Radiofrequency Ablation of Inferior Turbinates With Laser Posterior Nasal Nerve Neurolysis for the Treatment of Chronic Rhinitis

Posterior nasal nerve neurolysis (PNNN) is a potential approach for treating chronic rhinitis among patients unresponsive to pharmacological therapy [1]. However, the treatment response was not immediate. Studies by Lee and Takashima found a response rate of 67.5%–76.2% at 3 months and varied up to 80.6%–85.5% at 12 months [2, 3]. These radiofrequency (RF) PNNN devices have also been patented and can only be legally used in the US; hence, other countries have been left with no effective modality to support the use of PNNN. Other modalities to perform PNNN include Krespi et al., who proposed using a diode laser to perform PNNN [4], and Samy et al., who used RF ablation of the posterior end of the inferior turbinate to treat the peripheral branches of the posterior nasal nerve [5] showed significant improvement in chronic rhinitis symptoms.

With this background, we hypothesized that combining radiofrequency ablation of inferior turbinates and intraturbinate segments of the posterior nasal nerve (RAPN) with laser PNNN (collectively abbreviated as RPN3) may improve short-term response rates and enhance symptom control.

The inclusion criteria were: age 18–65 years, chronic rhinitis refractory to medical treatment for >6 months with at least 4 weeks of medical treatments, rTNSS ≥ 5, rhinorrhea ≥2, and congestion ≥2. The exclusion criteria were rhinosinusitis, difficult posterior nasal passage, concurrent other or previous nasal surgery in the nasal and oral area, and rhinitis medicamentosa.

RPN3 surgery was performed as day surgery under local anesthesia in the operating room. Septoplasty was not performed in all cases. First, RAPN was performed using an Olympus Celon Elite ESG-400 (Olympus Europa, Hamburg, Germany) at 15 W with a needle RF probe. RF was applied to the turbinate and ablated the head, middle and posterior aspect of the inferior turbinate, including the mulberry, and the superior, medial and inferior aspect of the posterior end of the turbinates, aiming to reduce the intraturbinate segment of the posterior nasal nerves, with 15–20 punctures on each turbinate. Second, laser PNNN was performed using a 2-W continuous wave laser with the AcuPulse CO₂ laser (Lumenis Ltd., Yokne'am Illit, Israel) transmitted via a nasal probe with a straight-tip 90°mirror. Each side takes 2–3 min to complete the ablation. After the procedure, the inferior turbinate head was covered with Hemopatch (Baxter International, Deerfield, US) to prevent bleeding, which could be removed within 1 week and keeps the inferior meatus patent after removal.

Of the 54 enrolled in the study, 50 completed the 6-month follow-ups. The enrolled patient's characteristics, procedure information, and baseline rhinitis data are reported in Table 1.

Both rTNSS and NOSE scores showed significant post-surgical improvement. From baseline scores of 8.7 (95% CI, 8.2–9.2) and 61.6 (95% CI, 56.8–66.3), respectively, rTNSS decreased to 1.46 (95% CI, 1.9–1.1) and NOSE to 2.9 (95% CI, 4.4–1.4) at 6 months (both p < 0.001). Response rates were consistently high, reaching 100% for both measures by 6 months, with strong early response rates from the first month onward. Subscore analysis showed significant change in all subscores (p < 0.001) when comparing each follow-up timepoint to the baseline. The rTNSS subscores showed an improvement of 74.9%–92.4%, while the NOSE subscore showed an improvement of 93.3%–97.7% (Figure 1). During the 6-month follow-up, one case developed anterior nasal bleeding that was resolved after 3 days of merocel packing.

The clinical response rate of PNNN, defined by a ≥30% reduction in the baseline total rTNSS, has been reported to range from 67.5% to 85.5% at follow-up [2, 3]. Our proposed RPN3 approach achieved response rates of 94% at 1 month and 100% at 6 months, establishing its efficacy for chronic rhinitis management.

The proposed RPN3 offers three key advantages: initial RAPN created an optimal working space for laser probe insertion, immediate symptom relief through RF turbinate reduction, and superior hemostasis with deeper nerve ablation compared to conventional methods. Huang et al.[6] demonstrated significantly better outcomes with RPN3 versus RAPN alone at 3-month follow-up, validating the benefits of this combined approach.

This study has three key limitations: (1) potential selection bias due to its retrospective design, (2) lack of head-to-head trials to differentiate the individual benefits of RAPN versus laser PNNN within the RPN3 procedure, and (3) relatively short follow-up period of 6 months. Future prospective studies with longer follow-up and comparative analysis are needed.

The proposed RPN3 technique is a minimally invasive surgery that significantly improves chronic rhinitis symptoms with early response rates.

Yi-Li Hwang, Ying-Shuo Hsu, Ming-Shao Tsai, and Chien-Yu Huang designed and coordinated the study. Chien-Yu Huang, Jyun-Yi Liao, and Ting-Yu Shih enrolled the study participants and conducted the surgery. Chien-Yu Huang, Jyun-Yi Liao, Ting-Yu Shih, and Han-Lo Teng collected the clinical data and drafted the article. Chien-Yu Huang, Jyun-Yi Liao, and Han-Lo Teng contributed significantly to the manuscript writing and documenting in most cases. Chien-Yu Huang, Jyun-Yi Liao, Ying-Shuo Hsu, Ming-Shao Tsai, Bor-Hwang Kang, and Ying-Shuo Hsu critically revised the manuscript for important intellectual content. All authors have read and approved the final manuscript.

Study approval statement: The study was approved by the Ethics Committee of Chia-Yi Christian Hospital (IRB no: CYCH2024022).

The Institutional Review Board waived the need for informed consent due to the study's retrospective nature.

The authors declare no conflicts of interest.