NEW ORLEANS — Laser ablation of the posterior nasal nerve provided durable relief from rhinitis, and use of rhinitis medications decreased substantially, results of a small prospective series showed.
Rhinitis symptoms decreased by more than 50% within the first 30 days after surgery and persisted to 90 days. Rhinorrhea and congestion improved by a similar extent, and medication use declined by 70% from baseline to 90 days.
The laser treatment had a similar impact on allergic and nonallergic (vasomotor) rhinitis, and the benefits have persisted for as long as a year and a half, reported Yosef Krespi, MD, of the New York Head & Neck Institute in New York City, at the American Academy of Otolaryngology-Head and Neck Surgery Foundation meeting.
“Laser ablation of the posterior nasal nerve is a well-tolerated, safe office or ambulatory procedure,” said Krespi. “The results are similar to other treatment modalities, such as surgery and cryotherapy. Ongoing analysis of long-term outcomes in a much larger series in a multicenter environment are the next steps.”
Though surgical treatment for rhinitis has a long history, the few available options have not won a large following in the U.S. otolaryngology community. Both vidian neurectomy and posterior nasal neurectomy provide effective symptom relief for allergic and nonallergic rhinitis but require general anesthesia, said Krespi.
Cryotherapy for rhinitis dates back to the early 1970s, he continued. Early cryoprobes did not have a good anatomic fit and were inconvenient to use. The recent availability of a new-generation cryoablation device that offers endoscopic access has revived interest in the treatment.
Krespi has adapted newer cryotherapy techniques to laser ablation of posterior nasal nerves. The procedure can be performed in an office with topical or local anesthesia. If nasal anatomy does not allow endoscopic access, a procedure can be performed in an ambulatory surgical center with general anesthesia.
Using a 940-nm diode laser with clear-tip fiber in non-contact mode, the operator raises tissue temperature to 65-70°C, which causes superficial mucosal blanching and penetration to just below the nasal mucosa to ablate the posterior nasal nerves.
“By keeping the temperature under 70°C, we achieve denaturation, which is partially reversible and may be a form of early coagulation,” said Krespi. “We want to ablate the nerve without causing a permanent lesion.”
The procedure causes minimal crusting or swelling and offers improved targeting of the lateral inferior and lateral superior posterior nasal nerves in the back of the nose, he added.
To date, 31 patients have been treated with laser ablation. Procedures were performed in an office setting in 10 cases and an ambulatory surgical unit in the remaining 21. One patient could not be treated because of limited endoscopic access. The remaining 30 patients had 30- and 90-day follow-up data.
No laser-associated complications occurred, and Krespi said none of the patients had bleeding, crusting, headaches, facial pain, or ear blockage. The patient-rated pain score averaged 1.8 on a 10-point scale.
At the 30-day follow-up evaluation, the mean Total Nasal Symptom Score (TNSS) had declined from 7.1 at baseline (on a 12-point scale) to 3.2, representing a 55% reduction. Additionally, the 30 patients had a 48% improvement in rhinorrhea and a 53% improvement in congestion.
At 90 days, the mean TNSS remained 51% below baseline, rhinorrhea score 44% lower than baseline, and congestion 48% improved versus the preoperative state. Additionally, medication use (decongestants, antihistamines, steroids, and anticholinergics) decreased by 70% from baseline to 90 days.
In response to a question, Krespi said he began using laser ablation 2 years ago, and control of rhinitis symptoms has persisted for as long as a year and a half.
The laser technique is one of several minimally invasive options for treating chronic rhinitis, including other laser devices, noted William Yao, MD, PhD, of UTHealth in Houston.
“There are a number of things that can be done to the [posterior nasal nerves],” said Yao, who moderated the session that included Krespi’s presentation. “There is also cryoablation, which is FDA approved, and I think you can get similar effects with heat.”
“[Krespi] said this can be used for both allergic and nonallergic rhinitis,” he added. “In the past, it was all based on vasomotor rhinitis, but it doesn’t have to be vasomotor rhinitis. It can be used for significant postnasal drip that is allergy derived.”
Candidates for minimally invasive treatment or surgery are patients who have not obtained adequate symptom relief with medications or who cannot tolerate medication.
“Specifically, these are patients who have postnasal drip or rhinorrhea, and postnasal congestion is more secondary,” said Yao. “The procedure will not treat the inferior turbinate head, which is more important for nasal obstruction.”
Krespi disclosed no relevant relationships with industry.
last updated 09.17.2019