Interventional procedure overview of cryotherapy for chronic rhinitis

Balai E, Gupta KK, Jolly K et al. (2022) Posterior nasal nerve neurectomy for the treatment of rhinitis: a Systematic Review and Meta-Analysis. European annals of allergy and clinical immunology

Systematic review and meta-analysis (descriptive analysis)

n=463 (8 studies)

This systematic review identified there is some limited evidence to suggest cryotherapy or radiofrequency ablation of the posterior nasal nerve can improve TNSS in adults. However, this is from a limited number of trials with short follow up. Future research should focus on prospective RCTs with more people and medium to long term follow up to help draw more valid conclusions regarding the true effectiveness of PNNN in this patient cohort.

This systematic review combined the results of 6 studies using cryotherapy, 1 study using radiofrequency, and 1 study using laser. All the 6 studies relevant to cryotherapy are included in the main evidence of this overview. The systematic review undertook a meta-analysis of the 2 RCTs available, 1 RCT (Del Signore 2021) is included in the main evidence of this overview and the other RCT (Stolovlzky 2021) assessed the effect of radiofrequency neurolysis.

Fan T, Chandna M, Gorelik D et al. (2022) Correlation between middle turbinate insertion in relation to sphenopalatine foramen and failure rates of cryotherapy and radiofrequency treatment for chronic rhinitis. International Forum of Allergy and Rhinology

Case-control (retrospective)

n=31

The OR of patients failing in-office procedures for chronic rhinitis due to unfavourable MT attachment was 8.2 (95% CI 0.9 to 76.6; p=0.07). This study reinforces the existence of great disparities for natural middle turbinate anatomy.

This study evaluated the relationship of the middle turbinate attachment to the sphenopalatine foramen (SPF) to treatment failure rates for chronic rhinitis.

Gorelik D, Choi A, Desisto N et al. (2022) Indirect comparison of the efficacy of radiofrequency neurolysis and cryotherapy in the treatment of chronic rhinitis. International Forum of Allergy and Rhinology

Indirect comparison of radiofrequency neurolysis and cryotherapy

n=141 (2 studies)

The findings suggest that radiofrequency and cryotherapy are equally efficacious in treating chronic rhinitis. Direct comparison of the 2 devices in a long-term RCT is necessary to confirm the results.

Of the 2 included studies, only 1 study (Del Signore 2022) is for cryotherapy and included in the main evidence.

Haight JS and Gardiner GW (1989) Nasal cryosurgery and cautery: should the septum be treated and is a diagnosis relevant? The Journal of otolaryngology 18(4): 144-50

Non-randomised comparative study

n=48 (cryosurgery, n=12; cautery, n=12)

follow up: 10 to 16 weeks

The results showed that there is no benefit to treating the septum, and that cryosurgery is more effective in those whose symptoms respond to topical steroids, while cautery works better in those who do not. Histology showed no change in the capacitance vessels (sinusoids) after either modality, and xylometazoline caused a marked decrease in nasal resistance, suggesting that vascular smooth muscle function was intact. Irrespective of the change in airway resistance, most patients felt that there had been an improvement.

Studies with larger samples or better designs using a modern device are included in the main evidence.

Hwang PH, Lin B, Weiss R et al. (2017) Cryosurgical posterior nasal tissue ablation for the treatment of rhinitis. International forum of allergy & rhinology 7(10): 952-6

Pilot study

n=27

Follow up: 1 year

Office-based cryotherapy of the PNN region is safe and well tolerated. Symptom scores were significantly decreased by 7 days postprocedure and remained lower at 30, 90, 180, and 365 days.

This study was included in Kompelli (2018) in the main evidence.

Senanayake P, Wong E, McBride K et al. (2022) Efficacy of vidian neurectomy and posterior nasal neurectomy in the management of nonallergic rhinitis: a systematic review. American journal of rhinology & allergy 36(6): 849-871

Systematic review

n=229 (9 studies)

Cryotherapy: 3 studies

Endoscopic vidian neurectomy (EVN), surgical posterior nasal neurectomy (SPNN), and cryoablative posterior nasal neurectomy (CPNN) are similarly efficacious for patients with NAR refractory to medical management. SPNN and CPNN are associated with lower rates of complications (dry eye and palatal/cheek numbness) compared with EVN.

Of the 3 relevant studies, 2 studies (Yoo 2020; Chang 2020) are included in the main evidence and 1 study (n=14; Virani 2021) in the appendix.

Steele TO, Hoshal SG, Kim M et al. (2020) A preliminary report on the effect of gabapentin pretreatment on periprocedural pain during in-office posterior nasal nerve cryoablation. International forum of allergy & rhinology 10(2): 159-64

Non-randomised comparative study

n=26

Pre-procedure gabapentin significantly reduces immediate and delayed post procedural patient discomfort following PNN cryoablation.

This study focused on the effect of gabapentin on patient-reported pain following PNN cryoablation.

Varshney S and Chandra K (1997) Cryosurgery in allergic rhinitis. Indian Journal of Otolaryngology and Head and Neck Surgery 49(1): 66-9

Case series

n=104

The results drawn the inference that cryosurgery provides an excellent relief with regards to symptoms of nasal obstruction while a satisfactory one in rhinorrhoea. Overall it provides great benefit to the patient's symptoms which can further be improved upon with more experience in this regard.

This study was included in Kompelli (2018) in the main evidence.

Virani FR, Wilson MD, Beliveau AM et al. (2021) The impact of surgical posterior nasal nerve cryoablation on symptoms and disease-specific quality of life in patients with chronic rhinitis. Ear, Nose and Throat Journal

Case series

n=14

Follow up: mean 16.5 weeks

This study shows that PNN cryoablation significantly improves symptoms and disease specific quality of life in patients with allergic and non-allergic rhinitis as measured by TNSS and mini-RQLQ.

Studies with larger samples or better designs are included in the key evidence.

Wengraf CL, Gleeson MJ, Siodlak MZ (1986) The stuffy nose: a comparative study of two common methods of treatment. Clinical otolaryngology and allied sciences 11(2): 61-8

Case series

n=13

Follow up: 6 weeks

Rhinomanometry suggests that cryotherapy causes more destruction of the submucosal vascular plexus than submucosal diathermy. Scanning electron microscopy 6 weeks postoperatively shows that both treatment modalities cause widespread damage to the mucociliary epithelium.

This study was included in Kompelli (2018) in the main evidence.

Wojdas A, Zielnik-Jurkiewicz B, Rapiejko P et al. (2004) Surgical treatment of nasal obstruction in allergic and non-allergic rhinitis. International Review of Allergology and Clinical Immunology 10(2): 55-8

Non-randomised comparative studies

n=102

Based on obtained material and results, authors proved conchoplasty to be more effective, and outcomes of nasal obstruction therapy in allergic rhinitis are better. Authors obtained nasal airflow resistance referential values using active anterior rhinometry method.

Limited outcomes reported.

Yan CH and Hwang PH (2018) Surgical management of nonallergic rhinitis. Otolaryngologic clinics of North America 51(5): 945-955

Review

A study of office-based cryotherapy in people with vasomotor rhinitis and allergic rhinitis showed that TNSS decreased significantly up to 365 days after treatment, particularly in the symptoms of rhinorrhoea and congestion. There were no postoperative instances of dry eyes or palate numbness.

Review article