondence
Aatin K. Dhanda, Department of Abstract
Otolaryngology – Head and Neck Surgery,
Objectives: Posterior nasal nerve (PNN) ablation is a minimally invasive treatment
Rutgers New Jersey Medical School, Newark,
NJ, USA. option for patients with chronic rhinitis. Recent evidence shows that parasympathetic
Email: [email protected]
innervation of the nasal cavity is more extensive and there are many fibers posterior
to the lateral attachment of the middle turbinate. We describe a modified ablative
technique that targets the extensive innervation of the posterior nasal nerves.
Methods: Description of the technique and retrospective cohort analysis. In addition
to the traditional radiofrequency and cryoablation targets, three additional treatment
sites posterior to the middle turbinate were targeted using radiofrequency ablation,
as well as one focused treatment posteroinferior to the middle turbinate attachment
using cryotherapy ablation. The primary outcome collected was a 30% improvement
in overall rhinitis symptoms.
Results: Forty-five patients received treatment and completed 3-month follow-up
using the modified technique for radiofrequency and cryotherapy PNN ablation. Pre-
viously, our institution documented a 64.5% responder rate at 3 months. After intro-
ducing the modified technique, the response rate at 3 months significantly improved
(64.5% vs. 91.1%, p = .004).
Conclusions: This report suggests improved efficacy with implementation of the
modified technique for in-office PNN ablation. Given the extensive nature of the
post-ganglionic parasympathetic fibers of the nasal cavity which often emerge poste-
rior to the middle turbinate attachment, a modified technique to target these

This research was presented at the American Rhinologic Society 68th Annual Meeting, Philadelphia, Pennsylvania, September 9–10, 2022.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2024 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.

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branches should be considered. Prospective randomized studies comparing this modi-

fied technique to the traditional technique are needed.
Level of Evidence: III.

KEYWORDS
chronic rhinitis, cryotherapy, middle turbinate anatomy, posterior nasal nerve ablation,
radiofrequency therapy

1 | I N T RO DU CT I O N Board. Patients with chronic rhinitis (both allergic and non-allergic

subtypes as reported by patients) 18 years and older who underwent
Chronic rhinitis (CR) is a common disease affecting up to 30% of the cryotherapy ablation or TCRF neurolysis of the PNN from July 2021
US adult population.1 The treatment of CR begins with medical ther- to February 2022 were reviewed. Patients included had to have failed,
apy including intranasal steroids, anticholinergics, decongestants, or or not tolerate, some form of medical therapy for chronic rhinitis.
antihistamines.2 However, in studies of allergic rhinitis, medical thera- Patients with a diagnosis chronic rhinosinusitis were excluded. Chart
pies have been found to fail to control nasal and ocular symptoms in review of the electronic medical record was conducted for demo-
approximately 20% of patients.3 Traditionally, following failure of graphic information, procedure type, as well as post-procedural
appropriate medical therapy, surgical options targeting three primary follow-up/response.
areas can be attempted; including the inferior turbinate, posterior Regarding the techniques performed, cryoablation was done
nasal nerve (PNN), or vidian nerve (VN).4 The etiology of non-allergic using the Clarifix device (Stryker, Kalamazoo, MI) and the RhinAer
rhinitis is partly thought to arise from a dysfunction of sympathetic device (Aerin Medical, Inc., Mountain View, CA) was used for TCRF.
and parasympathetic innervation, leading to increased mucous pro- Two board certified rhinologists (M.T. and O.G.) conducted all proce-
duction and vascular permeability.5,6 Vidian and posterior nasal neur- dures in office, with preceding application of aerosolized lidocaine/
ectomy aim to target these aberrant parasympathetic pathways. oxymetazoline spray. The traditional technique included four to five
While reasonably successful in controlling CR symptoms, vidian neur- non-overlapping treatments in the posterior middle meatus and three
ectomy can have significant complications, most notably eye dry- to four treatments along the inferior turbinate using temperature-
ness.7,8 Thus, vidian neurectomy has fallen out of favor and been controlled radiofrequency neurolysis (Figure 1A) and two treatments
superseded by PNN neurectomy with fewer adverse effects, but to the posterior middle meatus anterior to the lateral MT attachment
patients may nevertheless have unsatisfactory symptom resolution.4 with cryotherapy (Figure 1C). We modified the technique to target
In recent years, office-based posterior nasal nerve (PNN) ablation 3 additional treatments posterior to the MT with TCRF neurolysis and
has emerged as a popular option for patients who fail to respond to focus one treatment just below and posterior to the attachment of
medical therapy.9,10 Two equally effective and frequently used the MT with cryotherapy ablation (Figure 1B,D). Intraprocedural
methods are cryotherapy and temperature-controlled radiofrequency images are demonstrated in Figure 2.
10
(TCRF) neurolysis. These procedures offer a relatively convenient The primary endpoint was subjective patient-reported overall
option compared to traditional surgical treatments. Despite their improvement of their nasal symptoms at 3 months, as collected at
widespread use, randomized controlled trials report that up to 33% of follow-up visit. Patients who did not have office follow up were tele-
patients have limited response to treatment.9,10 The standard phoned to obtain relevant response data. Patients were categorized
approach to these procedures assumes the PNN is primarily located as responders in a dichotomous fashion (yes/no), if at least 30%
within the posterior middle meatus where treatments are targeted. improvement in overall rhinitis symptoms (anterior rhinorrhea, postna-
However, recent evidence shows that parasympathetic innervation of sal drip, congestion, sneezing) was reported. Pearson chi-square test
the nasal cavity is more extensive and there are many fibers posterior was used to find the association between categorical variables. The
11–13
to the lateral attachment of middle turbinate (MT). In light of Mann–Whitney U test was used to compare continuous and ordinal
these findings, this is an exploratory study to assess the effectiveness variables. All statistical analyses were conducted using SPSS version
of a modified technique for PNN ablation, which targets treatment 24 (IBM corporation, Armonk, NY).
sites both posterior and anterior to the posterior lateral attachment of
the MT.
3 | RE SU LT S

2 | METHODS In total 76 patients were identified who underwent PNN ablation.

Thirty-one patients were treated with the standard technique, and
A retrospective cohort study was performed at a single institution and forty-five patients received modified technique treatment and com-
approved by the Houston Methodist Hospital Institutional Review pleted 3-month follow-up.
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GORELIK ET AL. 3 of 5

F I G U R E 1 Depiction of treatment
sites for office-based posterior nasal
nerve ablation. (A) Standard temperature-
controlled radiofrequency (TCRF)
treatment sites. (B) Modified target sites
(circles) using TCRF involving regions in
the posterior middle meatus, posterior to
the middle turbinate, and along the
inferior turbinate. (C) Standard
cryotherapy treatment sites. (D) Target
sites (circles) using cryotherapy neurolysis
at the posterior middle meatus and
inferior-posterior to the middle turbinate
attachment.

F I G U R E 2 Intraprocedural nasal endoscopic view of modified technique, demonstrating application of treatment posterior to the lateral
attachment of the middle turbinate along the lateral nasal side wall. (A) Treatment of posterior middle meatus. (B) Treatment posterior to middle
turbinate on lateral wall. (C) Treatment posterior to the lateral attachment of the MT on the lateral nasal wall. MT, middle turbinate; NS, nasal
septum; PMM, posterior middle meatus.

Of the patients who received the modified treatment, 6 (13.3%) introduction of the modified technique. The cohorts differed in proce-
patients underwent cryotherapy, and 39 (86.7%) patients underwent dure type, with patients treated with the standard approach more
temperature-controlled radiofrequency neurolysis ablation. Previ- often undergoing cryotherapy (80.6%) and patients treated with the
ously, our institution documented a 64.5% responder rate (defined as modified technique undergoing radiofrequency (86.6%) ( p < .001)
4
at least a 30% improvement in rhinitis symptoms) at 3 months. After (Table 1). However, differences in proportion of cryotherapy or radio-
introducing the modified technique, the response rate at 3 months frequency procedures performed were not significantly affected by
significantly improved (64.5% vs. 91.1%, p = .004). Patients treated which surgeon performed the procedure ( p = .214).
with the traditional technique compared to the modified technique Amongst the modified technique, no significant difference was
were significantly older on average (67.1 [SD ± 12.9] vs. 57.1 [SD noted between surgeons' success rates (n = 21 successful/22 per-
± 16.6], p = .006). A sub-analysis of patients older than 50 years like- formed, 95.46% and n = 20 successful/23 performed, 86.86%)
wise found that the response rate significantly improved with the (p = .608). In addition, for patients receiving the standard technique,
modified technique (64.3% vs. 88.5%, p = .038). Four adverse events no significant differences were noted in surgeons' success rates
were noted. Two bleeding events occurred prior to introduction of (n = 12 successful/ 21 performed, 57.1% and n = 8 successful/10
the modified technique, and two bleeding events occurred after the performed, 80.0%) ( p = .262).
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4 of 5 GORELIK ET AL.

TABLE 1 Baseline characteristics and technique success rates.

Variable Total (n = 76) Standard technique (n = 31) Modified technique (n = 45) p-value
Age (years)
Average ± SD 61.2 ± 15.9 67.1 ± 12.9 57.1 ± 16.6 p = .006
Age within subgroups
≤ 50 years olda 40.5 ± 7.1 41.0 ± 5.7 36.7 ± 14.6 p = .773
>50 years old b
69.63 ± 9.2 68.9 ± 11.0 70.4 ± 7.9 p = .561
Race/Ethnicity
Caucasian 56 (73.7%) 24 (77.4%) 32 (71.1%) p = .125
African American 10 (13.2%) 3 (9.7%) 7 (15.6%)
Hispanic/Latino 3 (3.9%) 3 (9.7%) 0 (0.0%)
Asian 5 (6.6%) 1 (3.2%) 4 (8.9%)
Declined to answer 2 (2.6%) 0 (0.0%) 2 (4.4%)
Gender p = 0.357
Male 32 (42.1%) 15 (48.4%) 17 (37.8%)
Female 44 (57.9%) 16 (51.6%) 28 (62.2%)
Procedure type p < 0.001
Cryotherapy ablation 31 (40.8%) 25 (80.6%) 6 (13.3%)
Radiofrequency neurolysis 45 (59.2%) 6 (19.4%) 39 (86.7%)
Procedure outcome p = 0.004
Success 61 (80.3%) 20 (64.5%) 41 (91.1%)
Failure 15 (19.7%) 11 (35.5%) 4 (8.9%)

Mean and standard deviation calculated for subgroup of total population, where n = 22.
a

Mean and standard deviation calculated for subgroup of total population, where n = 54.
b

4 | DISCUSSION addition to the standard middle meatus site, a treatment site at the
inferior meatus was added.14 In their study, cryoablation of the infe-
PNN ablation offers a reasonable in-office treatment option for CR rior meatus was effective but did not augment treatment response.14
patients. Consistent with the published literature, our institution pre- In contrast, we found that our modified technique using both TCRF
viously identified a 64.5% response rate to PNN ablation.9–11 The and cryoablation was able to augment and significantly improve
present study demonstrates that the introduction of a modified tech- treatment response. Recent devices also aim to better target the
nique may improve response rate, with a reported 91.1% subjective innervation of the nasal cavity. Neuromark (Neurent Medical Ltd.,
response at 3-month follow-up. Galway, Ireland) is a radiofrequency ablation device which engages
The concept of ablating the parasympathetic fibers posterior to the lateral nasal wall with multiple points of contact in an attempt to
the MT is supported by recent literature.11,13 Ogi et al. recently increase access points to nerve rich areas including posterior to the
described the extensive nature of the post-pterygopalatine ganglionic lateral MT attachment.15 In a single arm study of chronic rhinitis
13
parasympathetic fibers of the nasal cavity. Many of these nerve patients, the device was found to have a positive response in 78% of
fibers exit foramina posterior to the MT and do not course in the typi- patients. While encouraging, this was the first single arm study look-
cal location of the posterior middle meatus. Failure of PNN ablation ing at outcomes for Neuromark, and there is a paucity of long-term
13
can be partially explained by missing these potential targets. Fan safety or efficacy data. Single contact point radiofrequency and
et al. also described the anatomic variability of the MT in relation to cryoablative devices, as employed in our analysis, have been estab-
the sphenopalatine foramen where large branches of the PNN enter lished as safe and efficacious, and we highlight here how a simple
the nasal cavity.11 Failure of PNN ablation was significantly higher modification of the existing technique has potential to improve
with unfavorable MT anatomy. Targeting areas posterior to the MT outcomes.16,17
along the lateral nasal wall, by partially medializing the posterior por- In our experience, TCRF and cryoablation generally have favor-
tion of the MT, can potentially improve outcomes in patients with able safety profiles, and the introduction of the modified technique
unfavorable anatomy. has not resulted in increased adverse events. In a study of a national
Other groups have attempted improve outcomes of PNN abla- adverse events reporting database, for the Clarifix cryoablation
tion by addressing multiple locations along the lateral nasal wall. Yen device, epistaxis was found to be the most common reported adverse
et al. reported on a modified cryoablation technique, where in event (9/12, 75%).18
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GORELIK ET AL. 5 of 5

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