Surgical Management of Nonallergic Rhinitis.

Nonallergic rhinitis (NAR) describes chronic symptoms of nasal congestion, obstruction, and rhinorrhea unrelated to a specific allergen based on skin or serum testing. Vasomotor rhinitis is the most frequent subtype of NAR. Although medical management is the first-line treatment of NAR, there is a role for surgical therapy when medications fail to improve symptoms. Surgical options for NAR include inferior turbinate reduction and botulinum toxin injection as well as more directed targeting of the autonomic nerve supply to the nasal cavity through vidian neurectomy, posterior nasal neurectomy, and cryoablation of the posterior nerve.

Surgical management of vasomotor rhinitis: a systematic review.

BACKGROUND: Vasomotor rhinitis (VMR) is one of the most prevalent forms of nonallergic rhinitis. In the past, when maximal medical therapy failed, surgical options were limited. Vidian neurectomy (VN) was one option; however, it was fraught with complications and limited success. The advent of endoscopic sinus surgery revitalized interest in surgical procedures for VMR. This study was designed to review the available literature and assess the safety and efficacy of surgery on the vidian and posterior nasal nerves for treatment of VMR and when possible, compare the different approaches to one another in regard to safety and efficacy. METHODS: A systematic review was performed of English language articles using Ovid and PubMed. Search terms included "endoscopic vidian neurectomy," "vidian neurectomy," "endoscopic posterior nasal neurectomy" (EPNN), and "posterior nasal neurectomy." Only clinical trials performed on humans with safety and or efficacy data were included. Independent extraction of articles by two authors using predefined data fields was performed. Safety defined by complication rates and efficacy defined as objective improvement on outcomes scores along with the overall length of benefit were the primary measures of treatment effect. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement for reporting systematic reviews was followed. RESULTS: In comparison with open VN, endoscopic techniques were not associated with any long-term sequelae. Rhinorrhea and nasal obstruction were shown to improve after endoscopic VN (EVN) and the benefits were maintained for several years after surgery. CONCLUSION: EVN is well tolerated, safe, and effective in a majority of patients. Overall, the literature has shown that the endoscopic approach is associated with less morbidity than the traditional transantral approach. Currently, no literature exists on the effect of EPNN in patients with vasomotor rhinitis and further study is needed to elucidate the efficacy of this procedure in this subset of patients.

[The original splint-electrode for endonasal electrophoresis].

The objective of the present study was to improve the effectiveness of the treatment of the patients presenting with deflection of the nasal septum and vasomotor rhinitis by developing a method for endonasal electrophoresis in the postoperative period. The study involved 102 patients allocated to three groups. All of them underwent septoplasty including splinting of the nasal septum and submucous laser vaporization of the inferior turbinate bones. The patients of group 3 were treated with the use of an original septal stent with the integrated electrode that allowed to reduce the injurious effect of the procedure of nasal electrophoresis and thereby to decrease the duration of the rehabilitation period following the intranasal surgical intervention; moreover, this approach enhanced the effectiveness of surgery.

Cytologic alterations in nasal mucosa after sphenopalatine artery ligation in patients with vasomotor rhinitis.

BACKGROUND: Vasomotor rhinitis (VR) seems to be related to an imbalance between cholinergic and adrenergic activity in the autonomic nervous system. The nerve fibers of the sympathetic and parasympathetic nervous systems reach the nose through the posterior nasal nerve, which, after crossing the sphenopalatine foramen, distributes to the mucosa following the branches of the sphenopalatine vessels. This study was designed to evaluate the effect of sphenopalatine artery ligation on nasal function and nasal cytology in patients with VR. METHODS: Thirty patients with VR and bilateral inferior turbinate hypertrophy (ITH) were randomly assigned to receive endoscopic inferior turbinoplasty either with or without sphenopalatine artery ligation. Pre- (baseline) and postsurgical (1-year follow-up) assessment included fiber endoscopy, active anterior rhinomanometry, measurement of mucociliary transport time (MTt), and nasal cytology examination. RESULTS: At 1-year follow-up there was a statistically significant improvement in nasal resistances in both groups but not on intergroup comparison; MTt significantly decreased in both groups (p < 0.01) and was significantly better (p < 0.05) in the group that had undergone sphenopalatine artery ligation. Among the patients in this group, significantly fewer were found to have altered ciliated cells (p < 0.005) or a hyperchromatic supranuclear stria (p < 0.005) on nasal cytology; the differences were statistically significant also on intergroup comparison (p < 0.005 and p < 0.001, respectively). CONCLUSION: In patients with vasomotor rhinopathy and ITH, improvement in symptoms, nasal resistance, ciliated cell trophism, and MTt was observed after sphenopalatine artery ligation.

Headaches and cerebral blood flow disturbances in patients with chronic nasal pathology.

Study aimed at research of cerebral blood flow and blood NO contents in patients with chronic non-surgical nasal pathology with accompanying headaches. Eighty five patients with non-surgical chronic nasal pathology with accompanying headaches were investigated. Patients were divided in two age categories: 1st group of 58 patients (18 to 55 years), and 2nd group of 27 patients (>55 years). Control consisted of 30 age-matched healthy individuals. CBF was studied by means of Transcranial Doppler Imaging in patients and control. Free blood NO and NO - complexes were measured by Electron Paramagnet Resonance (EPR) method. Statistics performed by SPSS-11.0. In both age categories of patients the mean blood velocity in middle cerebral artery, anterior cerebral artery, basilar artery of patients was significantly increased against control (p<0.05). Pulsation index (PI) found to be decreased compared to control. The blood free NO signals were non-significantly increased against control. The intensive EPR signals of HbNO and FeSNO were revealed in patients and no signals were detected in control. No differences were revealed between clinical groups regarding the blood EPR signals of NO and NO-complexes (p<0.5). Negative correlation was found between the PI and intensity of headaches (r=-0.37; p<0.01). Multivariate linear regression analysis found the significance of longevity of chronic nasal pathology, Pulastion Index and blood hemoglobin contents for Intensity of headaches (p<0.05). It is concluded that CBF disturbances in chronic nasal pathology may result in intensive headaches.

[Otorhinolaringologyc approach of the chronic cough. Clinical case]. / Enfoque otorrinolaringológico de la tos crónica. Caso clínico.

Chronic cough is defined as that which is persisting at least for trhee weeks without an evident cause. It is very common on the otorhinological practice to receive patients with chronic cough in order to rule out that their chronic cough is not produced because of an alteration in the high respiratory system. We show a clinical case with chronic cough and we make reference to the physical exploration, diagnostical method, and possibilities of medical and surgical treatment.

Enfoque otorrinolaringológico de la tos crónica. Caso clínico / Otorhinolaingology approach of the chronic cough. Clinical case

La tos crónica se define como aquella que persiste al menos tres semanas sin tener una causa evidente. En la práctica Otorrinolaringológica se hace muy habitual recibir enfermos con tos crónica para descartar que su causa no sea una alteración en el aparato respiratorio alto. Presentamos un caso clínico con tos crónica y hacemos referencia a la exploración física, metodología diagnóstica y posibilidades de tratamiento médico y quirúrgico

Chronic cough is defined as that which is persisting at least for trhee weeks without an evident cause. It is very common on the otorhinological practice to receive patients with chronic cough in order to rule out that their chronic cough is not produced because of an alteration in the high respiratory system. We show a clinical case with chronic cough and we make reference to the physical exploration, diagnostical method, and possibilities of medical and surgical treatment

CT assessment of the effect of fluticasone propionate aqueous nasal spray treatment on lower turbinate hypertrophy due to vasomotor rhinitis.

CONCLUSION: Fluticasone propionate (FP) aqueous nasal spray was objectively found to be effective and safe for the treatment of lower turbinate enlargement in patients with vasomotor rhinitis. OBJECTIVE: To assess the efficacy of FP aqueous nasal spray treatment in lower turbinate hypertrophy due to vasomotor rhinitis using CT. MATERIAL AND METHODS: Of 35 patients with hypertrophic lower turbinates due to vasomotor rhinitis, 20 were treated twice daily with FP aqueous nasal spray (200 microg/day) for 3 months continuously and 15 were treated with placebo vehicle as a control group. The local effect of the nasal spray was studied using CT and visual analog scales. RESULTS: Treatment with FP provided significantly greater relief from the symptom of nasal obstruction compared with placebo over the entire 3-month treatment period (p < 0.001). When the change from baseline was compared between the two groups, FP produced statistically significant reductions in the mucosal area of the lower turbinates and in the thickness of the nasal mucosa after 3 months (p < 0.05).

Association of autonomic dysfunction and mild obstructive sleep apnea.

BACKGROUND: Autonomic dysfunction (AD) has been independently associated with obstructive sleep apnea (OSA). Autonomic abnormalities are generally considered to be secondary to OSA. Autonomic dysfunction may also contribute to OSA. If AD contributes to OSA, we postulated that abnormalities may be present in mild OSA where the confounding causal effects of hypoxemia and sleep disruption are reduced. OBJECTIVE: We evaluated autonomic function tests and sleep studies in a cohort of subjects with no known diagnosis of OSA. METHODS: We prospectively enrolled a cohort without diagnosed OSA who were part of an ongoing study of vasomotor rhinitis (VMR) for testing. A battery of autonomic nervous system tests (sudomotor and cardiovagal), nonattended polysomnography, and three-site esophageal/pharyngeal pH monitoring were performed. RESULTS: Twenty of 22 patients completed the test battery and 12 (60%) met criteria for OSA (Apnea/Hypopnea Index "AHI" >5 events/hour). AHI correlated to mean tilt table blood pressure decrease (R = 0.58, P = 0.007) and the Valsalva-mediated phase 2 mean blood pressure decrease (R = 0.52, P = 0.017). OSA severity was related to sympathetic but not parasympathetic abnormalities. No differences in blood pressure responses were related to age, oxygen desaturation nadir, gastroesophageal reflux, VMR, or sleepiness. CONCLUSION: Autonomic abnormalities suggestive of decreased adrenergic tone are associated with mild OSA. These abnormalities may potentially be secondary but may also precede development of OSA.

KTP laser inferior turbinoplasty: an alternative procedure to treat the nasal obstruction.

OBJECTIVE: Nasal obstruction resulting from inferior turbinate hypertrophy (ITH) was treated with KTP laser inferior turbinoplasty (KIT). The effectiveness of the procedure was assessed. METHODS: A prospective clinical trial was carried out in King Chulalongkorn Memorial Hospital from October 1, 1998 to September 30, 2000. Forty-eight patients with chronic nasal obstruction underwent KIT. Nasal obstruction was pre- and postoperatively assessed, based on 4-point scale, by the patient and investigator. The scores were compared by paired t-test. The correlation of assessment by the patient and investigator was also demonstrated by weighted kappa test. Pre- and postoperative rhinomanometric evaluations were performed in 29 patients and were compared with paired t-test. RESULTS: Significant reduction of nasal obstruction was obtained from assessment by the patient (P<0.000) and by the investigator (P<0.000). The symptoms of sneezing, itching and rhinorrhea were significantly reduced postoperatively (P<0.000). The cure and improvement rate of nasal obstruction were at 70.8 and 100% (assessed by the patient) and at 77.1 and 100% (assessed by the investigator) respectively, and they showed a moderate correlation (Kw=0.65). Rhinomanometrically, the total airway resistance decreased but of not statistic significance (P=0.219), however, the inspired nasal airflow at 150 Pa and the volume of nasal cavities were significantly increased (P<0.00 and P<0.001, respectively). CONCLUSION: KIP was shown to effectively reduce the symptom and sign of nasal obstruction as well as other nasal symptoms without any significant complications. It should be an alternative method in treating the patients with nasal obstruction resulting from hyperplastic inferior turbinate.

Bipolar radiofrequency-induced thermotherapy of turbinate hypertrophy: pilot study and 20 months' follow-up.

OBJECTIVES/HYPOTHESIS: The present report is a pilot clinical study about a new bipolar ablation technique for the treatment of turbinate hypertrophy, which offers an alternative to conventional methods. STUDY DESIGN: Prospective, clinical. METHODS: From August 1999 to March 2000, a new bipolar radiofrequency system with acoustic feedback control was submucosally applied for the treatment of 38 patients with nasal airway obstruction of vasomotor (n = 31) or allergic (n = 7) genesis. The therapy was made ambulatory with surface anesthesia. Data were collected by questionnaire and rhinomanometry preoperatively and 2 and 20 months postoperatively. RESULTS: Nearly all patients reported an improvement of their nasal breathing, with 68% of them reporting a full and 29% a partial recovery. No significant differences were reported with regard to the response of the allergic versus the vasomotor rhinitis. On average, a definite benefit was observed after 2 weeks. Side effects, such as bleeding, synechia, or atrophic changes of the mucosa, which would have to be treated, were not observed. CONCLUSION: The new bipolar radiofrequency thermotherapy presents an efficient option for the treatment of turbinate hypertrophy, which meets the requirements for an outpatient treatment.

[Characteristics of autonomic dystonia in children with vasomotor rhinitis]. / Osobennosti vegetativnoi distonii pri vazomotornom rinite u detei.

Data obtained at analysis of tables of screening diagnosis, cardiointervalograms, tilt tests used in examination of 57 children with neurovegetative vasomotor rhinitis point to disorders in the autonomic nervous system (by initial vegetative tone), vegetative reactivity. Parasympathetic prevalence in the initial vegetative tone and cardiointervalograms stems from sympathetic hypoactivity in the majority of the patients. The above vegetative shifts dictate the necessity of vegetotropic medication inclusion into combined therapy of vasomotor rhinitis.

Grading the severity of allergic rhinitis for treatment strategy and drug study purposes.

Grading the severity of rhinitis symptoms is essential for the evaluation of drug efficacy. However, a uniform grading system has not been standardized. A review of 44 journal articles and symposia from Japan, Copenhagen, and the World Health Organization indicates major differences among systems. All except the World Health Organization used a sum of rhinitis scores. The lack of standardization limits comparisons of subjective symptom changes after comparable treatments. Corrective measures include the use of evidence-based definitions of independent nasal symptoms, avoidance of biases in evaluation, and establishment of international consensus for a standardized scale in this era of globalization.

A comparison of partial inferior turbinectomy and cryosurgery for hypertrophic inferior turbinates.

A variety of surgical procedures are performed for treatment of hypertrophic inferior turbinates, but there is no completely effective therapy. We evaluated subjectively and objectively 52 patients who underwent one of two procedures: partial inferior turbinectomy (PIT) or cryosurgery of the inferior turbinates (CS). The results of PIT showed good functional results in 77 per cent of cases for long-term effectiveness. The results of CS showed that effectiveness was reduced from a 62 per cent success rate after one year to 35 per cent later, but CS was a simple procedure which was performed on an outpatient basis with no post-operative morbidity.

The nasal response to isometric exercise in non-eosinophilic intrinsic rhinitis.

The exact pathophysiology of intrinsic rhinitis is not fully understood. The generally held belief is that it is due to an imbalance between the outflow of the nasal sympathetic and parasympathetic nervous systems, perhaps due to excessive parasympathetic or reduced sympathetic activity. In this study the nasal airway response to a predominantly sympathetic stimulus, isometric exercise, was studied in 19 patients with intrinsic rhinitis and compared with 16 normal patients. Isometric exercise took the form of a handgrip stimulus using a hand dynomometer. Following sustained handgrip, a small fall of nasal resistance in the normal group (0.058 kPas/1) and a moderate rise in nasal resistance in the rhinitis group (0.242 kPas/1) was found. Pulse and blood pressure changes were the same in both groups with a significant rise in pulse rate and diastolic blood pressure. The study shows that there is an abnormal response to isometric exercise in intrinsic rhinitis, perhaps due to relative nasal sympathetic hyposensitivity.

[Ambulatory laser and turbinectomy in the treatment of nasal obstruction. Apropos of 68 cases]. / Analyse du laser ambulatoire et de la turbinectomie dans le traitement de l'obstruction nasale. A propos de 68 cas.

The purpose of this prospective study was to compare subjectively and objectively the efficiency of laser vaporisation against surgical procedure in treatment of nasal obstruction related to vasomotor rhinitis. 40 inferior nasal turbinates laser vaporisations were compared to 28 surgical inferior turbinectomies. This trial was based on rhinomanometric data before and after laser or surgical management and on appreciation of individual nasal comfort. The results obtained with conventional surgery were slightly better than laser vaporisation; however this new procedure succeed in 75% of cases with a mean of one year follow-up. The rhinomanometric++ findings appeared especially contributing when significant disorders exist before treatment.

Endoscopic transseptal vidian neurectomy.

OBJECTIVE: Evaluation of the endoscopic transseptal approach of vidian neurectomy. DESIGN: A case series, with a follow-up of 12 to 24 months. SETTING: A referral center. PATIENTS: A consecutive sample of 11 adult patients with resistant vasomotor rhinitis: eight with severe rhinorrhea and three with recurrent nasal polyposis. All patients had a negative history of allergy and negative skin tests. All patients completed the study. INTERVENTION: The rigid nasal endoscope was used through a transseptal approach to reach the sphenopalatine foramen and to cut the vidian nerve. MAIN OUTCOME MEASURES: Intraoperative identification and cutting of the vidian nerve under direct endoscopic vision. Postoperative evaluation of rhinorrhea, sneezing, and recurrent disease. RESULTS: The vidian nerve was identified and sectioned bilaterally in all cases. Immediate and complete cessation of rhinorrhea uniformly occurred. Paroxysms of sneezing were vastly reduced. No recurrence was detected, except in one case. Three patients complained of dry eyes, but they had symptomatic relief with artificial teardrops. CONCLUSION: The technique of endoscopic transseptal vidian neurectomy is a minor surgical procedure with high efficacy and minimal postoperative morbidity. More cases and longer follow-up are necessary to provide long-term results.

Chronic fatigue cured by nasal surgery.

Two cases of severe unexplained fatigue with mid-facial pain and rhinitis are presented. Sinus computerized tomography (CT) findings were minor, but both responded to functional endoscopic nasal surgery with resolution (Case 1) or near resolution (Case 2) of chronic fatigue. Possible mechanisms linking nasal disease and chronic fatigue include reflex etiology and sleep disturbance associated with abnormal nasal airflow. Often not considered by the primary care physician in differential diagnosis of fatigue, chronic sinusitis should be explored as a cause in unexplained cases.

[Etiology of nasal obstruction]. / Etiologie des obstructions nasales.

The most frequent causes of impaired nasal breathing in children and adults are reviewed. Attention is paid to the pathogeny of this disease.