Position Statement: PNN Ablation for the Treatment of Chronic Rhinitis

Chronic rhinitis is a common condition that affects about 60 million Americans, and presents with symptoms of nasal congestion, rhinorrhea/postnasal drip, nasal pruritis, and sneezing^1,2. Although medications such as intranasal saline, intranasal corticosteroids, intranasal anticholinergics, oral/topical antihistamines, and/or oral/topical decongestant are first-line therapy, many patients do not receive benefit from medical management alone.

Reducing parasympathetic innervation to the nasal cavity can improve symptoms of chronic rhinitis, and because of the risk of dry eye in vidian neurectomy^3,4, recent interventions have focused on the distal branches of the nasal parasympathetic system, called the posterior nasal nerves (PNN). The PNN can be accessed through the middle meatus, making them amenable to minimally-invasive PNN-targeted procedures.

Posterior nasal nerve neurolysis techniques such as radiofrequency ablation and cryotherapy thermal application methods have been used to disrupt the PNN in the posterior aspect of the middle meatus in the region of the sphenopalatine foramen. Multicenter, patient-blinded, sham-controlled RCTs have been performed for radiofrequency ablation^5,6 and cryoablation⁷ and have demonstrated clinical benefit for nasal symptoms. For both methods, validated quality of life surveys have demonstrated statistically significant improvement with treatment^8-10, with therapeutic effect^{11, 12}.

Based on these safety and efficacy data, the AAO endorses the use of PNN ablation for the treatment of medically-refractory chronic rhinitis. We do not consider these treatments to be experimental.

References

1. Bernstein, J. A. Allergic and mixed rhinitis: Epidemiology and natural history. Allergy Asthma Proc 31, 365-369, doi:10.2500/aap.2010.31.3380 (2010).
2. Settipane, R. A. & Charnock, D. R. Epidemiology of rhinitis: allergic and nonallergic. Clin Allergy Immunol 19, 23-34 (2007).
3. Robinson, S. R. & Wormald, P. J. Endoscopic vidian neurectomy. Am J Rhinol 20, 197-202 (2006).
4. Konno, A. Historical, pathophysiological, and therapeutic aspects of vidian neurectomy. Curr Allergy Asthma Rep 10, 105-112, doi:10.1007/s11882-010-0093-3 (2010).
5. Takashima, M. et al. Temperature-controlled radiofrequency neurolysis for treatment of chronic rhinitis: 12-month outcomes after treatment in a randomized controlled trial. Int Forum Allergy Rhinol, doi:10.1002/alr.23047 (2022).
6. Stolovitzky, J. P. et al. Effect of Radiofrequency Neurolysis on the Symptoms of Chronic Rhinitis: A Randomized Controlled Trial. OTO Open 5, 2473974X211041124, doi:10.1177/2473974X211041124 (2021).
7. Del Signore, A. G. et al. Cryotherapy for treatment of chronic rhinitis: 3-month outcomes of a randomized, sham-controlled trial. Int Forum Allergy Rhinol 12, 51-61, doi:10.1002/alr.22868 (2022).
8. Ow, R. A., O’Malley, E. M., Han, J. K., Lam, K. K. & Yen, D. M. Cryosurgical Ablation for Treatment of Rhinitis: Two-Year Results of a Prospective Multicenter Study. Laryngoscope 131, 1952-1957, doi:10.1002/lary.29453 (2021).
9. Chang, M. T., Song, S. & Hwang, P. H. Cryosurgical ablation for treatment of rhinitis: A prospective multicenter study. Laryngoscope 130, 1877-1884, doi:10.1002/lary.28301 (2020).
10. Lee, J. T. et al. Clinical and Quality of Life Outcomes Following Temperature-Controlled Radiofrequency Neurolysis of the Posterior Nasal Nerve (RhinAer) for Treatment of Chronic Rhinitis. Am J Rhinol Allergy, 19458924221109987, doi:10.1177/19458924221109987 (2022).
11. Ehmer, D. et al. Long-term Outcomes Following Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Chronic Rhinitis. Allergy Rhinol (Providence) 13, 21526575221096045, doi:10.1177/21526575221096045 (2022).
12. Gerka Stuyt, J. A., Luk, L., Keschner, D. & Garg, R. Evaluation of In-Office Cryoablation of Posterior Nasal Nerves for the Treatment of Rhinitis. Allergy Rhinol (Providence) 12, 2152656720988565, doi:10.1177/2152656720988565 (2021).
13. Ehmer, D. et al. Temperature-Controlled Radiofrequency Neurolysis for the Treatment of Rhinitis. Am J Rhinol Allergy 36, 149-156, doi:10.1177/19458924211033400 (2022).
14. Kompelli, A. R., Janz, T. A., Rowan, N. R., Nguyen, S. A. & Soler, Z. M. Cryotherapy for the Treatment of Chronic Rhinitis: A Qualitative Systematic Review. Am J Rhinol Allergy 32, 491-501, doi:10.1177/1945892418800879 (2018).